What treatments are effective for managing health anxiety in individuals?

Treatment of Health Anxiety

Cognitive-behavioral therapy specifically designed for health anxiety (CBT-HA) is the first-line treatment, demonstrating sustained effectiveness over 5 years with superior outcomes to standard care. 1, 2

First-Line Treatment: CBT-HA

CBT-HA should be delivered as individual therapy (4-10 sessions) rather than group therapy due to superior clinical effectiveness. 1, 3 The core components include:

• Education about the relationship between bodily sensations and health anxiety to help patients understand how normal physical symptoms trigger catastrophic interpretations 1
• Cognitive restructuring to challenge catastrophic health-related thoughts and beliefs about illness probability and consequences 1
• Gradual exposure to health-related triggers such as medical information, bodily sensations, or avoided medical situations 1
• Reduction of reassurance-seeking and body checking behaviors which perpetuate the anxiety cycle 1

The evidence for CBT-HA is particularly strong: a large randomized controlled trial (n=444) in medical outpatients demonstrated significant improvement at 3 months that was maintained over 5 years with no loss of efficacy between 2 and 5 years. 2 Notably, patients in cardiology and gastroenterology settings showed the greatest gains, and nurses delivered superior outcomes compared to other therapists. 2

When to Add Pharmacotherapy

If CBT-HA is unavailable, not preferred by the patient, or symptoms are severe with comorbid depression, add an SSRI as first-line pharmacotherapy. 1

Medication Selection and Dosing

• Start with sertraline 25-50 mg daily or escitalopram 5-10 mg daily to minimize initial anxiety/agitation 4, 1
• Titrate sertraline by 25-50 mg increments every 1-2 weeks (target 50-200 mg/day) or escitalopram by 5-10 mg increments (target 10-20 mg/day) 4
• Expect statistically significant improvement by week 2, clinically significant improvement by week 6, and maximal benefit by week 12 4, 1

Critical Monitoring

• Monitor closely for suicidal thinking, especially in the first months and following dose adjustments (pooled risk 1% vs 0.2% placebo; number needed to harm = 143) 4, 1
• Common side effects include nausea, sexual dysfunction, headache, insomnia, and dizziness, which typically emerge within the first few weeks and resolve with continued treatment 4

Combination Treatment Strategy

For patients with severe health anxiety or comorbid depression, combination treatment (CBT-HA + SSRI) provides superior outcomes compared to either treatment alone. 1, 3 This approach is supported by moderate strength evidence from anxiety disorder trials. 5

When both depression and anxiety symptoms are present, prioritize treatment of depressive symptoms first, or use a unified protocol combining CBT treatments for both conditions. 1

Adjunctive Strategies

Beyond the core treatment, several adjunctive interventions enhance outcomes:

• Provide psychoeducation to family members about health anxiety symptoms and treatment 1, 3
• Teach specific anxiety management techniques including breathing techniques, progressive muscle relaxation, grounding strategies, sensory techniques, and mindfulness practices 1, 3
• Recommend regular cardiovascular exercise, which provides moderate to large reductions in anxiety symptoms 3

Critical Pitfalls to Avoid

Avoid benzodiazepines as first-line treatment due to risks of dependence, tolerance, and withdrawal; reserve only for short-term use. 4, 1 Research suggests that high-potency benzodiazepines may actually have a detrimental impact on CBT outcomes. 6

Never discontinue SSRIs abruptly—taper gradually over 10-14 days to avoid discontinuation syndrome, particularly with shorter half-life SSRIs like paroxetine. 4, 3

Avoid paroxetine as a first-line SSRI due to higher risk of discontinuation syndrome and potentially increased suicidal thinking compared to other SSRIs. 4

Treatment Monitoring

Assess treatment response at baseline, 4 weeks, 8 weeks, and end of treatment using standardized instruments. 1, 3 This allows for timely adjustment if response is inadequate.

If inadequate response after 8-12 weeks at therapeutic doses, switch to a different SSRI or intensify CBT-HA. 4 The presence of personality abnormality is not a barrier to successful outcome with CBT-HA. 2

Cost-Effectiveness Considerations

CBT-HA is cost-effective in terms of health anxiety outcomes and offsets the cost of treatment, with total costs similar to standard care over 5 years (£12,590 vs £13,334). 2 While not cost-effective in terms of quality-adjusted life-years measured by EQ-5D, the lasting clinical benefits over 5 years make it a highly valuable intervention. 2