What is the appropriate diagnostic and treatment approach for a patient presenting with significant health anxiety versus paranoia?

Distinguishing Health Anxiety from Paranoia: Diagnostic and Treatment Approach

Health anxiety and paranoia are fundamentally different conditions requiring distinct diagnostic approaches: health anxiety centers on fear of illness with reassurance-seeking behavior, while paranoia involves beliefs about intentional harm from others, often with psychotic features requiring immediate psychiatric evaluation. 1, 2

Immediate Safety Assessment

First, assess for psychosis, severe agitation, or risk of harm to self or others—these require emergency psychiatric referral with one-to-one observation and immediate harm-reduction interventions. 1, 2

• Paranoid presentations with psychotic features (fixed false beliefs, disorganized thinking, hallucinations) mandate urgent psychiatric evaluation 2
• Health anxiety alone does not typically present with psychotic symptoms or imminent safety concerns 3, 4

Key Diagnostic Distinctions

Health Anxiety Characteristics:

• Core feature is the cycle of worry and reassurance-seeking regarding health concerns, not conviction of illness 3, 4
• Patients fear having or developing serious illness despite medical reassurance 4
• Excessive internet browsing about symptoms (cyberchondria) is common 3
• Lifetime prevalence is 6% in general population, up to 20% in hospital outpatients 3
• Patients maintain insight that their fears may be excessive 4

Paranoia Characteristics:

• Paranoia involves beliefs about intentional harm from others, with elevated perception that neutral events are threatening 5
• Patients with paranoia attribute intentionality to negative events that anxiety patients do not 5
• Paranoia uniquely involves biased perception of neutral events as risky, whereas anxiety focuses on negative events 5
• May present with persecutory delusions requiring antipsychotic treatment 5

Structured Diagnostic Assessment

Rule Out Medical Causes First:

• Order thyroid function tests (TSH, free T4) to exclude hyperthyroidism, which commonly mimics anxiety 1, 2
• Assess for hypoglycemia, pheochromocytoma, cardiac arrhythmias, and substance-induced causes 2, 6
• Medication side effects can cause anxiety symptoms in medically ill patients 6

Quantify Severity with GAD-7:

• Administer GAD-7 (scores 0-21) to all patients presenting with anxiety symptoms 1, 2
• Scoring: 0-4 (mild), 5-9 (moderate), 10-14 (moderate-severe requiring intervention), 15-21 (severe) 1
• This standardizes assessment and guides treatment intensity 2

Conduct Comprehensive Diagnostic Interview:

• Identify specific symptoms: panic attacks, trembling, sweating, tachycardia, palpitations for anxiety 7, 2
• For paranoia, assess for beliefs about intentional harm, persecution, or conspiracy 5
• Evaluate functional impairment in social, occupational, and other life domains 1, 2
• Interview collateral sources (family, primary care providers) to corroborate symptom patterns 7, 2

Treatment Algorithm Based on Diagnosis

For Health Anxiety (GAD-7 ≥10):

Initiate combination treatment with sertraline 50 mg daily plus cognitive behavioral therapy (CBT), which is superior to monotherapy. 1, 2

• Sertraline is the preferred first-line SSRI for anxiety disorders 1
• CBT has large effect sizes (Hedges g = 1.01) and includes psychoeducation, cognitive restructuring, and graduated exposure 1
• Continue pharmacotherapy for 12 months after achieving remission before tapering to prevent relapse 1
• Antidepressants have some efficacy but psychological treatments (CBT, mindfulness, acceptance and commitment therapy) are more effective long-term 3

For Paranoia with Psychotic Features:

• Refer immediately to psychiatry for antipsychotic medication evaluation 2
• Do not attempt to manage paranoid psychosis in primary care settings 2
• Ensure safe environment with one-to-one observation until psychiatric evaluation completed 1, 2

For Mild Symptoms (GAD-7 0-9):

• Provide psychoeducation about anxiety and its treatment 2
• Recommend self-help resources based on CBT principles 2
• Prescribe structured physical activity, which may be beneficial 8
• Active monitoring with reassessment in 4-6 weeks 1, 2

Follow-Up and Monitoring

• Reassess symptoms every 4-6 weeks using GAD-7 to monitor treatment response 1, 2
• After 8 weeks, if symptoms persist despite good compliance, alter the treatment course (add intervention, change medication, or refer to individual psychotherapy) 7, 2
• Assess compliance with referrals monthly, as avoidance behavior is common in anxiety 7, 2

Critical Pitfalls to Avoid

• Do not attribute all anxiety symptoms to psychiatric causes without ruling out hyperthyroidism and cardiac conditions first 1, 2
• Do not use benzodiazepines as first-line or long-term treatment due to dependence risk, cognitive impairment, and higher mortality 7, 8
• Do not treat moderate-severe anxiety (GAD-7 ≥10) with monotherapy—combination CBT plus SSRI is superior 1
• Do not discontinue SSRIs before 12 months of remission, as premature discontinuation increases relapse risk 1
• Untreated health anxiety leads to premature mortality through unnecessary medical contacts and missed serious conditions 3
• Do not miss deteriorating medical status (cardiac, pulmonary) by misattributing symptoms solely to anxiety 6