What is the recommended management for illness anxiety disorder?

Management of Illness Anxiety Disorder

Cognitive behavioral therapy (CBT) specifically designed for health anxiety is the first-line treatment, with SSRIs (particularly sertraline or escitalopram) as pharmacological alternatives or adjuncts when psychological treatment alone is insufficient. 1, 2

Initial Treatment Selection

Psychotherapy as Primary Treatment

• CBT targeting health anxiety should be offered first because it directly addresses the core psychopathology—the cycle of worry and reassurance-seeking about health—and has the highest level of evidence for anxiety disorders 1, 2
• Individual CBT sessions following structured protocols are preferred over group formats due to superior clinical effectiveness 3
• Internet-delivered CBT (iCBT) is a highly effective alternative if face-to-face therapy is not feasible or desired, with 84% of patients showing clinically reliable improvement compared to 34% in control groups (effect size 1.39) 4
• The iCBT approach typically involves 6-12 lessons with clinician guidance over 12 weeks, addressing maladaptive cognitions, body hypervigilance, safety behaviors, and intolerance of uncertainty 4

Pharmacotherapy Options

When medication is indicated (marked distress, functional impairment, or inadequate response to psychotherapy alone):

First-line agents:

• SSRIs are suggested as first-line pharmacotherapy, with sertraline and escitalopram preferred due to favorable safety profiles and low drug interaction potential 5, 2
• Start sertraline at 25-50 mg daily or escitalopram at 5-10 mg daily, titrating gradually at 1-2 week intervals 5
• SNRIs (venlafaxine) are appropriate alternatives if SSRIs are ineffective or not tolerated 3, 2

Agents to avoid:

• Benzodiazepines should not be used for routine treatment due to risk of dependence, tolerance, and lack of efficacy for the core psychopathology 2
• Paroxetine and fluoxetine should generally be avoided due to higher rates of adverse effects and drug interactions 5

Treatment Implementation Strategy

Core Therapeutic Principles

• Minimize reassurance-seeking and excessive medical testing, as these behaviors perpetuate the anxiety cycle rather than resolve it 1, 6
• Maintain an empathic, curious, and nonjudgmental stance toward the patient's health anxiety while avoiding reactive medical workups 1, 6
• Consolidate care with a single provider team to prevent compulsive reassurance-seeking from multiple providers, which interferes with learning productive coping skills 6

Responding to Health Concerns

When patients present with new health worries:

• Use the concern as an opportunity to reinforce CBT principles rather than ordering tests or providing reassurance 6
• Integrate CBT concepts into all patient interactions, including medical decision-making 6
• Train all staff and family members to communicate consistently using the same approach 6

Combination Therapy Considerations

• There is no formal recommendation for combining pharmacotherapy with psychotherapy based on current evidence for anxiety disorders generally 3
• However, in severe cases with high healthcare utilization, integrating CBT principles into all medical care while using SSRIs may be necessary 6
• The decision should prioritize the treatment modality most likely to address the core reassurance-seeking cycle 1

Treatment Monitoring and Duration

Assessment Timeline

• Evaluate treatment response at 4 weeks and 8 weeks using standardized measures of health anxiety (e.g., Short Health Anxiety Inventory) 5
• Monitor for symptom relief, functional improvement, reduction in healthcare utilization, and adverse effects 5

Treatment Adjustment

If symptoms are stable or worsening after 8 weeks despite good adherence:

• For psychotherapy: Consider switching from group to individual CBT, or adding pharmacotherapy 5
• For pharmacotherapy: Switch to a different SSRI or SNRI, or add CBT 5
• Reassess for comorbid depression, as anxiety may be symptomatic of underlying depression requiring prioritized treatment 5

Maintenance Phase

• Continue medications for at least 6-12 months after symptom remission for a first episode 5, 2
• For recurrent or chronic illness anxiety, longer-term or indefinite treatment may be beneficial 5
• Taper SSRIs gradually over 10-14 days when discontinuing to avoid withdrawal syndrome (dizziness, paresthesias, anxiety, irritability) 5

Common Pitfalls to Avoid

• Never provide repeated reassurance about the absence of serious illness, as this reinforces the anxiety cycle and prevents habituation 1, 6
• Avoid ordering excessive medical tests in response to health concerns unless clinically indicated by objective findings 1, 6
• Do not make reactive medication changes in response to each new health worry 6
• Ensure collaboration between all medical providers to prevent fragmented care that enables reassurance-seeking behavior 1
• Do not abruptly discontinue SSRIs without gradual tapering 5

Special Populations

Elderly Patients

• Start SSRIs at lower doses (sertraline 25 mg or escitalopram 5 mg) and titrate more gradually at 3-4 week intervals 5
• Monitor for hyponatremia, falls risk, and drug interactions with other medications 5
• Escitalopram has the least effect on CYP450 enzymes, making it preferable in patients on multiple medications 5