How should I treat my illness anxiety disorder?

Treatment of Health Anxiety (Illness Anxiety Disorder)

Cognitive behavioral therapy (CBT) specifically designed for anxiety disorders is the first-line treatment for health anxiety, with individual sessions preferred over group therapy, and if medication is needed, start with an SSRI such as escitalopram 5-10 mg daily or sertraline 25-50 mg daily. 1, 2

Primary Treatment Approach

Psychotherapy as First-Line Treatment

Individual CBT should be your initial intervention, structured over 12-20 sessions to achieve meaningful symptomatic and functional improvement. 1, 3 The therapy must include these specific components:

• Psychoeducation about the psychophysiology of anxiety reactions and how health anxiety perpetuates itself through checking behaviors and reassurance-seeking 1, 4
• Cognitive restructuring to challenge catastrophizing, over-generalization, and all-or-nothing thinking patterns about bodily sensations and health threats 1, 3
• Graduated exposure to health-related fears, including reducing checking behaviors (body scanning, internet searches, doctor visits) in a stepwise manner 1, 3
• Behavioral goal setting with contingent rewards to reinforce progress 1
• Relapse prevention strategies to maintain gains 3

Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness. 1, 2 If face-to-face CBT is unavailable or undesired, self-help materials based on CBT with professional support (approximately 9 sessions over 3-4 months, totaling ~3 hours of therapist contact) is an acceptable alternative. 1

Pharmacotherapy When Indicated

First-Line Medications

If CBT alone is insufficient, unavailable, or the patient prefers combined treatment, start with an SSRI:

• Escitalopram: Start 5-10 mg daily, increase by 5-10 mg every 1-2 weeks, target 10-20 mg/day 5, 2
• Sertraline: Start 25-50 mg daily, increase by 25-50 mg every 1-2 weeks, target 50-200 mg/day 5, 2

Critical timeline expectations: Statistically significant improvement may begin by week 2, clinically meaningful improvement by week 6, and maximal benefit by week 12 or later. 1, 5 Do not abandon treatment prematurely—full response requires patience. 5

Common Side Effects to Anticipate

Most adverse effects emerge within the first few weeks and typically resolve with continued treatment: nausea, headache, insomnia, sexual dysfunction, dry mouth, diarrhea, dizziness, and somnolence. 1, 5 Starting at low doses and titrating gradually minimizes initial anxiety or agitation that can occur with SSRIs. 5

Critical warning: All SSRIs carry a boxed warning for suicidal thinking and behavior (pooled risk 1% vs 0.2% placebo, NNH=143). Monitor closely, especially in the first months and after dose adjustments. 5

If First SSRI Fails

After 8-12 weeks at therapeutic doses with inadequate response:

• Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa) 5, 2
• Consider an SNRI: Venlafaxine XR 75-225 mg/day or duloxetine 60-120 mg/day 5, 2, 6
• Add or intensify CBT if not already implemented 5, 2

Paroxetine and fluvoxamine are equally effective but reserved as second-tier options due to higher discontinuation symptoms and drug interaction potential. 5, 2

Combination Treatment

Combining CBT with an SSRI provides superior outcomes compared to either treatment alone, particularly for moderate to severe anxiety. 5, 2, 3 This should be strongly considered when:

• Symptoms cause marked distress or functional impairment 1
• Monotherapy (CBT or medication alone) has been insufficient 5
• The patient has comorbid depression or other anxiety disorders 7

Adjunctive Non-Pharmacological Strategies

These should be incorporated alongside primary treatment:

• Structured aerobic exercise (active walking, jogging) provides moderate to large reduction in anxiety symptoms 5, 4
• Breathing techniques, progressive muscle relaxation, and mindfulness are useful adjuncts 5, 4
• Sleep hygiene education to address commonly co-occurring insomnia 5
• Avoid excessive caffeine and alcohol, both of which exacerbate anxiety 5

Treatment Duration and Monitoring

• Continue effective medication for 9-12 months minimum after achieving remission to prevent relapse 5, 6
• Monitor monthly until symptoms stabilize, then every 3 months using standardized scales (GAD-7, HAM-A) 5
• Taper medications gradually when discontinuing to avoid withdrawal symptoms, particularly with shorter half-life SSRIs 1, 2

Critical Pitfalls to Avoid

• Do not prescribe benzodiazepines as first-line treatment—they carry risks of dependence, tolerance, and withdrawal, and should be reserved only for short-term use if absolutely necessary 5, 2, 6
• Do not use bupropion—it lacks efficacy for anxiety and may worsen symptoms due to its activating properties 5
• Do not overlook functional impairment—even mild symptom scores may mask significant daily-life disruption requiring treatment 5
• Do not underestimate treatment adherence barriers—patients with anxiety commonly avoid follow-through on referrals; proactively address obstacles 5
• Do not use beta-blockers, antipsychotics (quetiapine), or tricyclic antidepressants as primary treatments—they lack guideline support and carry unfavorable risk-benefit profiles 5, 2