Hypochondriasis Treatment & Management

Basic management principles

• Establish a firm therapeutic alliance with the patient.
• Educate the patient regarding the manifestations of hypochondriasis.
• Offer consistent reassurance.
• Optimize the patient's ability to cope with the symptoms, rather than trying to eliminate the symptoms.
• Avoid performing high-risk, low-yield invasive procedures.
• Close collaboration among all treating providers to prevent investigative duplication

Physician concerns and influence

The most powerful therapeutic tool is the physician and his or her team's attention, concern, interest, careful listening, and nonjudgmental stance, which can potentially break a pathological cycle of maladaptive interactions between the patient and movement from physician to physician (see the image below).^[37]

One difficulty with which physicians struggle is related to countertransference (ie, physicians' own emotional reactions to the patient). Typically, physicians feel angry, hopeless, and/or helpless because their assessments and interventions are not effective and efforts at reassuring the patient are usually met with resistance and even escalation of physical symptoms. These feelings may lead physicians to reject or withdraw from patients with hypochondriasis.

Inpatient care – Psychiatric

As with the other somatoform disorders, inpatient psychiatric hospitalization for the somatoform disorder itself is rarely necessary. As these patients are at risk for concurrent mood, anxiety, and personality disorders, a psychiatric admission may be necessary to manage episodic decompensation of the comorbid psychiatric conditions or suicidal ideation.

If the patient experiences suicidal ideation or makes a suicide act based on comorbid depression or personality disorder or develops uncontrollable anxiety, then an inpatient psychiatric hospitalization may be indicated. In such a case, a hypochondriasis diagnosis may be established in the context of an inpatient admission.

Formal psychometric testing may be of help.

The hypochondriacal patterns of behavior can be addressed in ward therapy interventions.

When patients are discharged following recovery of behavioral stability, the hypochondriasis treatment model described below may be implemented.

Inpatient care - General Medicine

Patients with hypochondriasis should be admitted to general medicine and surgery services based on the medical and surgical acuity, not solely to facilitate work-up.

Due to the enigmatic nature of various physical symptoms, occasionally patients with hypochondriasis are admitted to the general medical-surgical hospital for an extensive work-up.

When hypochondriasis is suspected in a medical or surgical inpatient, a psychosomatic medicine consultation should be performed to elucidate the diagnosis and address psychiatric comorbidity.

If clinically recommended by the psychosomatic medicine consultant, psychotropic medication interventions can be recommended.

As in the outpatient care model, patients should not be exposed to high-risk invasive procedures.

Numerous other strategies appear to benefit patients with hypochondriasis (see the image below). These strategies may prevent potentially serious complications, including the effects of unnecessary diagnostic and therapeutic procedures.

Establish one primary care physician as the patient's main physician.

Review the patient's medical history to build an alliance and rule out medical disorders.

Premature reassurance, prescription of psychotropic medications, and referral for mental health services may suggest to the patient that he or she is not being taken seriously. Therefore, while such treatments may be indicated at some time (in the future), prematurely offering a diagnosis or psychiatric treatment may, in fact, impair the establishment of a trusting patient-physician relationship.

Acknowledge the patient's pain and suffering.

Couple reassurance statements of normal findings with statements that that the patient will not be abandoned. For example, “Mr. Smith, it appears that you are still having concern about having a “several medical disorder” despite all the workup, which, so far, has not showed any abnormal finding. I will continue to work with you to maximize you overall well-being and health.”

Reassure the patient that evaluation will be ongoing.

Set up regularly scheduled visits approximately every 4-8 weeks and gradually taper visits when the patient is less symptomatic.

Explain to the patient that he or she is not crazy and that symptoms are not just "in his or her head."

Understand the “the fear” of having an unknown medical disorder as a form of emotional communication.

Search for underlying medical and psychiatric disorders potentially amenable to treatment.

Use good judgment when deciding whether to perform elaborate diagnostic evaluations.

Seek consultation or refer the patient to a colleague if establishing an alliance proves difficult.

Allow for time-limited structured discussions about somatic concerns.

Spend sufficient time on health care maintenance issues such as diet, experience, smoking cessation, and cancer detection.

Treat comorbid psychiatric disorders concurrently.

Be aware of emotional reactions toward the patient (ie, anger, hopelessness, helplessness) and seek frequent informal consultation when possible.

Focus on care of the patient with hypochondriasis, not exclusively on “a cure” for the disorder.

Psychotherapy

Several authors have suggested a cognitive-educational approach to understand the development of the severe anxiety associated with hypochondriasis (see thefirst image below) and the factors that maintain the long-term anxiety (see the second image below). Randomized controlled trials now suggest that cognitive-behavioral therapy (CBT) is efficacious in the treatment of hypochondriasis^{[38, 39, 40, 41]} and may be the recommended treatment for patients with hypochondriasis. Bibliotherapy, using CBT principles, may also be useful.

Treatments target selective attention,^[42] compatibility between distressing physical symptoms and physical health and longevity,^[43] the cycle involving fear and autonomic overactivity,^[42] and explanations for symptoms and fears.^[43]

In a corollary vein, controlled studies of patients with noncardiac chest pain show that patients who accept psychological factors as the major cause of their symptoms report a significant decrease in pain.^{[44, 45]}

In a survey of patients with hypochondriasis, psychological treatment (ie, CBT) was preferred as the first choice by 74% of respondents, medication was preferred by 4%, and an equal preference for both was indicated by 22%. Of respondents, 48% said they would only accept psychological treatment.^[46]

Exposure and response prevention and cognitive therapy have been shown to be equally valuable in the treatment of patients with hypochondriasis.^[39]

In general, patients with hypochondriasis who show little response to cognitive-behavioral therapy interventions have a higher level of preexisting hypochondriasis, more somatic symptoms, more general psychopathology, and greater psychosocial impairment.^[47]

Group therapy interventions have gained prominence in recent years, including a cognitive-educational approach.^[48] Positive^{[49, 50]} results have also been shown for community and group therapy interventions.^{[51, 52]}

Psychoeducational approaches provide accurate information (ie, somatic symptoms are exceedingly common, with only a small proportion caused by disease and most compatible with physical health). They also explain that selective attention to one part of the body makes a person more aware of sensation in that part than in other parts (eg, paying attention to vague chest pain while ignoring a badly sprained ankle). Accurate information about the relationship of a threatening stimulus and its somatic consequences can influence the severity of autonomic responses, subjective distress, and behavior. Group psychoeducation has demonstrated short- and long-term (follow-up at 6 mo) improvement.^[51]

Psychotherapy can counter maladaptive iatrogenic beliefs. Evidence indicates that patients frequently either forget information or distort it. Giving a small amount of information at one time and repeating it appears best.

Complex developmental, environmental (eg, medical care, family, social network supports, work/disability, sociopolitical, institutional), and cultural factors also influence hypochondriasis (see the image below). Individual, group, and family psychotherapeutic modalities are uniquely qualified to address these factors.

Individual CBT has been compared to paroxetine and placebo in a recent randomized trial of 112 patients.^[53]

A number of other psychotherapy methods have been used to treat hypochondriasis. In one study, psychoanalytic psychotherapy achieved satisfactory results for only 4 of 23 patients. Psychodynamically oriented therapies may be less desirable in the treatment of hypochondriasis.

Behavioral treatments emphasizing exposure, based on the belief that hypochondriasis is a disease phobia, have been examined. Uncontrolled trials suggest that these strategies help a substantial portion of patients. Persuasion techniques, similar to psychoeducation, have been used to convince patients that symptoms are not due to medical illness.

For patients who do not respond to psychotherapy, some authors have advocated more intensive treatments in specialized inpatient units, including those aimed at changing the patient's habits, motives, and goals.

Future research may need to focus more on the relative effects of different forms of psychotherapy, their effect size, identification of the “active ingredient,” and long-term clinical outcomes.^[54]

Tyrer et al have initiated the Cognitive Behavior Therapy for Health Anxiety in Medical Patients (CHAMP) trial, a randomized controlled trial of adapted CBT for health anxiety/hypochondriasis, with 466 patients and an active treatment arm of 5-10 sessions of CBT.^[55]

Pharmacotherapy

No medication is FDA approved for the specific treatment of hypochondriasis. Off-label usage is used and have being studied for hypochondriasis. Initial case reports reported positive effects from fluoxetine, clomipramine,^[56] fluvoxamine, and imipramine.^[57] More recently, additional reports have cited positive effects for fluvoxamine (originally approved for OCD), nefazodone (now off the market), and paroxetine.

A recent 16-week, randomized, placebo-controlled trial compared CBT, paroxetine, and placebo in 112 patients. In the completer analysis, paroxetine (average dose 40 mg/d) performed better than placebo and was not statistically significant compared to CBT, based on the Whiteley Index scores. The responders in the completer group were paroxetine, 38%; CBT, 54%; and placebo, 12%. The responders in the intention-to-treat analysis (ITT) were paroxetine, 30%; CBT, 50%; and placebo, 14%. Overall, both CBT and paroxetine performed better than placebo. About 75% of this cohort of patients had a comorbid depressive, anxiety, or another somatoform disorder.^[53]

In a 12-week, double-blind, placebo-controlled trial of fluoxetine in 20 patients, of the 12 patients treated with fluoxetine, 8 responded, compared with 4 of 8 patients on placebo.^[58]

In another long-term study, 45 patients were randomized to fluoxetine or placebo, at 24 weeks 54.2% responded to fluoxetine compared with 23.8% for placebo (p=0.04). The mean dose of fluoxetine used at week 12 was 51.4 ± 23 mg. Response was defined by a Clinical Global Impression (CGI) rating for hypochondriasis of much or very much improved.^[2]

A study of 58 patients with hypochondriasis who had been treated with SSRI form 4-16 years (mean 8.6 y) found that 40% of the subjects still met criteria for hypochondriasis at follow-up. Longer duration of prior hypochondriasis, history of childhood physical punishment, and less use of SSRIs during the interval period were associated with persistence of hypochondriasis, whereas demographic characteristics, baseline hypochondriasis severity, and psychiatric comorbidity did not predict remission status.^[59]

Consistent with findings from studies in subjects with OCD or BDD, studies in subjects with hypochondriasis indicate that an adequate trial of medication is 3 months before concluding that it is ineffective; moreover, combination pharmacotherapy may be more effective than monotherapy.^[60]

Open trials have suggested the efficacy of monoamine oxidase inhibitors, tricyclic antidepressants, antipsychotics, and electroconvulsive therapy (ECT). Most of these treatment options should be reserved for treatment refractory cases and in patients with other severe comorbidities.

Pharmacotherapy has also been directed at anxiety or depression coexisting with hypochondriasis.^[61] In controlled trials, benzodiazepines, imipramine, phenelzine, propranolol, and alprazolam were found to decrease somatic symptoms in anxious patients. However, some of these medications are associated with significantly more adverse effects, and benzodiazepine could potentially be addictive for those with comorbid substance use disorder.

Treatment of delusional disorder, somatic type (monosymptomatic hypochondriacal psychosis or parasitosis) has been largely successful via pharmacotherapy. If the hypochondriacal fear is of delusional intensity, treatment with haloperidol, pimozide, thioridazine, risperidone^[62] , olanzapine, and other antipsychotics may lead to improvement. For parasitosis, 2 double-blinded, placebo-controlled studies revealed that pimozide is superior to placebo.^{[63, 64]}

A survey showed that most patients do not prefer medication treatment.^[46] Prematurely prescribing a psychotropic medication to a patient with hypochondriasis could potentially damage the therapeutic relationship. While medication may definitely be helpful, especially in the setting of a comorbid psychiatric disorder, establishing a therapeutic alliance and providing a caring nonjudgmental treatment structure is the foundation to treatment.

Other interventions

Other treatments for hypochondriasis include exercise, and ECT. Exercise increases psychological well-being. Patients who are hypochondriacal may be reluctant to follow this advice, but many patients greatly increase their physical activity as treatment progresses. Studies show conflicting results about the efficacy of ECT, which appears to be effective only if a comorbid mood disorder exists.

A number of psychiatric consultation interventions that have been successful for somatization disorder have yet to be evaluated for hypochondriasis. Efforts have been made to educate primary care physicians on the essentials of psychosocial assessment, interviewing, developing approaches to helping with patients with a somatoform disorder, or improving referral skills.

One randomized controlled trial revealed that referral to a psychiatrist was associated with a 12% reduction in health care costs and no deterioration in physical, mental, or general health. Two controlled studies have shown that consultation with a psychiatrist and an instructive letter to the physician about diagnostic and therapeutic measures resulted in a sharp reduction in health care charges and no change in patient satisfaction. Much like use of psychotropic medications, many patients may decline mental health referrals, especially in the early stages of treatment. Therefore, the primary care provider again will rely on his/her trusting relationship with the patient to facilitate a successfully psychiatric referral.^[65]

Psychosurgery is only recommended for patients with severe and intractable hypochondriasis.

Primary care physicians generally treat hypochondriasis, with psychiatrists providing consultation.

Patients with hypochondriasis should eat 3 meals per day to feel as healthy as possible. They should avoid substances that adversely affect mood, exacerbate anxiety symptoms, or reduce the quality of sleep (eg, caffeine, alcohol, nicotine).

Exercise increases psychological well-being. Patients who are hypochondriacal may be reluctant to follow this advice, but many patients greatly increase their physical activity as treatment progresses. Exercise helps to improve mood, reduce tension, and improve sleep in patients with associated depression, anxiety, or both.