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Hypochondriasis Treatment & Management

  • Author: Glen L Xiong, MD; Chief Editor: David Bienenfeld, MD  more...
 
Updated: Jun 10, 2013
 

Medical Care

Basic management principles

See the list below:

  • 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).[38]

Pathological cycle of bodily concern and anxiety i Pathological cycle of bodily concern and anxiety in hypochondriasis.

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 started.

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.

Factors that maintain anxiety in patients with hyp Factors that maintain anxiety in patients with hypochondriasis.

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.

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.

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).[39] Randomized controlled trials now suggest that cognitive-behavioral therapy (CBT) is efficacious in the treatment of hypochondriasis[40, 41, 42, 43, 44] and may be the recommended treatment for patients with hypochondriasis. Bibliotherapy, using CBT principles, may also be useful.

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Surgical Care

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

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Consultations

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

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Diet

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).

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Activity

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.

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Contributor Information and Disclosures
Author

Glen L Xiong, MD Associate Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California, Davis, School of Medicine; Medical Director, Sacramento County Mental Health Treatment Center

Glen L Xiong, MD is a member of the following medical societies: AMDA - The Society for Post-Acute and Long-Term Care Medicine, American College of Physicians, American Psychiatric Association, Central California Psychiatric Society

Disclosure: Received royalty from Lippincott Williams & Wilkins for book editor; Received grant/research funds from National Alliance for Research in Schizophrenia and Depression for independent contractor; Received consulting fee from Blue Cross Blue Shield Association for consulting. for: Received book royalty from American Psychiatric Publishing Inc.

Coauthor(s)

Donald M Hilty, MD Chair and Program Director, Department of Psychiatry, Keck School of Medicine of the University of Southern California

Donald M Hilty, MD is a member of the following medical societies: American Psychiatric Association, Association for Academic Psychiatry, American Association for Technology in Psychiatry, American Telemedicine Association

Disclosure: Nothing to disclose.

James A Bourgeois, OD, MD, MPA Clinical Professor, Department of Psychiatry, University of California, San Francisco, School of Medicine; Faculty Psychiatrist, Consultation-Liaison Division, Department of Psychiatry, Langley Porter Psychiatric Institute, University of California, San Francisco, Medical Center

James A Bourgeois, OD, MD, MPA is a member of the following medical societies: Academy of Psychosomatic Medicine, American Psychiatric Association, Association for Academic Psychiatry, American Neuropsychiatric Association

Disclosure: Nothing to disclose.

Peter M Yellowlees, MD, MBBS Professor of Psychiatry, Director of Health Informatics Program, University of California, Davis, School of Medicine

Disclosure: Received consulting fee from Medscape for independent contractor.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Shayna L Marks, BA, MA; Dandan Liu, BA; and Celia Chang, MD to the development and writing of this article.

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Pathological cycle of bodily concern and anxiety in hypochondriasis.
Mood, cultural, developmental, and environmental factors that influence hypochondriasis.
Factors that maintain anxiety in patients with hypochondriasis.
A cognitive model of the development of anxiety with hypochondriasis.
 
 
 
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