eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Hypochondriasis: Treatment & Medication

Author: Maria Sandra Cely-Serrano, MD, Developmental and Behavioral Pediatrician, Florida Hospital
Coauthor(s): Anna Maria Wilms Floet, MD, Assistant Professor, Assistant Professor of Pediatrics, Department of Pediatrics, Behavior and Developmental, University of Maryland School of Medicine
Contributor Information and Disclosures

Updated: Nov 5, 2008

Treatment

Medical Care

The goal of treatment is to aid the patient in managing the fear of serious illness and to help the patient to establish a greater sense of control in managing symptoms that remain. Appropriate education and a supportive relationship with a competent health care provider is the most important aspect of treatment.

Maintain regularly scheduled appointments to review symptoms and evaluate the person's coping mechanisms. At these appointments, acknowledge and explain test results. Merely making the diagnosis and linking it to psychological stressors can often be therapeutic. Telling people with this disorder that their symptoms are imaginary is not helpful. Mental health treatment can involve a variety of modalities (eg, individual psychotherapy, family therapy, group therapy, parent guidance).

  • Individual psychotherapy can use psychodynamic principles to help the child understand unconscious conflicts.
  • Eliminate sources of secondary gain.
  • Cognitive and behavioral approaches can be helpful and may prove to be the therapy of choice. Behavior modification provides incentives, motivation, and rewards to control the symptoms.
    • In adults brief (6 session), individual cognitive behavioral therapy intervention developed specifically to alter hypochondriacal thinking and restructure hypochondriacal beliefs appears to have significant beneficial long-term effects on the symptoms of hypochondriasis.
    • In one adult study, cognitive behavioral therapy and paroxetine were effective short-term treatment for subjects with hypochondriasis.4 Results from the combined therapy were significantly superior to placebo but did not significantly differ from the results of the individual therapies.
    • A meta-analysis of effectiveness of psychotherapies for hypochondriasis revealed that cognitive therapy, behavioral therapy, cognitive behavioral therapy, and behavioral stress management are effective in reducing the symptoms of hypochondriasis.5 However, studies included in the review used a small number of participants and did not allow for the estimation of effect size.
  • Family therapy focuses on awareness of familiar patterns of interaction and attempts to improve healthy interpersonal communication.
  • Group therapy provides support to learn how to cope with the symptoms and to learn strategies to improve social skills.
  • Education about the links between a person's psychological and physical states should be provided to the child and his or her parents or caregivers.
  • Development of coping skills, including relaxation techniques, cognitive restructuring, and refocusing, is helpful.
  • Involvement of school personnel and those in other social settings frequented by the child is helpful.

Medication

A review of somatoform disorder management in several adult psychiatric consultation-liaison services showed that recommendations were made for antidepressants in 40% of the patients, anxiolytics in 18%, sedatives in 18%, and antipsychotics in 10%. Pharmacologic management was consistent with comorbid psychiatric diagnoses of mood disorder in 39% of patients, of personality disorder in 37%, and of psychoactive substance use disorder in 19%.

Selective serotonin reuptake inhibitors (SSRIs)

SSRIs are chemically unrelated to the tricyclic, tetracyclic, or other available antidepressants. They inhibit CNS neuronal uptake of serotonin (5HT). They may also have a weak effect on norepinephrine and dopamine neuronal reuptake. They have also been used to treat anxiety, phobias, and obsessive-compulsive disorders. Growing evidence suggests the efficacy of SSRIs to treat hypochondriasis. Although controlled adult trials using fluoxetine revealed a high rate of improvement, many patients responded as well to a placebo. Medication has been particularly helpful when comorbid conditions (eg, anxiety disorder, depression) are associated with hypochondriasis.

SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

However, one study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants.6 This is the largest study to date to address this issue.

Currently, evidence does not associate obsessive compulsive disorder and other anxiety disorders treated with SSRIs with an increased risk of suicide. For more information, see the FDA Web site on Antidepressant Use in Children, Adolescents, and Adults.


Fluoxetine (Prozac)

Selectively inhibits presynaptic serotonin reuptake with minimal or no effect on reuptake of norepinephrine or dopamine.

Adult

20 mg/d PO every am; increase after several wk by 20 mg/d; not to exceed 80 mg/d

Pediatric

<18 years: Not established; initial doses of 20 mg/d in children aged 6-14 y have been used
>18 years: Administer as in adults

Inhibits CYP450 isoenzymes 2C9, 2C19, 2D6, and 3A4; increases toxicity of TCAs, diazepam, and trazodone by decreasing clearance; increases toxicity of MAOIs, CYP450 isoenzyme substrates, and highly protein-bound drugs; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan, 5-HT1 agonists [eg, sumatriptan]), discontinue other serotonergic agents at least 2 wk before SSRIs

Documented hypersensitivity; administration of MAOIs within last 2 wk

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hepatic impairment and history of seizures; discontinue MAOI administration at least 2 wk before initiating fluoxetine therapy

More on Hypochondriasis

Overview: Hypochondriasis
Differential Diagnoses & Workup: Hypochondriasis
Treatment & Medication: Hypochondriasis
Follow-up: Hypochondriasis
References
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References

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Further Reading

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Keywords

hypochondria, hypochondriasis, somatization disorder, hypochondrium, hypochondriac, musculoskeletal pain, depression, emotional disorder, disruptive behavior disorder, anxiety, oppositional defiant disorder, stomachache, attention deficit hyperactivity disorder, ADHD, psychiatric disorders, headache, somatic symptoms, body preoccupation, sexual abuse, learning disability

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Contributor Information and Disclosures

Author

Maria Sandra Cely-Serrano, MD, Developmental and Behavioral Pediatrician, Florida Hospital
Maria Sandra Cely-Serrano, MD is a member of the following medical societies: American Academy of Pediatrics and Society for Developmental and Behavioral Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)

Anna Maria Wilms Floet, MD, Assistant Professor, Assistant Professor of Pediatrics, Department of Pediatrics, Behavior and Developmental, University of Maryland School of Medicine
Anna Maria Wilms Floet, MD is a member of the following medical societies: American Academy of Pediatrics and Society for Developmental and Behavioral Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Angelo P Giardino, MD, PhD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, Harris County Medical Society, Helfer Society, and International Society for Prevention of Child Abuse and Neglect
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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