Medication Summary
Pharmacotherapy is used as an adjunct to psychotherapy and educational treatments. The goals of pharmacotherapy are to reduce comorbid symptoms and disorders (eg, depression), to prevent complications, and, in a few circumstances, to reduce hypochondriacal symptoms. Each medication has advantages and disadvantages. [45]
There are no medications approved specifically for the treatment of hypochondriasis, somatic symptom disorder, or illness anxiety disorder. Medications are usually started to treat the comorbid depression or anxiety disorder.
Antidepressants
Class Summary
These are typically used for depression or anxiety comorbid with hypochondriasis, although in some cases they alleviate hypochondriacal symptoms in the absence of another disorder. They are indicated for use in adults with depression, anxiety (eg, panic disorder, OCD, social phobia, generalized anxiety, posttraumatic stress disorders), and bulimia nervosa disorders.
Off-label uses include insomnia, attention-deficit/hyperactivity disorder, premenstrual dysphoric disorder, and other conditions. All SSRIs (eg, fluoxetine [Prozac], sertraline [Zoloft], paroxetine [Paxil], citalopram [Celexa], escitalopram [Lexapro], fluvoxamine [Luvox]), one selective norepinephrine and serotonin inhibitor (ie, venlafaxine [Effexor XR]), 2 TCAs (ie, clomipramine [Anafranil], imipramine [Tofranil]), and one MAOI (ie, tranylcypromine [Parnate]) have been listed; the latter should be used with care because of dietary restrictions and drug interactions. Data on bupropion (Wellbutrin) and mirtazapine (Remeron) are insufficient to warrant listing, but they may also be used.
Initial doses are listed below. The general principle in these patients is to start at a low dose and progress slowly, unless a psychiatric emergency (eg, suicidal ideation) is present. Once established, a well-tolerated and efficacious antidepressant should be continued as indicated for the comorbid condition (eg, 6-12 mo for a single depression or indefinitely for recurrent depression and an anxiety disorder). If used for hypochondriasis alone, for maintenance dosing, adjust the dose to maintain the patient on the lowest effective dosage, and reassess the patient periodically to determine the need for continued treatment.
Fluoxetine (Prozac)
Selectively inhibits presynaptic serotonin reuptake with minimal or no effect on reuptake of norepinephrine or dopamine
Paroxetine (Paxil)
Potent selective inhibitor of neuronal serotonin reuptake. Also has weak effect on norepinephrine and dopamine neuronal reuptake
Sertraline (Zoloft)
Selectively inhibits presynaptic serotonin reuptake, minimal or no effect on reuptake of norepinephrine, and clinically insignificant inhibition of reuptake of dopamine.
Venlafaxine (Effexor XR)
Selectively inhibits presynaptic serotonin reuptake, norepinephrine (at doses of approximately 150 mg PO qam), and dopamine (at doses of approximately 150-225 mg qam).
Clomipramine (Anafranil)
Affects serotonin uptake while affecting norepinephrine uptake when converted into its metabolite desmethylclomipramine.
Fluvoxamine (Luvox)
Potent selective inhibitor of neuronal serotonin reuptake. Does not bind significantly to alpha-adrenergic, histamine, or cholinergic receptors and, thus, has fewer adverse effects than TCAs.
Imipramine (Tofranil)
Inhibits reuptake of norepinephrine or serotonin at presynaptic neuron.
Phenelzine (Nardil)
Usually reserved for patients who do not tolerate or respond to traditional cyclic or second-generation antidepressants.
Citalopram (Celexa)
Selectively inhibits presynaptic serotonin reuptake, minimal or no effect on reuptake of norepinephrine.
Escitalopram (Lexapro)
Selective serotonin reuptake inhibitor (SSRI) and S-enantiomer of citalopram. Used for the treatment of depression. Mechanism of action is thought to be potentiation of serotonergic activity in CNS resulting from inhibition of CNS neuronal reuptake of serotonin. Onset of depression relief may be obtained after 1-2 wk, which is sooner than other antidepressants.
Beta-adrenergic receptor-blocking agents
Class Summary
Compete with beta-adrenergic agonists for available beta-receptor sites. Propranolol inhibits beta-1 receptors (located mainly in cardiac muscle) and beta-2 receptors (located mainly in bronchial and vascular musculature), inhibiting chronotropic, inotropic, and vasodilatory responses to beta-adrenergic stimulation.
Propranolol (Inderal)
Has membrane-stabilizing activity and decreases automaticity of contractions.
Benzodiazepines
Class Summary
Indicated for treatment of anxiety disorders and panic attacks, with or without agoraphobia, which are commonly comorbid with hypochondriasis. Use with caution because patients with hypochondriasis may have increased risk of substance abuse or dependence.
Alprazolam (Xanax)
For management of panic attacks. Binds receptors at several sites within CNS, including limbic system and reticular formation. Effects may be mediated through GABA receptor system.
Antipsychotic medications
Class Summary
Have been shown to reduce morbidity associated with this disorder, particularly in presence of comorbid anxiety or hypochondriacal worries that mimic obsessions or delusions. Because of potential for serious long-term adverse effects (eg, tardive dyskinesia), consultation with psychiatrist recommended to evaluate need for antipsychotic medication. Insufficient data to list other antipsychotics, although they have been used in patients with hypochondriasis.
Pimozide (Orap)
Indicated for Tourette syndrome for suppression of motor and phonic tics. Off-label use for psychosis, hypochondriacal delusions and parasitosis, and Huntington chorea.
Risperidone (Risperdal)
Binds to dopamine D2 receptor with 20-times lower affinity than for serotonin receptor. Improves negative symptoms of psychoses and reduces incidence of EPS. Indicated for treatment of psychotic disorders, including schizophrenia and bipolar disorder mania; also used for sleep.
Olanzapine (Zyprexa)
Binds to dopamine D2 and serotonin receptors. Improves negative symptoms of psychoses and reduces incidence of EPS. Indicated for treatment of psychotic disorders, including schizophrenia and bipolar disorder mania; also used for sleep
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Pathological cycle of bodily concern and anxiety in hypochondriasis.
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Mood, cultural, developmental, and environmental factors that influence hypochondriasis.
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Factors that maintain anxiety in patients with hypochondriasis.
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A cognitive model of the development of anxiety with hypochondriasis.
