Medical Care
Basic management principles
Basic management principles include the following:
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Establish a firm therapeutic alliance with the patient
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Educate the patient regarding the manifestations of hypochondriasis
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Offer consistent reassurance
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Optimize the patient's ability to cope with the symptoms, rather than trying to eliminate the symptoms
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Avoid performing high-risk, low-yield invasive procedures
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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]
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 illness anxiety disorder.
Psychiatric inpatient care
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, an illness anxiety disorder 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 treatment model described below may be implemented.
General medical inpatient care
Patients with illness anxiety disorder 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 illness anxiety disorder are admitted to the general medical-surgical hospital for an extensive work-up.
When illness anxiety disorder 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 illness anxiety disorder or 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.
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 illness anxiety disorder, 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 illness anxiety disorder and the factors that maintain the long-term anxiety. [39] Randomized controlled trials now suggest that cognitive-behavioral therapy (CBT) is efficacious in the treatment of illness anxiety disorder [40, 41, 42, 43, 44] and may be the recommended treatment for patients with this disorder. Bibliotherapy, using CBT principles, may also be useful.
In a meta-analysis of outcomes using CBT for illness anxiety disorder, higher pre-treatment severity and great number of CBT sessions is associated with higher effect size. [75]
Cognitive and exposure therapy also seems promising for illness anxiety disorder. [76, 77] Mindfulness-based cognitive therapy also appears to be effective when added to usual care. [78]
In clinical settings, both the availability of CBT and treatment adherence of patients with illness anxiety disorder to psychotherapy in general are major barriers to successful outcomes. It is possible that case management and integrated primary care and psychiatry programs may be especially suitable for patients with illness anxiety disorder and somatic symptom disorder. However, prospective treatment studies are urgently needed in this area.
Surgical Care
Psychosurgery is only recommended for patients with severe and intractable illness anxiety disorder.
Consultations
Primary care physicians generally treat illness anxiety disorder, with psychiatrists providing consultation.
Diet
Patients with illness anxiety disorder 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).
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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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.
