Psychotherapy

In a meta-analysis, treatment of Hypochondriasis with several types of psychotherapy was associated with significant benefits compared to waiting list control (i.e., no treatment): cognitive therapy, behavioral therapy, cognitive behavioral therapy, and behavioral stress management. Total therapist time ranged from 4-19 hours, and effect sizes correlated significantly with total therapist time (more time = greater benefits). Psychoeducation alone was not beneficial compared to wait-list control.

Treatment Choice and sequencing of Treatment

It is important to seize opportunities to identify and aggressively treat Illness Anxiety Disorder for several reasons. The condition seldom remits without treatment and is associated with functional outcomes akin to that seen in severe medical conditions with known organic bases. Without treatment, patients are likely to “doctor shop” and undergo many unnecessary and expensive medical examinations and investigations, which only serve to perpetuate the illness. Due to the likelihood of the patient seeking care from more than one doctor, psychiatrists and practitioners in other fields (e.g., family doctors) should work together to treat the patient in a unified way, ideally with joint patient meetings where possible.

Treatment of Choice

We recommend concomitant treatment with psychological intervention (e.g., cognitive behavioral therapy, ideally total therapist contact >10 hours) and an SSRI prescribed at a dose akin to those used in Obsessive Compulsive Disorder.

In addition, we recommend the following:

  • • Offer regularly scheduled follow-up visits. This can be useful in your efforts to reduce escalation, patient frustration, and “doctor shopping” and will encourage the development of a therapeutic alliance over time and facilitate monitoring of treatment response.
  • • Avoid changing the frequency and length of sessions as a function of symptom number or severity. This can lead to reinforcement of maladaptive healthcare seeking behaviors.
  • • Acknowledge the seriousness of the patient’s symptoms and the impact they are having on their life, however, the clinician should avoid giving categorical assurances that symptoms will improve or particular treatments will work.
  • • The onset of new symptoms or endorsement of symptoms should prompt the clinician to consider whether an underlying medical disorder could be present. They should not be ignored.
  • • Patients should be dissuaded from inappropriate visits to the emergency room.

Clinical Pearls for Illness Anxiety Disorder (Hypochondriasis)

  • • First-line treatment is psychological intervention (cognitive therapy / behavioral therapy, and stress management)
  • • Strongly consider also starting an SSRI, and titrating to doses used for OCD
  • • Regular but short scheduled appointments with a trusted clinician can help avert crises and inappropriate presentations to the emergency room
  • • Highly co-morbid with depression and anxiety disorders (GAD, Somatization Disorder, and OCD)

• Keep an open mind about the possibility of any underlying medical conditions but avoid feeding into patient anxiety and excessive medical investigations

Key References

  • • Abramowitz JS, Braddock AE. Hypochondriasis: conceptualization, treatment, and relationship to obsessive compulsive disorder. Psychiatr Clin North Am. 2006 Jun;29(2):503-19.
  • • Thomson AB, Page LA. Psychotherapies for hypochondriasis. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD006520.
 
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