Hypochondriasis Treatment & Management

Updated: Aug 02, 2016

 Author: Debra Kahn, MD; Chief Editor: David Bienenfeld, MD more...

SECTIONS

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 in hypochondriasis.
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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.
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, 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.
General medical inpatient care
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 hypochondriasis.
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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.
In a meta-analysis of outcomes using CBT for hypochondriasis, 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
hypochondriasis. [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 hypochondriasis 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 hypochondriais, somatic symptom disorder, and
illness anxiety disorder. However, prospective treatment studies are
urgently needed in this area.
Surgical Care
Psychosurgery is only recommended for patients with severe and
intractable hypochondriasis.
Consultations
Primary care physicians generally treat hypochondriasis, with psychiatrists
providing consultation.
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).
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.