Severe Illness Anxiety Treated by Integrating Inpatient Psychotherapy With Medical Care and Minimizing Reassurance

Abstract

Illness anxiety disorder (IAD, formerly hypochondriasis) is characterized by preoccupation with fear of serious illness despite medical reassurance. IAD is common, debilitating, challenging to treat, and results in high healthcare utilization. Outpatient management of IAD is challenging because patients can compulsively seek reassurance from numerous providers, which interferes with learning more productive coping skills. We present the case of a woman with severe IAD who presented to the emergency room with increasing frequency over several months, despite regular outpatient medical visits and escalating psychiatric care. We made the unusual decision to hospitalize her for IAD for 1 month, in the absence of typical hospitalization criteria. This hospitalization allowed us to consolidate all medical and psychiatric care into a single provider team and train all staff and family to communicate with her in a consistent manner. We successfully treated her by integrating a general cognitive-behavioral therapy (CBT) protocol into medical care and decision-making. In response to her numerous health concerns, we minimized medical work-up, reassurance, and reactive medication changes, and instead used the concerns as opportunities to reinforce the psychotherapy. This approach allowed us to simplify her medication regimen and manage her co-morbid hypertension and vitamin deficiencies. Though inpatient hospitalization is likely infeasible in most cases of IAD, outpatient providers may create similar treatment plans based on the example of our case report, without needing highly specialized expertise. Such a plan would require a straightforward understanding of IAD psychology, which we review here, combined with readily accessible tools including a universal CBT protocol, online CBT courses, and clinical symptom scales. We discuss our approach for responding to health concerns, maintaining therapeutic alliance, integrating CBT principles into patient interactions, and managing medications. Since patients with IAD share health concerns with all providers, staff, and family, we also include our own IAD communication guide, appropriate for a general audience, that demonstrates how to respond in these conversations.

Comparison of Perfectionism and Tolerance of Ambiguity in the Subtypes of Illness Anxiety Disorder

“…In this regard, Higgins-Chen et al ( 2019) believed that each time a care-avoidant patient receives medical reassurance, this reassurance may reinforce their previous maladaptive thoughts about the ineffectiveness of medical care. Conversely, less perfectionism provides an opportunity for the extinction of maladaptive thoughts (ineffectiveness of medical care) and behaviors (care-avoiding) (Higgins-Chen et al, 2019). However, as far as we know, no other research has directly compared care-seeking and care-avoidant subtypes of IAD concerning the subscales of perfectionism.…”

Validation of the Korean Version of the Coronavirus Reassurance-Seeking Behaviors Scale During the COVID-19 Pandemic

“…The CRBS is a self-report rating scale which was developed to measure reassurance-seeking behaviors related to COV-ID-19 infection. 14 Based on the illness anxiety disorder (formerly known as hypochondriasis) model, 6 fears of being sick may make a person anxious, thus inducing reassurance-seeking behavior. Relief from reassurance strengthens the original fear and increases preoccupation with the illness.…”

“…5 In this pandemic, people tend to be anxious about being infected and incurring physical illness or mental dysfunction. Based on the Illness Anxiety Disorder model, 6 fear can provoke reassurance-seeking behavior, which may relieve fear or anxiety transiently. However, repetitive reassurance-seeking behavior can lead, in turn, to increased anxiety, enhancing a preoccupation with the causes of the fear.…”

Exercise Participation during the COVID-19 Pandemic: Anxiety, Stress, and Precautionary Behavior

“…Researchers also found that the COVID-19 pandemic was highly correlated with negative emotions, including anxiety [ 22 , 23 ]. Anxiety refers to an emotion that individuals experience when faced with danger and threat [ 26 ], which can result from numerous negative events, such as severe illness [ 27 ] and unemployment [ 28 ]. Furthermore, individuals also feel anxious toward a pandemic [ 29 ].…”