HealthCareMagic is now Ask A Doctor - 24x7 | https://www.askadoctor24x7.com

Suggest Treatment For Hypochondriasis

Posted on Tue, 29 Apr 2014

Question: Hello Doctor, I am a 43 year old male professional. I have always been suffering from health worries and was diagnosed with hypochondria several years ago. I have continued to experience several bouts of serious health anxiety. Some times there are normal periods. But generally there is some niggling health worry of varying intensity either about me or close family. I have been managing for some years through counselling and support from a psychiatrist friend without medication. Probably because I am also concerned about long term side effects of medications on liver, kidney etc. However, as I was finding it more and more difficult to handle, for the past 5 months I have been prescribed Nexito (escitalopram) 10 mg(bedtime). I felt some relief for the first few months. Notably sleep improved, though some days I tend to sleep late and feel lethargic. But after the initial period the health worries have once again started continuing. Let me mention that I do not attend any formal counselling mainly as I understand there are no trained CBT professionals in my area. But I do try to rely on some prayer and CBT based self help to keep going. The issue is that when things are normal, it's Ok. But once an episode strikes (which is fairly regular) all that I've been doing and telling myself till then vanishes instantly. Then it's all anxiety, worry and panic at least until some doctor says it's not cancer. Though again many times I'm not easily convinced. My psychiatrist friend has now advised that I could try upping the Nexito dose to 20 mg. Feeling confused, I recently consulted a more XXXXXXX psychiatrist. He has now advised to change the medicine to Fluvoxmine - 50 mg (half at lunch and half bed time) while reducing Nexito to 5mg for now. He has also added another medicine Divalproex - 125 mg (ER) at bedtime. I understand that Fluvox is another SSRI like Nexito. I also understand that Divalproex is a mood stabliser usually used for bipolar or epileptic patients and could have serious side effects on liver function etc. I don't know why he could have prescribed this, as I believe I had told him that I do not experience substantial mood fluctuations. If it matters I could add that I presently take Telma 40 mg for BP control and Nexpro Fast -40mg for GERD. I am very confused what course of treatment to follow for my health anxiety now and would value your expert advice greatly to resolve my confusion. Regards

Answered by Dr. Jonas Sundarakumar (1 hour later)

Brief Answer: Divalproex not recommended in my opinion... Detailed Answer: Hello and welcome to Healthcare Magic. Thanks for your query. I understand that you are confused and rather worried about the medication that you have been advised for your health anxiety problem (Hypochondriasis). So, let me clarify this for you... (and my opinion is based on international guidelines and my own clinical experience) Firstly, the important thing to understand is that medication is not the mainstay of treatment for Hypochondriasis. Psychological therapy, more specifically C.B.T. is considered as the treatment of choice. However, practically, medication is very often used in treatment. The reasons are: 1) In many places, CBT may not be available or there may be long delays in accessing a CBT-trained therapist. 2) More often than not, people with Hypochondriasis have co-morbid problems like generalized anxiety, obsessions, secondary depression, etc. and these problems make the person's condition worse. With regards to the choice of medication, according to the international guidelines and expert consensus, two categories of medication are recommended. SSRI antidepressants are the most widely used group of medication. In a small proportion of cases (where the hypochondriacal fears become severe enough to become a rigid, unshakable belief - what we call a "hypochondriacal delusion") another group of medication called anti-psychotics may be used. Mood stabilizers have not been recommended in the treatment of hypochondriasis and there is no solid evidence to suggest that they have been helpful to patients with Hypochondriasis. Now, I'm not sure why the second psychiatrist has advised you to take a mood stabilizer. It could be that he thought that you had some mood fluctuations, which could be helped by a mood stabilizer like Divalproex. The other possible reason is that sometimes, mood stabilizers can be used to 'augment' the effects of anti-depressants. But this is tried only when multiple antidepressants have been tried at maximum doses and have not been effective. So, in my opinion, I don't think a mood stabilizer like Divalproex would help with your health anxiety. My thought would be to increase the dose of your current anti-depressant or try another SSRI anti-depressant. I hope I have helped in clarifying your confusion... Wish you all the best. Regards, Dr. Jonas Sundarakumar MRCPsych.(U.K.) Consultant Psychiatrist

Above answer was peer-reviewed by : Dr. Vinay Bhardwaj

Follow up: Dr. Jonas Sundarakumar (3 hours later)

Dear Dr Sundarakumar, Many thanks for your detailed replies. I have understood the overall import clearly. However I would greatly appreciate your specific views with regard to the following too before going in for a proper treatment regime. 1. In your opinion as I have been presently taking Nexito 10 mg for almost 5 months, do I follow the initial advice of continuing the same medicine and raising the dosage of Nexito to 20 mg. Or do you feel I ought to go with the second view and change the medicine to Fluvoxamine 50mg, slowly tapering down Nexito. The second doctor had expressed a view that Fluvox is better to control intrusive thoughts. Do you also think Fluvox has any such advantage over Nexito in treating health anxiety. 2. Should I ask the doctor who prescribed Divalproex anything specific before deciding not to take it as suggested by you? 3. Both the psychiatrists I consulted did not somehow show any faith in taking counselling. Probably because there are no such skilled people here. I live in Kochi, Kerala. Is there anybody in your professional circles who can offer CBT therapy as suggested by you? 4. Are all psychologists trained in CBT? How do I find out if there is anybody in my town who is qualified to give such therapy? 5.Are there any practical alternates to receiving CBT therapy in person in case no such people are locally available - like online or something. I realise I have asked several questions. Just trying to clear all the cobwebs before going forward. Once again, big thanks and regards

Answered by Dr. Jonas Sundarakumar (12 hours later)

Brief Answer: I have given answers to your specific questions... Detailed Answer: Hello again, Here are my views on your specific questions: 1) Though both Nexito (Escitalopram) and Fluvox (Flovoxamine) are SSRIs, clinical experience shows that Fluvox is indeed better at controlling intrusive / obsessieve thoughts. People with health anxiety often report such intrusive / obsessive thoughts and so, I personally feel that Fluvox would be sightly more advantageous than Nexito for treating health anxiety. 2) Yes, you could gently bring up this issue of the mood stabilizer and ask him why he felt that a mood stabilizer was required in your case. There is no harm in knowing what his opinion was after assessing you clinically. 3) Well, regarding CBT, many clinicians in India don't actively push it because of two reasons: a) well-structured psychological therapy is time and effort-consuming (it's easier and less-time consuming to just prescribe medication) and b) therapists / resources are limited. 4) Most psychologists would have knowledge and experience in CBT. However, only a few are 'certified' CBT therapists. Unfortunately, I don't have any such colleagues in Kerala. But, usually big institutions like medical college hospitals or specialized psychiatry care centres are likely to have psychologists who offer CBT. 5) There are online / computerized CBT options available, but most are targetted for general anxiety or depression. But it would be worthwhile trying to learn and benefit from the basic concepts of CBT (which are common for all disorders). I have given below links to a few such resources: https://moodgym XXXXXXX edu.au/welcome http://www.get.gg/cbtstep1.htm http://www.cci.health.wa.gov.au/resources/infopax.cfm?Info_ID=53 (THIS ONE HAS SPECIFIC HELP FOR HEALTH ANXIETY) Best wishes, Dr. Jonas Sundarakumar MRCPsych.(U.K.) Consultant Psychiatrist

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Jonas Sundarakumar (57 minutes later)

Dear Dr Sundarakumar, Once again many thanks for your comprehensive replies. I honestly wish I could come to Chennai and consult you in person. Do you personally feeling using faith and trying practises like reading the XXXXXXX from a psychological perspective on my own can be an effective substitute for formal CBT or ERP? And what happens to people who have already done CBT when they tend to relapse later? The other questions I have are about dosage and discontinuation of Fluvox. I have been adviced to start at 50 mg (half after lunch, half after dinner). I figure these are only starting doses. What optimum doses do you feel should be looked at? In your learned opinion is there any other drug which is also needed at this stage in addition to Fluvox? I also realise it takes a prolonged time period for the medicine to take full effect and still many relapse after. Is there any serious long term disadvantage in continuing an optimum dose for ever over life time if it comes to that? I know this is a needless premature worry. It's just that somehow thinking that way takes the pressure of taking the drug each day worrying about how to get off it. Regards

Answered by Dr. Jonas Sundarakumar (55 minutes later)

Brief Answer: Answers given below... Detailed Answer: Hi, My answers to your queries: - The faith-related practices that you have mentioned can be helpful, but I don't think that it would be a 'substitute' for structured and targetted psychological therapy by an expert. They can be used as supplementary help in addition to formal therapy. - CBT generally has long-lasting results because the focus is not on symptom-reduction, but actually on "changing the way you think and feel about yourself". However, practically, people may need "top-up" sessions to address relapses or to reinforce the things that they have learnt in the previous sessions. - Regarding the dose of Fluvoxamine, there is no 'one rule' for everyone. The dose requirement varies from individual to individual and according to the nature and severity of symptoms. Usually, the required dose is about 100 - 150 mg. However, if there is a strong obsessive element to your health anxiety, then generally, higher doses (around 200 - 250 mg) may be required. The usual practice is to start at the minimal dose and make gradual increments according to the treatment response and tolerability. - At this stage, I don't think any other drug is necessary. - SSRIs are among the safest group of psychiatric medication and many people are on treatment for years together. Long term treatment with SSRIs hasn't been shown to have any delitirious consequences. I hope I have clarified your doubts... Best wishes, Dr. Jonas Sundarakumar MRCPsych.(U.K.) Consultant Psychiatrist

Note: For further guidance on mental health, Click here.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar