Illness anxiety disorder — assessment and stepped management (MEQ)

(i) Definition and differentials. IAD: preoccupation with having/acquiring serious illness with absent or only mild somatic symptoms, high health anxiety, and excessive health behaviours (checking, care-seeking) or maladaptive avoidance, typically ≥6 months. Here: leukaemia fear, mild fatigue only, multi-hour checking/internet, care-seeking — classic care-seeking IAD. SSD: prominent distressing somatic symptoms plus disproportionate thoughts/feelings/behaviours. OCD: multi-theme obsessions/compulsions not limited to illness (can co-occur). Delusional disorder somatic type: fixed false belief of disease with psychotic process features; IAD retains anxiety-driven seeking and usually some capacity for doubt. Discriminators: symptom load, content breadth, insight/psychosis features.^[5][7]

(ii) Legacy hypochondriasis. DSM-IV hypochondriasis (disease fear based on misinterpretation, persisting despite evaluation) was reorganised: most cases with prominent somatic symptoms → SSD; minority with high health anxiety and minimal symptoms → IAD. Do not claim a simple rename of all hypochondriasis to IAD.^[5]

(iii) CBT model and treatment. Warwick–Salkovskis cycle: catastrophic misinterpretation of cues → anxiety → safety behaviours (checking, forums, ED visits, reassurance) → short relief → belief maintained. Specialised CBT for health anxiety: psychoeducation, cognitive restructuring, exposure to bodily sensations/cues, response prevention (checking/internet/reassurance), behavioural experiments. Evidence: Barsky RCT; Greeven CBT arm; Tyrer CHAMP CBT-HA in medical settings.^[1][2][3][7]

(iv) Pharmacotherapy. Sertraline 50 mg for 3 weeks is early; discuss continuation/titration toward a full therapeutic trial for anxiety/depression, or switch options with stronger hypochondriasis RCT anchors (paroxetine Greeven; fluoxetine Fallon, often starting 20 mg oral daily with titration and monitoring). Combine with CBT when possible; review early for activation and suicidality; adequate duration of weeks at therapeutic dose before non-response.^[2][4]

(v) Collaborative plan and risk. Single coordinating GP/medical home; scheduled reviews; both–and explanation (sensations real + threat system amplification); decline bone-marrow biopsy without haematologic indication; agree criteria for re-investigation if new red flags. Suicide risk: passive death wishes + PHQ-9 16 require full risk assessment and safety plan — hypochondriasis cohorts show elevated mortality including suicide. Involve family to reduce accommodation of checking.^[3][6]