Illness anxiety disorder

Somatic symptom disorder is one or more distressing or disruptive somatic symptoms accompanied by excessive, disproportionate thoughts, feelings, and behaviors about them, present for at least 6 months; the symptoms may or may not be medically explained. Management centers on one primary physician, brief regularly scheduled visits, minimized unnecessary testing, validated symptoms, and cognitive behavioral therapy, with an antidepressant such as sertraline reserved for comorbid depression or anxiety.

Generalized anxiety disorder is excessive, hard-to-control worry about multiple life domains occurring more days than not for at least 6 months, with at least 3 of 6 associated physical symptoms and functional impairment. Screen with the GAD-7 after excluding hyperthyroidism and substance use, then treat first-line with cognitive behavioral therapy and/or an SSRI or SNRI such as escitalopram or venlafaxine extended-release, reserving benzodiazepines for short-term severe symptom control only.

Obsessive-compulsive disorder (OCD) is defined by ego-dystonic obsessions and/or compulsions that are time-consuming or cause significant distress and functional impairment, distinguishing it from the ego-syntonic perfectionism of obsessive-compulsive personality disorder. Diagnosis is clinical. First-line treatment combines cognitive behavioral therapy using exposure and response prevention with a high-dose selective serotonin reuptake inhibitor, with clomipramine as an effective second-line tricyclic and an OCD trial that can take up to 10 weeks to judge full response.

Panic disorder is an anxiety disorder defined by recurrent, unexpected panic attacks, discrete surges of fear that peak within 10 minutes with 4 or more characteristic symptoms, followed by at least 1 month of persistent worry about further attacks, worry about their consequences, or a maladaptive behavior change. Medical mimics such as acute coronary syndrome, pulmonary embolism, arrhythmia, hyperthyroidism, pheochromocytoma, and hypoglycemia must be excluded first. First-line treatment is a selective serotonin reuptake inhibitor such as sertraline, started low and titrated slowly, combined with cognitive behavioral therapy; benzodiazepines are reserved for short-term acute control.

Delusional disorder is a primary psychotic illness defined by one or more non-bizarre, fixed delusions lasting at least 1 month, without meeting criteria for schizophrenia and with functioning preserved outside the delusional theme. Diagnosis is clinical after a substance or medical cause is excluded. Management leads with psychotherapy, since antipsychotics are not effective for the core delusion, reserving a low-dose second-generation antipsychotic such as risperidone for overt psychosis or agitation.

Major depressive disorder is a mood disorder defined by 5 or more of 9 major depressive episode symptoms, including depressed mood or anhedonia, present nearly every day for at least 2 weeks and causing significant functional impairment. Diagnosis is clinical, screened with the Patient Health Questionnaire. First-line treatment is cognitive behavioral therapy, a selective serotonin reuptake inhibitor (SSRI) such as sertraline, or both, escalating to augmentation, esketamine, or electroconvulsive therapy for refractory or acutely suicidal presentations.

Factitious disorder imposed on self, formerly Munchausen syndrome, is the conscious falsification, exaggeration, or induction of physical or psychological illness in oneself with no identifiable external reward, driven by an unconscious wish to assume the sick role. Diagnosis relies on objective evidence of deception, such as a suppressed C-peptide with exogenous insulin use or a low thyroglobulin with exogenous thyroid hormone; management is non-punitive disclosure, minimal further workup, and psychiatric referral.