Illness anxiety disorder — structured clinical viva

This is illness anxiety disorder (care-seeking) in a medical setting, not automatically SSD (somatic load is intermittent chest tightness with disease fear dominating after negative work-up) and not automatically delusional disorder if anxiety-driven checking and seeking dominate without a broader psychotic process. Poor insight is compatible with severe IAD; treat the health-anxiety pathway.[5][4]

Cardiology clinics have high rates of significant health anxiety — this presentation is common, not rare nuisance behaviour. Avoid pejorative “heartsink” framing; it predicts staff countertransference and missed treatable anxiety.[7]

Psychological plan. Warwick–Salkovskis cycle: catastrophic cardiac misinterpretation → pulse checking and angiogram seeking → brief relief → maintained belief. Offer specialised CBT for health anxiety (exposure, response prevention for checking/reassurance, behavioural experiments). CHAMP supports adapted CBT-HA for medical outpatients as clinically effective and cost-effective.[1][4]

Pharmacotherapy. Optimise SSRI for health anxiety and depression: options with trial anchors include paroxetine (Greeven RCT) or fluoxetine (Fallon RCTs), e.g. fluoxetine often starting 20 mg orally daily with titration and monitoring; sertraline is a pragmatic alternative. Combine with CBT when feasible; joint treatment showed incremental benefit in Fallon’s multi-arm design framework.[2][3]

Collaborative care. Named cardiology/GP medical home; written criteria for re-investigation if new objective red flags; scheduled reviews rather than on-demand angiograms; both–and formulation. Decline non-indicated invasive testing that maintains threat.[1]

Risk. Assess suicide thoroughly — hypochondriasis cohorts show elevated mortality including suicide. Treat depression actively.[6]