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Josh Spitalnick is a clinical and research psychologist with expertise in treating a variety of anxiety conditions with cognitive-behavioral therapy (CBT) and other evidence-based approaches. In this episode, Josh unpacks the four layers of anxiety—psychological, emotional, cognitive, and behavioral—highlighting why avoidance is the key feature that transforms ordinary worry into disorder. He explains why he continues to treat OCD and PTSD as anxiety conditions despite their DSM-5 reclassification, and he draws important distinctions between worries versus worrying and thoughts versus thinking. The discussion explores health anxiety, illness anxiety, and the impact of modern contributors such as wearables, social media, and the COVID era, while weaving in real-world case studies and Josh’s structured assessment approach. Josh also breaks down evidence-based treatments, from exposure therapy and cognitive-behavioral therapy (CBT) to acceptance and commitment therapy (ACT), along with the role of medication, lifestyle factors, and how shifting from avoidance to committed action can build long-term resilience.

We discuss:

• Josh’s professional background and his holistic approach to treating anxiety [3:00];
• Definition of anxiety and changes in the DSM-5 [5:00];
• The psychological and cognitive aspects of anxiety [10:45];
• Breaking down anxiety symptoms: triggers, fears, and hidden mental rituals [17:00];
• Thoughts versus thinking and worries versus worrying: what constitutes dysfunction [20:15];
• Health anxiety and the limits of medical reassurance: understanding illness anxiety and somatic symptom disorder [24:30];
• Triggering events for health anxiety, symptom fixation, heritability, and the role of nature versus nurture [36:30];
• Historical and modern shifts in health anxiety, from HIV/AIDS in the 1980s to today’s heightened fears of cancer [45:30];
• Modern factors and recent events that have amplified societal anxiety levels [47:15];
• Josh’s approach to patients with excessive health-related rituals and/or OCD using CBT and exposure therapy [54:30];
• Hypothetical example of treating a person with a fear of flying: assessment, panic disorder, and the role of medication and exposure therapy [1:03:15];
• The four types of exposure therapy and the shift from habituation to inhibitory learning [1:14:00];
• Treating people with OCD that manifests in disturbing and intrusive thoughts, and why therapy focuses on values over reassurance [1:21:00];
• Acceptance and commitment therapy (ACT): reorienting patients toward values-driven living rather than symptom elimination [1:31:45];
• Mindfulness as a tool to cultivate presence, awareness, and healthy engagement with life [1:36:30];
• Hallmarks of successful therapy and red-flags that therapy is not going well [1:38:15];
• The relationship between anxiety and substance use, and the therapeutic challenges it creates [1:44:45];
• Anxiety’s overlap with ADHD, OCD, autism, and physical health conditions [1:49:45];
• Debunking the harmful myth that health anxiety is a “made up” condition [1:51:30];
• Prevalence, severity, and evolving treatments for health anxiety and OCD [1:54:45];
• Treating health anxiety is about providing patients with skills to improve quality of life—a discussion on how to address symptoms often attributed to long COVID [2:01:30];
• Balancing the benefits of abundant health information with the risks of fueling health anxiety [2:06:30];
• Advice for finding a telehealth provider with expertise in health anxiety [2:11:00]; and
• More.

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