The Peter Attia Drive Podcast #362

Episode Title: Understanding anxiety: defining, assessing, and treating health anxiety, OCD, and the spectrum of anxiety disorders
Guest: Josh Spitalnick, Ph.D., A.B.P.P.
Host: Peter Attia, MD
Release Date: August 25, 2025

Episode Overview

In this insightful episode, Dr. Peter Attia sits down with Dr. Josh Spitalnick, a board-certified clinical psychologist specializing in behavioral and cognitive psychology and founder of Anxiety Specialists of Atlanta. Together, they explore the spectrum of anxiety disorders, focusing on health anxiety and OCD. The conversation covers definitions, assessment models, the pivotal role of avoidance, therapeutic strategies (with a strong focus on exposure therapy and modern CBT), as well as medication's place in treatment and the rising influence of technology and culture on anxiety in the 21st century. The episode is filled with practical distinctions, memorable clinical vignettes, and reconsiderations of stigma and therapeutic hope.

Main Themes & Purpose

• Demystifying the concept of anxiety: what it is, what it isn’t, and why avoidance is central
• Understanding distinctions between worries/worrying, thoughts/thinking, symptoms/behaviors
• Updated DSM categories, and why Dr. Spitalnick still considers OCD and PTSD anxiety conditions
• Deep dive into health anxiety, OCD, illness anxiety disorder, somatic symptom disorder
• Stepwise clinical assessment: psychological, medical, and behavioral symptom triad
• The mechanics and modern practice of exposure therapy
• Medication’s role: SSRIs, benzos, pitfalls of substance use
• Cultural context: social media, wearables, COVID-19 and the modern anxiety landscape
• Clarifying values, cognitive defusion, and building a resilient, fulfilling life

Key Discussion Points and Insights

What Is Anxiety? Layers, Symptoms, and Avoidance

[00:11–08:00]

• Anxiety is multidimensional: physiological, emotional, cognitive, and behavioral.
• “Avoidance is the thread between [all anxiety disorders] that identifies when we have someone who has worries... When I start seeing avoidance, we’re now going from someone that has a worry state to something that’s probably more problematic.” (Dr. Spitalnick, 06:10)
• DSM-5 moved PTSD & OCD out of the “anxiety” chapter, but Dr. Spitalnick believes this is artificial: “I don’t believe for one second they’re not anxiety disorders.” (05:22)

Worries vs. Worrying, Thoughts vs. Thinking

[08:01–20:35]

• Simply having worries or unwanted thoughts is not pathology; the pivotal moment is when one moves from passive experiencing to active mental or behavioral avoidance.
• “Thoughts are the burps, farts, and hiccups of anxiety. They just happen. But when you start thinking about those thoughts and trying to neutralize them... that’s a mental action.” (12:55)
• Internal mental rituals (rumination, reassurance-seeking in one’s own head) are just as destructive—and often less recognized—than behavioral avoidance.

Triggers, Obsessions/Fears, and Compulsions/Safety Behaviors

[15:10–20:35]

• Dr. Spitalnick uses a 3-category framework:
  • Triggers (T)
  • Obsessions/Fears (O/F)
  • Compulsions/Safety Behaviors (C/SB)
• These can be overt (observable) or covert (mental).

Real-World Example: Health Anxiety

[20:36–32:23]

• Differences between somatic symptom disorder (worry about unexplained physical symptoms) and illness anxiety disorder (preoccupied with having/acquiring serious illness, often without symptoms).
• Case vignette: Wife has pain, initially dismissed by multiple doctors, ultimately found to have a serious medical condition (liver mass). “Sometimes we have to trust our own bodies and sometimes we can’t trust the doctor.” (25:57)
• Discussion on excessive medical shopping, and the challenge of persistent negative tests feeding further anxiety.

The Diagnosis Dilemma & Doctor Shopping

[24:30–38:11]

• Safety behaviors can unintentionally make the problem worse.
• The rise of pseudo-experts and “quacks” exacerbated by information overload: “If you go to enough doctors, they’re going to find some problem and recommend some intervention... They want you to feel better.” (31:59)

Social Media, Wearables, and the Pandemic

[35:08–50:35]

• The proliferation of health information, direct access to medical data, and wearable technologies contribute to new forms of health anxiety.
• “My heart rate’s been up all week. Doesn’t that mean something? ... Yeah, it means your heart rate’s up, period.” (36:21)
• COVID-19 catalyzed societal hyper-attentiveness to health risk, changing personal and social behaviors—e.g., normalization of mask-wearing.

The Genetics and Environment of Health Anxiety

[40:16–45:32]

• Health anxiety’s heritability is about 30-40% (“on the low side”), with environmental learning (“training”) playing a major role.
• “It’s very rare for me to see someone who has health anxiety for which a first-degree relative doesn’t also have health anxiety.” (43:55)

Cultural Shifts and Diagnoses

[45:32–54:35]

• From HIV/AIDS as a primary focus of health anxiety to today’s cancer, neurological, and respiratory fears.
• Cultural/environmental triggers: “We’ve seen a significant spike in general anxiety since 2020, almost a twofold spike in most research studies.” (47:40)
• Mask-wearing is explored as both rational and potentially maladaptive depending on function and flexibility in context.

Assessment and the Therapeutic Process

[55:11–69:55]

• Therapy begins with understanding patient values and appraising readiness for change.
• Symptoms are rarely isolated; a cluster of safety behaviors is typical.
• Exposure therapy is the “gold standard” for anxiety and OCD: “You’re not going to come to my clinic... and not get some version of exposure therapy.” (63:01)
• Cognitive Behavioral Therapy (CBT), Exposure Therapy, and Acceptance and Commitment Therapy (ACT) often used in tandem.

Exposure Therapy: How It Works

[69:55–81:23]

• Four main exposure methods:
  • In vivo exposure: Real-life scenarios (public speaking, riding transport, etc.)
  • Imaginal exposure: Writing and repeatedly reading feared narratives.
  • Interoceptive exposure: Inducing feared physical symptoms (e.g., dizziness, chest tightness) in controlled settings.
  • Virtual/Media exposure: Using videos, VR, etc.
• The goal moves from mere physical habituation to new, inhibitory (corrective) learning: “Anxiety is about anticipating something and being colossally wrong. Thank God.” (75:58)

Intrusive Thoughts and the Difference Between Fantasies and Fears

[81:23–88:47]

• Not all distressing thoughts (e.g., fear of being a pedophile, harming others) reflect an intent to act:
  • Ego dystonic (misaligned with personal values; seen in OCD) vs. ego syntonic (aligned; seen in psychopathy)
• Reassurance-seeking, even from therapists, can be counter-therapeutic—“Therapeutic reassurance giving... is one of the best litmus tests [of a well-trained therapist].” (86:46)
• Real change comes from shifting life focus from avoidance/reassurance to value-based action.

ACT, Cognitive Defusion, and Shifting to a Value-Based Life

[89:51–96:28]

• ACT helps patients understand “I’m not my thoughts” and to move from negative reinforcement (“removing discomfort”) to positive reinforcement (expanding life opportunities).
• Behavioral goals are not to extinguish thoughts, but to change the response to them: “I don’t care what you think and feel. I care what you do next. And you’re coming to me because what you’re doing next is shrinking your life.” (90:00)

Medication, Comorbidity, and the Limits of Treatment

[67:01–109:39]

• SSRIs/SNRIs are effective for chronic/general anxiety, but not for acute panic; benzodiazepines may be used as urgent “band-aids” but pose dependency risks.
• “SSRIs don’t treat the tip of the peak of anxiety... It can help long term reduce chronic anxiety...” (67:22)
• Substance use (alcohol, cannabis, benzos) can undermine therapy: “If I can’t tap into that [distress response] because they’re numbed out, I can’t make those changes.” (106:05)
• Comorbidities: ADHD, autism spectrum, tic disorders, trichotillomania, substance use, and mood disorders frequently overlap.

Prognosis and Success Factors in Therapy

[98:24–104:51]

• True success is shown not just at the end of therapy but in sustained behavior change months later.
• Cognitive flexibility and readiness for change are key predictors of recovery.
• Homework, between-session practice, and willingness to “mess up” are crucial.

Prevalence, Stigma, and Future Directions

[114:49–118:40]

• About 4–8% of the population may have a form of health anxiety; a third of those with chronic illness experience significant health anxiety.
• One major myth: the belief that people with anxiety are “making it up” or “seeking attention.” In reality, these are debilitating and non-functional conditions.
• Combination of CBT and SSRIs remains the best-evidenced approach, but a subset are non-responders; research continues into TMS, ketamine, and newer modalities.

The Role of Information, Health Culture, and the Provider

[126:36–130:59]

• Modern health culture brings more good than bad, but also heightens perfectionism and an “answer-seeking” mentality.
• “If you can continue to do what you’re doing, but add elements of surprise and disruption... and not believing that any one thing solves anything, is all I would ask of you.” (127:27)
• Advocates for flexibility, curiosity, and avoiding dogmatic, one-solution thinking.

Memorable Quotes

• On avoidance:
  “Avoidance is a behavioral coping tool that’s highly effective in the moment for the anxiety, but ineffective long term for functioning that is shared amongst almost all the anxiety disorders.” (Dr. Spitalnick, 06:15)

• On thoughts vs. thinking:
  “Thoughts are the burps, farts, and hiccups of anxiety... But when you start thinking about those thoughts and trying to neutralize them... that’s a mental action.” (12:55)

• On reassurance in therapy:
  “If a therapist [gives repeated] reassurance... you’re barking up the wrong tree because now you are weaponizing that certainty principle, which is all the anxiety sufferer wants.” (86:46)

• On value-based living:
  “You spent your career trying to help people elongate now and down the road. I’m trying to help people not eat away what’s happening right in front of them. Their value system is mission critical.” (91:34)

• On functional outcomes:
  “I don’t care if they stop having thoughts... I don’t care if they feel less or more. I care that when those insidious and uncomfortable symptoms show up, they choose a healthy action that gives them life.” (90:00–93:00)

• On criticism of “one-size-fits-all” health approaches:
  “People want the one solution... Unfortunately, that’s a percentage of any population... that’s going to get trapped into looking for the single solution or the single medicine or the single biomarker and they’re going to go to great lengths to solve it. And in my work, that ruins people’s lives.” (130:15)

Important Timestamps for Segment Highlights

• 00:11–08:00 – Defining anxiety, unifying theme of avoidance, DSM-5 changes
• 12:55–15:09 – Thoughts vs. thinking; mental rituals
• 20:36–25:08 – Health anxiety in clinical practice
• 35:08–38:12 – Wearables, social media, body scanning, symptom fixation
• 47:16–50:01 – COVID-19, shifts in social behavior, epidemiologic surge
• 63:01–75:18 – Exposure therapy: how, why, and different forms
• 81:23–89:12 – Intrusive thoughts, OCD, and the line between fantasy and reality
• 98:24–100:28 – Good prognosis factors and therapy success indicators
• 114:49–118:40 – Prevalence, stigma, and the current state/future of therapy

Tone and Style

Dr. Spitalnick employs warmth, candor, and precision. He is humorous at times but always practical, emphasizing evidence-based care while acknowledging the complexity and humanity of those suffering from anxiety. Dr. Attia, as ever, is respectfully inquisitive, seeking to translate clinical nuance for a broad health-conscious audience.

Conclusion

This episode offers a nuanced, compassionate, and practical guide on understanding and approaching anxiety—especially health anxiety—in the modern age. It empowers both sufferers and health professionals to distinguish normal worry from disorder, identify avoidance in all its forms, and move toward effective, value-focused action with the help of both therapy and, when necessary, medication. It calls for flexibility, skepticism toward certainty, and living richly in the now.

For further resources, Dr. Spitalnick’s book and online support platforms were mentioned, and his practice offers telehealth in 40 states (excluding CA, NY, and 8 others).