#362 ‒ Understanding anxiety: defining, assessing, and treating health anxiety, OCD, and the spectrum of anxiety disorders | Josh Spitalnick, Ph.D., A.B.P.P.
In this episode of The Peter Attia Drive, Dr. Josh Spitalnick explains the complex nature of anxiety disorders, which can manifest through physical, emotional, cognitive, and behavioral symptoms. He describes how anxiety disorders are characterized by avoidance behaviors that provide temporary relief but ultimately intensify the condition, and discusses the genetic and environmental factors that contribute to their development, including the significant impact of the recent pandemic and modern technology.
The episode covers the primary treatment approaches for anxiety disorders, with a focus on Cognitive Behavioral Therapy (CBT) and exposure therapy. Spitalnick details how these therapeutic methods work alongside medication options like SSRIs and benzodiazepines, emphasizing the importance of developing long-term management skills rather than relying solely on pharmaceutical interventions. He also addresses the relationship between anxiety disorders and other conditions like ADHD, depression, and substance abuse.
This is a preview of the Shortform summary of the Aug 25, 2025 episode of the The Peter Attia Drive
Sign up for Shortform to access the whole episode summary along with additional materials like counterarguments and context.
1-Page Summary
The Nature and Symptoms of Anxiety Disorders
Josh Spitalnick explains that anxiety disorders manifest through physical, emotional, cognitive, and behavioral symptoms. These disorders can feel like they're "killing us on the inside," affecting sufferers through various symptoms such as excessive hand-washing or compulsive email checking. Spitalnick notes that in the DSM-5, PTSD and OCD were moved to their own categories, though they share commonalities with anxiety disorders.
A key characteristic of anxiety disorders, according to Spitalnick, is avoidance behavior. While this coping mechanism might provide temporary relief, it ultimately perpetuates and intensifies anxiety. He emphasizes the distinction between passive thoughts and active thinking, explaining how analyzing and trying to neutralize anxious thoughts can actually worsen the condition.
Therapeutic Approaches To Treating Anxiety
Spitalnick discusses several effective treatment approaches, with Cognitive Behavioral Therapy (CBT) and exposure therapy being the gold standards. CBT works by targeting cognitive distortions, while exposure therapy helps patients face their fears safely and gradually. He also describes Acceptance and Commitment Therapy (ACT) as enhancing CBT by helping patients develop psychological distance from anxiety-provoking thoughts and align their actions with their values.
Regarding medication, Spitalnick and Peter Attia discuss the careful integration of SSRIs and benzodiazepines with psychotherapy. While medications can be helpful, Spitalnick emphasizes the importance of developing skills to manage anxiety rather than relying solely on pharmaceutical interventions.
Contributing Factors and Comorbidities
Spitalnick reveals that anxiety disorders have a significant genetic component, with heritability rates of 30-40% for general anxiety and 50% for OCD. These conditions often co-occur with other disorders like ADHD, depression, and substance abuse, creating complex presentations that require careful diagnosis and treatment.
Environmental factors also play a crucial role. Spitalnick points out that the recent pandemic has nearly doubled general anxiety rates, while modern technology and social media can exacerbate symptoms. He notes that behaviors like googling symptoms for reassurance often worsen health anxieties rather than alleviating them.
1-Page Summary
Additional Materials
Counterarguments
- While CBT and exposure therapy are often considered gold standards, some patients may not respond to these treatments, and alternative therapies may be more effective for them.
- The effectiveness of ACT in enhancing CBT could be debated, as some may argue that ACT should be considered a standalone treatment rather than an enhancement to CBT.
- The integration of SSRIs and benzodiazepines with psychotherapy is a complex issue, and some may argue that the risks of medication dependency or side effects are not sufficiently highlighted.
- The genetic component of anxiety disorders is significant, but it's also important to consider that genetics do not determine destiny, and environmental factors can play a significant role in the development and management of these disorders.
- The statement that the pandemic has nearly doubled general anxiety rates might be challenged by emerging research that could offer a more nuanced understanding of the pandemic's long-term effects on mental health.
- The assertion that modern technology and social media exacerbate anxiety symptoms might be too broad, as there are also studies showing that technology can offer support and resources for those with anxiety disorders.
- The idea that googling symptoms for reassurance can worsen health anxieties might not take into account the potential benefits of increased health literacy and empowerment through information.
Actionables
- You can track your daily activities and emotions in a journal to identify patterns related to anxiety. By noting down when you feel anxious and what you're doing at the time, you might discover triggers or behaviors that contribute to your anxiety, such as compulsive email checking. This self-awareness can be a first step in managing symptoms.
- Create a "worry window" in your schedule where you allow yourself to focus on your anxieties. Set aside a specific time each day to contemplate your worries, which can help prevent them from overtaking your entire day. During this time, practice challenging any negative thoughts by asking yourself how realistic they are or what evidence supports them, which is a technique inspired by CBT.
- Develop a personal "anxiety toolkit" with items and activities that help soothe your anxiety when it spikes. This could include stress balls, calming playlists, a list of breathing exercises, or even a set of affirmations to remind yourself that the anxiety is temporary. Having these resources readily available can help you cope with anxiety symptoms as they arise.
Related Shortform Content
Get access to the context and additional materials
The Nature and Symptoms of Anxiety Disorders
Josh Spitalnick delves into the multifaceted nature of anxiety disorders, discussing the range of symptoms and behaviors that characterize these conditions and the importance of understanding their complexity.
Anxiety Disorders Have Subtypes With Distinct Symptoms and Presentations
Anxiety disorders encompass a variety of symptoms spanning physical, emotional, cognitive, and behavioral domains. Spitalnick offers a comprehensive view, suggesting that anxiety is not only a very physical and physiological experience but also includes substantial emotional and cognitive aspects.
Anxiety Disorders: Physical, Emotional, Cognitive, Behavioral Symptoms
Spitalnick emphasizes that anxiety specialists must address all domains of functioning, as anxiety disorders manifest in physical symptoms, emotional turmoil, thinking patterns, and observable behaviors. He notes that sufferers may experience anxiety internally as a feeling that is "killing us on the inside," indicating the severity of emotional and physiological symptoms. Worrying, as an active cognition, affects those with anxiety in distinct and varied ways, suggesting the cognitive symptoms that come with the disorder.
Behavioral symptoms, such as excessive hand-washing or re-reading emails multiple times, reflect the anxiety-driven rituals that sufferers use to try to alleviate their distress. The conversation references the wide-ranging behaviors of individuals with health anxiety or obsessive-compulsive disorder (OCD), which can significantly impair daily functioning and disrupt social interactions.
PTSD and OCD Moved From Anxiety Chapter In DSM-5
In the DSM-5, notable changes were made. Spitalnick points out that PTSD and OCD were moved out of the anxiety disorders category to their own special categories, despite the commonalities they share with anxiety disorders. OCD, in particular, was placed in a new category focused on rituals and repetitive behaviors. The criteria for OCD also evolved; the requirement of having both obsessions and compulsions in DSM-IV shifted to a need for only one or the other in DSM-5.
Avoidance Turns Worry Into a Disorder
Spitalnick suggests that anxiety disorders are characterized by a unifying symptom of avoidance. This maladaptive coping mechanism can be deceptively effective in the short term but it ultimately perpetuates and intensifies anxiety.
Avoidance Is a Maladaptive Mechanism That Perpetuates Anxiety
Avoidanc ...
Here’s what you’ll find in our full summary
The Nature and Symptoms of Anxiety Disorders
Additional Materials
Actionables
- You can track your avoidance behaviors in a journal to identify patterns and triggers. Start by noting down situations or thoughts you find yourself avoiding and how you feel before, during, and after the avoidance. This can help you recognize the frequency and impact of avoidance on your anxiety. For example, if you notice you're consistently avoiding social events, you might see a pattern of increased anxiety leading up to the event and temporary relief afterward, which reinforces the avoidance behavior.
- Develop a "thought vs. thinking" log to differentiate passive thoughts from active thinking. Whenever you catch yourself worrying, write down the initial thought and then track how much time and energy you spend actively thinking about it. This practice can help you see how much you're feeding into the cycle of anxiety by engaging with passive thoughts. For instance, if the thought "I might fail my test" leads to an hour of ruminating on potential failure scenarios, you're actively reinforcing anxiety.
- Create a personal anxiety symptom map to understand your unique ...
Related Shortform Content
Get access to the context and additional materials
Therapeutic Approaches To Treating Anxiety, Particularly Health Anxiety
Josh Spitalnick and Peter Attia discuss the various therapeutic approaches to treating anxiety, especially health anxiety, highlighting the effectiveness and challenges associated with Cognitive Behavioral Therapy (CBT) and exposure therapy, integrating these with Acceptance and Commitment Therapy (ACT), and the careful use of medication such as SSRIs and benzodiazepines.
Cbt and Exposure Therapy: Gold Standard For Anxiety Disorders
Cbt Targets Cognitive Distortions Fueling Anxiety
Josh Spitalnick discusses that a key component of CBT is targeting cognitive distortions that fuel anxiety. He mentions the importance of teaching people about healthy lifestyle habits and helping them not get fixated on damaging thoughts that can manifest somatically. As an example, he discusses giving clients a handout with 30 tips about flight mechanisms and safety to challenge the faulty thinking associated with fears of flying.
Exposure Therapy Reduces Avoidance By Confronting Feared Situations
Exposure therapy is described as an intervention that allows someone to face their fears directly in a manner that is safe, ethical, and compassionate, without putting them at ethical, legal, or medical risk. For example, for someone who is extremely reluctant to remove their mask due to health anxiety, Spitalnick suggests starting with small concessions, such as trying to remove the mask for a short period in an outdoor setting. Spitalnick discusses incremental exposure to build resilience and gradually reduce avoidance behavior. Treatment for panic disorder, which often accompanies a fear of flying, is highly responsive to exposure therapy, with interoceptive exposure being described as the "grand champion of interventions." This technique helps patients confront their triggers in a safe space, allowing them to experience and overcome the symptoms they dread.
Act Enhances Cbt With Cognitive Diffusion, Value Clarification, and Committed Action
Act Guides Patients to Live By Their Values
Josh Spitalnick indicates that ACT is situated under the broader umbrella of CBT and includes exposure therapies. ACT focuses on the concept that one is not defined by their thoughts and feelings but rather has thoughts and feelings. This perspective helps in providing psychological distance from one's anxiety-provoking thoughts. Spitalnick also stresses the importance of values in the therapeutic process, aligning therapy with the patient's core values rather than offering false assurance. He suggests that ACT helps people shift from a negative reinforcement process centered around avoidance to taking actions t ...
Here’s what you’ll find in our full summary
Therapeutic Approaches To Treating Anxiety, Particularly Health Anxiety
Additional Materials
Counterarguments
- While CBT is highly effective for many, it may not be suitable for all individuals, as some may not respond to cognitive-based interventions and may require alternative approaches.
- Exposure therapy, though effective, can be challenging for some patients to endure, potentially leading to increased distress if not managed carefully.
- ACT's emphasis on values and acceptance may not resonate with individuals who prefer more structured and symptom-focused therapies.
- The use of SSRIs and benzodiazepines, while helpful for many, can come with side effects and the risk of dependency, which might make them less desirable for long-term management of anxiety.
- SSRIs may not increase emotional resilience for everyone, and some individuals may experience adverse effects or no benefit at all.
- The recommendation against benzodiazepines during exposure therapy might not be applicable in all cases, as some patients may require medication to initially enga ...
Actionables
- You can start a "thought diary" to identify and challenge cognitive distortions in your daily life. Write down situations that cause anxiety, the thoughts that accompany them, and then actively dispute those thoughts by finding evidence against them or by reframing the situation in a more balanced way. For example, if you catch yourself thinking "I'll never be able to do this," challenge that by listing past successes or smaller steps you can take toward your goal.
- Create a personal exposure ladder to gradually face your fears. Begin by listing situations you avoid due to anxiety, ranking them from least to most anxiety-provoking. Start with the least frightening scenario and expose yourself to it until your anxiety decreases, then move up the ladder. If you're anxious about public speaking, start by speaking to a mirror, then to a small group of friends, and gradually increase the audience size.
- Develop a values-based actio ...
Related Shortform Content
Get access to the context and additional materials
Contributing Factors and Comorbidities of Anxiety Disorders
Josh Spitalnick and other speakers delve into the complex nature of anxiety disorders, looking at genetic factors and comorbidities that contribute to these mental health conditions.
Genetic Component in Anxiety Disorders: Heritability 30-40%
Trauma, Family History, and Social Context in Anxiety Development
Spitalnick touches on the heritability of anxiety disorders, noting a rate of about 30-40% for general anxiety and 50% for OCD, indicating a significant genetic component. In children or teens with OCD, there's often a first-degree relative with the same disorder, though they may not have sought treatment or agreed with the diagnosis. For someone with health anxiety, it is quite common for a first-degree relative to also exhibit health anxiety. Such patterns suggest the role genetics play in the development of these disorders.
Furthermore, the speaker argues that trauma and family dynamics provide both genetic and learned paths to anxiety disorders. Traumatic events can prompt emotional and physical symptoms previously termed as conversion disorder, while parents' hyper-vigilant behaviors or repetitive actions can be learned by their children, contributing to the development of anxiety disorders.
Anxiety Disorders Often Co-occur With ADHD, Depression, Substance Abuse, and OCD
Cognitive, Emotional, and Physiological Symptom Interplay Creates Complex Presentations
Anxiety disorders often manifest alongside conditions like ADHD, depression, substance abuse, and OCD. The interplay between cognitive, emotional, and physiological symptoms creates complex challenges in understanding and treat anxiety disorders. For instance, Spitalnick points to the avoidance of situations or substances as a symptom of anxiety, which may lead to self-medication with alcohol or marijuana.
Such avoidance behaviors complicate exposure therapy as they could dampen the anxiety response, hindering therapeutic progress. In addition, distinguishing anxiety from ADHD can be challenging due to intrusive thoughts that disrupt attention.
Spitalnick also explains that for individuals with OCD, intrusive thoughts provoke further rumination and emotional distress, activating the brain and leading to physiological responses. He discusses the distinction between egosyntonic experiences and egodystonic experiences, which are particularly taxing emotionally and cognitively for those with OCD.
Lastly, comorbidities such as tics, body-focused repetitive behaviors (BFRBs), and chronic medical issues like IBS and restless leg syndrome can often coincide with chronic anxiety, further complicating diagnoses and treatments.
Social Media, Technology, Pandemic Exacerbate Anxiety
Health Information and Awareness Can Worsen Anxiety
The speakers explore how anxiety is influenced by environmental factors including social ...
Here’s what you’ll find in our full summary
Contributing Factors and Comorbidities of Anxiety Disorders
Additional Materials
Actionables
- You can track your emotional responses to different situations in a journal to identify patterns that may indicate a genetic predisposition to anxiety. By noting when and how you feel anxious, you might discover certain triggers that align with your family history, helping you to understand your anxiety better and seek appropriate support.
- Create a digital detox schedule to mitigate the impact of social media and technology on your anxiety. Start with short, scheduled breaks from screens and gradually increase them, observing any changes in your anxiety levels. This can help you establish a healthier relationship with technology and reduce environmental stressors.
- Develop a personal "anxiety first-aid kit" with items and activitie ...
Related Shortform Content
Get access to the context and additional materials
Create Summaries for anything on the web
Download the Shortform Chrome extension for your browser
