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.
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Josh’s professional background and his holistic approach to treating anxiety [A: 3:00, V: 1:19]
- We’re going to talk about anxiety broadly and probably get into a specific subset of anxiety, which is around health anxiety, something that people like Peter are probably contributing to in some form or another
- It’s not something Peter wants to be doing, but inevitably it becomes a two-edged sword
- As you probe deeper into health, you end up doing this
- The term anxiety is so broad, but before we talk about that let’s start with your background
What is it that you do in your practice? Who do you work with?
- Josh is a licensed psychologist
- He’s board certified in behavioral and cognitive psychology
- He spends a significant amount of time focusing on how people think, how people act
- This includes how we can address their deficits and improve them to make their lives better
- At the end of the day, he’s a therapist
- His career has had many stages, and he’s spent most of the last 15 years focusing on anxiety conditions
Anxiety has many layers
- It’s a very physical experience, very physical, physiological
- It’s an emotional experience
- There are cognitive elements to it (how we think)
- Ultimately, the way we judge each other and how we see each other is the behavioral experience, so we see what people do and don’t do
An anxiety specialist is someone who really addresses all of those domains of functioning: how we physically, emotionally, cognitively, and behaviorally act in our own world and in relation to others
Definition of anxiety and changes in the DSM-5 [A: 5:00, V: 3:19]
Changes in the DSM-5 around anxiety disorders
Is there a DSM-5 criteria that you refer to or do you think about something that goes deeper and/or broader than what the DSM would have to say about anxiety?
- The DSM-5 altered anxiety disorders
- We’re probably going to be seeing the DSM-6 in a few years, and it’ll be interesting to see what it does.
- In the last iteration of the DSM, it actually pulled 2 pretty prominent anxiety disorders out of the anxiety disorders
Josh shares, “I don’t believe for one second that they’re not anxiety disorders. They’re anxiety disorders, but because of some special elements about them, some people much wiser than me and you decided that they should be in their own special categories.”
- Those 2 disorders specifically have some interesting elements to them and he understands why you’d want to separate them out
When Josh thinks about interventions
- The intervention sometimes dictates the disorder
- This is maybe a reverse order for how physicians are trained or how even some therapists are trained
- That may not be the most popular thing to say
- Most of the interventions we’re going to probably talk about today are going to be some version of cognitive behavioral therapy (CBT) and some version of exposure-based therapy
- Those are 2 of the leading interventions
- They are gold standard or first-line treatments of choice for almost any anxiety disorder of the 8-9 [types] that he likes to refer to
Anxiety is a loose category
⇒ For Josh, anxiety simply means that someone is emotionally, physically, cognitively, behaviorally, internally preoccupied with something that’s concerning them, and then undeniably they’re doing something about it (often doing the wrong thing)
- As an anxiety specialist and as someone who runs a large practice (he gets 1000s of referrals a year), he’s always tickled that his practice thrives because amongst all the anxiety disorders, they share one common symptom: avoidance
- He’ll talk about their different symptoms and criteria later
- Avoidance is the thread between all of them that identifies when we have someone who has worries, physiological anxiety, cognitive anxiety, behavioral anxiety
When Josh starts seeing avoidance, we’re now going from someone that has a worry state to something that’s probably more problematic
⇒ There’s many versions of avoidance, but 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
⇒ Anxiety is how people are thinking mostly about the future, how they’re feeling about their future, how they’re anticipating the future
- We start talking about anticipatory anxiety, risk calculations, worrying about something that’s going to happen (catastrophizing, plotting and planning), and then acting in advance of that
- Josh points out that Peter has built an amazing career in medicine around planning 30, 40 years in advance
- But the anxious person is using that in a way, they’re weaponizing that fortune-telling in a very unhealthy way, and it’s ruining their lives
If avoidance, which you’re describing as an action, is the sine qua non of all forms of anxiety, is the corollary of that a worry or distressed thought about the future absent a behavioral avoidance doesn’t cross the threshold of anxiety and therefore is not necessarily “pathologic”?
⇒ The DSM at its core is about dysfunction
- In every category of disorder in the DSM, from schizophrenia to medically-induced disorders, cancer-induced depression to post-traumatic stress and OCD, if there’s no dysfunction in life (that’s usually relationships, occupational functioning, social functioning, educational functioning), if we don’t see problematic behaviors in someone’s life → then they have worries, they have sadness
- So someone who is sad, who’s not feeling great, but they’re not acting in ways aligned with depression, it’s hard to diagnose them with some version of a depressive disorder
- If someone is not engaging in behaviors in advance of trying to eliminate the distress, the uncertainty, the concerns about what’s up ahead, then Josh has a hard time diagnosing someone with a disorder
- Josh is a national OCD specialist, he’s a national OCD treater and trainer for the International OCD Foundation
- He’s a national health anxiety specialist
- If someone is not evidencing compulsions or rituals (which is one part of OCD, the other part is obsessions), it’s hard for him to diagnose someone who’s doing nothing to mitigate or manage those distressing thoughts, if what they’re doing in turn is living their fullest life
Updates from the DSM-4 to DSM-5 changed that “dysfunction” criteria
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