#362 ‒ Understanding anxiety: defining, assessing, and treating health anxiety, OCD, and the spectrum of anxiety disorders | Josh Spitalnick, Ph.D., A.B.P.P.

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My guest this week is Dr.

Josh Spitalnik.

Josh is a licensed clinical psychologist who is board certified in behavioral and cognitive psychology and the founder of Anxiety Specialists in Atlanta.

Anxiety is one of the most common and misunderstood challenges impacting both mental and physical health, and understanding how to treat these two effectively is obviously essential for long-term well-being and resilience.

It's also something that comes up quite a bit when we think about some of the challenges of medicine 3.0, which of course requires doing a little bit more testing and early screening than one might otherwise do.

And of course, the result of this can itself be anxiety.

In this episode, we discussed the four layers of anxiety, psychological, emotional, cognitive, and behavioral, and why avoidance is the unifying symptom that turns everyday worry into a disorder.

how the DSM-5 reshuffled OCD and PTSD out of the anxiety chapter, and why Josh still treats them as anxiety conditions driven by the same mechanisms.

The crucial difference between worries and worrying, between thoughts and thinking, and the hidden mental rituals that make anxiety self-perpetuating.

A deep dive on health anxiety, illness anxiety versus somatic symptom disorder, doctor shopping, and Josh's medical, physical, and psychological symptom triad.

genetics, trauma, and environmental contributors, including social media, wearables, and the COVID era.

real-world case studies, mask wearing, fear of flying, intrusive harm, and sexual thoughts, and Josh's step-by-step assessment model for each, how exposure therapy works, integrating cognitive behavioral therapy, CBT, with acceptance and commitment therapy, ACT, cognitive diffusion, clarifying values, and shifting from avoidance to committed action.

how medication fits into the treatment, specifically SSRIs, benzos, and how alcohol and cannabis can quietly undermine the process.

So without further delay, please enjoy my conversation with Josh Svitalnik.

Josh, thank you for making the trip out to Austin.

I would imagine the temperature is not that different from where you're from in Atlanta.

Not much.

I left some humidity for pretty rigorous heat.

So thank you for that.

We trade humidity for heat here.

I'll take heat over humidity.

I will too.

So 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 me are probably contributing to in some form or another.

We're going to talk about that.

I wondered if you were going to bring that up.

You started there.

Great stuff.

So not something I want to be doing, but I think inevitably it becomes a two-edge sword as you probe deeper into health.

You end up doing this.

But before we get into that, I do think this term anxiety is so broad that I want to kind of just start with your background.

What is it that you do in your practice?

Who do you work with?

Help folks understand a little bit why I'm sitting down with you.

Sure.

I'm a licensed psychologist.

I'm board certified in behavioral and cognitive psychology, which means in addition to everything I do, I spend a significant amount of time focusing on how people think, how people act, and how we can address those and their deficits and how we can improve them to make their lives better.

Very basic.

So I'm a therapist.

At the end of the day, I'm a therapist.

And though my career has had many stages, I've spent most of the last 15 years of my career doing almost nothing but focusing on anxiety kinds of conditions.

For me, anxiety is many layers, as it is for most people.

It's a very physical experience, very physical, physiological.

It's an emotional experience.

There are cognitive elements to it, how we think.

And 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.

And so an anxiety specialist.

is someone who really addresses all those domains of functioning, how we physically, emotionally, cognitively, and behaviorally act in our own world and in relation to others.

So let's talk about the definition of anxiety.

I think everybody loosely understands what it is, and I'm sure most people have at some point experienced it.

But 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 actually altered anxiety disorders.

We're going to be seeing the DSM-6 probably in a few years, and I'll be interested to see what it does.

But in the last iteration of the DSM, it actually actually pulled two pretty prominent anxiety disorders out of the anxiety disorders.

It moved PTSD out of the anxiety disorders, and it moved OCD out of the anxiety disorders.

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.

And those two disorders specifically have some interesting elements to them that I see why you'd want to separate them out.

For me, when I think about interventions, and this is maybe a reverse order order for how physicians are trained or how even some therapists are trained, for me, the intervention sometimes dictates the disorder.

And that may not be the most popular thing to say, but most of the interventions we're going to probably talk about today are going to be some version of cognitive behavioral therapy and some version of exposure-based therapy.

Those are two of the leading interventions, gold standards, some people use the phrase, or first-line treatments of choice for almost any anxiety disorder of the eight to nine that I like to refer to.

So anxiety is a loose category.

Anxiety for me 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.

And so as an anxiety specialist and as someone who runs a large practice and we get thousands of referrals a year, Peter, I'm always tickled that our practice thrives because amongst all the anxiety disorders, they share one common symptom.

They all have different symptoms.

They all have different criteria.

We can talk about some of them, but they all share share one symptom, avoidance.

And so for me, avoidance is the thread between all of them that identifies when we have someone who has worries, physiological anxiety, cognitive anxiety, behavioral anxiety.

When I start seeing avoidance, we're now going from someone that has a worry state to something that's probably more problematic.

And so 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.

So anxiety is a loose category, and it's how people are thinking mostly about the future, how they're feeling about the future, how they're anticipating the future.

So we start talking about anticipatory anxiety.

We start talking about these risk calculations.

We start talking about worrying about something that's going to happen, catastrophizing, plotting and planning, and then acting in advance of that, which you've built an amazing career around in medicine to plan 30, 40 years in advance.

But the anxious person's using that in a way, they're weaponizing that sort of fortune telling in a very unhealthy way, and it's ruining their lives.

Aaron Powell, Jr.: If avoidance, which you're describing as an action, is the sine qua non of all forms of anxiety,

is the corollary of that, that worry

or distressed thought about the future absent a behavioral avoidance doesn't cross the threshold of anxiety and therefore is not necessarily I don't want to use the word, but pathologic?

Sure.

The DSM at its core is about dysfunction.

And every category of disorder in the DSM, from kidney disorders to schizophrenia to medically induced disorders, cancer-induced depression, to post-traumatic stress and OCD, if there's no dysfunction in life, and 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, then 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.

So the short answer is yes.

I think 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 I have a hard time diagnosing someone with a disorder.

I'm a national OCD specialist.

I'm a national OCD treater and trainer for the International OCD Foundation.

I'm a national health anxiety specialist.

I'll call myself an expert.

Some people don't like that phrase, but I'm a specialist in those two topics.

If someone is not evidencing compulsions or rituals, which is one part of OCD, the other part is obsessions, it's hard for me 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.

The DSM-4 to five changed that.

The DSM-5 said, first of all, moved OCD out of the anxiety disorders.

And now it's a category called the obsessive, compulsive, and related disorders, focused on mostly rituals and repetitive behaviors.

And And the criteria changed where it used to be, you have to have obsessions and compulsions.

That was DSM-4.

DSM-5 and 5TR now says, well, you have to have one or the other.

And so I'm talking on both sides of my mouth.

Current diagnostic criteria says if you have obsessions or obtrusive thoughts and you do nothing about it, we can still diagnose you.

I don't know if I believe that, because if you're doing nothing aligned with that anxiety, which for me, if it's aligned with it, it's shrinking your life.

And you're having these horrible thoughts and feelings and you don't really engage with them and no one really knows and you're out there living your fullest life.

I don't define that as being someone who is impaired or dysfunctional.

The problem is I've never met someone who has intrusive thoughts and obsessions and who does nothing.

So now we're getting into the next layer of what anxiety is.

And you sort of mentioned the word behavioral avoidance.

Anxiety has two kinds of coping.

And some of them we can see, we call those overt rituals or behaviors.

And some of them are more covert.

So right now in this room, I'm using my hands and I'm talking with you and I'm doing stuff to sort of engage with you and I'm answering your question.

But in my head, Peter, you may not know that I'm second-guessing what I just said, wondering if you believe what I said, wondering if I sound good, questioning if I should even be here, wondering if this is going to be a good podcast.

And if someone's in that state of thinking about all those things, though we can't see that, I'm starting to talk about a concept called a mental ritual.

And so in the last 10 to 15 years, we've seen in the anxiety space anxiety specialists, not just focusing on what people do behaviorally, but also what they're doing in their head and their mind.

And now we start doing the difference between thoughts, which are passive experiences, and thinking.

Thoughts I don't control.

I call those the burps, farts, and hiccups of anxiety.

They just happen to us.

But when you start thinking about those thoughts, and trying to neutralize those thoughts and acting in advance of those thoughts and analyzing them and looking them up online and questioning them.

That's a mental action.

So now we just opened up Pandora's box.

Anxiety just got bigger.

It went from a condition where you're having these unwanted thoughts and feelings and avoiding maybe using substances, maybe trying to avoid a situation, not showing up to a presentation, staying in bed longer, doing things to not deal with it.

In certain conditions, you're washing your hands extra, maybe doing certain things to your body.

Those are behavioral actions or rituals.

But now we have a whole nother space of actions or reactions.

And those mental rituals are, if not as problematic, sometimes worse, because the person with lived experience with anxiety often doesn't know their mental rituals.

They just think they're obsessing all day long.

I hear that a lot.

I obsess all day long.

And I go, are you obsessing all day long?

Or do you have obsessions?

Or are you sitting there stewing on it?

Oh, you're stewing on it?

That's a rumination.

Yeah, that's an obsession.

No, no, you're ruminating.

You're fixated on it.

You're trying to quantify it.

You're trying to solve it.

That's a mental action.

Why?

Because you're trying to diffuse the bomb.

You're trying to deal with uncertainty.

You can't tolerate uncertainty.

You can't tolerate the distress.

You're trying to solve this Rubik's cube that's missing a puzzle piece.

And so most therapists can't see that.

And the person with lived experience just thinks they're just worrying all day long.

And so we start separating the difference between worries and worrying, thoughts and thinking.

The first one is on the house.

The first one is your body doing exactly what it's supposed to do.

The second one is you trying to solve a puzzle that you probably won't be able to solve.

And you're going to keep doing it and keep doing it and dig deeper and deeper into a hole until you can't get out of it.

So most of us are familiar with behavioral manifestations of coping, but mental rituals are equally as destructive and worse, hard to identify and see if you don't know what you're asking.

So anybody who's spent any time meditating will be very familiar with what you just said about the difference between thoughts and thinking.

I was actually just talking about this with somebody this morning as it pertained to mindfulness.

So the idea for folks maybe not as as familiar with the idea that if you practice a form of mindfulness meditation, very quickly, you're almost blown away at the torrent of thoughts that exist in your brain and how you can't turn them off.

So if you sit there and try to practice a ritual of paying attention to your breath and figuring out how many milliseconds you can go focusing on your breath and nothing else, you realize that the answer is a very short period of time.

Maybe unless you've reached some state of enlightenment that I'll never reach.

But what's basically happening is you're sitting there focusing on your breath and immediately you're going to be thinking about what you want for breakfast.

And then you lovingly bring yourself back to thinking about the breath.

And about a millisecond later, you realize you got to do that thing after school.

You know, it's just a nonstop.

It's a ping-pong math.

It's not going to be.

It's incredible.

So say a little bit more about that.

Again, for the individual who has not practiced this highly uncomfortable exercise of mindfulness meditation, help people understand what you mean about the distinction between thoughts and thinking.

It is important.

I think it's uniquely important when we talk about anxiety.

I like to talk about the W's of that level two thinking.

I'm going to break it into three categories.

We haven't gotten to the third one yet, which is going to get real scary in just a second here.

But I like to talk about the W's, the who, what, where, when, why,

how ends in a W, and what if.

When I hear someone asking a question that starts with a W, and whatever the statement is, ends with a question mark, in my work, if it's about their anxiety core issue, so if someone has social anxiety, the fear of public speaking, if someone has a fear of snakes, the fear of being bitten by a snake, when they're asking questions about, is that snake going to be there?

Does that garden have snakes?

Is that public speaking event tomorrow?

And what am I going to do about it?

And what if they laugh at me?

When I hear those questions, most of us just think that someone's worried.

But that looks productive.

It looks like you're trying to figure something out.

And for most of us, we just move on with our day.

For the anxiety sufferer, it is an attempt to resolve uncertainty.

It is an attempt to figure out something that you don't have the chance to figure out because that time has not happened yet.

It's a fortune-telling mindset of mental action.

Worrying, the verb, is an activity.

And most of us do it and move on with our lives.

It's like Teflon.

It slides off of us.

But for the anxiety sufferer, worrying looks like they're trying to solve something.

The problem is, is when they get their answer, they're not done.

And that's the epidemic of anxiety, That whether you do a ritual that looks more behavioral, like scrubbing your hands, praying excessively, asking the police officer if they got a report if anyone got run over in the intersection, which is called hit and run OCD, rereading your email 17 times, or wondering about your email, questioning, did I send that out?

Was there a typo in there?

Are they judging me?

What if they say something back to me?

Those don't look like rituals or compulsions, but it's our ability to resolve angst, to solve uncertainty, to deal with this inner feeling that is killing us on the inside.

And it is its own designation of symptoms.

So maybe just to step back, the first thing I'm doing in therapy with almost anyone I work with is breaking down symptoms into three categories.

And there's two acronyms I'll use.

It doesn't matter for me amongst all the anxiety disorders.

And I can get kind of cutesy with this, but it's category one, category two, and category three, very basic.

When I use letters, it's T's, O's, and C's.

If I'm dealing with O C D, which stands for triggers, obsessions, and compulsions.

And for almost every other anxiety disorder, it's T, F, and SB, triggers, fears, and safety behaviors.

And every DSM, every anxiety specialist, anyone who treats anxiety, and anyone who battles anxiety should know those three levels of symptoms.

Triggers are the things that bother you, the events, the people, the places, the things that are out of your control.

It's God messing with us.

Sometimes just you sitting around and a thought pops in your head can be a trigger, unfortunately.

Sometimes a physical symptom can be a trigger.

The middle column, which I use the letter O or fear, O for obsession, F for fear, is the internal experiences you're having.

And I use the word having, not doing, that are out of your control.

Breathing, heart rate, yucky thoughts, upset tummy, a twitch, a feeling, an aura.

For most of us, we call those...

worries or fears or obsessions.

Sometimes it's an urge.

And those are not up to us.

That means your body's working.

Sometimes it's working in overdrive.

Sometimes it means your prefrontal cortex and your limbic region.

We'll talk about brain stuff in a few minutes, I'm sure, are not communicating properly.

But that means that something went off in your body as a signal of, uh-oh, there might be danger.

And so it's happening to you.

The next thing that happens in the most basic behavioral paradigm, Peter, is stimulus and response.

And what happens between stimulus and response is where all the magic happens.

And one's ability to make decisions effectively between stimulus and response is where therapy really takes action.

That response and all the anxiety disorders is avoidance.

Rituals, behavioral or mental.

And so it's a therapist's job to figure out those symptoms, the T's, O's, and C's, to educate the patient on what they are, because most patients, and honestly, probably most therapists, confuse worries.

from worrying, thoughts from thinking.

And most therapists are going to put anything between your your ears in category two.

And in the last 10 to 15 years online, there's been language and descriptions of something called pure O

C D, P U R E pure O O C D.

And what that was was people thinking, I just have obsessions.

I'm a purely obsessional subcategory of OCD.

And I have pure O O C D on my website.

I write about it.

I blog about it.

Because I want people who think they have that to find our website and to find us because I want to reverse engineer what what they think is going on.

They think they're just having obsessions because it's all happening up here.

What's really going on is they're having obsessions and then spending all day long up here trying to solve an existential crisis, which I would call a mental ritual.

Let's help people understand

that.

And we can either use, in fact, I'd like to do both.

I'd like to use thoughts versus thinking.

And I'd like to use worry versus worrying to help people understand when they've crossed that threshold.

Start with whichever one you want and let's pick a real world example that you might experience in the practice.

Well, I want to talk about health and medical stuff.

So someone's having a bunch of physical symptoms and they're afraid that they might have cancer.

They're afraid that they might have cancer.

That's a worry.

They're afraid that these might be symptoms of a heart attack, of an MI event.

That's a worry.

What if I'm having a heart attack?

All of a sudden, you're trying to figure it out, which by the way, asking that doesn't figure it out.

And Googling Googling it doesn't figure it out.

And calling your cardiologist who hasn't seen you doesn't figure it out.

But when you go, what if this is a heart attack symptom?

You're beyond worrying about it.

The worry is I might be sick, in this case, having a medical event.

And you're trying to figure out like, what if this is the thing?

And when you're trying to figure it out, that's no different than Googling it.

That's no different than looking it up online, calling your nurse or doctor friend or in-law and saying, do you think this is what it is?

So when I go to someone and go, hey, do you think that's what this is?

Most people would call that reassurance seeking, which is a classic ritual.

It's a behavioral thing.

Me asking you, hey, you have not evaluated me.

You're my brother-in-law.

Do you think this is a medical event?

But when you ask yourself that, how is that any different?

We haven't evaluated you.

There's no lab work.

We're not really going to get the answer.

And are you really just looking for one answer?

You're fine.

So the dilemma is, is when you go from that worry state to, oh my gosh, I'm terrified I might be sick, to what if I'm sick?

What if this is the event?

People can spend not that little moment, but all day wondering, is that another thing?

Is that a heart issue?

Is that a symptom of stroke?

My eyes twitching.

Does that mean I'm having a seizure?

When they start asking themselves a litany of questions, that's not the worry.

The worry is just, I'm scared something's wrong.

I'm scared something bad's going to happen.

When you sit there and start questioning it all, to me, it's no different than just sitting there and googling all day long.

What are these symptoms?

Anyone will look at that and go, of course that person's ritualizing.

But when you do it inside, It's the same mechanism.

It's you trying to get to the end of the story.

You're using your crystal ball or time time machine to get to the end of that story sooner than you actually need to.

And in that case, if you're having a real medical event, I'd go to the doctor.

I'd actually go see a physician.

But sitting there questioning it doesn't solve anything.

So you went from a state of having worries, I'm afraid I'm sick, I'm afraid something's wrong to sitting there, I won't use the word persevering because that usually means something else, but ruminating on it.

It looks functional, but it's actually quite dysfunctional.

Is it dysfunctional because of the duration?

Is it dysfunctional because it comes at the expense of doing something else?

Or is it dysfunctional because if an objective person were to evaluate it on its face, it doesn't make any sense?

Now, I know I've said a lot there, but to me, this is the crux of it.

I'm going to be able to answer that with one word.

Yes.

It's dysfunctional because it's taking you away from your life.

It's dysfunctional because the duration or intensity of it doesn't match the thing, meaning that if you're spending all your time doing that and not going to the doctor, this is not going to solve anything.

So in a single moment, anyone freaking out, I don't think that's dysfunctional.

That's what any one of us would do.

You sent an email and go, oh, shoot, did I just do that?

We all do that.

Oh, man, this feels tight in my chest.

What is that?

We all do that.

Even the criteria for something like health anxiety, the DSM criteria, require six months of being concerned about whether it's about symptoms or diseases.

We'll talk about different kinds of health anxiety in a few minutes.

Six months.

So in a singular moment, it's nothing more than you being inquisitive and curious.

But the point is, is that's not going to solve whether it's a medical event or not.

Going to your doctor is, getting an EKG is, asking your nurse sister if you're having like a stroke, what does she know?

So it doesn't solve the problem.

And it's trying to get to the end of a story or resolve some uncertainty or some ambiguity in a way that's not actually going to solve it.

So it's just not a functional way to process.

In a singular moment, in a single moment, the first time, I don't care.

You don't care.

It's what someone does.

But when you're doing that multiple times a day, multiple times a week, or for months on end, that's the disease.

Now, what about the individual who goes out to seek medical attention for something, but the pattern is so illogical?

So they just keep having unexplained symptoms and they create a story that says this is cancer or this is heart disease or this is whatever.

And they follow through with the medical checkup.

As they should.

And the medical checkup keeps coming back crystal clear.

You're fine.

You're fine.

You're fine.

You're fine.

You're fine.

And the goalpost goalpost keeps moving.

So it's, I think I've got this, I think I've got that, I think I've got this, I think I've got that.

Everything they get checked up for is fine.

Is that health anxiety?

That's possibly health anxiety.

And first of all, health anxiety is not a disorder.

It's a class of disorders.

It's a buzzword online.

It's something you can Google.

But the disorders within them, there's breakdown into really two, sometimes three disorders.

One's called illness anxiety disorder, which used to be called hypochondriasis.

And one's called somatic symptom disorder, which used to be called somatiform disorder.

And then there's a third one that's a bit curious, which is conversion disorders or functional neurological disorders.

But what you're saying is, is in this case, someone has some set of symptoms.

And whether the symptoms stay or change, they're going to doctor after doctor.

They've had all the appropriate medical workups.

And every doctor said, negative result, negative result, negative result.

I have to be careful how I talk about this.

I've done other podcasts where I've said a story like this that I'm about to share, and I've triggered some people.

And I'm not trying to upset people or trigger people, but in your situation, I feel very comfortable probably saying it sounds a lot like a health anxiety kind of disorder.

You're having physical ailments.

You're going to doctors to figure out what's going on.

We would most commonly diagnose that as somatic symptom disorder.

If your medical charts are clear, if the doctors have consistently said, ma'am, sir, I'm sorry, but there's nothing there.

The problem is, is you and I both have anecdotal stories of someone getting a breast exam, going for their annual, going for a PAPSMA.

They've had all the medical clearance.

And all of a sudden, a month later, they find a P-size shape under their armpit.

Oh, my goodness, they have breast cancer.

So I have a personal story.

I won't spend too much time on it, where my wife, I was almost a widow about a decade ago, which is not funny to me.

She was having some radiating discomfort and pain going up her right abdomen and backside.

And she's thin and healthy, and we have no history of medical issues.

Went to a primary care doctor who we trusted dearly, and he's checked her out and said, you might have a tiny umbilical hernia.

You're young, you're healthy, you're thin, don't worry about it.

And we said, okay, we'll see what happens.

And a week later, she's still complaining.

We then go to her OB, and OB did a a full exam and found absolutely nothing.

We then went to a surgeon who the OB recommended just to make sure.

I don't remember honestly what the surgeon did.

I know we had, I think, an ultrasound and a CT, I believe.

And the surgeon said, I would not do an umbilical surgery right now.

You're fine.

You're young.

Let's wait on it.

Nothing's going on.

Those are three doctors who basically gave her a clean bill of health with some superficial observation and then some very basic non-invasive procedures.

And then about a week later, she said, Josh, it's not going away and something's not right and it's raiding up my back.

And they checked for gallstones.

They checked for kidney stones and all this sort of standard stuff, blood work, urinalysis, all of it.

Someone said, why don't you go to a GI specialist and see what's going on?

And she went there and she had a mass on her liver that was compromised over 50%.

That required immediate surgery.

If that had ruptured her blood out, she would have possibly died.

The liver is one of the, the only organ that regenerates itself.

So we got very lucky, had a significant resection, liver surgery.

She's doing well today.

But if we waited on that and took three no's as, okay, I guess she's take some ibuprofen, stretch, maybe it's gas, figure it out.

I don't want to know the answer to that end of that story.

So the problem is, is sometimes we have to trust our own bodies and sometimes we can't trust the doctor.

In your situation, I think if you're chasing symptoms, you've been to multiple doctors with multiple workups and everyone's saying it's nothing that we can diagnose.

For most of us, we're describing that you have some physical anomalies going on that maybe don't require medical intervention.

And so now in the health anxiety spectrum, we're now starting to describe symptoms in three categories.

Symptoms that are medical, symptoms that are physical, and symptoms that are psychological.

So in all the health anxiety spectrums, we break those symptoms into three categories.

If they're medical and require medical intervention and you worry about them, no kidding.

So you and I would as well.

And whether we call that an adjustment reaction, Peter, or something else, if you have a medical condition that requires medical intervention, you worry about it, most of us do.

And I don't require a therapist or medication for that unless that's something that you want.

If you're having physical symptoms that are not deemed medical, either because the lab reports are not back yet, or because the doctor hasn't talked to you yet, or because the lab results are negative.

At some point, we have to admit, maybe there's nothing medical here unless we're like waiting for lab results.

But the worry associated with that, we would typically describe as somatic symptom disorder.

You don't know what you have yet.

You may have nothing.

And you're worrying about it and not leaving the house and doctor shopping and going online and checking your labs and wearing a pulse oxometer and all the things you're doing to constantly monitor physical symptoms, body scanning, checking, pretty common ones.

At some point, your quality of life is going down.

Could something medical come from that?

Absolutely.

But currently, we have no data to support that you have a medical condition and you're still worried about it.

We have an issue.

And then the other categories when it's all psychological.

A long time ago, it was about AIDS.

We don't see that that much anymore, but someone's afraid they're going to get AIDS.

They're afraid they're going to have a stroke, a brain tumor.

No symptoms to support it.

They're just worried about getting an illness or disease.

Back in the day, people would call that person hypochondriacal.

The disorder was called hypochondrias.

And today we call that illness anxiety disorder.

People can have all three.

They can have medical issues, A.

They can have physical issues that are not medical and worry about them.

And they can also worry about getting other diseases, which we would call illness-anxiety disorder.

But the most common presentation that I see in my practice and that people reach out to me for is when someone has a combination of physical things.

and they're convinced it's something.

And usually by the time they're reaching out to me, they've been to multiple doctors.

When someone reaches out out to an anxiety specialist with physical things, the first thing I would say and you would say is, go get a workup.

So I'm never going to get in the way of medical care, not first, second, and third opinions.

I think it's a smart thing to do.

But at some point, when is enough enough if every doctor who is of quality and competence has ruled out whatever you think is going on?

And even then, people go to great lengths.

I've had patients get spinal taps off the record for cash to determine if they have a leaking CSF because they think they're having a stroke or having early Enzyme Alzheimer's.

That's one of the things, I guess, I would say that makes that playbook challenging is in this day and age, you have more and more, I don't know, for lack of a better word, just quacks out there that are going to come up with every reason under the sun for your symptom.

So you will find somebody who will come up with an explanation for your symptom.

It'll be the mold in your house.

It'll be the slight elevation of cadmium in your blood or radon, cat litter, go down the list.

Absolutely.

Now we've opened a Pandora's box, which is this individual who's feeling a little fatigued, can't figure out why.

Something's wrong with them.

They're fatigued.

Maybe it's fill in the blank.

I don't know what it is.

First doctor they see does traditional workup and says, all your hormones look great.

Everything that I can see.

But you're going to find that person within the first three, depending on which door you open, who's going to come up with an explanation.

And they're typically going to have a solution for you that's pretty off the beaten path.

If you go to a car mechanic and say your car is squeaking in the engine, they're going to have a wonderful solution for your engine, even if it's not required.

If you go to a psychiatrist and say, I think I need meds, guess what they're going to give you?

Medication.

And if you go to enough doctors, they're going to find some problem and recommend some intervention, whether it's homeopathic, whether it's diagnostic, whether it's a prescription, something.

They'll give you something because they want you to feel better.

Yeah, I think part of it is that when you're a hammer, everything is a nail syndrome.

And that would be the most charitable explanation for what I think is going on, which is truly there are just a lot of real charlatans out there that are just not practicing any form of reasonable medicine, not even evidence-informed.

Evidence-based, I get, has its limitations, and I will fully acknowledge the limitations of evidence-based medicine.

Agree.

But there is at least still a threshold of evidence-informed medicine.

But when you start saying that the answer to your slightly elevated cesium level,

which, by the way, no lab has ever documented what the upper limit of that should be anyway, but let's just assume that my arbitrary level is too high and you're slightly above it.

So that's clearly the explanation of everything that's going wrong with you.

And I'm going to hand you some supplement that, by the way, I happen to also sell.

Happened to sell.

I just happened to sell.

How lucky are you?

Look, it's your lucky day.

It's right here, too, by the way.

It's in the office.

You found the guy that knows how to cure elevated cesium levels.

That's the challenge, I suppose, I have.

That's the challenge I have.

We're in the same boat.

You're asking me, as a non-medical person, to make sure that someone is getting advocated for, spoken for, and referred to by providers.

They're going to go to find anyone.

It's above my pay grade to know whether that doctor knows what they're doing, whether they're recommending medications or off-label things that are, how am I going to argue against that?

So most anxiety specialists like myself who work in the space of a lot of health and medical, and I have a career where we haven't talked about where I've done lots of medical training, medical work in my career.

I'm informed.

I'm knowledgeable.

I also have medical people in my family.

I can ask the right things, but I'm trusting the medical people around me.

So I'm on faculty at a university in Atlanta.

I'm adjunct faculty there.

I got colleagues there.

I got medical people around me.

I surround myself with people that I think are sharp, psychiatrists, physicians, oncologists, just in case.

And still, my patients are going to go to other doctors because they're just looking for the answer.

To me, that's sort of within that Health Insight spectrum.

If every doctor you've gone to that I trust has given you the best medicine possible or the best assessment possible, and you're getting no answer and you go to the next person, you don't need the DSM to go, maybe this is more than just a medical issue.

I'm still going to advocate for the medical needs.

I'm still going to support them and join them.

And I'm still going to help them see that your physical symptoms are real.

Physical symptoms are real.

That doesn't mean they're indicative of or prognosticate a medical condition.

Half the battle I'm doing is education around that topic.

Yeah, I think it's worth stating that again.

If a person says, I'm experiencing this pain, that's real.

100%.

You're just saying, don't assume necessarily that that means that there is an underlying medical reason for that or even something that you would find on the total best case scenario diagnostic.

More often than not, there's not a great medical diagnosis or category that fits into the things that someone like I, I mean, I see.

I mean, I don't specialize that much in FND or that functional neurological space of pseudo-seizures or tingling arms or body parts that can go numb.

That's a whole nother space of conversion disorders.

But I'm talking about people that have chronic headaches, tummy issues, leg cramps, bones that feel sore.

And they've had every workup you could imagine that would be considerate for someone who has bones that are sore.

And there's about three or four conditions most of us are going to jump to when you say your bones are sore.

And when that's all been rolled out and they're trying to convince you, but my thigh, like I can feel the bone, I can feel the marrow.

It feels like it's tearing itself up.

And we're talking about pain conditions.

We're talking about neuropathic conditions.

At some point, the intervention, which is them doctor shopping, becomes worse than the pain itself.

At some point, someone will prescribe you something.

And hopefully we're not dealing with opiates at that point, but someone will prescribe you something thinking that they have the magical cure to fix your distress, your pain.

And that scares me.

And my job is to sit with them and say the pain is real, the sensation is real, the symptom is real, but it may not really be indicative of the thing that you think it could be.

And by the way, going on WebMD or Google, or because a social media influencer said, if you have this, this is probably what it is, does not diagnose you.

And so there's really this wonderful space of social media, wearable devices, which I'm a big believer of, and the access that we all have to our medical records scares the hell out of me because we are now patients being our own advocates and showing up to doctors saying, this is what I found out online, and I think I have this, or this is what this person said, and I think I have this.

I'm looking at my watch here.

My heart rate's been up all week.

Does that mean something?

Yeah, it means your heart rate's up, period.

Doesn't have to mean anything else, except your heart rate is up.

Most people would assume that that means you're, you know, at risk for a heart attack or a stroke.

Or it means if you stare at your watch long enough, you don't have hair on your head like I do.

But if we talk about lice, guess what's going to happen in a few seconds?

We're both going to be doing this because that's what happens.

And if I mention your left pinky toe, Peter, have you thought about your left pinky toe this entire time we've been together?

Because you are now.

How's the toe next to it doing?

And by the way, now how's the right pinky toe going?

Now we get to think about that.

So if you think about that long enough, you're going to feel your left pinky toe.

It's going to be tactile and sticky and maybe sensory.

It was there the whole time.

Your brain didn't have to think about it.

How's your breathing right now?

We don't think about breathing.

And I treat people who get fixated on swallowing, breathing.

There's got to be something in here.

I have thyroid cancer.

I have esophageal cancer because I feel something in there.

You probably do feel something in there.

And by the way, if you do this all day long, and you create some bruising, you're going to feel a whole bunch of more stuff in there.

You know that better than I do.

But to convince someone that there may not be something in there because they've been scoped and tested and blood checked, and there's no signs of anything that's anatomical or physical in their throat, but they can feel it.

It's not my job to say it's fake.

It's my job to say you're struggling with something.

And what are we going to do about that?

Is the message there...

Do you go one step further and say, you're creating this?

Or are you saying, no, I don't need to go that far?

I just need to get them to understand that there's another explanation for this.

There's no need to do that.

If I take that stance, I'm now the next person who's the naysayer.

I'm the next one who's invalidating them.

And almost no therapist that I know would ever basically weaponize that or blame them for that kind of thing.

What I can say is you may not have created it.

You probably didn't create it.

Leg pain's not being created.

But if you sit there and focus on your left pinky toe or if you talk about likes long enough, it's going to create head sensations of itch.

That's how it works.

When you focus on something long enough, you pay attention to it.

And if you pay attention to it, you're more aware of it.

And if you're more aware of it and your brain actually works, it'll feel it.

Phantom limb syndrome research has demonstrated that.

People putting a dummy arm and a fake arm in a mirror and whacking an arm, we can feel that in our nerve endings because our brain's processing information.

So do we have a dead arm that's not connected to that's actually causing pain?

No.

Do we have a pain reception or an information processing thing going on?

Probably.

That's fascinating research.

The point is, is I don't have to tell them that it's your fault or that you're creating it, but I can tell them that the thing you're doing is keeping it active.

It's keeping it prominent in your focus.

And as long as you focus on that, you're not focusing on anything else.

And if you're not focusing on anything else, we have a whole nother disease.

Disease one, there's something wrong with your thigh, maybe not medical.

Disease two, you're fixated on it.

You won't leave the house.

You're demanding opiates.

You're complaining to people.

Your husband doesn't want to hear it anymore.

Your doctors have cut you off.

And I've worked with patients in Atlanta that have been blacklisted from two or the three major hospital medical systems because they've done so much doctor shopping and so much fighting with their doctors that it's a stress on the system.

But they have the wearables and the social media and the online and access to their patient portal that proves that something's wrong.

And just as an example, what types of things would they actually be doctor shopping for?

What's a symptom that's a real world example?

The ones I usually see the most are memory loss or memory slip-ups, which some people would actually put into the functional neurological disorder spectrum.

A lot of chest pain that has had every EKG and medical workup you can imagine, sensations like ants crawling or physical pain, neuropathic pain, for which it has no explanation.

Let's just take each of those in as much as you know details.

I mean, what would be triggering events?

I'll tell you where I want to kind of go with this, which is I want to understand

the genetic factors that would predispose a person to this versus the environmental factors that would predispose an individual to this.

I've had a number of folks on this podcast where we've talked at length about the heritability of various psychiatric illnesses.

Using concordant and discordant twin studies, we can get a pretty good sense of how these things work.

And we know that with health anxiety, the heritability is about 30 to 40%.

So it's on the lower side.

So it's low

to where we see with schizophrenia, schizophrenia, autism are very high.

On the 70s to 80s sometimes.

So we're on the low side, but it's there.

There's a genetic loading that's there.

Yep.

But when you say 30% heritability, I hear environmental heritage.

So do I.

So do I.

I hear in the diathesis stress model, yeah, the diathesis is there, it's low, but it just takes that right context to make it come alive.

And for some populations, for some people we work with, trauma can induce this, trauma can cause all sorts of physical manifestations of discomfort and distress and pain.

Whether that's a physical or sexual trauma or an emotional trauma or loss, there's enough research and large-scale studies to demonstrate, even with seizures, PNES, psychogenic, non-epilectic seizures, that emotional and physical traumas can demonstrate then bodily reactions that are not explained, which we used to call conversion disorder.

So trauma is a notable thing.

Family history of it where parents are complaining and describing similar symptoms.

So I see see that quite a bit.

I see that both with OCD.

OCD has a heritability rate of about 50%, 40 to 50%.

Health anxiety is a little bit lower.

I mean both populations.

And what about general anxiety?

So general anxiety, I go by disorder, unfortunately.

Okay.

So if I go by disorder, I can tell you, but in general anxiety, I assume it's probably still in that 30 to 40% range, just in general.

I don't know of any other disorder outside of OCD that has a higher heritability rate of there's nine anxiety disorders I usually refer to.

That one usually has the highest genetic.

And that's the 40 to 50%.

That's the 40 to 50%.

So I assume across the board, if we merge them all together, we're going to be in that 30 to 40% range at best.

It's very atypical for me to meet a child or teen with OCD and to not have a first-degree relative who has it.

Doesn't mean the first degree relative has sought treatment or agrees with it, but almost every child's like, oh, yeah, my mom does the exact same thing.

And do you think that it is a learned behavior in that sense?

Well, we have to not deny that there's a genetic component to it, but when you are in a household where someone is doing things in a very hyper-vigilant way constantly, or always washing down the counters, or always doing things on repeat, like tapping the door or asking you to say something over and over and over again, at some point, social learning kicks in.

And they won't necessarily be the same.

So in other words, if mom washes her hands a hundred times a day, Johnny could easily manifest, what, clothing folding or ruminating on some other yeah, you're describing a lot of the sub-content areas of OCD.

I don't know if there's any research study out there that has demonstrated that parents' sub-classification of OCD mimics child's, but at a macro, OCD falls down to the next generation.

It's pretty well documented.

If I've seen 100 people in the last year with OCD, I haven't seen that many in the last year.

I'd be shocked if more than 15 didn't have a first-degree relative that had OCD.

It'd be very atypical.

That they see, that they live with?

That they live with or have lived with.

Yeah.

So it would just be very uncommon.

Which makes it difficult to parse out how much.

It's very difficult to know nature versus nurture.

It's very difficult.

Health anxiety for me is almost identical.

So I view health anxiety as a subcategory of OCD.

I think probably 20 years ago, people viewed the HIV focus much more as an OCD condition.

Today, we would call it illness anxiety disorder.

But most of the colleagues I work with, the people I've done research with, the people that I talk about stuff with, view health anxiety as a subcategory.

Academically, it's its own special category in the DSM.

But I see the exact same things that you're asking about, which is that it is very rare for me to see someone who has health anxiety for which a a first-degree relative doesn't also have health anxiety.

And health anxiety, OCD for most populations usually starts around age seven, eight, nine, prepubescent.

Health anxiety usually starts around the teenage years.

A few kids I've seen can have health anxiety.

Epidemiological research would support that health anxiety typically starts in teenage years and young adulthood.

I see kids with emetophobia, fear of throw-up, kids that complain of tummy aches because they're afraid to go to school.

I think they're more focused on situational symptoms in response to situations than what you and I would think about more existential dread about health anxiety.

So it would be a little bit unconventional for a kid to be thinking about morbidity and mortality and things like that because kids are not developed to worry about that in general, though it can be the case.

But it'd be very unconventional for me to see someone who has health anxiety where they wouldn't say, yeah, my mom also worried about that.

Emetophobia is no different.

Fear of throw-up.

Very common in family dynamics.

So first thing when I see someone who has a fear of throw-up or emetophobia is, which one of your family members also has that fear?

It's like the first question you ask.

Oh, that one.

Great.

Now that I know.

Biologic, behavioral, both.

So you've referenced HIV and AIDS twice.

Is that really the first big landmark introduction of widespread health anxiety?

Or is it just the most recent one prior to our current?

It's probably the loudest.

You can go back, if you want to do research on this, go back in Grecian, ancient time.

People focused on this stuff and did brain mapping.

And I joked before we started talking, I used the word trephonation, all sorts of crazy psychobrain surgeries.

to help people alleviate stuff.

But the HIV epidemic probably became the most prominent thing in the last 30 to 40 years that got people's awareness of what if I get that terrible disease because we don't know enough about it.

The treatments weren't available at the time.

The life expectancy was short.

And that scared everyone.

But you could look at trends in the last 10 years.

And when I get together with all my colleagues and we nerd out about this stuff, you can see trends during Black Lives Matter movement a few years ago and the hashtag Me Too movement when you see people coming in.

fearful of like, what if I say a racial slur?

What if I get accused of sexually assaulting someone in the past?

And you see those socio-driven moments where you see spikes of people coming in concerned about that.

COVID lit that on fire, literally.

And there's still lingering effects of that that we can discuss.

But I don't know if I've seen an HIV concern in the last five to 10 years.

I mean, I just don't hear it, but I've done a lot of work in HIV and STD prevention.

I've worked in HIV clinics.

I did an NIH research fellowship on HIV and STD.

I'm a weird psychologist, but I've done lots of medically based research and clinical work.

So I've been in the HIV space actually for about 20 years as an OCD anxiety specialist.

I'm sure I have colleagues that could speak to this.

I haven't heard someone complain about HIV, concerned about getting it in my career, probably in the last 10, 15 years.

But you name every other condition, stroke, heart attack, Alzheimer's, Parkinson's, every kind of cancer.

I mean, cancer is the most notorious.

It's the loudest.

It's the scariest.

It's what everyone talks about.

Is that signal getting louder?

Yes.

Okay, so let's now go over the three things you alluded to earlier.

Social media, wearables, and access to medical records.

Is there anything else that you think is contributing to that?

Let's assume genetic drift is not increasing the genetic predisposition to that, so that the increase that you see in the incidence is environmental or triggered.

Anything else driving it besides those three, you think?

Those are research-based me citing those things.

I'm going to speak more on a personal anecdotal level.

I have a general sense that in the last five years, since the pandemic and since we've seen a shift in culture around medical access and insurance, and people getting proper care and political things and turmoil.

I think most mental health providers and EPI research would show this, Peter, that we've seen a significant increase in mental health awareness, a significant increase in people coming to therapy for the first time, a significant increase in people staying in therapy longer and longer.

And we've seen a significant spike in general anxiety since 2020, almost a two-fold spike in most research studies.

So all of that combined with a general sense of not being able to afford health care or frustration with your health care providers, I just feel like we're hitting this unfortunate, perfect, terrible storm of people being more vigilant about their medical and mental health needs in good ways, trying to be advocates and trying to seek services.

But also, I think we are, as at least in the United States, there's just a general sense of increased anxiety and stress on all of us.

And as you know, stress and anxiety turn somatic, turns biologic.

But I think those three big areas of social media, wearables, and access to healthcare are big players.

But COVID got all of us to think about this stuff.

And I was joking with some of your team before I came in here, but I even on the flight over here, someone was coughing in the row behind me.

And I thought, crap, what am I going to come home with?

2019?

Never would have thought that, honestly.

2018, I mean, I have kids.

I have a kid going to college and a 14-year-old.

When they were kids, they had snots and boogers and gross and diarrhea and you pumped them with meds and sent them to preschool.

You just didn't care.

Today, when your kid's sick, you're thinking, how many days of work am I going to miss?

Somewhere in the last few years, and I don't battle health anxiety.

I don't get too caught up on that.

I think about it more than I want to because of the work I do, but somewhere in the last few years, we've all become more in tune to our upper respiratory stuff.

And people are wearing masks before they never did.

In other countries, in China and Japan, we saw people wearing masks before the pandemic.

We see this all over the United States now.

I was at a restaurant just a few minutes before I came over here and three people wearing masks.

Do they have it?

Are they trying to prevent me from getting it?

Are they afraid of them getting it?

I don't know.

But five years ago, I didn't see any restaurant person wearing a mask.

By the way, would there be any pathology there?

Explain.

Well, if you see a person wearing a mask, and let's just say you make the assumption that they're not sick.

So they're not.

I'm not making that assumption.

No, no, no, I know.

I'm making that assumption.

If you see people walking through airports with masks, and again, I'm not trying to ask this question through any lens other than pure inquiry, and I realize these are very loaded questions.

But what I'm really trying to understand is if a person's walking through an airport wearing a mask and you knew that they were not sick, so they were doing it for fear of getting sick, Is there any reason to say that person's not psychologically functioning on all cylinders at the moment?

It depends on their situation.

Sorry, let me further assume that she was battling cancer.

No, yeah, let me get you.

No, no, no, I'm going to throw all that out.

So you're not immune compromised.

You're a 40-year-old, perfectly healthy person who's not undergoing chemo.

You don't live with someone who's undergoing

categories.

Yeah, yeah, yeah, yeah, yeah.

No, I'm just trying to get at you're a person who pre-COVID would have never thought of wearing a mask, but you haven't escaped the COVID mindset.

You could argue it's not causing anybody harm.

It's their face they're covering up.

I mean, aside from the fact that the barista at Starbucks can't take their order, like no one's actually paying a price.

Is there any maladaptive behavior there?

Possibly.

Sounds like a real therapist here, a real psychologist.

Possibly.

I think if that mask is being used as a cover to avoid social interactions, as a way to get out of other events, to make sure you're not working in a certain part of the restaurant, possibly, when you really don't need to do so.

If you're just wearing the mask because you're just a little bit extra cautious and don't want to get sick, again, if we don't care about it and you stay employed, let's say it's an employee or you're walking through the airport, I don't think there's anything pathological about that.

I think that's no different than someone taking what are those vitamin C packets before they get in a plane.

People do that all the time.

Costco and other companies sell boxes and boxes of that stuff.

Do I think this stuff works?

Not really, but people are pounding that vitamin C powder stuff.

to make sure when they go on their flight or their travel, they don't get sick.

Is that any different?

I don't know if it's any different.

I think we all take our own approaches for homeopathics.

And I put the mask in that category of people who are taking over-the-counter kind of things or supplements to boost their immunity or to prevent themselves from catching something that would compromise their immunity.

I think good for them, and I don't think anything about it.

What about driving with a mask on?

If you're not an Uber driver or a driver.

The other day saw someone driving down the freeway.

They're the only person in their car.

I assume it was their car, but there was nobody else in it.

And they were driving with a mask.

If it wasn't a rental car, and if it's a rental car, you might go, gosh, like I could see what if they thought, again, I think that's pathological to me.

And I think we can probably say both are, but if you're in a rental car, and you and I both know how the transmission of respiratory issues go, and you're in a rental car that's whether it's been cleaned or not, someone smoked in it, someone coughed in it, by the time you get in it, we're beyond that potential range of infection from COVID or other respiratory ailments.

Wearing a mask isn't going to do a darn thing medically.

I'm not a medical provider.

I got to be careful.

I say that on this end here, but I know enough about the science that that's not how you're going to get some kind of disease.

That baffles me.

Is that pathological?

It looks funny.

It doesn't make sense to me.

Maybe it's, they're going to be going to the next place and they forgot to take it off.

Maybe they are immunocompromised.

I don't know what their situation is.

But if to your point, if someone doesn't have an illness and they're not trying to spread it, and we don't believe they have any state of immunocompromised status and they're wearing a mask, it seems off.

And so should the majority of people who are not wearing masks look at that person with empathy as opposed to disdain, which is probably how most people look at that individual.

I think anyone who's in a situation like that would look at someone with empathy, with compassion and think that that's not my situation.

And I hope that whatever they're going through is okay.

But again, we start talking about like what you can see and what you can't see going back several discussions ago about mental versus behavioral.

I've never been in a podcast and someone said, hey, what do you think about people taking emergency or vitamin C or whatever, whatever those powders are?

No one's ever asked me that.

Is that different than wearing a mask?

Not to me, but we can see the mask.

It is a little different.

And I think that's the point.

If you take the vitamin vitamin C pack, you're putting it in your water, you're drinking it.

For all intents and purposes, you're taking a bunch of electrolytes.

The person who takes that next step to put a mask on, presumably in an environment where nobody else is wearing it.

Oh, I'm sorry.

I was talking about the airport and other situations, the restaurants.

In a car situation, that feels pathological to me.

Sure, no, even in the airport.

My point is they're doing it in an environment where nobody else is wearing a mask.

That to me is a higher threshold.

They're more concerned.

Absolutely.

They're focused on it more than the rest of us.

And one might argue, well, then maybe the rest of us should be focused on it as well.

And I just don't feel like I have to do that.

How would you talk to that person?

So let's assume that I'm making this up.

This is completely untrue.

Let's say my wife can't stop wearing a mask everywhere we go.

This is not true, just for all her friends listening.

I'm not ratting out my wife, who never wears a mask.

But let's just assume my poor wife can't stop wearing the mask.

And I'm getting kind of annoyed.

I'm like, honey, this is getting a little ridiculous.

Every time we go out for dinner, you're wearing a mask.

Frankly, I'm embarrassed.

And she's like, Peter, I just don't want to get sick.

I don't want the downtime.

She comes up with whatever seemingly rational argument she has.

And I said, I get it, honey, but when I'm sitting across from you at dinner, I like to see your face.

Sure.

She's like, I appreciate that you like my face, but I just can't afford to get sick.

I like my health.

Yeah.

Yeah.

And so let's say we present to you for therapy.

Tell me how you're going to engage.

First of all, I see this all the time.

It's just metaphorically, it's not the mask.

It's the romantic partner that I see quite a bit in my work because I run national romantic partner support groups, free support groups for people around the world.

Me and a colleague in California.

And yesterday from my hotel, I ran one of those.

We see this all the time.

It's just a lot of fun.

And feel free to come up with a better example.

This is just a dumb one I came up with.

No, the example is, I have a romantic partner and his or her partner come in saying, my partner is never going to events, or my partner is constantly scrubbing down the counter, or my partner makes sure that we have to have our shoes off before we walk in, or my partner makes me say, I love you, 17 different ways before we go to bed because the version I said wasn't good enough.

It's the same point, which is what the person with, I'm going to use the phrase lived experience, which is a pretty colloquial common phrase for a mental health person to say that someone has some things.

I guess I'm already making the case that they might have a condition, but I see quite often when the person with lived experience is doing excessive behaviors that's causing impairment and disruption to the people around them.

So we'll use your mask example.

You said, Josh, she can't, that word means a lot to me, can't take it off.

She won't.

I can't even see her face at dinner.

In that first meeting, I'm trying to figure out not, Peter, what's wrong with that?

Why can't you get over it?

Because I know why you can't get over it.

I'm trying to understand from my wife's perspective, what is it doing for her life?

What is she solving?

And I'm trying to hear her story to figure out, do I have any in-roads in here to figure out how rational this is really getting, how functional it really is.

And so in the Interventions for Health Anxiety or OCD are starting to talk about cognitive behavioral interventions, I'm using motivational interviewing techniques and Socratic questioning with a lot of compassion and kindness to try and hear her story, hear her concerns, because you're just the husband.

You're sick and tired of it.

You've lived with her.

I'm coming in with a short fuse at this point.

But my job is to help her figure out, is there any wiggle room in wearing this?

And I probably may not do that in the first meeting, but I'm going to start assessing other areas of her life that she's not doing that are probably more protective.

And every person who does my work knows the research is undeniable.

Not getting on a plane is the funniest thing in the world because if you drive a car, you're not paying at all to statistics.

Because driving in a car within five miles of the radius of your house is the most likely place you're going to get into.

Maybe not a fatal car accident, but a car accident.

Airplanes, despite all the stuff in the last six months to two years, is still by far statistically the safest form of transportation by the millions and millions of people that fly.

But it feels terrifying when we start seeing planes colliding and things happening and changes with the FAA and stuff.

But no one looks at that and goes, I'm going to change my situation.

I'm just not going to get in an airplane, but they drive.

So I'm trying to find those moments with your wife.

I'm trying to figure out what is the value for her.

Does she see that it's impacting her husband and her friendships?

Does she see that it's limiting opportunities in her life?

I'm trying to find what's the cost and is there any way for that cost to outweigh the benefit of what she is not being immunocompromised for.

I'm also trying to find out what other curious behaviors she's doing that look like the mask as well.

Is she washing her hands a little bit extra?

Does she keep hand sanitizer on her?

Does she refuse to shake hands?

Does she make sure she brings her own straw?

So how often do you see that where a person shows up and there's sort of one chief complaint, but then upon further probing, there's a series of concentric circles they're building out from it.

It's the whole point of the success of of therapy because the answer is all the time.

Okay.

It is rarely isolated.

Very rare where I see a single anomalous symptom, behavior, or action being the only thing that is worthy of attention or treatment.

You can go as far as to play this out in substance abuse and eating disorders.

There might be the primary substance or eating behavior someone's engaging in.

Trust me, there are other characterological and other tendencies that someone's engaging in that may not look as dysfunctional or impairing, but they're there.

They're under the surface.

And a lot of them are probably happening.

So So I'm assuming that she's spending time at the restaurant also scanning who's coughing, also seeing when the waiter brought the credit card machine, if that still exists, the fold, out of their butt back pocket.

How disgusting is that, Peter, that the waitresses stick that in their butt back pocket or in their pants and they pull it out and ask us to pay for it?

Like that's foul.

Does that make you stop from paying?

No.

Most of us don't care about that, but that's pretty messed up.

Do you really think that the person didn't go to the bathroom and do you think they washed their hands every single time?

Of course not.

But if you don't see it, you don't think it.

So I'm starting to assess in her this out-of-sight, out-of-mind concept.

What are the things is your wife paying attention to that she's aware of?

What are the things, and this gets a little fun, should she be paying attention to that she probably doesn't want to?

And that's thinking, great, thanks, therapist.

Now you're making me worry about all the other stuff out there.

And my point is to say, maybe the mask is a bit of an overreach.

Maybe it can be sometimes modified.

And so if someone is completely vigilant about doing said behavior, in this case, the mask, and she can't take it off with you with her bow at a restaurant in the corner, I think we have something to work on there.

If she's like, well, okay, I can do it at least when I'm with Peter.

Okay, we've broken some ground.

We have some wiggle room there.

But often someone has no wiggle room and they're not willing to give up whatever that thing is.

And that's where we start talking about doing various interventions.

And interventions for this are a combination of addressing cognitive flaws.

understanding the behaviors, mental and behavioral that he or she is doing that are way more pervasive than just the mask, starting to ask them to make minor modifications to those behaviors, which we typically call ritual prevention.

And then if I get lucky enough, we actually get into a place called exposure therapy.

And we haven't talked at all about that, but a real anxiety therapist, going back to the very first thing I said to you, you're not going to come to my clinic and be seen by an anxiety specialist, no matter what their degree, credential, years of service are, and not get some version of exposure therapy.

And all exposure therapy is, is an intervention that helps someone approximate their fear, facing it head on in a safe, ethical, compassionate way without putting them in any ethical, legal, or medical risk.

Some people might think it puts them at risk, and some people might think they can't handle it.

But exposure therapy, which goes back to the 60s, is the leading intervention for things like PTSD, phobias, social anxiety, OCD, and health anxiety.

But to get someone to get there means you have to get them across this process of readiness for change, this model of pre-contemplation to contemplation to ready to take action.

And if your wife is like, I am never going to take off this mask, she is so pre-contemplation, I've got to figure out then what concessions or changes can she make.

Maybe her and Peter go to a cafe or restaurant outside that's completely aerated, not inside, and she tries to take off the mask even for five minutes.

And if she can do that, Peter, we're breaking ground.

We're now putting some wiggle room between a dogmatic, anxiolytic, no way wiggle room action.

And now as long as it's outside air, and when the waiter comes over, she puts it back on her face.

Okay, I'm okay with that.

But now you get to see her beautiful face.

You guys can eat outside.

And now you're going to start picking cafes that are outside more than inside restaurants to slowly start building some resistance or strength, bravery for her to try it in different locations.

And if she does it and gets sick the next day, you're going to fire me and hate me.

But if she doesn't, then maybe we're starting to break around and find other things that she can modify or change slowly that meets her pace and that makes you happy.

That's all a good anxiety therapist is going to do.

So is the idea that you use cognitive behavioral therapy to bridge the gap until they're ready for exposure therapy?

Sometimes.

Sometimes if someone's so pre-contemplation or so wedded in their rituals, and we see people who are literally scrubbing walls with Lysol and bleach where the walls are down to the studs, that's more for things like contamination-based OCD.

People are doing behaviors that require almost hospital-level care.

Some of them are not ready for exposure-based therapy.

And in that case, I'd probably recommend someone if they're not on medication, probably can be seriously consider medication.

But exposure therapy is the first-line treatment for almost everything to do with OCD and health anxiety.

Once you get them ready for the exposure.

You can say that once you get them ready, but I'm never walking into a client with OCD or health anxiety not thinking, I'm not going to do exposure therapy.

They're going to be getting it some version or another.

I'm an exposure therapist.

Okay, so I don't know if this is a realistic enough example.

So if it's not, just say, Peter, that's not how these people present.

So let's say I said, Josh, I travel a lot for work.

But I got to tell you, with all this news around air traffic controllers losing sight of airplanes, I don't know if I can fly anymore.

This has now actually posed a real risk to my career.

My career depends on me being able to get on a plane every week to go and meet my clients or whatever it is I do.

This is a real world scenario, by the way.

There are people that are having increases in aerophobia or fear of flying way more than we had in the last few years

because of stuff that's going on.

This is real stuff.

Yeah.

So the environmental trigger is there has been a rash of airplane crashes coupled with objective data that say air traffic controllers are overworked and the system is failing and something bad is going to happen.

And unfortunately, my job necessitates that I'm on the road all the time and I can't take buses.

It's too far.

I can't take trains.

Basically, I'm going to lose my job if I'm not willing to get on a plane every Monday and come back every Thursday.

I just don't know how to do it.

And I've got two weeks of PTO.

I'm going to do a little bit of medical leave, but I'm running out of options.

How the hell are you going to get me on a plane?

First of all, that person is trying to figure out values.

They're trying to figure out what's more important, the belief that I'm going to die in a plane crash versus my job and my livelihood.

And they're in the trenches in that.

So I want to join them there before we do anything.

I'm going to do an assessment.

We're going to have that first meeting or two, but I'm trying to figure out.

Tell me a bit about the assessment.

You mentioned this earlier.

Yep, yep.

So almost any therapist is going to do an initial intake evaluation, which is gathering a lot of information that they have filled out in advance, going through that, and then interviewing them for usually between 60 to 90 minutes.

to really better understand their story, what they're coming to treatment for, what their history of treatment is.

In situations like this, have they had other moments of fear of flying, fear of driving, other significant avoidant behaviors?

Ultimately, the goal of an intake evaluation, a first meeting, is trying to figure out diagnostically what's going on.

And so once you know what that diagnosis is, treatment commences from there.

So by the end of a first meeting, a first intake, they have filled out generic survey forms, some forms that we would describe as evidence-based assessments that have been demonstrated and researched to be the best.

for specificity and sensitivity of getting to symptoms of a diagnosis.

And in each sub-disorder, depression, social anxiety, OCD, there's everyone sort of has their tried and true, that are research grade that we all sort of know are standard in the field.

And someone's going to fill those out, fill out some general packets about their life and medical history.

And I'm going to meet with them to try and help understand their story, to try and build rapport, to try and connect with them.

Because ultimately, I want to have them run through that brick wall with me at some point in therapy.

For this person, it'll eventually be getting back into flying.

Is that five sessions or 50 sessions?

I don't know right away.

And it's based on a lot of factors.

But in the first meeting or two, I'm gathering a lot of raw data to put together a story, which we would call a case formulation, that explains their diagnosis or diagnoses and tell them what the treatment options are.

And in a case like this, more likely, Peter, someone's probably come in saying, do you prescribe benzos?

And I don't prescribe.

And honestly, if they have to get in a flight right away and they don't want to miss up travel and PTO, I'm not a fan of medication in general, though I know it helps people and it definitely saves lives.

I'm definitely not a fan of medication that has a high addiction potential.

But sadly, when it comes to things like panic attacks or not being able to get in an airplane, he or she's probably not going to drive 24 hours or 12 hours across the country.

Then unfortunately, what people usually do is they drink heavily or take benzos to get at least through the flight.

And what happens down the other side?

They're now inebriated.

So they got through the flight by white knuckling it and getting under the influence, but now they can barely get off the plane.

That's not a great solution, but it does end up being what people often do with fear of flying because that's the only way they can get through that flight.

To get through TSA and to get in the plane is going to be some sort of pharmacological, whether it's alcohol or pills or a combination.

But that's not my goal.

What about alternative medications?

So what about SSRIs or SNRIs, which again, have this sort of bad rap as being antidepressants, although they're probably a much broader category than that.

Do medications like that have a role in at least being part of the tip of the spear to create some increase in psychological resilience?

In a story like this, to be blunt, probably not.

If the story is that this person has never really seen a therapist before, has never really struggled with things like anxiety or depression, have never taken a medication, and this is an end of one kind of situation where they're like, yeah, I'm terrified of flying and it's ruining my life.

An SSRI is going to take, or an SNRI is going to take several weeks to take action.

I'm trying to be careful not speaking out of turn as a PhD.

I don't usually speak too much about medication, but I'm speaking the way almost anyone who knows about it knows.

SSRIs don't treat the tip of the peak of anxiety.

So someone who's having a panic attack, SSRIs have been on them for six months, doesn't help with the panic attack.

It can help long-term reduce chronic anxiety, which itself can reduce panic attacks.

But if you're in the throes of a panic episode, which is what often fear flyers experience, an SSRI in that moment acutely does not solve that issue.

Does it help you as a therapist by increasing the absolute sort of emotional resilience that then makes them more open to therapy?

If this is just about fear flying in this unique situation, probably not again.

But if someone has a multitude of symptoms and problem areas, and this has been going on for a while, so if this gentleman's missed a few meetings because he doesn't love public speaking, he has to sit around a table and present stuff.

And he doesn't love going to parties because he just doesn't do well unless he drinks at parties.

And he's kind of become a little bit more of a recluse recently, especially in the last few years, maybe because of medical issues or health issues, or he's just in a funk of life.

Oh, there's also this flying issue.

I think an SSRI in this situation might be a good thing to at least help calm.

some of the things that we're talking about.

We're talking about basically an increase in serotonin availability in the brain.

An SSRI could be helpful here, but it's really just a medication for us to actually get to the real tools I want to teach him.

Because if this is much more of a long-standing issue, an SSRI might help him, but I want to teach him skills where he can basically have his own tools, his own skills, where long term he's both off the SSRI and doesn't need a therapist anymore.

But in this flying situation, honestly, if I was involving a medical person, I'd probably recommend nothing more than a benzo, which I'm not here supporting or in love with.

But that's more likely to get someone in that immediate moment through TSA on the flight and to the other side.

You're saying we're going to give you a benzo because you have to get on a plane on Monday and it's Thursday.

Yeah.

And you're going to lose your job.

I need a band-aid.

And it's going to be a very, very, very tiny dose of Xanax such that it just gets you on the plane and not freaking out.

But that's it.

Now let's talk about what your ongoing CBT exposure therapy is to get him, let's say, six months from now to be feeling like his old self.

Yeah.

So fear of flying is an interesting one because it is so in a unique way, a hard one to ultimately do the real exposures with because you don't have a flight simulator?

Well, I used to.

So I worked for six years in a virtual reality company that actually pioneered virtual reality interventions for fear of flying, fear of public speech.

Yeah, yeah.

In the 2000s, after graduate school and I was on faculty at University in Atlanta for a few years, I'm still adjunct there.

I left a research and clinical career working in a hospital.

to then work for a startup and worked in a private practice who actually had fear of flying simulators that had virtual reality goggles, a platform that would vibrate, an olfactory system.

You could click buttons and make the smell of diesel fuel and like a stinky ham sandwich next to you and perfume.

A full sensory experience to have that suffocating, horrible fear of flying experience.

But again, there's a few clinics around the country.

There's not many that still use these kind of things.

It's kind of a clunky system.

So most of us who treat fear of flying don't have access to simulators and those kind of things.

I mean, prior to 9-11, many people would actually take short flights with their clients and patients because you could afford it and do like a, in Atlanta, I could fly to Savannah and back in an afternoon and it wasn't very costly.

Today, it's almost impossible, shy of me going to the airport, maybe getting up to TSA, having the person buy a plane ticket that's refundable to go through TSA to sit by the terminal to then leave the airport and then get their money back.

That's probably the closest real world exposure.

But what we're doing is we're addressing all of the cognitive distortions or the faulty thinking, faulty logic associated with the fears of flying.

I have a 30-tip handout that I often give people about understanding what flights are like, that air pockets in the flights are not real things, though people feel things, and that the wings can go in each direction.

When we see wings sort of wobbling, they can go almost seven feet in each direction.

So, 14 feet worth of movements.

When you see the wing doing this, it's not breaking off.

And that there's all these mechanisms in place when the pilots are flying to keep things safe.

That flights going one direction are at a certain altitude, and flights going the other direction are at different altitudes.

They don't have head-on collisions in air.

Basic facts to teach people stuff that sometimes helps people.

How much is there fear based on facts that your sheet is addressing?

Sometimes in this fictional situation, am I afraid of a mid-air collision?

Am I afraid of the landing because the air traffic controller loses us?

Am I afraid of something as vague as turbulence because I don't understand what turbulence is?

It's almost none of those.

Honestly, the most common aspect of fear flying is having a full-on panic attack on the flight inside of a Metal 2

that you can't get out of.

Ironically, though, people have a fear of dying and a fear of crashing and a fear of mid-air collisions.

What they're really afraid of is having that feeling of losing their mind on the plane and that they're stuck on it.

And so, yes, there are some real elements of teaching people the basics.

They're correct in that assessment, by the way.

Yes.

But then the treatment gets focused much more on panic disorder.

So when we're treating fear of flying, you're almost inevitably treating panic disorder, which again, by the way, highly responsive.

to exposure therapy.

In fact, the leading intervention for panic disorder, unless you go back to my scenario, you have to give someone a benzo, which I don't prescribe in those acute moments, just to get through a singular moment.

And usually, if a psychiatrist would prescribe that, they wouldn't have them take their first dose on the flight.

You'd usually try that, as you pointed out, Xanax, a low dose of Xanax, a few days before, just to see how your body responds.

That would be a pretty standard medical care practice thing.

But when we're treating these kinds of conditions like panic disorder, something called interoceptive exposure or treating someone to their intraceptives or bodily sensations is, of all the things out there, the undeniable grand champion of interventions.

It is super effective.

It is highly compassionate.

It is not hard to learn as a therapist.

And it teaches someone that they are not having to respond to these bodily sensations that they think are going to lead to a full-on panic attack.

So it would be very rare for me to be treating a fear of flying, a fear of being in a car, a fear of being in sort of situations by also not treating some version of a fear of panic reaction.

where you feel like you're going to lose your mind, you're going to hyperventilate, you're going to pass out.

That pretty much goes along with whether you diagnose both conditions panic disorder and fear of flying the dsm would say you wouldn't but in this situation i'm treating both situations i'm sorry misunderstood what is the exposure therapy for that specifically let's step back exposure therapy again is one of usually four techniques one of them is called in vivo exposure and that is latin for in life meaning you're actually doing real things with real objects if i had a fear of podcasting and public speaking Coming in here would be a great in vivo exposure.

There's something called imaginal exposure.

Imaginal exposure is actually writing a narrative down or a story, which sometimes we do it with trauma, sometimes we do it with imaginal situations that have never happened.

So those are two different kinds of imaginal exposure, but you're essentially coming up with a story that you're going to write down and record and listen to.

So this is just the first part of exposure therapy as I'm describing.

There's a second part that's even more important to me.

The third kind of exposure is interoceptive exposure.

And that's commonly used for people who have health anxiety, physical symptoms, or panic disorder.

And in this case, we're actually inducing real, low-grade physical symptoms like eye blurriness, rapid breathing, sweating, tummy aches, arm soreness.

If you and I sit here and do a two-minute plank, my arms are going to be wobbly.

So I'm inducing things that people experience in the real world that immediately make them freak out, think they're having a panic attack, think they're having a stroke.

You're saying if somebody is worried about eye blurriness, you're going to put eye drops in their eye?

I'm not going to put eye drops in their eyes.

We're probably going to look at an iPad that has these cool visuals that's going to make their eyes, there's all these optical illusions I like to use.

What about the tummy aches?

How do you induce that?

You have someone spin in a chair.

You have someone sort of do some cardiovascular exercise in your office, like sitting up and down, sitting up and down very quickly.

You have someone spin on a baseball bat, creating nauseousness and queasiness is not hard to induce.

We're not having someone eat something or ingest something because that's going, I think, one step further than you need to.

But you can create any sort of physical symptom from leg soreness to a headache kind of symptom to a tummy ache to tight shoulders to cotton mouth, people who have a fear of swallowing, fear of something getting clogged in their throat.

You can recreate almost any physical, not medical, physical symptom safely.

If you and I are going to a treadmill and work out, we're going to create 95% of the symptoms that people experience when they have a panic attack.

If you go to a really high level of a treadmill or an elliptical, I'm going to create all those symptoms, but I'm not going to bring exercise equipment to my office.

So I am helping people bring real-world physical symptoms to light in my safe laboratory, in a safe place.

And I'll get to the second part of the point of exposure in a second, just so they can experience a thing that they're terrified to experience, but they already experience it out there.

Nothing we do in exposure therapy have they not already experienced.

The fourth kind is just called media augmented or virtual reality exposure therapy.

And that's that people who are using either 3D goggles, virtual reality goggles, videos, audio clips to use AV audio visual tools that are kind of mimicking the in vivo and imaginal and intraoceptive experience.

And that can be something as elaborate as real world simulators, virtual reality goggles, or even like watching flight land on YouTube 20 times in a row to see what happens when the flight comes down.

All those things.

We treat people who have audio and tactile things like mesophonia, which is a high sensitivity to sounds, or people who are afraid of hearing something.

So anything that brings that tool into the place using audio video.

That's part one of exposure therapy, which is you and a patient have come up with an elaborate hierarchy ladder, a list of easy, medium, and hard scenarios in their mind that they think that they could some point do.

Most people think they can never do the hard ones and they almost always do successfully.

And you're coming up with this hierarchy based on what you asked about that first meeting, that first session, that second session.

I'm collecting a lot of raw data to figure out what are the things in their life that are triggering them that I can recreate to help them face their fears head on and come up with new learning.

And so, Peter, back in the 60s and 70s, we thought that habituation or just getting used to it was the creme de la creme of exposure therapy.

And we found out that that wasn't really solving it.

And then we started shifting more towards cognitive models, not just habituation and being in a distressed moment, but actually now coming up with new meaning about it, which is called inhibitory learning.

That was really started at a seminal article in 1986 by Michael Kozak and Edna Foa.

Edna Foa is one of the pioneers of exposure therapy, both in PTSD and OCD, has done amazing work out of UPenn.

Her, Marty Franklin, a bunch of people at the UPenn were the pioneers of exposure therapy.

In 86, they pioneered an article that taught us that habituation or just getting used to symptoms, it helps, but it's not really getting people moving further.

And so when you start having these corrective experiences, when you start unlearning what you thought was going to happen, which anxiety is all about anticipating something and being colossally wrong, thank God.

We need to get people to experience being wrong in a situation that mimics what they actually experience.

So exposure therapy has shifted from just a behavioral physiological model to a cognitive model.

And that cognitive model is helping people process that information after the exposure.

So you just did some weird stuff for 20 to 45 minutes, whether you're huffing and puffing, practicing giving a speech to a screen, putting yucky things on your hands if you have germ O C D, if you're afraid of bugs and spiders, maybe going to a local pet shop and looking at spiders behind a glass tank or putting spiders that are in like resin, fake spiders that are dead, like on your arms, all sorts of things that start.

whatever it is that you can create that sense of fight, flight, or freeze, that sense of fear, that sense of dread.

So your amygdala starts producing the chemicals that you experience in your own life in my private safe place sometimes we go out in the community we go to restaurants and shops and do odd weird things and so we're doing that to have people experience that stuff but also not engage in rituals and compulsions so exposure therapy is a combination of doing things that bring on a sense of safe predictable, but uncomfortable emotional and physical feelings, while also not doing the mental and behavioral things that bring it back down.

And if you can stay in that state for 30 to 45 minutes and do that multiple times a week, Peter, you start learning real distress tolerance, real resiliency skills.

You start disproving that the thing that I thought I had to do either to avoid it altogether or to undo this sense of dread or feeling, if I don't undo that and I sit with it, maybe, just maybe when it happens in the real world, I don't have to pop a pill.

I don't have to run home.

I don't have to wash my hands.

I don't have to wear the mask.

And so we're combining inducing a sense of arousal, psychophysiological arousal, cognitive interpretations that are usually faulty, not doing things to bring it down and stay with that, doing a few different interactive things through 30 to 45 minute experiences, and then afterwards processing those lessons learned, making meaning out of these weird situations, finding out that you're stronger than you thought you were, finding out that no one died, finding out that in that moment, you didn't do that horrible thing you were wondering if you were going to do.

Again, we're treating things like people are afraid of being pedophiles, pedophiles, people are afraid of getting horrible diseases, people afraid of killing themselves or killing other people, people afraid of contaminating things and ruining someone down the road.

Some things are imminent and some things are you won't know for a few years from now.

And so we're really tapping into this intolerance of uncertainty, this belief that I can't deal with the fact that something terrible is going to happen.

So I've created this fabricated world around me, wearing the mask to make sure it doesn't happen.

You gave an interesting example there.

You said people have a fear of being a pedophile.

Yes.

Okay.

This is very controversial.

Yeah, I was about to say, is this a person?

So let's just posit that this is a person who's never acted out any such thought.

Absolutely.

Do they fantasize about pedophilia?

Not fantasize, but they have thoughts and feelings about it, just like you and I have thoughts and feelings about driving off the bridge, thoughts and feelings of robbing a bank.

Every time I see an armored truck, I'm thinking, that'd be fun to take those $4 million, but what do I do?

Move on with my day.

So everyone has intrusive thoughts.

99.9% of us have thoughts about sex, drugs, rock and roll, horrible things.

And for most of us.

Wait, those things are bad?

Sorry, never mind.

Depends on the band.

93 to 94% of the population, so there's about 4% to 6% of the population that battles OCD.

They just Teflon right off of us.

I thought about like punching someone at a restaurant.

I have the thought, stabbing them in the eye and moving on.

Road rage, I have a thought of tailing that person and doing something back to them, and I just move on.

But for the person who has OCD, that thought doesn't go away so easily.

And then they start thinking about it.

And then they start wondering about it.

And again, if I start making you think about your left pinky toe, you're going to feel your left pinky toe.

If you have these unwanted, intrusive thoughts about a kid or her body parts or doing horrible things, guess what's going to get lit up if we did a brain scan on you?

The parts of the brain that regulate sex and arousal.

And guess what happens when that part of the brain gets lit up?

Things down there start getting lit up because your brain's working.

So I'm going to be very clear because I have a few people out in social media, colleagues and dear friends of mine who have been attacked on social media.

These are not influencers, though they might be influencers.

These are evidence-based, science-backed, amazing clinicians who use their advocacy and knowledge for good to help people to destigmatize some really wonderful people out there.

And they've been attacked by some creepy people out there saying, you're endorsing pedophilia.

Absolutely not.

When we talk about OCD in these kind of conditions, we talk about people who have ego-syntonic versus ego-dystonic experiences.

Ego-syntonic is, I want to be here on this podcast.

I want to be a little bit nervous coming in here because it matters to me.

It matters whether you like me.

It matters if I sound good.

That means this is aligned with my values.

I want to put information out there.

I want to be a voice of reason and I want to educate your community about all these sort of anxiety conditions.

That's aligned with my values.

That means it's ego-syntonic both to be nervous, but also to want to do well here.

I'm okay with that.

Ego dystonic means you're having thoughts and feelings that are not aligned with your values.

And so in OCD, it's epidemic that the things you're afraid of do not align with your values, whether it's about hurting someone accidentally because you didn't wash your hands from chicken or stabbing someone or killing someone or molesting someone or getting punished by God.

There's all sorts of topics that people get really fixated on accidentally and they get terrified by that and they spend time thinking about it because they're trying to get rid of it or doing something about it like not going to the park.

Does that mean that an ego dystonic person rarely, if ever, will act on the impulse because it is creating so much internal tension?

Not only will they not act on the impulse, they don't even want to talk about it.

They don't want to think about it.

I don't want to be gross or offensive here, but I don't care about saying the word pedophilia.

It doesn't faze me at all because I don't think about it.

It doesn't bother me.

To someone who has what's acronymed as P-O-C-D, pedophilia O-C-D, they don't even want to hear the word.

They don't even want to see it on a checklist.

How does that differ from a pedophile?

A pedophile is completely at peace with the fact that they think about it.

Whether they're at peace or not, whether they ever eventually actually hurt a child, they think about it.

They're turned on by it.

They want to pursue it.

And we'll start talking about the difference between ideation, which is just a clinical work for thought, versus want, intent, and action.

And so someone who's a pedophile or someone who wants to hurt someone else, someone who wants to rob a bank, thinks about it, plots it, and whether they're lucky enough to do it or not, robbing a bank, maybe they do, maybe they don't, but they have full intent on it.

And maybe they don't have the guts to rob a bank, but they want to.

So that's someone who's aligned with that value.

People who have OCD are not aligned with anything associated with hurting other people, wanting to bother other people.

In fact, it's a common knowledge in sort of my work.

Those are usually the gentlest and kindest of souls.

They're tortured by the notion of having the most impure thoughts, thoughts of harm.

Your goal is to help those people understand they're not bad people, and you want to reinforce you are not going to be acting out on this impulse.

Actually, I won't do that.

You won't do that.

No, because that's therapeutic reassurance giving.

Probably from the very beginning, back to the first meeting, I'll probably say, I know who you are.

I know what's going on here.

Welcome home.

We have groups.

We have podcasts.

We have meetings.

You're in a safe place.

And I know this is not aligned with your values.

And I'll probably say to them, this might be the last time in our relationship, if I see you for 15 to 20 sessions, this might be the last time I ever say to you, I know you're not a pedophile or I know you don't want to hurt a kid.

And they look at me like, wait, what?

Because in therapy and in life, reassurance seeking is one of the most insidious classic symptoms in OCD.

We see it in health anxiety as well.

But reassurance seeking is asking for clarity and for permission and for confession and wanting to get that back.

And if a therapist does that, this is for me, one of the best litmus tests when I say, go find that anxiety specialist.

When I find an anxiety specialist, rabbit ears, anxiety specialist, does reassurancing and says, you're going to be fine.

I'm sure you don't have cancer.

I've never said to someone, I'm sure you don't have cancer.

I don't know if yes, you don't know.

I have no idea.

I'm sure you're not going to have a stroke.

You're never going to get Alzheimer's.

I'm sure you're not a pedophile.

When I hear that from a therapist, They weren't trained by me or someone like me, and you're barking up the wrong tree because now you are weaponizing that certainty principle, which is all the anxiety sufferer wants.

I can't promise you're not going to die in a plane crash, Peter.

And I can't promise if your wife takes off her mask, she's not going to get sick at the restaurant.

What I can promise is, is if she takes it off, her husband gets to enjoy her more.

I can promise if she takes it off, she may be able to do other things that feel risky and scary, but actually add to her life.

That if she takes it off, maybe she'll have more opportunities.

But I can guarantee you if she keeps it on, she's losing her husband, her friendships.

She's like, I don't care.

I just want to get sick.

Okay.

Well, now you're choosing your own values here.

And is that exactly where you need to get people?

Absolutely.

That is the risk calculation.

There is no risk-free asset here.

The only thing I can promise someone in this world is that they're not going to live at some point, which sounds morbid and terrible.

I'm actually wearing a bracelet that one of my patients gave me that says, you're not dead yet.

The only thing I know in this world is that at some point we're both not going to be here.

Between now and that data point, what do you want to do to have the biggest and best life?

But if I sit sit here and promise them that they're going to be okay and that's going to be, I can guarantee you it's 14 sessions.

I guarantee you that Prozac's going to work for you.

I'm selling them a false sense of hope.

I hope it works.

I'm assuming you're not going to molest someone, but that's not my job here.

My job is to help you understand what are your values, which I already know what their values are.

What are you doing aligned with them?

Trying to not think about stuff and trying to be the best person possible.

I already knew that.

What things are you missing out on because you're so scared that your values could get compromised?

I can't go to birthday parties or I can't see my aunt and uncle because of the niece and nephew.

Okay.

So how do we start approaching those situations?

If you believe that you don't want to hurt anyone and you want to approach them, what things are going on in the inside in your body and your mind that are preventing you from going there?

How do we start that process?

Before we're doing exposure therapy, we're trying to figure out how do we start chipping away at some of those rituals, some of those avoidant tendencies that you're doing.

So walk me through that example.

Again, this is such a fascinating one that never even crossed my mind as a condition, but it also strikes me as if you can fix something like that, you can almost fix anything.

So you said something a second ago about within 14 or whatever, 15 sessions, I'm never going to once but this first time reassure them.

Okay.

The implication of that to me is you think this person's going to be fine in six months potentially.

Most likely.

Pre-pandemic, I was seeing people pretty consistently 10 to 15 sessions.

In most research studies for most of the conditions that I treat and that we've discussed today, Deviation from the manual a little bit.

We like to talk about how to customize an intervention for the person, but it's very evidence-based.

10 to 15 sessions, 13 to 16 sessions is pretty standard.

Post-pandemic, people want to talk about everything, and it's my job to figure out how do we get to the core of what we're working on.

I'm seeing people for way more than 15 sessions traditionally now.

Don't love that.

We never thought I was going to be doing that.

But most of my colleagues around the country would agree that we have now elongated the length of therapy, not because we want to, but because people have more stuff they want to unpack, more things they want to discuss.

When that person leaves your care, whether it's 15 or 20 sessions later, do they have just as many thoughts about children as they did when they came in?

So, in general, I find that people have many less of those accidental, internal, unwanted symptoms in general.

But I'm going to say something that might be upsetting to the people listening or the people that I've supported.

I don't care.

I don't care how many thoughts they do or don't have because you and I are not defined by our thoughts.

We're not defined by our physiology.

We're not defined by our hunger cravings or what we think until you say them or act on them.

We are judged by our outward objective or when we avoid actions and inactions.

And that's why when people were not taking anti-racist actions, I understand why people were judged for that because that's still in action.

If you chose not to vote, you voted for whoever won.

So all of those principles apply to me.

And I tell this to my clients, 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.

And I know who you are and I know what you want, but you're not pursuing that because you're so afraid that that bad thing might happen.

And so in any situation, fear of flying, fear of contamination, fear that you might hurt someone, fear that you might have a disease, I know you don't want to die, but all the things you're doing to prevent cancer are costing you financially.

You can't see doctors.

Your family doesn't want to talk to you.

You think you're trying to prevent dying.

You're dying right now.

I call health anxiety the cancer of psychiatry, which is what it is to me.

It's eating you from the inside.

It's its own pathology.

It's killing you and spreading everything around you.

And you think you're trying to prevent this horrible disease down the road.

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.

And so their value system is mission critical.

So now in our discussion here, we're shifting from cognitive behavioral therapy, which was really, I think, the biggest change in the field of psychiatry.

to help people find evidence-based, randomized, controlled trial interventions at a research grade that really help people to the next wave, which is still under cognitive behavioral therapy.

And we talk about exposure.

Now we're talking about ACT, acceptance and commitment therapy, which CBT

historically did not talk about these kind of things like values.

What do you really want in this world?

Who are you on the inside?

And so ACT is an extension of doing CBT.

And I guess CBT is the umbrella.

Exposure therapy is underneath that.

And I'd put ACT underneath CBT.

ACT, pioneered by Stephen Hayes and other wonderful researchers and therapists, really developed this six construct called the hexaflex, this six construct paradigm that identifies your ability to accept things that are happening inside of you, thoughts and feelings, without it defining who you are, your ability to be present in moments, even if you're having like a toothache, if you had like a medical pain right now going on, that your ability to be present in the moment, to be able to use yourself as a self-concept that I'm not defined by my thoughts and feelings.

I just have thoughts and feelings.

And so we teach people when they have the thought like, God, what if I kill someone?

Or like, what if I'm gay?

There's something called sexual orientation OCD, which we haven't talked about.

Or like, what if I get cancer?

You can shift that to, I'm having the thought, what if I have cancer?

I'm having the thought, what if I kill someone?

You've now created some space between you and your thoughts.

That's a powerful skill.

And there's a bunch of techniques out there.

called cognitive diffusion that help people separate themselves from their content of their thought.

And now we're looking at thought as a process rather than an object, Peter.

Very powerful stuff.

Within that act hexaflex is values.

And values are mission critical because for the work that I do with anxiety, for the work that you do in your work, you and I actually kind of have the same goal.

We have the goal of people today living their healthiest and richest lives and elongating that as much as possible.

So when they get to the end, the end doesn't happen as rapidly and as destructively as it sometimes does.

We're doing the same thing here.

But when psychiatry and anxiety come together, values fall apart.

People's values become focused on intolerance of uncertainty.

I use the word yucky a lot with three-year-olds and 50-year-olds, making yucky go away, not feeling, not thinking.

Your values shift to a negative reinforcement process of doing things or not doing things to remove some bad outcome.

And your position, and mine is as well, is doing things that increase good outcomes.

And so I'm trying to shift people, and I have this sheet I use in my office all the time, from the right side of the paper, doing or not doing to remove some bad thing that's going to happen, which is called negative reinforcement, to doing or not doing whatever you want that has the, not a guarantee, but the possibility of increasing your lifespan, increasing your marriage, increasing your sex life, increasing your health, increasing your cardiovascular functioning, increasing your ability to go to the doctor and hear the results.

And if you have questions, ask them appropriately.

And if you don't believe them, go to one more doctor.

And after that, move on with your life if you can.

Because at some point, all of the fact-finding that you're doing, it's like the worst puzzle ever.

I gave you a thousand-piece black puzzle with no corners, and I took one piece away and I snuck it in my pocket.

And I just haven't told you that yet.

And you're trying to solve this puzzle, and you're never going to solve it.

And your value is solving the puzzle at all costs.

I'm not leaving the house.

I'm not going anywhere.

I'm going to quit my job.

I'm not even going to eat until I solve this puzzle.

That's not solvable.

So your value shifted from doing a puzzle to only solving the puzzle.

And the problem is in my work, most of my patients can't solve the puzzle.

They have to drop the rope and pick a different game.

And that's the game of life.

Values, people, love, health.

Therapy is about getting people to see that shift, that cognitive shift, that paradigm shift from removing uncomfort, removing ambiguity, removing uncertainty, to doing things that make your life bigger and better.

There's no guarantee for that, but that's a much more exciting life to support someone in than just making symptoms go away.

So I don't care if they stop having thoughts.

That's ideal.

And we often see that with medication and talk therapy.

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.

They do that.

I'm done seeing them.

And I don't care what the topic is.

I don't care what the disorder is.

If they have the skill of stepping back from their internal symptomatology, and choosing a healthy action that increases their world, they're their own therapist.

We have talked about this directly and indirectly a couple of times, which is it's been referenced through being present, directly through mindfulness.

We've talked repeatedly about the space between stimulus and response.

Is mindfulness meditation as a formal practice a part of this therapy with anxiety?

Absolutely.

I don't typically teach breath work or meditation per se, but anyone who has the capacity to cognitively or physiologically be present with themselves and with the world around them and stay in control, it's a winning intervention.

So meditation has a place in this.

Mindfulness has a place in this.

Relaxation training has a place in this.

If taking a cold plunge or going into a sauna is going to get you to a place of recognition of what your needs and values are in this world, that has a place for it.

I find exercise, even though I'm a therapist who does cognitive behavioral therapy, I'm a pickleball fanatic.

I can't get enough of it.

I find exercise to be the best form of meditation and mindfulness.

You can't play or do the sports.

I'm not talking about just like weightlifting or walking on a treadmill, high-level sports, which I'm an amateur.

I just play pickleball with people at a local community center, but I like to play pretty intensely.

You can't do that and not be both mindful of what's happening around you and in this state of almost euphoria, which I view meditation to be.

And that's why paddle sports are always viewed as some of the best sports for longevity of life, for cognitive functioning, for hand-eye coordination, for staying present.

And obviously for cardiovascular functioning, if you don't break a hip or break a leg, which some people do, I think any of those interventions or activities that increase your sense of awareness, your sense of how your body operates, and that encourage you to do things that are healthy and increase healthy actions, all of those have a place, as does extracurricular activities, prayer, knitting, clay, drawing, painting, all of those.

None of those suck away your life.

None of those keep you away from loved ones unless they become an obsession or an addiction in a bad way.

What are some signs or things that you see in therapy that give you concern that a person is not going to recover?

And maybe we start with that question, which is, what is the success rate?

Success defined as a person who, after some finite number of sessions, gets to the point where actions and behaviors are remediated independent of thoughts.

I'm going to make a statement on that question, and I promise you I'll answer it because there's a lot of controversy in the field of psychotherapy research.

And even in my world of OC and anxiety researchers about what research is and what real outcomes are, the medical field does not debate this.

I wish the psychotherapy field of research didn't debate this either.

It's not just about when you're doing better after therapy, which I don't think is that hard to achieve.

It's doing better after months of no therapy.

I know my patients are doing better when I don't hear back from them, when they truly become their own therapist.

So the best research to me in psychotherapy and the best RCTs, randomized controlled trials, show when there's six months, 12 months, eight months of follow-up that is demonstrating continued symptom remittance or sub-diagnostic gain.

So my answer to your question is when someone, this is funny because we're talking about health anxiety, when someone is therapist shopping, usually call it doctor shopping, it'd be therapist shopping, when they've been to five to seven therapists in a short amount of time, that scares me.

Because what that tells me is they're looking for a certain answer or a certain kind of therapist, and no therapist is matching their needs.

And that's no different than finding a romantic partner.

When someone has been through multiple partners in a short amount of time, they're the consistency in that, that concerns me.

When someone is a yeah, but in therapy, that really scares me.

Because again, that means that they know all the answers.

They're struggling with what we call cognitive flexibility.

And in acceptance and commitment therapy and in CBT, cognitive flexibility is mission critical.

Unfortunately, I'm going to be teaching you, this goes back to the FOA and Kozak 1986 article about corrective information, that maybe you're wrong.

And when someone is characterologically, unwilling to be wrong, you're not going to do well in therapy.

It's just a fact.

And you figure that out how soon?

Within the first two, three sessions.

I think most therapists have a general sense.

I would say in the first two, three dates, someone knows whether there's an attraction here.

I think in the first two, three sessions, most therapists know whether or not there's some wiggle room in here.

To be fair, I'm in a 25-team practice.

We have therapists in three states, Georgia mostly.

We see people in 40 states.

We're a mega practice.

In the state of where my career is at, I'm very privileged to say this.

I'm very appreciative that I can say this.

I see the sickest of sickest.

That's what turns me on intellectually.

It's what what gets me going.

I could treat a dog phobia.

We treat that.

I could treat someone who's having weird eating issues.

I can treat panic attacks.

I did that years ago.

So I'm seeing people who are very ill, who have been to hospitals, who have failed medication trials, who have tried TMS and ketamine.

I'm seeing very ill people.

And I'm not perfect that.

I'm not getting 100% results here, but I'm seeing people who think that they have no chance to get better, but they want to.

And they're desperate for information.

And they're desperate for someone who can see them and understand what's going on.

And so so my success rate is probably not better than the other people I saw that were easier to treat, but I'm seeing people who shouldn't be getting better and they still get better.

But it's because they want it, they're willing, and they're trying everything they can, even if they're stubborn, even if they're hopeless, even if they're not doing well.

So for me, I don't know if I'd use the word characterological, but there are these sort of intrinsic cognitive states that people are in where they just can't see anything but what's in front of them.

And if I can't push them beyond that, I'm going to be the next therapist that they fire.

And I'm aware of that.

When people are open and willing to new ideas, to weird interventions, if someone's never had exposure therapy, I see plenty of people who have been to multiple therapists who have never even had exposure therapy.

And to me, that's like you treating someone for, I don't know, what medical condition and not giving them cholesterol medication when that's like, that's the no-brainer.

I see people who have a condition that the only intervention they should get is some version, at least of cognitive behavioral therapy, and they haven't had that.

They're seeing a supportive therapist, an analyst, or they're doing soft therapy.

And I'm like, it blows my mind.

So when I see someone who is not willing to hear my ideas, when I see someone who, when I share with them videos or clips, they're not willing to watch them.

I'm watching that resistance play out and I'm like, how do I connect with them?

Another major factor, and this has been proven in psychotherapy research across psychotherapies, is the in-between session experience.

Your sessions are weekly, typically, or?

Typically weekly.

I see most people weekly.

When I'm seeing someone that's...

needs a high level of care, sometimes I'm seeing two or three times a week.

We have an intensive outpatient program where I don't manage or run see patients that have a staff that does that, but typically weekly.

And there are in-session interventions, things I'm doing with the person, funny moments we have, light bulb moments and techniques we practice.

And then I don't like to use the word homework, but then there's homework.

The research is undeniable in a homework-driven, structured kind of therapy like cognitive behavioral therapy, dialectical behavioral therapy, acceptance and commitment therapy, mindfulness-based CBT, all the interventions that utilize skills between sessions.

This is no different than working out with the trainer.

If you go with the trainer and don't work out for the rest of the week, guess what happens in week two?

You've gained nothing.

If you practiced with your golf instructor in week one and you did no practicing in the course between the next appointment, your stroke's not going to be any better.

And psychotherapy research is no different.

If you're not doing the assignments between sessions, you're not learning and messing up.

I love when people mess up their assignments.

I don't care if they do them right.

I just care that they try them.

Because if they mess up, guess what I get to do?

Correct information.

So this is all about learning and messing up, learning and messing up and learning from that and building from that.

So that's another critical ingredient.

When I see someone, when they ask them like, what did you guys do between sessions?

Nothing.

Would they ask you, would they assign you?

I really didn't do it.

Or I didn't like what they gave me.

I'm like, oh, okay.

Am I going to give them the right assignment?

Are they just going to block me as well?

So I fall that under, again, more cognitive inflexibility or they think they know the right way.

But interventions between sessions is where we gain mastery of skills.

And then they come back and I refine them.

We practice them and then they practice them and then I come back.

And that in-between stuff is actually pretty important.

And when someone doesn't do work between sessions, if there's work to be done, I'm having groundhog day.

I'm having the session of like, well, let's talk about what we talked about last time and what got in the way.

And did I not assign it right?

Did you not understand it?

And we're having a little bit of playback, which can be defeating in therapy when you think you know what's best for them.

And sometimes we're wrong.

And then you try something else.

But if they're not trying it, I can't learn from their mistakes.

Does anxiety, whether it be health anxiety or any of the subsets that we've talked about today, does it tend to traffic with other comorbidities, either health comorbidities directly or more importantly, psychiatric comorbidities?

I said earlier, one of the most common symptoms in anxiety, it's really the most common is avoidance.

So it's not shocking that we see low-grade, we're not a substance abuse specialty clinic, but we see people dabbling in alcohol and marijuana use and opiates and stimulants to feel better.

So you'll see pretty common co-occurrence of substance-related usage, maybe not full-on abuse.

And the causality there, Josh, you think is I am using the substance to medicate the anxiety or is it the other way around?

Both.

It's probably bi-directional, but there's definitely an element of I'm self-medicating because I don't want to deal with my stuff.

That's not shocking to most of us.

And so, especially if we're doing exposure therapy, having someone who is muting their anxiety response, who's muting their sympathetic, parasympathetic activation, if I can't tap into that, to have their amygdala and limbic region light up if I was doing brain imaging, to then have them feel that, to then teach them some corrections.

If I can't tap into that because they're numbed out, I can't make those changes.

So that's one sub area.

I want to dig into that a bit more.

How do you manage that then?

So when you get under the hood of somebody who's coming to see you and you realize actually they're kind of high every day, not with you.

Let's just assume that they come in and they're not, that they're basically using marijuana every single day.

They're using alcohol or whatever it is.

How do you manage that?

Do you say, listen, I can't really help you until we get you off this because I need to experience you in your native state?

Or how do you?

sometimes it's a black and white if you're at this level of usage even if it's not impairing their lives completely I may not be the right therapist for you but I come from a harm reduction model I've worked in abstinence only models and I'm a believer that if we can reduce this and get it into a moderate state of whatever it is you're using as a starting point this is the concept of working out the hierarchy of exposure therapy I can't ask them just to quit that's not even a concept to me so we're taking baby steps if someone's willing to make a concession or two what if they say but doctor listen I have to use this is actually helping me.

No one's probably going to actually say that on alcohol because I think they're not going to be able to do it.

They'll say it on benzos.

Yes, they'll say it on benzos and they'll say it on marijuana.

They're saying, you don't understand.

This is an anxiolytic.

This is actually reducing my anxiety.

We shouldn't be cutting this back.

I've seen patients who use weed chronically, but are functioning in most areas of their life in general, occupationally, their partner smokes with them or their partner doesn't care, but they're coming in with anxiety issues.

It can create a real dilemma.

I need pockets of time where they're not just always feeling, not going to say good, numb.

I want them to feel distress in small doses.

I want them to have these hiccups where they can feel and have differentiation.

Ultimately, the short answer is, is if someone is wedded to using a substance and it's just going to get in the way of my work, I will probably refer them to someone who's more likely to work with them.

I don't know who that person is sometimes because most therapists don't want to work with someone who is chronically using a substance that's causing impairment and they're not willing to give it up.

And if they're not willing to go for treatment for that, then we have a different issue.

I think more often what I'm finding is I'm like, okay, so the first three sessions, I'm going to discuss this.

I'm going to bring it up.

I'm going to ask if there's any way for us to change it and to see, again, if there's any wiggle room, if there's any flexibility in there to make changes in anywhere of your life, can we just give it up on Tuesdays?

Can you just make sure you don't smell like weed when you walk into my office?

In Georgia, it's not legal, but people still smoke it like everywhere else.

But if you're smoking and driving, that's DUI.

That's DWI.

That concerns me.

So in general, I'm in a harm reduction model.

I'm like, how can we do things that bring less harm to your life and open up your life more?

If someone is wedded to anything in their life that I find to be destructive and I think it's going to get in the way of our therapy, I'm not the right therapist for them.

Having said that, there's, again, an interesting sub-area of research in the exposure literature for which exposure therapists who get really literal and very dogmatic won't do exposures for people who are under the influence.

They won't do exposures on the day where someone's taking a benzo.

And so in a lot of exposure research, again, if you think about PTSD populations, Peter, where polypharmacy is honestly usually the baseline where people are taking sometimes an SSRI, one or two benzos, one long acting, one short acting, maybe a a stimulant and maybe even a low-dose antipsychotic.

You're doing a research study.

If someone is taking a benzo on the day of exposure, you can't tap into the things we're trying to tap into, into that bulb of the amygdala, that bulb of emotional centeredness to have that lit up so we can have some corrective experiences.

So you'll see in research studies whether people noted people were not allowed to take benzos on the day of exposures.

And so that becomes a challenge.

When I'm doing anxiety work and someone's doing something, I don't view it as a legal or ethical issue, but it's muting my ability to tap into real real presence, talk about presence.

I may not be the right therapist.

That's really the message, right?

It's not a judgment.

It's simply an efficacy question.

It's just that I can't actually help you effectively.

What you want from me and what I'm able to offer you is attenuated by the fact that we're not going to remember this conversation the same way.

That's not good for us.

The question about comorbidity, ADHD, or I'll say attention issues is pervasive.

And we see lots of kids in our clinic, but I can't even tell you the chicken and egg of do you have ADHD or anxiety or both or neither neither half the time.

And even the best diagnosticians can't tell you, because if you have pervasive, intrusive thoughts, Peter, how the heck are you not constantly interrupted in your prefrontal cortex?

How?

If you're thinking about raping and killing or health or disease or dying or morbid topics, how can you possibly be attending to all the things in the room?

And so people who have anxiety have these attentional biases and disruptions.

OCD and health anxiety related conditions, we don't know all the mechanisms, but there's a breakdown between executive function operation and the emotional or limbic region.

Like there's a breakdown there, there's a disruption there.

And so attention is pervasive.

In the OCD community, we're seeing higher rates of co-occurrence of autism, and OCD is pretty common.

And then when you get into the molecularity of OCD, we see a lot of people that have these interesting areas like ticks, body-focused repetitive behaviors, something called trichotillomania, which is hair pulling of different parts of your body, or dermatilomania, which is skin picking.

And so we see co-occurrences of ticks.

Trichotillomania and dermatilomania are called body-focused repetitive behaviors.

So they're called BFRBs.

So ticks, BFRBs, medical issues, a lot of co-occurrence of like chronic medical issues like IBS, restless leg syndrome with people that have chronic anxiety, ADHD, autism.

I mean, it's really a little bit of everything.

So in an anxiety center, like I said, we all, the centrifuge of it all, all treat the primary nine anxiety disorders and then all of this dabble in.

Some do autism, some do ADHD, some are doing more mood disorders, some are doing a lot of irregular relationship and emotional dysregulation stuff.

You have to know the science and molecularity of anxiety to understand that.

And if you're not the right person to treat that, we'll make a referral out or referral within our team.

What do you think is the biggest myth about health anxiety?

That someone's making it up, that someone's looking for attention, that there's secondary gain.

It is disheartening and sad to see a medical professional or a loved one tell the person that they're just drug seeking or seeking attention.

I know that's the case on an occasion, but nobody wants to have, I'll say OCD as well, nobody wants to have OCD or health anxiety.

It is not functional.

It is not fun.

It is not enjoyable.

It is not adaptive.

And when someone says, oh, my OCD helps me like be better at work.

That's not OCD.

You're talking about something else there.

Whether we're talking about perfectionism or OCPD, obsessive compulsory personality disorder or something else, there is not an ounce of functionality with OCD in anyone who I've worked with, anyone who I care for, all my social media friends that are out there that are on Instagram and TikTok who are amazing humans destigmatizing these conditions.

No one believes that OCD has any adaptive healthy aspects to it.

Health anxiety for me is terrible because you and I are in different professions, but we're trying to help people live their best quality of lives, live their fullest lives.

And it breaks my heart when I see someone who has health anxiety who is convinced, and I'm not talking like they're wondering, they're convinced that there's something wrong, despite my loving, compassionate guidance.

Five to seven doctors who have told them they're crazy, which is what they end up hearing, or go to the ER or go see a shrink.

That's the message they get.

They're 100% syntonic convinced that there's something wrong with them.

And it's absolutely heartbreaking to see that.

And until you can get them to shift that needle and be a little more flexible, they're stuck and they are losing their quality of life.

And the thing they're trying to preserve is the exact same thing they're killing.

So I think that sense of, I'm making it up, I'm fabricating it, I'm looking for attention, or I'm just looking for drugs is just not the case.

And I know, again, anecdotally, I'm sure it's out there.

We all know that, but these people don't want to be this way.

They don't want to be seeing doctors.

They don't want needles.

They don't want all the exams they go through, but they're willing to do it.

I've written about this, and I put out a book a year and a half ago that's in our book.

I have a health anxiety online platform that people come to for support groups and information and cool challenges and weird stuff that's all out there.

And we hear this unfortunate story all the time.

I'd rather just have cancer.

I'd rather have my arm amputated.

I think I have an osteosarcoma in here.

I'd rather just have that nerve clipped.

I'd actually rather be paralyzed so I don't feel my leg pain anymore.

And you're thinking, did you just say that?

You'd rather have finality of impairment or disease that every physician has told you you don't have rather than a different approach that I'm trying to offer you.

And whether that's some medication, talk therapy or something else, you'd rather be impaired or a quadriplegic or have the diagnosis of cancer that you don't have just so you stop worrying about it.

Like, wow, that's another level of willingness to get answers.

And that's how insidious and how disgusting and how horrible these sticky, tricky conditions are, which I'm mostly referring to OCD and health anxiety.

They have these thoughts and belief systems that are so entrenched and so believable, and it's the biggest ruse in the world.

And if I can get them to hear that, if I can get them to realize that maybe if we can drop the rope and come back and try it a different way, maybe, just maybe trying to figure out whether you have cancer or not is not the most important thing you do today.

Do you have a sense of what the prevalence is today of people that are as ill as you just described?

EpuResearch in the last 10, 15 years is pretty consistent.

About 4% to 8% of the population has has some version of health anxiety in their life.

Of people who have chronic illnesses, a third.

Over 30% of people who have chronic illnesses, Crohn's, cancer, diabetes, sickle cell, et cetera, over a third have some version of health anxiety.

Most studies I've read and I've gone through and when I report this and share this, about 20 to 30% of us have consistently some subclinical health anxiety notable preoccupations.

As we get older, it obviously increases because we have more health and medical issues.

And there was an interesting Swedish, I think Swedish study that came out a year or two ago and then a 2024 big study post-pandemic that health anxiety has skyrocketed in the last four years just because of whatever the pandemic has done to the world and people's hyper-focus on stuff.

So the level of people that I see, I think in the OCD and health anxiety community, if we're saying that six to eight percent of the population has OCD or health anxiety, probably over a third of them are at that severity level where you start wondering about insight.

You start wondering about their ability to reality test.

And that's why medication, in this case, Peter, I think, is usually pretty fundamentally critical.

It is pretty rare for me to see someone with severe OCD or health anxiety who does not benefit from or who would not benefit from an SSRI or an SNRI of some kind.

And often you'll see psychiatrists add a low dose of an atypical antipsychotic for a lot of mood instability.

Thorazine or?

Yeah, Cyprexa, Seroquil.

Oh, Seroquil.

Yeah.

Thorazine is a little bit older, but Abilify, which is sort of in that mixed class, just to help with the mood issues.

So at least a third of the patients that come to our clinic, and we see the wide range of everything, and the patients that my colleagues see, I'd say at least a third are at that such severe level, and there's not enough providers out there.

And is the medication temporary to get them through the therapy?

It's necessary to get them through the therapy.

Sometimes for certain people.

How many of them can get off the medication?

I don't have an answer to that.

I'd rough estimate probably at least a third, half.

But for a lot of people, they're afraid to come off the medications if they're at a stable point.

And I'm a believer in if you're on the medication doing well and you want to stay on it, great for you.

Some people try and come off and it creates a spike in symptoms and we immediately get back on.

That's why most people will taper down and not just go off medication.

My bigger concern is when someone is unfortunately, not because they're trying to be, when they're unfortunately treatment resistant, which has a much more pejorative term than I want to be, but they're treatment non-responders is what I should say.

They're not responding to the normal pharmacology.

And that's why we see people today, I have very little knowledge of the science and mechanics of of this, so I can't speak much about it, but I see people now getting deep brain stimulation, ketamine, and other kind of pretty new age medication interventions or device interventions.

I know in the last few years, there's been research looking at things like MDMA and other sort of hallucinogens, sometimes with veteran populations, trying to figure out like what other medications out there, what other poorly controlled medications out there can help people.

That excites me.

It scares me because people go, oh, I can take low-dose psilocybin and like get better.

You're not taking regulated low-dose psilocybin.

You're experimenting experimenting with mushrooms.

That's not the same thing.

You're trying ecstasy.

That's not controlled MDMA.

So all these new age technologies and medications are important because unfortunately there's going to be a population out there that doesn't respond to CBT.

Still, even with the best studies, these kind of interventions are like 60 to 65% effective.

There's other interventions out there, like other metacognitive therapies and an intervention called inference-based CBT.

So like other cognitive-based interventions that people have been developing and refining and improving, but that's still in that CBT range.

60% is not enough.

And so, you know, I'm excited to see next wave genetic research and testing and medication research to figure out what are the ways can we find a way to fix where the brain is falling apart and where genetics kick in.

You mentioned TMS briefly.

Where do you see the promise there?

I don't right now.

I mean, I think it's still in experimental phases.

You know, there's people that have short-term memory losses.

My experience is that people have an initial improvement early on and then it fades.

That's been my anecdotal experience of maybe knowing 15 to 20 patients in Atlanta.

And Atlanta has a few TMS centers and ketamine infusion centers.

I'm seeing actually more psychiatrists right now, actually, psychiatrists in private practice, not even at like the universities I belong to and I go to, are now offering ketamine infusions in private practice, which to me is brand new kind of thinking.

They're trying everything they can to offer patient stuff.

So I don't know enough about the research and the science behind TMS and ketamine to speak to it at a large scale and then whether people should try it.

But these are options that researchers and psychiatrists are looking into because we know that, again, CBT is 60% effective.

SSRIs on a good day are 40% to 60% effective.

For most studies, the combination of an SSRI or SNRI and CBT is usually the best outcome, but they're still not treating everyone and not everyone can access them.

And I love what I do.

I'm a pretty awesome therapist.

I'm proud of what I do.

I've trained a lot.

I disseminate it.

I try and make it as available and accessible and affordable to the people that come to our clinic.

I'm in a Facebook group of about 5,000 specialists in a very closed private Facebook group.

This is all we discuss, this kind of stuff, 24-7.

It's an amazing Facebook group.

It's been around for about eight or nine years.

For practitioners only?

Only for practitioners.

There's tons of Facebook groups and social media platforms out there and other kind of things out there.

And I'm on 20 other Facebook groups, but I'm in this one special one out there that two of my colleagues launched, I think, 2017, 2018, that has right now almost 5,000 OCD, body folks behavior, BFRB, like specialty, specialty specialists of junior trainees to as senior and seasoned as they get, which I'm getting to that stage in my career.

And we all have these discussions.

We all debate, like, what are the medication options?

What are the alternative interventions?

What do you think about this thing that someone podcasted about?

And we're all trying to figure out how do we get another five to 10% efficacy with these populations who are just not getting better.

Hospitals in the last few years have changed.

About 10 years ago, I felt like there were more hospital centers willing to take on residential patients.

And right now, there's only about five that I know of in the country that I would view as the best OCD centers.

There's tons that pop up every day and things at IOP and PHP centers that sort of show up.

And I'm always supportive of them, but not if they're not doing evidence-based practices.

There's not enough of what I do out there, Peter, to meet the needs.

And so hopefully other biologies and genetic testing and other interventions sort of increase this.

But at the end of the day, the kind of work that I do and that my staff does for cognitive behaviorally based, exposure-based work for health anxiety and OCD, sometimes with and without medication seems to be the most effective, the most available, and the most that gives people their life back afterwards.

That excites me.

I love that.

How much are you guys seeing long COVID that may or may not be long COVID?

I mean, it's not something I know anything about, so I want to be mindful of not actually demonstrating just how ignorant I am, but I'm not sure what long COVID is.

I'm sure that there is undoubtedly a subset of people who had COVID who are having an ongoing issue as a result of it.

My intuition is there are also a lot of people who think they have that.

And in reality, they either don't have anything medically wrong with them or maybe they have something else medically wrong with them.

So you're probably far closer to that, but what are you seeing?

I'm going to join you in the ignorance and humility of I don't know enough about to say anything major, but I think prior to COVID, people described identical symptoms that they're describing now and now attributing it to long COVID.

And so if you look at that, I've been practicing for almost 25 years.

You can look at it and go, well, if it wasn't long COVID then, because that word didn't exist and that phrase didn't exist, how could it be so high today?

I don't know the answer to your question, but I see people coming with a set of head fog, fuzziness, inattentive stuff, low-grade depression, not feeling great, having a hard time articulating.

I had COVID a few times.

I'm wondering if it's that.

And I'm joining them thinking, I'm wondering if it's that too, but I have no idea.

That doesn't serve my needs.

How do I help you be adaptive?

How do I help you function?

So I don't have a good sense of that, but I think it's an easy thing to latch on to.

And people have gotten on disability for this.

People have sought out medication treatments for this when in the past, they just assumed that they had ADD or headaches or they had some head stuff going on.

But is there a benefit in that situation of saying, everything you just said, which is actually, I don't know what it is, but I want to help you.

I want to help you adapt to it.

Can you take the next step and say, let's assume, for example,

that whatever you're feeling, which is real, we're going to acknowledge that it's real.

Let's assume it's not attributable to a biologic symptom.

And then we go down the same pathway.

Is that a helpful framing?

Remove that second part.

Let's assume it is or is not.

a byproduct of biologic.

You don't have a solution for it if it is biologic.

I have solutions for it whether it is or isn't.

What do you want to do next?

So I really do stay in that gray space of, I don't know if you have cancer.

Even in the book, I have a case report that a kind person allowed me to share where I treated her for health anxiety of GI track, esophageal issues, Peter.

And it was very successful and it went great.

And she was starving herself and losing weight and losing her life to a new medical conditions.

And a year and change later, she writes me and says, by the way, I have thyroid cancer.

Now, did we miss that?

And the answer is no, because she was being followed by a thyroid specialist and was on synthroid and other stuff.

But it's tricky because I don't take away from the words.

No, it keeps you dead.

Yeah.

I don't know what I don't know.

What I do know is your life is not as good as it could be.

Can we try some stuff?

I don't know whether you're going to get cancer or not.

33% of us, I hate to say this to people who are going to watch us, 33% of us are going to get cancer.

I have patients that don't know that we're born with cancer cells.

Boy, does that piss them off when I tell them that?

By the way, I don't know if it's going to express itself or not, but we all have cancer cells.

Don't tell me that.

So I don't know which people I'm going to see that are eventually going to have that thing that they were terrified of.

I don't know the people I'm seeing right now that have something that's been unassessed and undiagnosed.

What I know is there are things that I can teach someone of mind and body, you're not doing anything much different, you're just doing much more in the medicalized space, that can give you a better life today, that can elongate your life today, that can have you more present in your life today.

And if you die tomorrow or six years from now, will you regret the things that we did to improve your life?

I'm serious, like this bracelet, you're not dead yet.

You're not dead yet.

So what do you want to do about it now?

Because the other stuff you're concerned about, go to a doctor or not.

Go to an immunologist or not.

Go to your ENT or not.

that's your space here's what I can offer you I'm a believer of mind over matter and you are what you think and you are what you do and there are so many things that we don't tap into in our physical and mental capabilities I love that part of my work as a CBT specialist it's why I got board certified you can get board certified in like 17 domains I got board certified in this CBT space it's called behavioral and cognitive because there's so much that we can teach people about diet, nutrition, and exercise.

These are things that are bigger for you than they are for me, about healthy lifestyle habits, about not getting fixated on thoughts like greed and regret and guilt that really eat at people alive.

They're poisons to us and they manifest somatically.

Those things come out of us.

So when someone comes to me and says, I think I have this condition, whether it's seizure disorder, cancer, or long COVID, I get to play, I don't know anything about that.

What I do know is, here are a set of skills I can teach you.

If you want to join me in that process, I can make your life a little bit better or a lot better.

What do you want to do?

Now you have agency.

Now you get to choose.

And you might have that thing.

Go do that thing.

Go follow up with that doctor.

But ultimately, at the end of the day, people are going to make decisions for themselves that are either going to be about removing discomfort, ambiguity, and uncertainty, negative reinforcement, and or it's not just or, doing things that give them a chance to improve their quality of life, relationships, romance, financial status, whatever it is.

And so I like to help people do that, build rather than just remove bad.

But people come to someone like you and me and say, can you help me get rid of my symptoms?

I'm like, I can, but can we also like add to your life?

And that's what positive reinforcement is.

That's what living the fullest life is possible until you and I no longer have that time.

Finally, I want to get a sense of where you think the balance lies between the abundance of information we have today about health and whatever we want to call it, the triggering of more health anxiety.

So at the outset of this podcast, we talked about, hey, look, I'm sure indirectly, well, directly, but inadvertently, I'm contributing.

People like me contribute to health anxiety.

But of course, we contribute to a lot of good things as well.

We contribute to a lot of good.

I think we're a far net positive.

So what steps could someone like me take to,

without diminishing the good, reduce the bad?

I appreciate you asking me that because the work that you're doing is having people go to unbelievable lengths with biomarkers and physical things for now and in the future.

And my career and the things I focus on are about letting go of the future and focusing on the now.

So there's a little bit of

tension there.

And I appreciate you acknowledging that.

I think one of the nicest and kindest things that you can do is make sure that people are not absolutely dogmatically looking for a singular answer or a singular diagnosis or a singular cure.

And I know you don't, but I would get concerned if someone was going to great lengths because they believe that there's only one fuel, one vitamin, one diagnosis, one biomarker that answers everything.

And people who think that way, you and I both know we're set up for failure because nothing is 100%.

That's point one.

And the work that you do is to not purport the belief that if we just solve that one genetic anomaly or if you just build more muscle mass, you're set.

Because people hear that and your word is God, they're going to do that.

And they're not going to be able to fulfill that.

I also think teaching flexibility, cognitive flexibility is critical.

So you're asking people to take on a lot of new ideas.

You're asking people to try new things, explore new things.

And that cognitive flexibility includes, hey, let's try something different than the thing you wanted to try.

Exposure therapists are funny cats.

We do weird stuff.

I mean, if you came to my office, Peter, we got stumps, like dead stumps, fake fake dead stumps and fake blood and fake semen and needles and animal skulls and band-aids and weird outfits we wear, all sorts of, like we are disrupting a lot.

And disruption is a good idea, especially when someone's not expecting it and they get better for it.

So I think in your space, if you can continue to do what you're doing, but add elements of surprise and disruption where it's not linear.

and it's not a silver bullet and you thought it was this and then you publicly say, well, we thought it was this.

We're changing our course.

That level of disruption and flexibility just promotes that we're all trying to achieve this final linear option, but we're never going to get to linearity.

There's going to be so many paths that we're all unique on and keeping people curious and flexible and not believing that if I take this shake and do this thing and find this biomarker, I'm going to live the best life possible because even you know that's not true.

But people want that.

People want the one solution.

You know, we have these wonderful medications right now that are helping people lose weight.

That's fantastic, but that's one of a thousand other options out there.

It's the quickest and maybe the easiest for certain people with and without side effects, but those are not the only options.

And so I think when we start looking at these sort of medical and biologics that are so effective and so efficient and so quick, I think the medical industry sells that a little bit too much.

And that's why people don't want to come see someone like me because they don't want to do therapy.

They don't want to do this for 15 to 20 sessions.

They don't have to like learn stuff.

Just give me the pill or the laser and I'll be great.

I always get worried about when physicians or medical people are selling wonderful, lovely ideas that make your life better, but they're so, this is like Jurassic Park.

You're jumping science and going right to like the single thing and you've jumped science and learning and knowledge.

And have you not learned from your past mistakes?

And so that curiosity and that flexibility, I think should be built into anything that you're doing, anything that I'm doing.

And with my patients, I'm trying to be curious.

I'm not right about everything.

I'm probably wrong about half the things I'm telling them, but I'm going to keep trying and keep learning.

And we're going to have this relationship that is collaborative.

And it's going to be, we call it collaborative empiricism.

And we're going to learn together.

And hopefully we're, as you said, net positive, more right than we are wrong.

But inevitably, a small percentage of the people that follow what you and other people put out there about living your best, healthiest life, which is fantastic, are going to take it one degree too far and believe that that is all they can do.

And unfortunately, that's a percentage of any population out there 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 that.

And in my work, that ruins people's lives.

So it doesn't discredit all the amazing things you do.

It's just.

Staying flexible and curious and not believing that any one thing solves anything is all I would ask of you.

You mentioned that your practice takes care of patients in 40 states.

So I assume that means telemedicine is a big part of what you guys do.

Yeah.

Prior to the pandemic, a lot of states for psychologists came together and developed a jurisdiction approval called SIPACT, P-S-Y-P-A-C-T.

This started before the pandemic, which was very innovative.

And then in the pandemic, it sort of just exploded.

Where therapists, if they got approved by this, with going through a few check boxes, probably paid a few fees, which I paid and filled out your credentials and history and proved you have no bad stuff, become a SIPACT SIPACT eligible provider.

And that means I can see people in the 40 states that have agreed interstate jurisprudence or allowance that has expanded our ability to do telehealth.

Prior to the pandemic, I already did telehealth in the state of Georgia.

There's plenty of rural pockets or people that just want Atlanta traffic sucks.

People don't like driving to Atlanta, so I was doing telehealth anyways.

SIPACT has allowed providers who have doctorate-level degrees to be approved to see people in those many states.

What are the 10 that don't?

You can guess.

You can guess two of them that want to hold on to their money and regulations.

Who do you think those two are?

I would guess California, New York.

Yep, those two.

That's all I'd say.

We'll stop.

The other eight I don't care about, but those two are probably never going to agree because of all the reasons that are just so wrong, unfortunately.

And I only ask because I know that people listening to this are going to want to have an opportunity to probably reach out and work with you.

So sadly, people who live in California, New York, you are not able to work with.

Unless you're licensed in that state, you cannot do telemedicine with people in that state, sadly.

There's no good reason for that.

The other eight states, I couldn't tell you what they are, but it's probably just because they haven't addressed it or approved it yet.

And currently, there's an equivalent thing called Compact for the master's level providers out there that are trying to do the same level of interstate access.

And you can't get a California license?

I can, but I'm not going to.

I see.

The cost and the time to get a California license.

By the way, I have a ton of California colleagues that are fantastic and do great work.

Same thing in New York.

So ironically, despite those two states that I can't do that, they have an abundance of people.

They have plenty of people who are doing great stuff there.

Got it.

At a master's level, there's another thing called Compact that might come around in the next year or two, increased access, increased availability to these kind of vulnerable interventions.

But yeah, so we've been doing telemedicine.

And I think in the last year or two, as we've been monitoring it, we're probably doing more than 50% sessions on video, possibly close to 60%.

I don't love it.

I do it.

I love it when I'm doing it with people who need it because they can't get to someone like me any other way.

I don't love it doing it with people who just don't want to drive across town or just want to find the easy way out.

I get that.

But it has increased the ability for someone like me and colleagues in my space who are doing what I hope is described as best practices and being very ethical, being very compassionate, and helping people get their lives back as soon as possible.

It's increased our availability and accessibility, which I think is absolutely fantastic and should be the way.

Well, Josh, appreciate you coming out here.

This has been a really interesting discussion.

Honestly, this is more complex than I had imagined, but I think that's often the case.

Whenever I do an interview on a podcast, I always come out learning much more than I thought I would learn even.

So thanks for sharing your expertise and thanks for what you're doing.

I appreciate it.

Thank you.

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