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

We discuss:

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

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View the Show Notes Page for This Episode

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Charles Duhigg is a Pulitzer Prize-winning journalist and best-selling author known for distilling complex neuroscience and psychology into practical strategies for behavior change, performance, and decision-making. In this episode, Charles explores the neuroscience behind habit formation, including how cue-routine-reward loops drive nearly half of our daily actions and why positive reinforcement is far more effective than punishment. He explains how institutions like the military and Alcoholics Anonymous engineer environments to change behavior at scale, as well as discussing the limits of willpower and how to preserve it by shaping context. The conversation also covers the real timeline of habit formation, how to teach better habits to kids, the role of failure and self-compassion in lasting change, and the power of social accountability. Charles further discusses how cognitive routines enhance productivity and creativity, how to gamify long-term goals through immediate rewards, why identity and purpose are often the strongest forces behind sustainable behavior change, and the potential of AI to power habit change.

We discuss:

• How Charles’s background in journalism and personal experiences led to his interest in habit formation [3:15];
• The science behind reinforcement: why positive rewards outperform punishment in habit formation [10:15];
• How the military uses habit science to train soldiers using cues, routines, and rewards [17:15];
• Methods for creating good habits and eliminating bad ones: environmental control, small wins, rewards-based motivation, and more [24:00];
• How parents can teach kids to build habits and strengthen willpower [32:15];
• How adults experience changes in motivation and cue effectiveness over time, and why willpower must be managed like a finite resource [34:30];
• Keys to successful habit change: planning for relapse, learning from failure, and leveraging social support [38:00];
• Advice for parents: praise effort, model habits, and normalize failure [47:45];
• The time required for making or breaking a habit [50:45];
• The different strategies for creating new habits vs. changing existing ones, and the crucial role of cues and reward timing [55:15];
• How to create habits around long-term goals when the rewards are delayed (like saving money) [1:01:45];
• How to stick with good habits that offer no immediate reward: designing reinforcements and identity-based motivation [1:11:15];
• The potential for AI to provide social reinforcement [1:16:45];
• Mental habits: how thought patterns and contemplative routines shape deep thinking, innovation, and high-stakes performance [1:23:30];
• How cognitive routines boost productivity and habit formation but may stifle creativity [1:35:15];
• Contemplative routines: using stillness to unlock deeper productivity and creativity [1:40:45];
• How habits reduce decision fatigue and enable deep, high-quality productivity [1:44:15];
• New research that reveals the power of environment and social feedback in habit formation [1:49:45];
• How AI may transform work, identity, and our sense of purpose [1:53:45];
• The potential of AI-powered habit change, and the essential—but often lacking—element of motivation [2:02:30]; and
• More.

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