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HEALTH ANXIETY

Quick Takes

1. The Double-Edged Sword of Mind-Body Tools

The same psychological techniques that can help someone stop fixating on minor symptoms can also convince them to ignore serious ones. If we can talk someone into worrying about their "little pinky toe," we might also talk them out of legitimate health concerns.

2. The Misdiagnosis Reality Check

Many patients find themselves returning to physicians again and again for years before finally receiving a diagnosis that leads to an effective treatment. This is true of many autoimmune diseases. Also, conditions like fibromyalgia, chronic fatigue, and irritable bowel syndrome were all very recently dismissed as "psychosomatic" until science caught up.

3. The Identification Problem

Even experienced practitioners cannot reliably distinguish between anxiety-driven health concerns and legitimate physical symptoms that happen to occur in anxious people. Years of practice don't solve this fundamental diagnostic challenge.

An additional challenge is that inflammation, the root of most conditions, also is at the root of much anxiety.

4. Historical Pattern of Dismissal

From Freud's "hysterical women" to "psychosomatic" to "embodied suffering” to “functional neurological disorder” we keep rebranding the same problematic approach of treating physical symptoms as mental health issues, particularly when these narratives serve pre-existing biases by discounting the problems expressed by certain marginalized groups.

Favorite Finds

It’s not that I don’t believe in mind-body approaches, of course.

After a person has received a thorough initial evaluation, the following can help, even when ongoing evaluation and treatment for physical causes continues.

The Tapping Solution

The Tapping Solution is based on Emotional Freedom Technique (EFT), which combines elements of cognitive therapy, exposure techniques, and acupressure point stimulation. You tap your fingertips on specific meridian points on your face and upper body while focusing on negative emotions or issues, accompanied by verbal statements that acknowledge the problem and promote self-acceptance. The practice has been shown to reduce stress, lower cortisol, improve sleep, diminish anxiety, and relieve pain.

Limbic Retraining

Limbic retraining programs like the Dynamic Neural Retraining System (DNRS) and Gupta Program are self-directed, drug-free programs grounded in neuroplasticity science. They target overactive neural circuits in the brain responsible for chronic stress and threat responses, helping interrupt the cycle that keeps the nervous system in a persistent fight, flight, or freeze state. These programs are especially well-suited to conditions like chronic fatigue syndrome, fibromyalgia, multiple chemical sensitivity, long COVID, and POTS by retraining the limbic system to calm down and react less to triggers.

Safe and Sound Protocol (SSP)

The Safe and Sound Protocol is a non-invasive application of Dr. Stephen Porges' Polyvagal Theory designed to reduce stress and auditory sensitivity while enhancing social engagement and resilience. It uses specially filtered music that highlights specific sound frequencies to help regulate the autonomic nervous system and stimulate the vagus nerve. The five-hour intervention is commonly used by mental health professionals as an adjunct therapy to help patients regulate their nervous system and attain a grounded state where they feel safe and calm.

Deep Dive:

The Dangerous Certainty in Health Anxiety Treatment

A recent podcast addressed the topic of illness anxiety disorder in great detail, with Peter Attia, MD, interviewing Josh Spitalnick, a psychologist who specializes in OCD, health anxiety, and phobias (Attia, 2025).

The podcast opens with Spitalnick introducing the possibility that many patients have symptoms which are not explainable by the physicians they've seen, and that these symptoms may simply be manifestations of anxiety (Attia, 2025). He believes the techniques he's expert in can help relieve these symptoms.

But then Spitalnick describes his own wife's story—she had symptoms that couldn't be diagnosed by several different doctors and it finally turned out they were caused by a liver tumor that had to be resected (Attia, 2025). So he admits he understands that sometimes people's symptoms aren't health anxiety (also called "illness anxiety disorder"), but are in fact difficult-to-diagnose medical conditions.

The Historical Pattern of Dismissal

The history of not believing women is incredibly long. It started with Freud developing a theory that women's psychological development was shaped by a lifelong search for a substitute for the penis, which resulted in the condition of "hysteria," a "characteristically feminine" problem. 

Later, this situation where someone complains of something which no doctor can find a physical cause for was renamed "psychosomatic," and when that acquired a negative connotation, "embodied suffering." We now call it "functional neurological disorder (FND).” We keep changing the name, but the orientation is the same: treating physical symptoms as fundamentally mental, justifying addressing them only with therapy, including cognitive behavioral therapy and other approaches.

We know that our diagnostic tools are sometimes misleading. For example, advanced imaging techniques had to be invented before patients with multiple sclerosis were vindicated. We also have a serious problem of doctors (and other people) generally thinking they are supposed to tell people what to think and how to think—which is basically the definition of gaslighting. The history of FND in all its iterations is deeply intertwined with the gaslighting of women in the medical system—treating their symptoms as psychological, discounting their suffering, or shutting down advocacy for physiological explanations (Fobian & Elliott, 2019).

Many patients I've met over the years have completely lost their trust in doctors, have felt belittled, insulted, and generally made to feel unimportant, annoying, and stupid. This is the context in which we're having this discussion of “health anxiety.”

The Little Pinky Toe Problem

Josh Spitalnick goes on to explain that if you just think about something too much—for example, "your little pinky toe"—it starts to feel uncomfortable and you may think there's something wrong with it (Attia, 2025). He states that his techniques are so powerful that anyone who listens to him, watches his videos, and believes him, can be helped (Attia, 2025).

The evidence for psychological interventions is compelling. For example, clinical trials demonstrate that cognitive behavioral therapy (CBT) programs result in significant and sustained reductions in multiple sclerosis (MS)-related fatigue, with benefits lasting up to a year or more compared to standard care (Gay et al., 2024). CBT can also reduce physical pain, help manage chronic symptoms, and increase resiliency, regardless of the underlying neurological pathology (Anusuya and Gayatridevi, 2025). Most remarkably, CBT alone improves fatigue to a similar degree as the stimulant modafinil, suggesting it has a true and lasting impact on core physical symptoms of MS—not just mood or anxiety (Braley et al., 2024). Furthermore, combining CBT and modafinil does not result in further improvement in fatigue, suggesting they operate through similar channels (Braley et al., 2024).

The Misdiagnosis Reality

The concern, of course, is that one would waste time teaching and practicing CBT techniques and ignore a treatable medical condition. In long-term studies of patients diagnosed with FND, up to 4% within 5 years are found to have a diagnosis that would require a different intervention (Stone et al., 2005). However, the rate of misdiagnosis may have been up to 29% in the 1950s, and 17% in the 1960s (Stone et al., 2005). Though the 4% figure has been stable since the 1970s, one wonders if eventually even those might soon be found to have different conditions. The authors doubt that possibility, but that defies anyone's experience in medicine, especially if one's career spans almost 40 years as mine has. Chronic fatigue, fibromyalgia, interstitial cystitis, even irritable bowel syndrome were all thought to be entirely psychosomatic and now we have physiological correlates for them. We must be whittling away at the 4%.

Spitalnick, in fact, describes treating a woman with persistent symptoms—his treatment was a great success and her symptoms abated, but she was then diagnosed with thyroid cancer (Attia, 2025). He doesn't feel responsible for missing the thyroid cancer because he's not a physician, and she had a thyroid specialist (Attia, 2025).

Studies and patient surveys reveal that misdiagnosis and rediagnosis are common among patients with chronic, unexplained illnesses. For instance, almost half of Australian women with chronic disease reported their condition was rediagnosed at least once, and the 2012 US National Health Interview Survey estimated that fibromyalgia is misdiagnosed in about three quarters of respondents (Merone et al., 2022). For lupus, misdiagnosis or delayed diagnosis is the norm, with an average time to correct diagnosis often exceeding 6 years and nearly half of patients initially being misdiagnosed (Merone et al., 2022). In myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), misdiagnosis rates are reported to be high, with many patients being told their condition was psychological or "medically unexplained," only to later receive a specific diagnosis when science caught up (Malato et al., 2023).

Here's my concern: If you can convince someone that there's something wrong with their little pinky toe by telling them to think about it, unfortunately, you can also convince someone that there's nothing wrong with their little pinky toe when there actually is something wrong.

This parallels what happened with repressed memories, which over time turned out to be almost nonexistent. Most of the time, the problem came from therapists literally causing the person's mind to create memories that weren't real. Mind over "reality" is a real problem.

The Humility Imperative

We shouldn't be so sure of ourselves. We want to relieve suffering, but we don't want to mask or confuse people's understanding of their bodies and symptoms.

So this is what we know about health anxiety:

• Yes, some people are anxious about problems that are generally thought to be minor, but the question is whether anxiety causes symptoms

• No, you cannot tell whose symptoms are from a physical cause vs. whose symptoms would be too faint to notice if they were not anxious, not even after decades of practice

• More importantly, telling someone they are wrong to have an emotion such as worry is weird

• When your specialty is health anxiety, you have very powerful tools at your disposal that can inadvertently result in harm

• Patients should make sure their health care providers understand this

• Patients are vulnerable to being exploited by people who pretend they have a cure when they don’t believe there is really a problem

• And even vulnerable to unnecessary care by people who truly believe in the cure they recommend but actually are completely wrong

But let's not roll back the clock to a time when patients had little say in their diagnosis and treatment. We are in a new era—the internet (and some AI tools even more so) results in many informed patients, and doctors must partner with them.

People's problems benefit from a variety of approaches, many of which actually do not mean anything about the root cause(s).

People also benefit from understanding how their symptoms and situation came about, which is usually a combination of issues including psychosocial and purely physical factors, and the recognition that the way we see reality is translated by our brain into physical changes involving nerve cell communication, gut bacteria, immune cell function, fluctuations in hormone and other signaling molecules, epigenetic changes, and more.

REFERENCES

Attia, P. (Host). (2025, August 25). Understanding anxiety: defining, assessing, and treating health anxiety, OCD, and the spectrum of anxiety disorders [Audio podcast episode]. In The Peter Attia Drive. https://peterattiamd.com/joshspitalnick/

Anusuya, S.P. and Gayatridevi, S. (2025). Acceptance and commitment therapy and psychological well-being: A narrative review. Cureus.

Braley, T. J., Ehde, D. M., Alschuler, K. N., Little, R., Ng, Y. T., Zhai, Y., von Geldern, G., Chervin, R. D., Conroy, D., Valentine, T. R., Romeo, A. R., LaRocca, N., Hamade, M., Jordan, A., Singh, M., Segal, B. M., & Kratz, A. L. (2024). Comparative effectiveness of cognitive behavioural therapy, modafinil, and their combination for treating fatigue in multiple sclerosis (COMBO-MS): a randomised, statistician-blinded, parallel-arm trial. Lancet Neurology.

Fobian, A. D., & Elliott, L. (2019). A review of functional neurological symptom disorder etiology and the integrated etiological summary model. Journal of Psychiatry & Neuroscience.

Gay, M. C., Cassedanne, F., Barbot, F., Vaugier, I., Thomas, S., Manchon, E., Bensmail, D., Blanchere, M., & Heinzlef, O. (2024). Long-term effectiveness of a cognitive behavioural therapy (CBT) in the management of fatigue in patients with relapsing remitting multiple sclerosis (RRMS): a multicentre, randomised, open-label, controlled trial versus standard care. Journal of Neurology, Neurosurgery & Psychiatry.

Malato, J., Graça, L., & Sepúlveda, N. (2023). Impact of misdiagnosis in case-control studies of myalgic encephalomyelitis/chronic fatigue syndrome. Diagnostics, 13(3), 478.

Merone, L., Tsey, K., Russell, D., Daltry, A., & Nagle, C. (2022). Self-reported time to diagnosis and proportions of rediagnosis in female patients with chronic conditions in Australia: A cross-sectional survey. Women's Health Reports, 3(1), 895-904.

P, A. S., & S, G.

Stone, J., Smyth, R., Carson, A., Lewis, S., Prescott, R., Warlow, C., & Sharpe, M. (2005). Systematic review of misdiagnosis of conversion symptoms and "hysteria". BMJ, 331(7523), 989.