Speaking of Psychology - How to handle health anxiety, with Karen Lynn Cassiday, PhD

Episode Date: August 28, 2024

For those with health anxiety, worrying about sickness can be a constant struggle that can harm their mental health, relationships and even physical health. Karen Lynn Cassiday, PhD, author of the book “Freedom from Health Anxiety,” talks about how to recognize health anxiety (once known as hypochondria), why the internet and “Dr. Google” can make health anxiety worse, and what to do if you or someone you love struggles with health anxiety. Learn more about your ad choices. Visit megaphone.fm/adchoices

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Now, Hank has a line out the door. Hank makes the pizza. Co-Pilot handles the spreadsheets. Learn more at M365Copilot.com slash work. Illness is a part of life. But for people with health anxiety, worrying about sickness can become a constant struggle that can harm their mental health, their relationships, and even their physical health. Today we're going to talk to an expert in anxiety disorders about where health anxiety comes

from, how to know whether your worries about illness are actually health anxiety, and what you can do if you or someone close to you is struggling with it. So how common is health anxiety? What's the difference between health anxiety and just being careful about your health? Did the pandemic cause an uptick in health anxiety or exacerbated in people who are prone to it? What about the internet and Dr. Google? And what are the most effective research-backed treatments we have for health anxiety? Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association that examines the links between psychological science and everyday life. I'm Kim Mills. My guest today is Dr. Karen Lynn Cassidy,

the owner and clinical director of the Anxiety Treatment Center of Greater Chicago. She's a former president of the Anxiety and Depression Association of America and a nationally recognized expert in diagnosing and treating anxiety disorders in children, teens, and adults. Her 2022 book, Freedom from Health Anxiety, understand and overcome obsessive worry about your health, or someone else's and find peace of mind, offers readers practical advice for overcoming health anxiety. Dr. Cassidy has spoken widely to the media on anxiety disorders, including through the New York Times, the Wall Street Journal, The Chicago Tribune, and The Today Show. Thank you for joining me, Dr. Cassidy.

Kim, thank you so much. I'm glad to be here. Let's start with a basic question. What exactly is health anxiety? Is it a separate and formal diagnosis in the DSM or any other diagnostic manual? Well, the good news is it actually has its own category called illness anxiety disorder. And that's in the DSM. And prior to that time, it was one of those orphans where clinicians would see it. We'd wonder, is it OCD? Is it just a warrior who's stuck on illness?

Is it somebody, you know, a hypochondriac? And research has shown this is actually a distinct disorder. And that's very helpful because it means now that medical providers can more accurately understand what happens when someone's worry is making them seek excessive treatment or reassurance or avoid them. It means that we have good research about how to work with it, as opposed to just thinking of it, oh, that's those chronic warriors or those people who just want attention from medical people. So are there specific characteristics that you have to have in

order to meet the diagnosis and what are those? Yes. And so here's the interesting thing. You have to actually have some kind of physical symptom. The dilemma is that many people think, including medical doctors, that this is something you make up or manufacture. But we see it always starts with someone noticing something and it could be their stomach doesn't feel right. their stool looks different, they're dizzy, they see a rash. And then what happens next is the person gets excessive, uncontrolled worry and they start believing it could be a sign of something serious. And serious usually means either something that could kill you or something that could

disable you. And it has to last. So this isn't just something that haps for a week or two. It's got to go on for, you know, six months. And most people I work with, it started in childhood, that they can remember when they were a kid, when they were in health class, someone talked about heart attacks, and then they're worrying, they're having a heart attack, and they're only in fifth grade. Or they're in college, and they're thinking, you know, they have some, you know, multiple sclerosis,

you know, because they were hung over and they were dizzy, and they, you know, weren't sure if that was a serious change. So that's what we see is the uncontrolled worry. It's focused on illness. It's been going on and they can't get rid of it. And then the other thing we see is the person then reacts to that worry with either reassurance seeking. And this is where Dr. Google comes in or having, you know, a long-term relationship with WebMD or constantly talking to others to see, oh my gosh, you know, have you ever had this?

you okay? Was it something serious? Reading obituaries to see have other people my age died from that? You know, is it more likely I have that? Or avoidance. And we have people where they're afraid to see the doctor because they're convinced they're going to get the horrible news this time. And sadly, they forego necessary and helpful health care. Now, it used to be called just hypochondria or hypocondriasis. Why was the name changed? Well, for very good reason, that name had a lot of connections to, I'm going to say, old school Freudian psychology. And the implication was there was a subconscious reason that you wanted to be sick, that it was somehow a, you know, diversion of your need for attachment or

your need for relationships onto medical personnel or medical situations. And so when they were coming up with a name, they really wanted to make people understand this is an anxiety disorder. And one of the unique things about all anxiety disorders is in order to have them, you could be anyone. You could have any kind of wonderful coping or very poor coping. And in fact, what you really need to get an anxiety disorder is a genetic pre-loaning. And then a background where people are showing you it's bad to be scared and you better seek reinsurance or check or get help or avoid. And then you have those things mixed together, then we end up with anxiety disorders and also illness anxiety disorder.

And what's so interesting is I've yet to meet a patient who has illness anxiety disorder who doesn't know someone in their family who was always going to die. And one patient told me, oh, my God, I didn't know there's a thing. You know, my mom, she was always, you know, going to die. She knew it. She would be saying novenas. She would be doing all these special things. And then she'd get past it.

And then it would be another thing. And so we see, that's probably that learning component where you see someone showing you how you should handle information about illness anxiety. There's one other important point about illness anxiety where we see this group of people with anxiety disorders is different from other anxiety disorders. And that is they view illness and death and dying as being unusually tragic. And so instead of seeing the process of aging or getting sick or having things happen to people's health as I'm going to say a normal part of life or a challenging part of life, they view it as especially terrible and awful and tragic. And then we think that also sort of predisposes them

to overreact to the idea of having a serious illness. Now, you mentioned that there might have been a family member who was always worried about being sick and dying. Does that indicate that there is some kind of a genetic component or is it just something that you learned by example? Actually, if we were to look at people with anxiety disorders, 70 to 80 percent of them, including illness anxiety disorder, have a first-degree relative who might have an anxiety disorder or a mood disorder. And then we also see about 70 to 80 percent of them have a second or a third or a fourth anxiety disorder.

So we see they're inherited in clusters. And so the typical course is most of my patients I see for illness anxiety disorder, have it other times met criteria for panic disorder or OCD or a specific phobia or social anxiety disorder. And so what you inherit is the tendency to get anxiety disorders in general. And then we believe that life circumstances or accidental role modeling, you know, someone who also has that anxiety makes it happen. And one thing I forgot to mention is you can have illness anxiety disorder about someone you love. Okay. So some of you can remember your mother constantly checking you for fever

and not letting you play if you had any sign of anything and taking you to the pediatrician way more than you realized other children were going. I'm going to put my money on a possible diagnosis of health anxiety there. Well, how common is actual illness anxiety disorder? That's an interesting question. If we look at the most recent studies, we're looking at anywhere from 3 to 4.5% or 5%. However, because this diagnosis is relatively new and isn't often included in these large population surveys, we're not exactly sure. And one of the things that many clinicians who work with anxiety disorder see is, it's kind of like now that we have a diagnosis, all of a sudden, the rates are going up. And we think that's because many of these people

were included in other categories like OCD or panic disorder or generalized anxiety disorder. So some people are estimating it could be double that amount. We just don't know for sure. And I'm hoping, you know, probably in the next 10 years or so, we'll have a much better picture. And then the other dilemma is you mentioned the pandemic. And one of the things that is certainly true is when there are large-scale news stories about, I'm going to say, frightening health things, such as Ebola or when the coronavirus first came out, we see that the rates go up. And we think that's people who are vulnerable. they hadn't yet been triggered. And then they're getting constant uncertainty. And we see that uncertainty is the thing that people with illness, anxiety, have trouble with because they detect a real symptom.

But it's almost never actually a serious symptom. And it's the kind of symptom that other people would probably sit on and say, I'll wait a few weeks before I get worried about this rash. Or, okay, you know, I was partying hard the last couple of nights. maybe I won't worry about this dizziness that I have. It's possibly a hangover. So they pull the trigger fast getting that. And so we did see during the pandemic way, way more calls and people worried about it.

The other thing we saw during the pandemic is that anxiety disorders in general are going up, especially for people age 35 and younger. and we see that this population appears to be uniquely vulnerable. We think some of it may be because of the culture of parenting we've had the last 30 years that has de-emphasized risk-taking, tolerance of uncertainty, and de-emphasized trusting your own judgment. And so when you don't trust your own judgment, then you always think, I've got to have an expert like a doctor or a nurse help out.

You know, another dilemma that goes with the pandemic and with media is, you know, once you look something up, then the AI system in your computer and on the internet is going to feed you that like a fire hose. And then the more that happens, the more you get. And then that gives people the misperception, you know, oh my God, this is terrible. So you might have recently seen there was a big article about microplastics and how they're everywhere. And I can't remember was it at the Atlantic, the New York Times or the Wall Street. It's one of those prestigious publications that people

go, they're credible. Well, then of course what happened to many of my patients, they saw that. So all of a sudden they had all these people terrified that they were going to get all kinds of cancers and heart disease due to microplastic pollution and trying to figure out how could you eliminate it from your life and just going nuts over it. And it was an artifact of the way we receive information. And then also, you've got to remember, if you are a news outlet and you want someone to pay attention, something that scares people or is gruesome gets their attention better and it's more likely gets them to click on it or to look longer than something neutral. And I kind of think of it this way.

You know, when the pandemic started, you had the National Public Radio headline. Unusual virus outbreak in city in China, scientists investigating. And then you had, you know, the ABC one, which was dangerous virus, you know, getting loose in China might infect millions. And then you had the Fox News headline of millions could die because of terrible virus. And I literally saw these headlines all in one day. And this is before we even realized there was going to be a pandemic. And, you know, if you are someone that has the tendency for an anxiety disorder, then your brain can do something special that's kind of inconvenient. it can do single trial learning or it can have one exposure to something that's scary,

one trigger, and then it gets set in, where people that didn't inherit that might take quite a few more exposure to something before they start getting scared and worried and their body reacts. And, you know, so when those things all work together, it's really tough if you are one of those people that gets worried about serious illness. It's kind of like you have to learn to cultivate what your news environment is going to be, what your social media is going to be, as well as doing the things that would help you get better. Have you ever rearranged your furniture and discovered the carpet underneath looks brand new while the rest of it looks, well, not so new? It's time for a carpet upgrade. At the Home Depot, we have stylish choices at simple prices from

all the top brands. Best of all, we can install it for you, starting at only 49 cents per square foot. So all you have to do is pick your perfect floor. Start your carpet project today at the Home Depot. How doers get more done. Exclusions apply for licenses, see Home Depot.com slash license numbers. Now, we talked a moment ago about Dr. Google, and I'm just wondering about the advent of the internet and how that may have affected the prevalence of health anxiety.

I mean, back in the old days, if you wanted to know about illness, you had to go to the library and go get a Merck manual and look things up. But now, yeah, you remember that, right? But now... Yeah, you had to find a medical library even. You couldn't even go to the public library. You had to find the nearest medical school. And now it's everywhere, but a lot of the information is not great.

So what's happening as a result of everybody being out there able to diagnose themselves for a person who doesn't have illness, anxiety? It's pretty terrible. but somebody who actually has it, it just must be magnified a thousand times. It is. I think of the internet like crack cocaine for people that have illness anxiety disorder. It is, it's so hard to manage that. And I can't tell you how many patients I have where they have all these quick tabs for various

medical sites. They're on Reddit. They're on various social media. They're photographing pictures of symptoms or them and the way they walk to see if anybody thinks it looks weird. And I believe, and many of the experts in the field believe this has, I'm going to say, help lower the threshold for people who are at risk for getting it. And it's definitely increased the problem for people and made it, I'm going to say it's, well, it's the same problem we have with fentanyl in the substance use world, is that we have drugs out there where you can get addicted fast and they're terrible. The internet is like that for people that worry about their health. And then the other thing, I think that's so difficult, and I have to say all of you who are listening,

I am so proud of you for being smart and coming to a site that vets its information and has very high quality standards for how information gets conveyed to the public, there are a million and one people who claim to be an expert or who claim to have published something. And if you follow it through, you find that's not true or it was a self-published thing as opposed to peer reviewed, which means experts decided it was worthy. And that is, I'd have to say with every single patient I have, unless it's someone who for some reason is not using the internet, that is their greatest struggle. It's the internet. It's easier to manage all the other things.

The internet is the big, big addiction. But what about doctor shopping? I mean, is there some responsibility on the part of the medical establishment where they keep seeing these people who over and over and over again, you know, I need to have another mammogram? I just had one last month, but I felt a lump yesterday. Well, you're bringing up a very interesting problem. This is where I'm going to say capitalism and the anxiety threshold of the medical provider and the patient can all interact in a bad way.

So some clinics and establishments are happy to keep doing more and more procedures because they make money. that the most profit-worthy things in a hospital system or a clinic are going to be procedures and labs. And so we see pressure on doctors. I have friends who are physicians and nurses, and depending on the system there, and there's pressure to use those procedures codes and to order them. It helps them stay profitable or to get paid. Then we have another problem, which is what happens if you run into a provider who's always worried about making a mistake. And providers can have illness anxiety disorder. And they can have generalized anxiety disorder where they're worriers.

And I've talked to many people who are saying, well, I got worried, you know, what if this time? Because the patient is saying, well, maybe I've been okay. I've made it this far. But this time it feels different. Doctor, my stomach is different. I really think it's colon cancer. And then if that physician can't or nurse can't,

stay grounded in their standards for what they use for anyone, then they start getting swayed to give in. And then we have the people who believe their kind. And you have to remember, the average medical provider has had three months, if at all, of training in a psychiatric unit unless they're a psychiatrist. And so they don't know how to diagnose an anxiety disorder. They haven't been given any training. It's not considered part of their purview. And many providers think, well, you know, okay, if we just do this MRI, then they won't worry about brain cancer. If we just do this mammogram, you know, we'll just make them feel better. If we just do this lab or do another one, then that, they do that. And when you have those three different phenomena

not happening, it makes the person who's suffering worse because it plays into their anxiety and they can never discover, I can tolerate the uncertainty. I can trust my own judgment that nothing bad is happening and I don't need to get reassurance or be scared or think that the odds have changed for me. You know, another dilemma that I see for patients is the medical record where you can go on and you can see your lab results before the doctor ever gets to review them or the radiologist. And this is a new pain point for many, many people where I have patients where part of our treatment is you can never look at that until a trained person observes it and interprets it to you. Why?

Because there's a wide range of normal. And just because your result is not perfectly in the green zone because my, you know, my chart, whatever, it has green, yellow, red. And for all my patients, they feel like, you know, it's trying to get an A plus on a test. I want everything to be in the green zone. And they don't understand. Most people aren't always in the green. There's some yellows in there, and that's normal.

And so that's another area where this attempt to be, you know, have all this technology is backfiring for this particular group of people. So you just mentioned one technique to help people. people who have this anxiety. How do you treat it? How do you get people to come off the ledge and stop worrying about their health day in and day out? The great news is we've got a lot of research and it shows us several things that are very helpful. So the first one is if you've never had any treatment before, the best thing you can do is to find someone who does cognitive behavioral therapy that focuses on exposure to the things you're scared of and the situations you're scared of. And what that means is learning to have a symptom without immediately going to Dr. Google or

WebMD, without talking to someone to find out if it's normal or if others have it, without reading stories or doing research, and to learn that your anxiety is going to go down. Another component it is to do a special kind of worry exposure practice where you imagine yourself to have the terrible thing that you're scared of. And the reason this works is that for people who worry about that, they think of it in sort of scary little spurt, but they never process it fully and they never get used to it. And it's kind of like if you ever saw an old scary movie, you know, when you were a kid and then ran out of the room and then never saw it again. You got more and more scared. But then probably when you're older, you went back and you watched it and you're like, what was I so scared of? Oh my gosh,

that wasn't that bad. Well, we do the same thing where you create a movie in your mind about your scary story and you listen to it over and over. And what happens is your body gets used to it. Your mind starts to realize this is just a scary idea. It's not reality. It's not happening me now, and you can respond appropriately. And then the cognitive therapy, where we can use inference-based cognitive therapy, regular cognitive therapy, acceptance and commitment therapy, all focuses on the same thing, which is learning. I don't have to believe the scary signal I get every time I think about serious illness or

I accidentally imagine I might have the beginning symptoms of it. And I can teach my body to relax, to tone down, and I can get through the moment, and then it keeps getting easier and easier and easier. And that's the beauty of that exposure-based therapy. And then the other thing that we see is helpful is if you have the misfortune of being, from having a lot of relatives and ancestors who had anxiety, or you have other anxiety disorders that are very difficult, then medication might be very helpful. And when medication works, what it does is people say, I feel normal. The thoughts don't get stuck the way they used to. My body doesn't get over-accelerated

the way I used to. And we see that it just sort of slows down the process in your body and your mind so that you have a fighting chance to think healthy thoughts and to respond appropriately. And so I want to let people know, you know, my standard is if after two months we aren't seeing some visible progress, then we think about possibly adding medication, you know, because we don't want someone to suffer because we see these cognitive behavioral therapies are very effective and can work quite rapidly when we get you to do it. And then the other thing you got to do is there's a response prevention component. And that's where you realize I have to give up all these things that I do for a quick fix of

reassurance. So I can't research anymore. And so we try to cut that back or cut it out altogether. I may have to tell my doctor or my nurse practitioner, I have illness anxiety. And when I start to repeat the same questions, could you please just remind me I'm getting anxious and say you can't talk about it anymore. I even have a script in my book that you can hand to your doctors so they know a kind way to talk to you because most physicians and nurses want to be nice. They don't want to hurt you. They just don't know how to talk to someone who's anxious. And they don't realize saying don't worry isn't effective. And then it means also that you need to give up checking your body. So you might want to use one of those, a washcloth when you're washing yourself so you're not

feeling for lumps or bumps or rashes. You might want to, you know, put a poster over the bottom of your mirror. If there's a part of your body, you keep checking to see if something changed and there's cancer growing. And then you might need to tell your partner or your anxious support system, we can't talk about illness anymore. And what I'd love for you to tell me when you see that I'm worrying. And usually your support system knows exactly when you're doing it to just say, it looks like

you're anxious. What are other things you can do that are helpful? And that would be the very best way to support someone. And then the other thing you may have to do, if you're one of those people that worries about other people, you're going to have to accept that you need to retire from practicing medicine without a license. And you need to realize that there's a reason they tell physicians and nurses don't treat your own family.

It's because you can't really be objective because you care too much and emotion can cloud your judgment. And so you may need to look at this and say, I'm not a good person to keep checking them. I need to let my partner or the other parent check this child. I need to let my parents take care of their own health thank you or my siblings, my partner, and realize that whoever their health care provider is, they have a vested interest in their good health. They aren't sloppy.

They just aren't worrying. And one of the mistaken beliefs that any good warrior has is that when I worry, I'm being responsible. I'm being caring. I'm showing love to my health, to other people's health. when I look at them, when I ask these questions, when I do all this deep research. And my advice to anyone is the only time you're permitted to do any medical research is when you've actually been diagnosed with that problem.

Otherwise, you have no business doing that. And also, I'd like to mention to people that this is a case where if you have medical knowledge and I realize this audience probably has a larger than normal base of knowledge about medical and mental health things, you need to accept you're still not the one to diagnose yourself or someone else. Leave it to the experts and realize getting into that assumption thing is just going to promote worry. How common is it for somebody who has a health anxiety disorder to actually transfer it to say, their children. I mean, you mentioned, you know, the mom who might be checking, taking the kid to the

pediatrician too often. Does that happen a lot? And that's a very common aspect of this disorder? It is. I'm not aware of statistics I can tell you, but I can say in my 30 plus years of working with patients, I'm going to say 80% of the time there is a parent or a grandparent. And it could be either one, into male or female, who is role modeling that and doing a lot of checking. And this is just the way they grew up. And it's very interesting. We have a lot of patience that their idea, you know, when I say we're going to stop doing this, their first reaction is, that's dangerous. How could I stop looking at this or reading about it or not consulting about it or not monitoring it? And the reason they're saying that is because they've never sent

seen people not do that. And they're considering the rest of the world to be very sloppy with their health care. And as opposed to realizing that a certain amount of benign neglect is good for peace of mind and good to give you time to do other more productive things. But what about the line between this, what we're talking about, and factitious disorder, which we have talked about on speaking of psychology, where that's where the parent is, not only taking the child to the doctor a lot, but is actually doing things to make the child ill. Yes. Yes, this is very different from factitious disorder. And in fact, Kim, I'm so glad you mentioned that because sometimes people assume this must be that when they have an anxious parent. And I can give

you an example where I got a call from a pediatrician thinking this mother was doing that because every time her son got a fever, he was four. She would bring him into the ER and he'd have ice packs under each armpit and a neck ice pack. And she would be so terrified that he was going to have febrile seizures. He'd never had them. But this was a worry of hers that he would get febrile seizures and then become cognitively impaired. Why? Because she had had a cousin who had that happen at a young age, got, I think it was Rubella or German measles, something like that, got extremely ill and became, you know, extremely cognitively impaired. Well, there's a really easy way to tell, okay, if you're thinking about yourself or someone else. The first thing is, when we see

factitious disorder, the reactions of the parent are different than that of an anxious person. So we see they may show concern. They may have a lot of medical knowledge or information about the disorder, you know, or the things they're worried about. But we also have a child who is sick. Something's bad is happening to that child, where in this case, normally we would have a child or a spouse who's perfectly healthy. They just have something that's benign.

That's one. And then also what we see is an anxious person cannot be reassured or consoled and that the reassurance is very short-lived where we see with factitious disorder as soon as there's this medical interaction, then that person is showing signs of, I'm going to say the parent I'm speaking about is basically showing satisfaction. You know, you're interacting with me and my child and they're seeming to be very cooperative. The other thing, you know, that we see is they don't express anxiety to the same degree and they aren't expressing this sort of terror of something terrible in the same way. And, you know,

I want you to think of it like this where if you've ever been anxious, you know, that feeling like you're being held under the pool too long, a car's about to hit you. Uh, you. Uh, or if you yourself have ever had a worry, what if this time it's cancer? Think of how you come across your actions, you're sweating, your heart rate, you're shaking, things like that. We don't see those same symptoms coming across the same way with factitious disorder. And that's one thing that tips off clinicians who are good observers is we don't see that consistent.

This is in response to anxiety in the parent. and to a symptom that is benign, as opposed to factitious disorder, we see the things they're doing to this person are dangerous and life-threatening, even, in many instances. Well, last question, any final words of wisdom to our audience, whether they themselves are anxious or they know somebody who has health anxiety? Well, the first thing I'd want to tell them is you don't have to continue with this, because many people I see come in telling me, I've never talked about this. My friends think I'm a worrywart.

You probably can't do anything. And I think that's because it just hasn't been highlighted in the media as a disorder, as a solvable problem. So there is so much you can do treatments work well. The other thing I would want to tell you is a little bit of Buddhist, mindset is very helpful for that tragic kind of thinking. And one thing that we don't talk about a lot in Western culture is that we are going to die and we're frail and we're going to get sick and that dying and suffering are a normal part of our life and getting ill or having different

things happen that affect our health is normal. And we want to learn to accept that. And for most of us it takes a lifetime to truly accept it. So by the time that we face our death, we feel peaceful about it. But it's worth thinking about and realizing we all have to get sick. We all have to age and we all have to die. And we can think about it in a peaceful accepting. It must be possible because all of humanity has done this for all time versus that anxious way of imagining it to be something much worse than it is. And one of the best ways you can get in touch with this is if you've ever watched videos of people who are terminally ill or talked with them, I worked on an oncology unit a long time ago. I was expecting everybody to be all depressed and mournful. And they basically

told me, honey, we aren't talking about death. We aren't talking about dying. We want to have fun. We're planning a picnic. And we planned fun things. This was a bunch of vets in Mississippi. And they had it right. They realized the very best antidote to death and dying is living a productive, meaningful life now, no matter what your circumstances are. And so I'd say, I want you to think about that and realize that's a skill we can all learn. It doesn't take anything special to be able to do that.

Well, that's great advice. I want to thank you, Dr. Cassidy, for joining me today. This has been very enlightening. Thank you so much, Kim. This has been a joy. You can find previous episodes of Speaking of Psychology on our website at www. www. speakingof psychology.org or on Apple, Spotify, YouTube, or wherever you get your podcasts. If you have comments or ideas for future podcasts, you can email us at speaking of psychology at APA.org. Speaking of psychology is produced by Lee Winerman. Thank you for listening.

For the American Psychological Association, I'm Kim Mills. Enjoy more ways to save at Ralph's, like low prices in every aisle. And when you download the Ralph's app, you can clip and save more with digital coupons every week. Plus, you can earn fuel points to save up to $1 per gallon at the pump. At Ralph's, you can enjoy more ways to save and more rewards every time you shop. so it's always easy to save big every day with savings and rewards. Ralph's SoCal for over 150 years. Savings may vary by state.

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