GAD-ing

My instinct is to make a joke about how this will not be about Gilderoy Lockheart's best-seller Gadding with Ghouls, but I realize not everyone would get this obscure harry potter reference so. . .

The DSM-5 defines Generalized Anxiety Disorder as :

1. Excessive worry about a variety of events for at least 6 months
2. Worry that difficult to control
3. The worry is associated with at least three of these symptoms: restlessness, easy fatigue, difficultly concentrating, irritability, muscle tension, or sleep disturbance.  (only one symptom needed for kids)
4. The anxiety causes significant distres or impairment in functioning socially or with work
5. You can not attribute the worry to the effects to a medical condition (like hyperthyroid) or drugs (Cocaine)

I've had GAD since I was about 5 or 6 yrs old.  I remember staying in the bath tub until the water was cold and I was shivering because I was afraid that ALF - yes that ALF - was going to eat me.  I loved muppets but for some reason Alf always wanting to eat the cat made me worried that he would one day turn his taste to children.  My older siblings would chase me around the house saying "Pac-Man" making alligator type arms to demonstrate how large Pac-man would be if he was out of the screen, and how he would probably eat me if he could.  

Between the ages of 7-9, I started realizing how scary the world was.  I realized that at anytime I could die.  I had a lot of deaths in my early life; so I thought about it quite a bit.  I would worry every day my father drove me to school that we would get into an accident and die. I worried when I was carrying scissors from room to another that I would trip and they would go into my eye and I would die.  I worried that The sharp edge of the TV tray that was often up in the family room would be sharp enough that I could fall and it would impale me.  I worried walking home from school to my grandmother's house that I could be hit by a car or abducted.  Those were the big fears.  There were always the smaller fears of failing a test, disappointing my parents or family, or generally not doing something correctly.  

Some of this can be explained by being born into my  amazing family. Three generations of Graduate school graduates (on both sides) and over a dozen Doctors (MD &PHD) is a lot to live up to.  The fact that my elementary school was in inner city Cincinnati in Walnut Hills, which used to be an upperclass black neighborhood and in the 80's had seen better days, could account for some of my neighborhood fears.  Even a  8-year-old knows car accidents are common.   However all of these factors don't explain why these thoughts kept me up at night and a fairly stressed child.  It also lead to a slight break down in 7th grade.  

For each class, in 7th grade, I would change my attitude and personality to be what I thought the other students and teacher expected of me.  The only ones which were similar were Latin and English.  All of the changing and trying to live up to expectations took its toll.  Around the end of first quarter I had a breakdown while working with my best friend Anjali on a Latin project in the library after school one day.  I don't remember what quite set it off; it may have been a minor argument.  I do remember putting a book on the shelf, saying good bye, walking down a hall, riding the bus home, and being in my basement.  I have no memory of anything in-between, but I have a clear feeling of being outside of my body.  That disassociation was way more scary than disappointing some teachers or classmates.  After a few hours of crying in my basement and another month of school I was finally myself for all classes. 

My coping mechanism, that I figured out around age 10, was to figure out what the worse case scenario  for each situation and prepare myself for it.  As long as I was prepared for the worse then I could deal with everything else.  What if I'm a disappointment and dishonor my family?  Just work harder and do something original (like going to peace corps) so they have to keep you.  What if I don't pass my medical boards?  Study harder, take some time off and do them again in 3 months.  Make sure I have money saved or work arrangements so I can support myself.  But this drives me to study harder now.  What if I get pregnant but there is a chromosomal anomaly like Trisomy 21, 18, or 13 where my child could not have a complete life?  We get genetic testing at 10 weeks so if I have to terminate it will be early and do all of the other things I can possibly do to have a healthy pregnancy.  This has led me to saying things to my husband such as "So if you are going to leave me, please do it now so I can recover enough for: medical boards, residency interviews, Medicine Senior rotation, etc."

The other part of my early coping mechanism was likelihood.  I could be impaled by the corner of the TV tray, but how likely is it?     My computer could explode sending shards of glass into my heart and causing me to bleed out right now.  However, it is not likely.  I could be sued tomorrow for a mistake I made medically as a first year resident, causing me to never be able to practice medicine again and the government take all of my belongings because I owe over 300,000$ for my education, and have to live on the streets.  But it is not likely. . . I hope.   As a scientist this plays well into my desire for data and evidence.   Having the numbers helps put my fears in their places. 

Not all anxiety is bad.  Because I grew up when HIV was being discovered I was extremely careful about washing my hands, checking for rogue syringes everywhere (including under movie theater seats),  and delayed intercourse until well into my 20's.  My highly educated family instilled a drive to uphold the name.  I traveled the world, have multiple graduate degrees and even an extra fellowship on top of my residency.  I had the wonderful honor of being hooded by my big sister the  orthopedic surgeon at my medical school graduation.  The continued desire for data and to do the right thing keeps my medicine evidence based and documenting as much as I can for my patients.  Even though there are multiple times I wish I could be lazier. 

The down side are things out of my control or that I can't prepare for.  Hospital credentialing and trying to find someone to notarize one of the forms literally left me shaking in my front room and crying at an insurance office.  My schedule changing frequently - which it did in residency and now in an area of physician shortage - causes insomnia, tension to migraine headaches, and trying not to fall apart in the hospitalist dictation room.  Oh and panic attacks are a major down side.  Panic attacks are full on activation of your sympathetic nervous system i. e. the "Fight, Flight or Freeze" system.   When I found out that I did worse on my MCAT than I did on my first practice test, I ran to the highest stair well, took about 30 minutes to stop hyperventilating  (okay it was probably more like 10 minutes but it felt like 30), and called my best friend 14 times zones away at 3am.  Panic attacks literally make you feel like you are going to explode and implode at the same time.  I'm fortunate that for my last one I could walk myself through the sympathetic nervous system and talk myself out of it.  Panic attacks are terrible.  

Over the years I have picked up more coping strategies: yoga, deep breathing, exercise, and open honest communication.   I had counseling in public health school, medical school and residency which was extremely helpful each time.  My counselor in residency convinced me to actually try medication; Celexa was amazing.  Just 10mg helped make everything a little bit easier.  As soon as the whole TTC adventure is completed - either with a small person or an IUD and a dog - I am planning on restarting Celexa.

The thing about GAD is that so many people have it, but like all mental health problems it is stigmatized.  Society doesn't look favorably on people who are "nervous," need counselors, or have had breakdowns.  Anxious kids are often either seen as "sensitive" if they cause an outburst or ignored if they are not causing problems.  GAD is a chronic disease.  I know it's not going away.  GAD has been with me my entire life and will be there until the end.

Thankfully my laptop did not explode while making this blog . . . yet.