Everyday anxiety or anxiety disorder?

But they were wrong. Melissa fretted about her son, Cody (What if he lost the quarters she had given him to buy a snack? What if he went outside for recess without his jacket? What if he didn’t eat enough for lunch? What if he ate too much for lunch? What if he didn’t eat lunch at all?); her husband (What if he for­got to stop at the pharmacy and pick up his prescription? What if he had a car accident on the way to work? What if the pain in his back was something really serious?); her brother; her sister; and her parents (Did they remember what they were each supposed to bring to Christmas dinner? Would they allow enough time to get there in holiday traffic?); and the innumerable variables that con­stitute modern life (What if the airline canceled their flight and they missed her niece’s confirmation? What if the pediatrician had vaccinated Cody with expired chicken pox vaccine and it didn’t work — hadn’t she just read something about that in a magazine?).

As I listened to Melissa talk, I was struck by how much insight she had regarding the things that were making her anxious and how aware she was that 95 percent of her anxiety was, as she put it, totally, undeniably irrational.

“Over the last six years I’ve been to four hospital emergency rooms and every ‘-ologist’ you can think of,” she said. She had seen not one but two cardiologists because she needed a second opinion after the first one said her heart palpitations were most likely anxiety-related, and then she consulted a neurologist who confirmed what she secretly believed: that both her frequent headaches and her difficulty concentrating on even menial tasks were due not to neurological problems but rather to stress. Some months earlier she had made an appointment with a gastroen­terologist because a friend had been diagnosed with irritable bowel syndrome and Melissa thought perhaps she had it too since she had been having a lot of indigestion and upset stomachs (the doctor gave her some antacid samples, and, shortly afterward, the symptoms abated and had not returned). She had made an ap­pointment with an endocrinologist for the week after she first came to see me and was hoping he would diagnose her with hy­perthyroidism, which would at least explain her palpitations, skittishness, and fatigue.

Like many women with chronic, severe anxiety, Melissa had had the “million-dollar workup” and emerged with a clean bill of health among dozens of other bills. Ironically, during all the years of running from doctor to doctor she recalls only one who recom­mended she get psychiatric help, although after telling me this she backpedaled and admitted that others might have said the same thing, only she hadn’t been ready to hear it.

You’ve got to understand,” she said, “I’m not making this stuff up — the headaches are real; the palpitations are real; the breathlessness is real. It’s not just in my head.”

“Isn’t your head part of your body?” I asked.

Melissa and I discussed her symptoms, but before making a diagnosis and developing a treatment plan I needed more information: family history (“My mother and her mother were ‘total worriers’ ”); caffeine intake (three to four cups of coffee a day); alcohol use (“None —I  hate feeling out of control”); what types of situations made her tense, worried, or nervous (“Are you kidding? What doesn’t make me nervous?”). Had her career been affected by it? (“Oh, yes; I should have lost the ‘assistant’ part of my title over two years ago, but I’ve taken so much sick leave that I haven’t been promoted.”) How about her relationship with her husband and son?

Video   What makes women worry? April 20: TODAY hosts talk to Jerilyn Ross, author of “One Less Thing to Worry About,” about why women feel anxious and what they can do to ease their worries. Today show

“That’s probably what bothers me the most,” she said. “Dan is so kind and patient, yet I snap at him for the most insignificant things. I’m so on edge all the time that it takes very little for me to get irritated. The same thing with Cody. One minute I’m smothering him, telling him he can’t spend the night at a friend’s house because he sneezed twice three hours ago, and the next minute I’m yelling at him because he’s spending too much time alone playing video games. Let me tell you — I wouldn’t want me for a mother or wife.”

“How many days during the past six months would you say that you’ve experienced excessive anxiety and worry?” I asked.

“I would say ...” Melissa closed her eyes briefly before answering. “You know, I can’t remember a single day when I didn’t feel anxious.”

“Are there specific events or activities that are especially worrisome to you?” This unleashed a barrage of worries.

“I know Dan is faithful and I hate myself for thinking this, but sometimes when he comes home late I start wondering if maybe he’s having an affair.”

“What do you do when you have thoughts like that?”

“I’m embarrassed to admit this, but I call his cell phone and make up an excuse about why I’m calling. Then I start a conver­sation and try to find out exactly where he is.”

“And when he tells you he’s at the office, do you believe him?”

“Well, yes, but ... this is so stupid, but even though I know that he is where he says he is, sometimes I start getting heart pal­pitations and I get all sweaty and my mind starts racing and thinking that he’s not telling the truth.”

“What do you do about it?”

“This is so embarrassing. I don’t know if I can say it.”

“That’s fine; you don’t have to unless you want to.” She paused for a moment. Her face was flushed when she spoke again.

“Okay. Here goes. One time, I actually went online and looked up the extensions of everyone in Dan’s department. Then I started calling around until this woman picked up the phone and I made up a phony name and asked if Dan was there. So she’s like, ‘You’ve got the wrong extension, but he’s in his office so hold on and I’ll transfer you —’ and I hung up.

“And that’s not all. One time I actually drove by his office to see if his car was still there. I put Cody in the car and drove around the back of the building until I saw his car, and then I drove home. Now, I realize this is totally crazy. I  don’t believe for a minute that my husband would cheat on me. He’s never given me any reason to suspect he would do something like that. Intel­lectually, I know my anxiety is crazy. But I still can’t stop the neg­ative thoughts from creeping into my head and taking over my body.”

“Are there other things you worry about that you know aren’t really a danger to you?”

“Absolutely. I worry that we won’t be able to save enough money to send Cody to college. This is also crazy because Dan and I make decent salaries and we’ve already put quite a bit of money away for college. The other night I actually had what I think is a panic attack in the middle of the night. I’m lying there thinking, What if something happens to Dan or me and we can’t work any­more and we have to use Cody’s college fund to pay the mortgage? and on and on until I was a ball of sweat and had to get out of bed and walk around until I calmed down. And it’s not as if Cody is leaving for college any time soon; he’s only nine years old!”

Lack of sleep made Melissa exhausted all day, which then made her cranky and irritable all evening. When Dan recom­mended they go jogging together as an antianxiety activity, Melissa said she would give it a try. But their ?first time out she went a few blocks, became short of breath, and panicked, think­ing she was having a heart attack. She hadn’t put on her running shoes since.

Although Melissa felt beaten up by her anxiety, she was not clinically depressed. Sure, she said, there were times she felt she just couldn’t stand feeling this way, but she never felt hopeless or so down that she couldn’t function. I asked if she had ever had suicidal thoughts.

“No — never,” she said. “Why would I want to kill myself? It’s not that I don’t want to be alive; it’s just that it’s so hard. At times I look around me and think, I’m so much better off than most people: I have a good marriage, a wonderful kid, a nice house, and work I enjoy. So why does everyone else look so calm and re­laxed and I always feel like I’m about to disintegrate? You know, I’m so accustomed to feeling anxious that I can’t even imagine what it would be like not to feel that way and to not always be worried about being worried.”

It didn’t take long for me to diagnose Melissa with general­ized anxiety disorder (GAD). Unlike the everyday, normal anxi­ety we all feel from time to time, the physical and psychological symptoms associated with GAD are often so intense that they stop people from doing the very things they want and often love to do. In Melissa’s case, her inability to concentrate, frequent headaches, and insomnia- related fatigue were interfering with her ability to keep up with the demands of her job and get pro­moted to a better one. That’s what had finally driven her into my office (along with an event I’ll describe later). She knew that her relentless anxiety and anxiety-related symptoms were different from those that many women feel while trying to juggle mother­hood and career; she actually felt she had those areas well under control. I trusted Melissa when she described how helpful her husband was with their son; how well adjusted, mature, and in­dependent Cody was; and how tolerant her boss was when she took time off for doctor visits or because she was too exhausted to work. Melissa’s anxiety was not, as far as I could see, related to her lifestyle. She clearly had an anxiety disorder: GAD.

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