Confessions of a Digital Diagnosis Success Story
I was an anxious kid.
I don’t mean that I was sometimes upset when my parents left me at daycare, or that I was scared of haunted houses at Halloween (although both of those things are definitely accurate). I mean that I was, to my core, terrified all the time— of what, I couldn’t tell you, but fear followed me like it was a costume cape I’d accidentally double-knotted around my neck, impossible to remove, but somehow my fault.
Let me offer some examples. I would plan to wake up exceedingly early every day in elementary school, and if I accidentally overslept, even on a weekend, the disruption to my schedule would send me into a tantrum spiral that my parents, despite their best efforts, could do nothing to stop except to let me tire myself out. None of their reassurances that me sleeping through my alarm by 20 minutes actually had no effect on my day had any impact once the train had left the station. I was convinced that, by disrupting the schedule I had arbitrarily set for myself, I had ruined my day irreparably. When my dad would travel internationally for his job, which happened a lot during my middle and high school years, I adopted almost compulsive superstitions to push away the fear of what I was sure was his inevitable demise in a fiery plane crash that was just one missed bedtime ritual away. I would stare, unblinking, at clocks until they showed numbers that felt “lucky” to me. Some kids said prayers at bedtime because their parents made them to, or because of a genuine interest in building a fledgling relationship with their deity — I prayed to God specifically to keep my family and friends safe, and to ward off anything bad that might happen. I was convinced that if I forgot to say my prayers in the right order, every night, bad things would happen, and I would be responsible for them. I constantly carried around a collection of worry stones, stuffed animals, and other good luck charms to get out ahead of the curses I was sure were lurking just around the corner.
For most of my childhood and adolescence, I kept this anxiety tinged with hints of obsessive-compulsive tendencies shockingly well-hidden. I was a precocious child, picking up books like Harry Potter and The Chronicles of Narnia and teaching myself to read them at the age of five, an age that was sufficiently impressive to garner praise from the adults around me, but not so early as to have anyone check in on my other faculties. As an only child, I lived largely in my own head, which gave me as many wonderful lucid dreams as it gave me nightmares. I cultivated a rich inner world, fostered by parents and teachers who supported my creativity and encouraged me to explore it. My anxieties generally weren’t social, at least when it came to performing, so I could be paraded out in front of groups of adults who would applaud politely when I would parrot some fact I’d learned in a book or show a drawing I had made, affirming that I was indeed an old soul. I preened under the positive attention, and quickly learned that adults liked me as the clever, well-spoken gifted kid, but that the side of me that devolved into uncontrollable sobs when my routine was disrupted was less desirable.
I don’t say this to make myself seem like some superprodigy. I was no more gifted than your average gifted kid — now, in my last year of medical school, academia has more than caught up with me. I didn’t skip any grades or file any patents or show any talents that were above and beyond those developed by a child left unsupervised with books and the arts for most of their formative years. I was just a smart child. A smart, anxious child.
When you’re driven and you’re anxious, you can combine those two things until a great deal of your drive is fundamentally rooted in your anxiety. That was exactly what I did, riding my overactive sympathetic nervous system all the way to an undergraduate degree at Vanderbilt and a soon-to-be medical degree from Duke. Fueled by the kind of terror that traditionally accompanies being pursued by a hungry bear, I breezed my way through a decade of a blistering schedule of class, assignments, research, work, extracurriculars, and even a semblance of a social life. It was great, until it wasn’t.
Remember how I said earlier that academia caught up with me? It’s maybe more accurate to say that my own brain caught up with me. Around my junior year of college, some family disruption led me to knock sheepishly on the door of the Vanderbilt Psychological Counseling Center, the kind of just-off-campus run-down concrete building where college students across the country seek solace and comfort. I was paired with a therapist who diagnosed me with generalized anxiety disorder, and as a psychology and neuroscience major, this was surprisingly difficult for me. After all, nobody had ever worried about me being anxious before, right? If anything, I had plenty in my life to be anxious about — my relationship with a partner that didn’t look like it would last past graduation, intermittent family dramas, trying to get into medical school, serving as president of my acapella group — it was adaptive, really, for me to be a little on edge. I compartmentalized my diagnosis and tucked it into my back pocket, hoping I would forget it was there and it would dissolve in the wash.
There are some statistics from the CDC that put me in good company — or, at least, company — in 2018, 13% of Americans were on antidepressant medication, and that number has only increased since the onset of the COVID-19 pandemic. As I approach my third year on antidepressants, I can’t decide if I find that number comforting or terrifying or somewhere in between. People much more thoughtful and eloquent than me have talked at length about what this means for and about the field of psychiatry (in fact, P.E. Moskowitz’s interview on Binchtopia was the impetus for this piece). I’m not here to add any noise to the conversation. My main intention by describing my winding journey to psychiatric medication is to set the stage for what happened next.
Heading into 2020, I was cruising. I had made it through two of the most intense rotations of my clinical year of med school, I was set up with a research mentor and a plan to spend my third year doing research in New York City at Weill Cornell, and I had just started dating my current partner, who alleviated many of my anxieties alone by just being a good boyfriend. My mental health wasn’t perfect, but with a combo of Lexapro 10mg daily and 60-hour weeks spent too busy on the wards to think about much else, it seemed like everything was on the upswing.
And then, in the words of Bo Burnham, the funniest thing happened.
I don’t need to rehash what it felt like to be a person in March 2020. As a medical student, though, there were some extra-weird parts about my early COVID experience. We were plucked off of the wards mid-week with no warning, told to take an early spring break while administration scrambled to figure out what in God’s name they were going to do with their second years. None of us knew if we would have to take an extra semester or year to graduate, or even if that would be an issue, because how bad was this going to get? The news coming out of places like New York City was dystopian, chilling. The sense of dissociation I felt as I sat in my boyfriend’s suburban home in Raleigh, staring at an endless scroll of refrigerated trucks transformed into morgues, hospital workers’ faces chafed and weathered by their PPE, patients on ventilators in packed hallways, I was trapped between relief that I was not yet essential enough to be at risk, and a powerful desire to do something.
I had treated my anxiety with therapy and medication for enough time that I could escape what would have previously pushed me into a panic attack. The flip side of that coin, though, was that without the persistent panic that had been my normal for so many years, it was increasingly hard to get up and do anything, whether that was study, exercise, clean, cook, or even shower.
It’s that saying, about objects in motion versus objects at rest. Yanked forcibly out of motion, I was totally unaccustomed to being at rest in any capacity. Without the external structure of rotations, and with no outlet for my existential dread, I became frozen. Was I depressed? Was my anxiety returning with the added pressure of the pandemic pressing in on me? Both seemed true, but not the whole truth. As the uncanny valley of 2020 continued to sprawl out before me, I couldn’t shake this feeling that had taken root within me when lockdown first began — that something inside of me was wrong.
It was around this time that my TikTok algorithm started showing me videos about ADHD. Like so many people, I downloaded TikTok at the beginning of the pandemic when searching for a combination of sourdough recipes and escapism. For the first few weeks, my landing page showed me the standard-issue 30-second dances, Tiger King memes, and family vlogger content that dominated the least-niche corners of the app in March 2020. But the algorithm learned quickly — it picked up on my sexuality, my involvement in medicine, the kind of music and TV I liked, and rapidly approached an asymptote of knowledge about me rivaled only by my partner and closest friends.
If you’re on the app, you know what I’m talking about. Writers have described the TikTok algorithm extracting knowledge about them from what seemed like thin air, even if it was knowledge they hadn’t fully articulated for themselves. And honestly, most of the time, it’s sort of fun — there’s a kind of brainless joy in letting the infinite scroll determine what you want to see, turning your agency off and handing the reins over to your digital overlords. That’s not me trying to be faux-deep and nihilistic — I’ve spent hours on TikTok, and my relationship with the app, while occasionally parasitic, is largely positive and fun. I even subject my partner to what I call “Content Hour,” where I sit him down and make him watch a curated list of videos I’ve saved because he doesn’t have TikTok and I thought he would like them. (He pretends to hate it but he’s not fooling me.) But there’s no denying that the engines behind the algorithm are very clever, and very effective. Their dark side is as well-documented as the lighter fare, putting impressionable people at risk of falling down alt-right rabbit holes in the same way that YouTube will guide you gently from videos about how to be a “real man” all the way to Alex Jones and Jordan Peterson.
For me, the algorithm seemed determine to push me one kind of content above all else — content that told me I was living with undiagnosed ADHD.
The idea felt laughable to me at first. I was, as I’ve established, a gifted kid — I never struggled with academics, and was always the first to finish the test, rather than needing extra time. The ACT and SAT felt natural to me, and I consumed knowledge with a focus that bordered on voracious. Far from being disruptive, I was the student that the teachers would use as a buffer for the classically hyperactive kids, seating them next to me in the vain hope that my oppressive external dullness would pacify them. (As to whether or not it worked, you’d have to ask my elementary and middle school teachers.) I never bounced off of any walls. In college, I staunchly avoided offers of Adderall for study or recreation, not out of any complex about pharmacology but out of a fear that I would simply enjoy it too much. I loved to focus too much for it to be a safe habit, I reasoned — I loved to get sucked into a hole of total engagement with a piece of media, learning as much as I could about anything from beat poetry to the 2013 sci-fi movie Pacific Rim. (Please ask me to talk about the 2013 sci-fi movie Pacific Rim.) Adderall, or drugs like it, would be too tempting.
But the algorithm persisted. Much of the content was the kind of Buzzfeed-y clickbait stuff with no scientific backing that you might expect from such a layman-driven platform — “stop scrolling! You’re going to want to see this!” “If this is on your FYP, you might have ADHD!” “Five signs you may have anxiety!” Et cetera. If you kept watching, what revealed itself was often vacuous, approaching horoscope levels in the way it walked the line of the Barnum effect, applicable to everyone and exclusionary of no one.
The content that really got me, though, focused on the lived experiences of people with ADHD and how their symptoms manifested. Rejection sensitivity, for example, is the word given to the experience of feeling like all of your friends and family must secretly hate you. That’s an oversimplification, but it’s the best I can manage — it’s the sensation when someone responds to your texts about plans with a “k” or “sure” instead of unbridled enthusiasm. It’s been studied in people with ADHD, autism, and other mental health disorders — it’s not unique to ADHD, but it’s an experience frequently cited by neurodivergent people. It’s an experience I’ve frequently had, too, and it felt validating to have someone apply meaning and description to the startling othering that rejection sensitivity creates.
From there, my clicks and views and likes led me to videos about the overlap between ADHD and eating disorders, neuroscientific explanations as to why I was always 10 minutes late to appointments, the sleep disturbances common in people with neurodivergence, and how women with ADHD may be less likely to be diagnosed in childhood due to a theorized tendency for women to be socialized towards inattentive rather than hyperactive behaviors — this is a difficult subject to simplify, but there are some good review articles that suggest that there is a disparity in diagnosis between genders. All of these videos included nuggets of persistent truth that dug under my skin and gorged themselves on my anxieties like so many ticks. I was starting to hold the pieces next to one another, hoping the image of the puzzle would emerge.
My med school therapist did her best, but she was far more equipped to help me with my garden-variety anxiety and depression, rather than this sense of nagging wrongness that was dogging me perpetually through my days as the pandemic stretched out to months, and then to more than a year. I tried to express what I was feeling — that I knew what anxiety felt like, that it had been my baseline for so long, and that this was not anxiety. Nor was it depression in any way that I had experienced before; I struggled to get out of bed before noon most days on a fluid, work-from-home research schedule, but once I got out of bed I felt perfectly able to derive joy from spending time with friends, making art, et cetera. This was something different, something deeper. Try as I might, I couldn’t CBT my way out of this.
I began the torturous search for further diagnosis. I had never seen a psychiatrist before — my therapist had recommended an SSRI, and then my PCP had prescribed and managed it from there. I started making naive cold calls to specialists like the Duke ADHD Center, who told me they were booked for the next calendar year, but they handed me off to another office, who told me they didn’t take my insurance, but I could pay out of pocket and get an ADHD assessment for the low, low price of $2,500. I told them I would consider it, and then I hung up the phone and burst into tears.
The next psychologist that I found took my insurance, and had an opening in his schedule. I made the virtual appointment, brimming with excitement. Finally, I would express myself, and someone would hear me, and they would help me. They would help me escape the slow sinking, the frog-in-boiling-water feeling I’d been dogged by since the pandemic began.
He did not.
He didn’t do anything wrong, per se. We talked for about two hours, and at the end, he essentially said that he thought I might have bipolar type II, that I didn’t have ADHD, and that for 24 years old I was “a very interesting case who had a lot going on.” (That’s a direct quote.) The people-pleasing gifted child in me bloomed with pride. The rest of me was crushed. This was totally unhelpful — no treatment advice, no recommendations on medication changes, and a diagnosis suggestion that I wasn’t opposed to, but that really didn’t seem to fit what I was experiencing. By this time, I’d been chasing down an answer for almost eight months, and I was tired. It didn’t seem like anyone was going to listen.
I muddled through a few more months, feeling like I was experiencing the world from a position just slightly up and to the left of my body. I remember telling a friend that it felt as though my brain was tuned to a slightly different radio station than everyone else’s — like they were all on 101.5FM, but I was stuck on 101.7. Every so often, the world would burst through the static, but it was mostly just noise.
My salvation finally came, full-circle, in the form of a targeted ad on Instagram. It advertised virtual assessment, diagnosis, and treatment for ADHD, from home, with counseling and therapy built in. I won’t name the company — this isn’t an endorsement — but you’ve probably seen the kinds of ads I’m talking about. And I was so exhausted, and I was so worn down, and I thought, fuck it. Why not. So I clicked the ad and entered my information.
I had no idea what to expect, but I don’t think I expected to have a twenty minute conversation with a psychiatric nurse practitioner only for them to say “Everything that you’re describing sounds like ADHD to me.” I couldn’t help but interject, giving life to the little voice in my head that had dogged me for so long — I’m a medical student, I know the language and descriptors used to talk about mental illness, so how can I be sure that I’m actually experiencing these symptoms and not just parroting the buzzwords needed to get a diagnosis? I realized that so much of my guilt was rooted in the idea that my sickness wasn’t real, but that instead I was lazy, undisciplined, looking for an easy way out through the gilded gates of stimulant prescriptions.
My provider seemed almost surprised by my question. “Well,” she said, “why don’t we just try you on ten milligrams of Adderall extended release to start, and see how you do for the first two weeks?”
It was that simple. I felt like someone was going to stop me at the register when I went to Walgreens to pick up my prescription; that I’d hand them my license and the pharmacist would squint at it and just shake their head disapprovingly before sending me home empty-handed. None of that happened, and the next day I took my Adderall for the first time.
The radio dial that had been stuck in between stations for so long suddenly jerked to the left, and I was on the right frequency. I was terrified that stimulant medication would be detrimental to my diet and trigger my eating disorder (something that I talked to my provider and therapist about extensively), but instead I found that I was actually able to eat intuitively for the first time in my life, rather than eating or avoiding food in desperate grabs for spare dopamine. On Adderall, I still felt hungry, but when I no longer felt hungry, I was able to stop. Within a week, I was waking up naturally before my alarm, and my sleep was better than it had been in years. I started cleaning my apartment regularly rather than my old habit of staring in paralyzed horror at my pile of unfolded laundry, the ring of pink in my shower drain that I couldn’t bring myself to scrub, the dishes doing Tetris in my sink.
A moment for a disclaimer: I know that plenty of neurodivergent people and people who have been prescribed other psychiatric medications including and besides stimulants have had much less positive experiences, and I’m not saying those people aren’t correct. I’m very fortunate that Adderall was a life-saver pretty much from the first dose.
I’ve now been on Adderall for about five months. Besides all of the positive feelings I have surrounding my experience with stimulant medication, there is a deeper layer of deep sadness, like bedrock. I have found myself mourning the girl I might have been, if someone had listened to me when I was young and searching for meaning in a world that my brain didn’t seem entirely suited for — I used to bring back tests riddled with “careless mistakes,” which my parents and teachers chalked up to me rushing and not being deliberate enough in checking my work. My parents used to call out of the car window in the mornings as they dropped me off for school, beseeching me to “take your time!” But no matter how much they reminded me, it never seemed to stick. Once my brain was done with a test or an essay, it was done for good.
Who might that girl have become, if she had been seen? I think of my ADHD, or my neurodivergence, or whatever you want to call the brain chemistry and anatomy that allows me to take an Adderall XR at 9am followed by a comfortable nap at 2pm when the mood strikes me, as the center of a wheel. My anxiety, depression, eating disorder and body dysmorphia, and other symptoms I’ve experienced are like spokes on that wheel — I’ve spent years trying to straighten and correct one spoke at a time, but the center of the wheel was what was preventing me from steering in the direction I wanted. When I targeted my ADHD, the spokes began to reorient themselves on their own.
And some of the spokes are good things — I’m fortunate in that I don’t feel that any of them have been taken from me since I started treating my ADHD. I still feel creative. I can still enjoy the experience of being sucked into deep focus on a task, or a piece of media, or a long drive. I have often wondered before writing something like this down whether sharing what has been an incredibly positive experience with this telehealth platform might be dangerous. Am I encouraging companies that prey on vulnerable people looking for an easy solution to problems they aren’t equipped to face? Are these psychiatric startups sustainable, or ethical? Then again, is it ethical for even a medical student, supposedly the most connected flavor of twentysomethings to the medical system, to struggle for months to get an appointment with a psychiatrist?
I don’t have an answer. I don’t think stimulant medications, or even medication in general, are the answer for everyone. They’re not even the answer for most people. There may come a time that I try on life without my Adderall again, or without the SNRI that I take alongside it. But as it stands, I exist in a strange netherworld within medicine — we are uniquely informed and education about psychiatric illness and medication compared to the general population, we experience these conditions at rates often 1.5x or greater than non-physicians, and yet we are still less likely than the average person to seek diagnosis and treatment for mental health. Despite concerns about whether these regulations violate the ADA, physicians seeking licensure in most of the United States are still required to answer questions about their mental and physical health, and whether they have ever sought treatment for any condition they may experience.
The state licensing board can require all of your medical and mental health records, including intimate details about your upbringing, your family and your spouse that you may have divulged in private psychotherapy sessions. Your license may be contingent upon sharing these records. Moreover, after sharing your records, the board can then dictate further evaluation and possibly send a physician to a physician health program (PHP). — The Washington Post
Even in writing this piece, I put myself on the line. My future licensing board could see this, and they could decide that the experiences I describe make me unfit to be a doctor, to be a surgeon.
I disagree. In fact, I think that doctors who have experienced illness, mental or physical, are vastly better physicians for it. My experience in navigating treatment for my mental health has made me more empathetic, more understanding of the system, more aware of what my patients go through when they try to manage their health.
There is no fundamental solution in these words — I can’t tell you whether we’re underprescribing, or overprescribing, or ignoring the way our experiences as a society in a pandemic have contributed to our mental health, or allowing the pandemic to serve as an excuse for other reasons our minds might be struggling. I suspect that the answer is somewhere in the middle of all of these swinging pendulums. An algorithm may have gotten me here, but it’s the humanness of what I sought — to be understood, to be heard, to feel able to exist fully in my body and in the world — that gave me my life back.
