Perfectionism. Over-responsibility. Discounting painful emotion or past trauma. Chastising yourself if you’re not counting your blessings. Always being there for others, but sharing very little of who you really are, or what actual problems you might have.

These are five of the ten traits of Perfectly Hidden Depression — a syndrome that I’ve been writing about for almost four years. These traits ensure that whatever perfectionistic mask you’re wearing, it stays on tightly.

Within the last few months, the need for identifying the danger of PHD has become even more evident. Researchers, such as Paul Hewitt of the University of British Columbia, are sounding the cry that perfectionism can be a helpful trait, but can also be also linked with self-dissatisfaction and significant stress on your body.

The harder you are on yourself, the more you analyze every detail of a situation, the less satisfied you may be with the outcome. And your body responds in kind.

But it’s also being shown that perfectionism can cause even greater damage.

Fatal damage.

Several studies within the last decade have reflected a strong correlation between perfectionism and suicide, including findings that 70 percent of 33 boys and young men who had killed themselves were described by their parents as placing “exceedingly high” demands on themselves. Gordon Flett, a lead researcher of perfectionism and co-author of the new book, “Perfectionism: A Relational Approach to Conceptualization, Assessment and Treatment” , stated in an interview in New York Magazine, “Other than those people who have suffered greatly because of their perfectionism or the perfectionism of a loved one, the average person has very little understanding or awareness of how destructive perfectionism can be.”

Why is this so scary?  Perfectionistic people are really good at hiding pain.

Yet what would cause someone with PHD to want to change? Or be able to reveal themselves or take off their mask? What my own patients (and hundreds of emails) have shared — it’s only when the burden of isolation, the despair of closeted-off feelings, or the suicidal urges to end the charade become too great, that someone with PHD might come into a therapist’s office for help, or tell a good friend or a parent about their struggles.

Yet those therapists, those friends and those parents have to see it. They have to know PHD exists. They have to recognize that depression doesn’t always look the same. It’s not always melancholy, or agitation. It’s not always lack of engagement with the world and isolation.

It can be perfectly hidden.

What’s the answer? If those with PHD actually want to heal, what are the steps to change?

There are five steps, perhaps basic for all change to take place. Yet there are specific directions that someone with PHD must travel to heal. I’ve termed them, “The Five C’s Of Healing.”

Consciousness first. You have to identify a problem as a problem before you can change it. You have to begin to understand and accept that it’s having a painful impact on both you and your relationships. Specifically, with PHD, you have to recognize that you’ve been hiding your true experience of life for years, creating instead a persona that looks good to others, and has served to keep you safe.

The second step is Commitment to a process that will be difficult, and involve not only change with yourself, but change with others. For someone with PHD, there can be immense fear experienced during this stage, which has to be confronted and worked through. She or he is thinking of giving up a way of surviving, or living their life. The third step is Connection with emotions, perhaps long unrecognized or accepted. There is likely to be trauma present in someone’s history, or some kind of childhood learning or experience that has created the avoidance or denial of painful feelings. The goal is to unravel what has been over-compartmentalized and stuffed away for many years.

Almost at the same time, the fourth step is taking shape — Confrontation of irrational beliefs, denial, avoidance — whatever is holding you back from moving in a direction where you can grow. Learning how to have more control of where your mind can take you is a vital skill for anyone, and especially for someone whose perfectionistic and highly critical yardstick is constantly present, its voice measuring each word, and each action.

During steps three and four, there is an ongoing process that I term “Deconstruction” and “Reconstruction.”  Think about the old game of Pick Up Stix or the more recent one, Jenga. The strategy to win involves careful assessment of what stick or what Jenga piece you can remove without the entire thing crashing down around you. Someone with PHD faces this very challenge. You decide where to begin the change, and slowly and with compassion for yourself, take down the persona, piece by piece, and replace it (or reconstruct it) with a healthier, more open, and more vulnerable, self.

When deconstruction is beginning, I hear words like this..

Well, this isn’t really a big deal, but I wanted you to know that I stopped myself from changing the subject, like I might have done before. Instead, I told my husband I was getting mad. I actually told him how I was feeling,” You can hear the change… the confrontation of the habit to avoid conflict, and stay hidden.

Here’s another example. “This may not really matter all that much, but I looked at some old pictures last week. I was six. The first thought I had was how many mistakes that child would make — how it would be better if he could stay a child. Why is that the thing that comes to mind?”  And tears came to his eyes. You can hear the growing awareness of highly critical perfectionism, and you can feel the sadness that connection brings.

It’s important not to discount these changes. These small realizations and beginning risks are huge for someone with PHD.


And they lead to Change. Change in what you do, in what you say, in what you feel — who you are — which is where you get your hope. You can see that you aren’t trapped by your past, and that you can look ahead to a future without feeling so lonely and disconnected.

That very change… those small steps taken to undo or deconstruct the patterns of perfectionism and hiding? And to risk or reconstruct new ones?

They lead to the cycle renewing itself. Each change, each risk leads to more consciousness, more commitment, more connection, more confrontation…

More compassion for yourself and others.

And there’s no longer a need for that mask.

If you wonder where you might fit on the PHD spectrum, please take this questionnaire. 

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