What is perfectly hidden depression? And how do you know if you’re suffering with it?

You have a perfect-looking life. But you’re inwardly struggling with depression, maybe even having thoughts of suicide or just getting out somehow. But others would never guess that you are. Why? You’ve become expert at keeping it from others. You may be aware you’re intentionally hiding pain (as in what’ s termed “smiling” or “high-functioning” depression) , but it’s also possible that you have no real clue, The dynamic may have entrenched itself so far into your very being that you may be largely unconscious of its presence, except for a deep tug in your gut that tries to whisper to you that something’s terribly wrong. 

You may have even searched online, trying to understand what that tug could be. You look at the criteria for depression, and you don’t fit. So what do you do?

Shame yourself for looking. And the highly critical, perfectionistic voice inside you gets louder.

So. let’s talk about a set of characteristics that are usually present in perfectly hidden depression. If any of basic information has resonated with you, it’s pretty likely you’re going to find yourself there. Remember, PHD isn’t a diagnosis. You won’t find the term in any other books or magazines. It’s a syndrome (a group of things usually found together) that’s created when a tremendous amount of effort is put into creating a perfect-looking life. And it can lead to desperate loneliness. 

1) You’re perfectionistic and have a constant, critical, and shaming inner voice.

Having a perfectionistic streak is one thing; you try to do your best. “If it’s worth doing, it’s worth doing well,” is a favorite motto.

Yet people with PHD silently berate themselves if they’re not at the top, at all times. You may allow one area where you’re not proficient — laughing and saying you couldn’t skate if your life depended on it, for example. But if it’s an activity or a pursuit that others will observe and evaluate, you are driven for it be perfect. Being a perfect mom, an accomplished lawyer, head of the class, or a fantastic best friend is a must.

2) You demonstrate a heightened or excessive sense of responsibility.

People with PHD are very aware of duty, obligation, and loyalty. You can be counted on in a crunch; you’re the first one to notice when something is going wrong, and look for solutions. You are a good leader, although perhaps not the best delegator.

This sense of responsibility can also be painful, as you will will readily blame yourself rather than taking a moment to understand the entire picture. This can be manipulated by those who rarely take responsibility, which just heaps more onto your plate which you accept without complaint.

3) You detach from painful emotions by staying in your head and actively shutting them off. 

I know when I’m sitting in front of someone and they’re talking about a loss or disappointment as they smile brightly at me, that I may have discovered someone who’s hiding. This isn’t always the case, but it’s a question I begin to ask myself as a therapist.

Anger is typically avoided, unless it’s about control. Sadness is banished to the back of the closet. You tell yourself disappointment is for whiners. If you have perfectly hidden depression, you may not even have the words to express these emotions. In more severe cases, you may have trouble expressing emotions at all. Rather than connecting with your heart, you stay in your head most of the time…analyzing, decoding, thinking through things.

4) You worry and need to control yourself and your environment. 

You aren’t someone who can stay easily in the present. If you do yoga, you may hate the final position, where you’re supposed to breathe and relax. Or if you love to cook, you may have a very hard time sitting with your diners and enjoying the meal. You look around at work constantly for how to stay on top of things and not let anything pass you by. 

The need for control is strong, and so you spend a lot of time worrying about the things that might occur to interrupt that control. It’s important to you to hide that worry from others, however, so you cover your worry with a smile.

5. You intensely focus on tasks and use your accomplishment to feel valuable.

You may strongly believe, ”You’re only as good as your last success.” You count on activity and accomplishment to hide your inner insecurities and fears.

We all do this to a certain extent. If you’re having a bad day, it feels good to get something done that perhaps you’ve been putting off. Or you get a promotion at work. Or someone emails you about how your kindness was so meaningful to them. There’s value in purpose and effort.

But if you have perfectly hidden depression you may carry it too far. You may not know how to express what you like about yourself, what brings you a sense of esteem, outside of your external achievements. Your sense of importance and contribution to the world isn’t coming from who you are inherently, only your most recent success.

6) You focus on the well-being of others, but don’t allow them into your inner world.

This is not fake concern for others; it’s not pretend or insincere. It’s real and it can be intense. because caring for others is what people who experience PHD do very well.

However, you don’t let others sense your own vulnerability; you don’t allow others to care for you the way you care for them. You also don’t reveal pain from your past to others. Perhaps your spouse might know, but it’s not discussed because there’s a wall up against anyone discovering that you’re lonely or fatigued, empty or overwhelmed.

Not letting anyone in can be especially frightening when suicidal ideation is present. Or if you do, it’s met with disbelief, “What you? Depressed? You’ve got everything in the world going for you.

That can be devastating. Because your pain is invisible to everyone but you. 

7) You discount or dismiss hurt or sorrow and struggle with self-compassion.

Compartmentalization is a skill. It’s the ability to be hurt, sad, disappointed, afraid or angry about something and put those feelings away until a time when you can deal with them better. Healthy people do it all the time. You can even do it with joy or happiness; sometimes it’s just not the time to burst out singing.

If you identify with PHD, you over-compartmentalize. You may have created very strong, insulating boxes where you habitually lock painful feelings in, and shove them back into dark recesses of your mind. This allows you to discount, deny or dismiss the impact of life experiences that caused pain in the past, or the present.

One woman identifying with PHD emailed recently that she had been diagnosed with PTSD, and she totally dismissed it. “What happened to me was no big deal,” she wrote. “Much worse things have happened to other people.”  That’s over-compartmentalization. That’s total lack of self-compassion. And it’s a set-up for hidden depression. 

8) You may have an accompanying mental health issues, such as an eating disorder, an anxiety disorder, obsessive-compulsive disorder, or addiction. 

People with perfectly hidden depression live their lives in a very controlled fashion. You might be expressing this with an eating disorder or obsessive-compulsive traits. You may also be turning to alcohol or sedative medications to escape your anxiety.

9) You believe strongly in “counting your blessings” as the foundation of well-being.

I believe in counting your blessings. It’s healthy and it can keep you optimistic, grateful, and grounded.

However, if you fit the bill for PHD,  you may feel guilt or even shame if you realize that not all things in your life are good. In fact, some are really hard. Even blessings can bring with them added responsibility, extra work, or some kind of disappointment. Babies born get colic. New jobs pay more, but the commute is longer. Recognizing the glass is, by definition, half-full and half-empty. Healthier, happier people live mostly in optimism, but they can also realize and accept when things go awry or are hard. 

10) You may enjoy success with a professional structure but struggle with emotional intimacy in relationships.

The vulnerability that is linked with true intimacy is hard for you if you identify with PHD. Although driven to be productive and achieve great success in your career or whatever you do with most of your life, you aren’t  likely to be someone who can easily relate on a deeply intimate level.You may have a partner who doesn’t know how to be vulnerable either. Your relationship will be based primarily on what you do for each other, rather than who you are for each other or your focus may be on the family and the children.

If you have any of these ten characteristics, you don’t have to hide. There’s no shame in being human. You can take this questionnaire to see where you might fall in the spectrum of PHD. You can listen to my podcasts on perfectly hidden depression to find out what to do about it. You can realize that there are many others, like you — who are hiding and keeping secrets.

I’ve been writing for over five years about perfectly hidden depression (PHD) and in November of 2019, New Harbinger Publishing will publish my book on this highly damaging syndrome. More to come!

If someone you love has these characteristics, please send them this post. They will hopefully feel seen, and loved. It could be the catalyst that would allow them to start a journey that might save their life.

If you’re a therapist, please realize that depression doesn’t always look the same, and don’t always present with depressed mood and anhedonia. They can look at you brightly, and say, “You know I don’t know why I’m here.” You have to notice that their smile is a bit forced. Their emotions, tightly tucked away. 

And the light in their eyes carefully masks the pain that they are so frightened to show.

You can hear more about depression and many other topics by listening to Dr. Margaret’s podcast, SelfWork with Dr. Margaret Rutherford. Subscribe to this website and receive her weekly blog posts and podcasts, as well as  free downloadable ebook, “Seven Commandments of Good Therapy.”!

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My new book entitled Perfectly Hidden Depression will be arriving November 1,2019! Its message is specifically for those with a struggle with strong perfectionism which acts to mask underlying emotional pain. But the self-help techniques described can be used by everyone who chooses to begin to address emotions long hidden away that are clouding and sabotaging your current life. More to come.

This was originally published on May 6, 2017 and was updated on May 11, 2019.