How to Know If You Have 'Perfectly Hidden Depression'

I’ve been writing for three years now about a syndrome called perfectly hidden depression (PHD). These are people who are inwardly struggling with depression — at times severe depression — but others would never guess they were. They can act both intentionally, but also unconsciously, to deny and avoid pain or suffering. And they do it quite well.

In fact, perfectly.

But what’s a syndrome? Here’s what the dictionary offers:

“Pathology, Psychiatry. a group of symptoms that together are characteristic of a specific disorder, disease, or the like.”

In PHD, it’s a set of behaviors, thought patterns and emotions (or lack thereof) that are often found together in someone. If you see one, you may be likely to see the other. Like red hair and freckles. Or salt and pepper.

Here are ten characteristics of perfectly hidden depression. They’re not all present in every person who might recognize themselves in PHD, but they’re fairly consistent. They were created from hundreds of email stories and interviews with people identifying with PHD.

1) Perfectionism with a constant, critical 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. They may allow themselves one area where they’re not proficient, laughing and saying they couldn’t skate if their life depended on it. Or they can’t tell a joke.

But if it’s an activity or a pursuit that is meaningful to them, it needs to be perfect — being a perfect mom, an accomplished lawyer, head of the class or a fantastic best friend.

2) Heightened or excessive sense of responsibility.

People with PHD can be very aware of duty, obligation and loyalty. They can be counted on in a crunch. They can be the first to notice when something is going wrong, and look for solutions. They’re good leaders although perhaps not the best delegators. This sense of responsibility can also be painful, as people with PHD will readily blame themselves, rather than taking a moment to understand the entire picture. This can be manipulated by those who rarely take responsibility.

3) Difficulty with accepting and expressing painful emotions.

I know when I’m sitting in front of someone, and they’re talking about a loss or a disappointment as they smile brightly at me, I may have discovered someone else who’s hiding. The avoidance or actual denial of regret, shame or any real vulnerability sticks out like a sore thumb.

Anger is typically avoided. Sadness is banished to the back of the closet. Disappointment is for whiners. A PHD person, or PHDP, may not even have the words to express these emotions, and in more severe cases they may have trouble expressing emotions at all. The PHDP stays in his or her head most of the time, rather than connecting with their heart — analyzing, decoding and thinking through things.

4) Worry/Need for control over herself and her environment.

The PHDP isn’t someone who can stay easily in the present. If she does yoga, she may hate the final position where you’re supposed to breathe and relax. He may love to cook, but has a very hard time sitting with his diners and enjoying the meal. The need for control is strong, and so a lot of time is spent worrying about the things that might occur to interrupt that control. It’s important to hide that worry, however. So it might not be obvious that the anxiety exists. Someone with PHD may look as if they do things easily and without effort. But the worry is hidden, right under the smile.

5) Intense focus on tasks, using accomplishment as a way to feel valuable.

“You’re only as good as your last success.” That’s what a PHDP may strongly believe. They do, all the time, and count on activity and accomplishment to hide their 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. Someone with PHD may carry it too far. They may not know how to express what they like about themselves, what brings them a sense of esteem, except for those accomplishments and tasks. That’s the problem.

6) Active concern for the well-being of others, while not allowing anyone into their inner world.

This is not fake concern. It’s not pretend or insincere. It’s real, and it can be intense. Caring for others is what people with PHD do very well. However, they don’t let others sense their own vulnerability. They don’t reveal pain from their past to others. Their spouse might know, but it’s not discussed. There’s a wall up against anyone discovering they are lonely or fatigued, empty or overwhelmed.

This can be especially frightening when suicidal ideation is present. And he can’t let anyone in. Or if he does, he may not be believed. “What, you? Depressed? You’ve got everything in the world going for you.” That response could be devastating.

7) Discounts or dismisses hurt or abuse from the past, or the present.

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 not the time to burst out singing.

People with PHD over-compartmentalize. They have developed very strong boxes they habitually lock painful feelings in, and shove them back into the dark recesses of their minds. This allows them 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 post-traumatic stress disorder (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 a very typical kind of belief system used in PHD.

8) Has accompanying mental health issues, involving control or escape from anxiety.

People with PHD live their lives in a very controlled fashion. So, you’ll find eating disorders and obsessive-compulsive disorder (OCD) traits are likely. Alcohol or sedative medications could be used to escape anxiety as well.

9) A strong belief in “counting your blessings” as the foundation of well-being.

I believe in counting your blessings. You bet. It’s healthy. It can keep you optimistic and grateful. A person with PHD feels guilt or even shame if he shows compassion toward himself, and allows himself to realize that not all things in his life are good. In fact, some are really hard. And it’s OK to feel that.

10) Intimate relationships may be difficult, but are accompanied by professional success.

The vulnerability that is linked with true intimacy is hard for someone with PHD. Although driven to be productive and achieve, and often finding great success, she isn’t likely to be someone who can easily relate on an intimate level. Someone with PHD may likely choose a partner, in fact, who doesn’t know how to be vulnerable either, or doesn’t have that capability. Their relationship will be based primarily on what they do for each other, rather than who they are for each other. The focus may be on the family and the children.

If you have these characteristics, you don’t have to hide. There’s no shame in being human. You can take this questionnaire to see how you score. You can listen to these two podcasts to find out what to do about it. You can realize that there are many others, like you, who are hiding and keeping secrets. 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 depression doesn’t always look the same. People don’t always present with depressed mood and anhedonia. You have to listen and look carefully.

You can hear more about Perfectly Hidden Depression and many other topics by listening to Dr. Margaret’s new podcast, SelfWork with Dr. Margaret Rutherford, or join her on her website.

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Thinkstock photo via jitloac