Avoidant Personality Disorder

If you live with anxiety, you might be familiar with some of the seemingly “harmless” but incredibly hurtful things people often say to those struggling with it. Sometimes these “harmless” comments come in the form of a question. ( Have you tried meditating?) Sometimes they come with a “solution” via personal anecdote. ( Becky used to get panic attacks, and once she started exercising again, her anxiety totally went away.) Most often, they come from a place of misunderstanding mental health struggles. And even though these “harmless” comments may come from a good place, they can often invalidate the struggles of someone living with anxiety. When someone with anxiety opens up about their struggles, oftentimes they aren’t looking for your “solution,” “advice,” opinions, DIY anxiety healing guide, etc. — they may just be looking for someone to listen and be there. We wanted to know what “harmless” comments people with anxiety have heard that actually hurt them, so we asked our mental health community to share one with us and explain what it feels like to hear it. It’s important to remember what may seem “harmless” to one person may actually be hurtful to another. No matter what anyone says, your feelings are valid, and you deserve support. Here’s what our community shared with us: 1. “Other people have it worse than you do.” “ ‘You’re lucky in comparison to others. It could be worse.’ This was said by an old ‘friend’ to whom I was saying I was struggling with depression after my father’s death few month before… I had the right to feel bad. We should remember we all have the right to feel how we feel.” — Albane L. “ ‘Other people have it worst than you.’ Just because I can do certain things and function a bit more than others with anxiety doesn’t mean I’m not struggling.” — Kayla D. 2. “You shouldn’t rely on medication.” “’You shouldn’t rely on medication. I have anxiety and I just deal with it. I don’t take medication.’” — Ashlee H. “ ‘You need to be strong so you don’t keep taking those medicines.’” — Rita T. 3. “You’re making a mountain out of a molehill.” “‘You’re making a mountain out of a molehill…’ People used to tell me this all the time, especially in school when I reported bullying.” — Taylor S. 4. “Have you been praying enough?” “‘ God will make it better.’ ‘Just pray…’ I probably have 100 more, but these are the ones I hear the most during a down period.” — Dezei R. “I was often told I didn’t have enough faith, implying my anxiety was my fault and a punishment. Put a bad taste in my mouth when it came to religion, and definitely didn’t make the anxiety any better. I know they thought they were being helpful, but it wasn’t in the slightest.” — Jessica A. “‘ Give it to God, then you can stop worrying about it.’” — MaryJane G. 5. “Everybody feels stressed sometimes.” “‘Everybody feels like that.’ Sounds innocent enough, but if I am disclosing how I am feeling to you then the last thing I want is you trying to shift the focus to ‘everyone’ else. I have opened up to you because I want to talk about me. Turning it into being about everyone else doesn’t help and just makes me feel like I am not valid.” — Lexie B. “‘I’m sorry you’re stressed. I’m stressed, too.’ I’m not stressed, I’m anxious and feeling extreme dread over everything and nothing. It’s not stress.” — Lindsey M. “‘Oh, I get anxious all the time,’ but [then they] talk about something that made them temporarily nervous.” — Kaitlyn T. “ ‘You’re not the only one who has bad days.’” — Will J. 6. “Just calm down.” “ ‘Just calm down.’ This is seriously one of the most detrimental things you can say to someone with anxiety. We seriously don’t wake up wanting to stress and worry and overall exhaust ourselves with everything around and inside of us.” — Kristy H. 7. “Stop freaking out.” “‘Stop freaking out, it’s not a big deal.’ Anxiety doesn’t care if it’s actually a big deal or not.” — Stephanie R. 8. “Again?” “When someone asks ‘again?’ when I tell them I’m anxious or feeling weird or express my panic or anything like that… like yes, it’s happening ‘again.’ It happens often at times and then I can experience breaks, but it never goes away and I know they don’t mean it to be mean, but it’s hard for me too having to go through anxiety attacks and feeling anxious every day…” — Jessica S. 9. “You need to change your mindset.” “Someone very close to me has said, ‘Can you just stop thinking that way? It’s not hard to change your mindset.’ That threw me into complete isolation of myself. I wish every waking morning, every sleepless night, when my anxiety gets the best of me, I can just not think like this. That if for one day, even one minute, I can feel like I’m ‘normal.’ They had the best intentions at heart, but they didn’t understand the weight and hardship my anxiety has put on me and my day-to-day life.” — Janell R. 10. “You don’t know what stress is.” “’You don’t get to be stressed. Keeping a roof over a family’s head is stress.” — Michael R. 11. “Well, go and get help then.” “ ‘Well go and get help then!’ is my dad’s answer whenever I’m struggling. Unfortunately I can’t share how I’m feeling with my family and that can sometimes make situations with them difficult. Particularly in publicly if I’m mid-attack and they’re just having a go at me. They’re not bad people, they just don’t understand mental illness.” — Lauren M. 12. “You need some work therapy.” “’You need some ‘work therapy,’ before directing me outside to clean the yard. I felt dismissed and made a mockery of. This was the day I was released from the hospital. Heartless. Even now (17 years later) it still makes me want to seriously hurt myself.” — T.B. 13. “I think you’re just looking for reasons to be upset.” “‘I think you are just looking for reasons to be upset.’ From my dad… I told my parents I felt shoved aside, so he said that.” — Anna G. 14. “Smile.” “’Smile. It will help.’” — Lexi L. 15. “You’re a hypochondriac.” “’You’re a hypochondriac.’ It makes me feel like I am more ill than I am. It makes me feel so upset and angry because it’s basically just ignoring me and telling me to shut up.” — Charlotte U. 16. “You’re overreacting.” “ I am constantly told I’m overreacting to damn near everything. To calm down. Chill out. Mind you, in tone that just feels so condescending.” — Patricia B. 17. “Get over yourself.” “ ‘Get over it/yourself.’ I shut down. I remove myself from people. I make it so I am not only bothersome to others. I disappear all together.” — Ellen S. 18. “You don’t seem like someone who would have anxiety.” “’You don’t seem like someone who has anxiety…’ Because I’m not walking around breathing into a paper bag 24/7? Made me feel completely invalid.” — Ruby C. 19. “ You were fine a minute ago.” “’You were fine a minute ago. You have no reason to be upset.’ This is a big one for me because the smallest things that happen to me can cause a panic attack. If I could stop these, I would, but I don’t have any control of them and saying stuff like that makes it worse.” — Madison U. 20. “Just breathe.” ‘Just breathe.’ Thanks. I didn’t realize humans could do that. Still doesn’t help my issue though. I get the intent behind it but… it’s not helping.” — Chelsey C. “‘Just breathe, you’re fine…’ There is an elephant on my chest and fire in my veins, so in this moment, I can’t breathe and am not fine.” — Jess F. If you or someone you know needs help, visit our suicide prevention resources page. If you need support right now, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text “START” to 741-741 . Getty Images photo via piyapong sayduang

Depression is a serious medical condition that causes feelings of sadness or lack of interest in normal activities. People with depression are not weak, but are facing a complex medical issue and usually need help from a doctor and/or therapist. Their symptoms might be physical, like headaches, stomach aches, or back pain that doesn’t have another explanation, or emotional, like crying, emptiness, or hopelessness. They may not have any explanation for why they feel this way, which can be even more frustrating. Depression affects about one in six adults, according to the Centers for Disease Control . It can happen at any age, to any gender, although women are twice as likely to develop depression. Finding a treatment plan that works can be difficult — that’s why we spoke with Mike Sumner, Chief Medical Officer at Orexo about  deprexis ®, a digital therapy that can be added to what a person is already doing to treat their depression , and about roadblocks people with depression face in seeking treatment. “For people trying to access psychotherapy, it’s difficult,” he said. “I can give you an example, I was looking for a therapist for a close friend. And even though we have a trained clinical psychologist on staff, it still took me four phone calls before there was an open slot [with a therapist they recommended]. The choice was either you come at 2 p.m. on Monday, or you can come at 2 p.m. on Monday.” Scheduling conflicts and transportation can make in-person psychotherapy logistically difficult. That’s where the online therapy deprexis ® can help meet the needs of people with depression. As a customized experience, deprexis ® uses artificial intelligence-guided technology to deliver tailored cognitive behavioral therapy (CBT)-based techniques to the user. CBT has been shown to be effective in the treatment of depression. deprexis ® is available to users who have access to an internet browser whenever and wherever they are ready to start a session and begin tackling their depression. “There are some people who would be nervous about going to a therapist. I don’t believe therapists are confrontational in any way, but to actually go in and see a therapist and be willing and open to talk about yourself is not a natural thing for everybody. So [deprexis ® ] gives them another choice,” said Sumner. Among the choices of digital therapy platforms, deprexis ® stands out as one of the most well-researched. Eleven clinical trials have proven it helps to reduce symptoms of depression in over a decade of research. Our research suggests that deprexis ® is one of the only digital therapy choices to integrate artificial intelligence, creating a personalized approach to each user’s therapy. The program is self-paced, and available anytime and anywhere the user has internet access. Cognitive behavioral therapy (CBT) is the backbone of the deprexis ® program. CBT is built on a foundation of recognizing problematic thinking and behavior patterns and changing them through applied practice. “We recommend people to use it up to 30 minutes, once or twice a week. And that is a part of delivering cognitive behavioral therapy.  It’s all about changing your thought process. So examining the inputs, things that might make you sad or don’t make you feel great, and then analyzing that and providing different options. That thought process change takes time. So we don’t necessarily want a person to run through the program as fast as possible. We want them to take in the content, practice it, and get it cemented into their behavior, because that’s what’s going to give them a longer-term clinical benefit,” said Sumner. deprexis ® is proven to help reduce depression symptoms. Improvement in depression symptoms among people who added deprexis ® to what they were already doing to treat their depression has been shown in different clinical situations . One study specifically looked at how long symptom improvement lasted after ending deprexis ®. Improvement was still present three months following the end of therapy. deprexis ® is available in nine languages including Spanish, French, German, and Portuguese. When an individual decides they’d like to try deprexis ®, they can begin by visiting the website . There they can get assistance with determining whether insurance coverage is available and purchasing an access code. For more information, call 1-833-DEPREXIS, or email contact@deprexissupport.com . deprexis ® is a web application indicated for the adjunctive treatment of chronic or recurrent depression or depressive disorders as a primary or secondary diagnosis (eg, as a comorbidity in multiple sclerosis or epilepsy) for patients 18 years of age or older who are experiencing a depressive episode. deprexis ® is not a healthcare provider and does not provide medical advice, diagnosis, or standalone treatment. If you need immediate medical attention, please contact your healthcare provider or go to the closest emergency room.

I’ve always described myself as an “after-reactor,” meaning I don’t typically react to things as they’re happening. I intellectually process what’s happening, whether it be bad news, an overwhelming task or a hard situation, but can often have a hard time feeling it. I can’t lie, this has served me well. I can be pretty great at handling stress, compartmentalizing and temporarily putting away feelings I’ve deemed unhelpful. It’s easy for me to “leave things at the door” when I go to work, because you can’t be distracted by things you’re not processing, right? This is how I learned to function in high school. This is how I juggled so much in college. This is largely still how I function now. Avoid bad feelings. Suppress and move on. Emotions can’t hurt you when you don’t feel them… It doesn’t take a psychologist to guess where this is going. Because of course, feelings you don’t feel don’t simply go away. They don’t seep into the ground never to return again. In fact, it’s more like the water cycle. Whatever the earth absorbs eventually comes back as rain. Except in this version of the water cycle, the more water that goes unused and unprocessed, the bigger the storm. Water you ignore comes back with fury, demanding your attention, raining big, angry drops on your head. For me, this rain can manifest physically through stomachaches and back pain no amount of stretching relieves. It comes out in bad thoughts, like, “I want to kill myself,” a sentence that sometimes (although, thankfully, not recently) runs through my mind, a placeholder for whatever negative emotions I didn’t process that day. Then, it comes out in bursts of emotion, triggered by seemingly “little” things. A change in dinner plans leaves me sobbing on my bed. One off-hand comment from a friend (combined with too many drinks), and I’m fighting self-harm urges in a public bathroom. Something happens in a TV show, and I cry as if it’s happening to me, suddenly unable to breathe by a fictional plot that is vaguely related to something personal. But yet, as things are actually happening, it’s still hard for me to feel. It’s as if my brain is trying to protect itself, working in overdrive so I can still function. It makes it hard for me to identify how I really feel about things. It makes it hard for me to process emotions in real time. During a fight with my boyfriend, he begged me to tell him how I was feeling. “Nothing,” I responded. And I meant it. “I feel nothing.” Later, while we were in the car, I screamed. I talk about this in therapy, but only after my wonderful therapist called me out. Even in her office, I tend to recount stories as if they didn’t happen to me, intellectually analyzing events and avoiding discussions about how things actually made me feel. My therapist isn’t big on worksheets or homework, so I was surprised when after one session, she excused herself to get something for me. What she handed me was a piece of paper I didn’t know I needed: a Wheel of Emotions. It’s a simple chart, with different levels of color-coded emotions, meant to help those who possess it identify how they’re feeling. I stared at it, and was hooked. My “Wheel of Emotions,” crinkled up from being in my purse. Maybe it’s because I’m a writer, or maybe it’s because the colors are nice, but I’ve found this to be one of the more helpful tools I’ve been given for my mental health. For me, what makes the Wheel of Emotions so great is that it starts out relatively vague, and then moves on to more specific, intense emotions. Now when I, for example, reference this tool when talking to my boyfriend (yes, this has happened), I start by looking at the emotions in the middle. Even if I think I feel nothing about what we’re talking about, I can usually at least choose an emotion to start. My options are: Bad, Fearful, Angry, Disgusted, Sad, Happy, Surprised. If I can’t pinpoint exactly how I’m feeling, but know, at the very least, I feel “bad,” I can then move on to the next layer. ( Do I feel Bored, Busy, Stressed or Tired?) Then, I can even go one step deeper. If I feel Stressed, do I also feel Overwhelmed or Out of Control? Do I feel both? Even if there isn’t one “perfect” label  to sum up how I’m feeling, it sets me in the right direction. It gives me some language to talk about how I feel. It’s better than “nothing.” According to American psychologist Dr. Robert Plutchik, humans can experience 34,000 distinguishable emotions. He developed a wheel of emotions that looks a little different than mine, which you can find here. As stated in the resource about navigating Plutchik’s Wheel of Emotions, the “deeper” you get on the wheel, the more intense the emotional response. No matter what your Wheel of Emotions looks like, the concept is still the same — humans are capable of so many vast and complicated emotions. Identifying them is a practice. Dealing with them can be a strength. I included a bigger (and hopefully easier to read) version of my Wheel of Emotions below so you can take a look: Click here to view full size version. Image via www.classtools.net. Even before I was given my new favorite piece of paper, slowly but surely I’ve been getting better at feeling my feels. Anger has gotten a little easier to process. I’m trying to take away shame from feelings I think are “illogical” or “wrong.” I’m trying to own myself as an emotional person, and remind myself that while burying “bad” emotions is tempting, and even “helps me” in the short-term, it always bites me in the end. It inhibits my growth, rather than helping it, and just because I can push through bad feelings doesn’t mean I have to. The magic thing about processing and identifying emotions while they’re happening is that afterwards, I often feel lighter. I can deal with what I’m going through without giving the storm festering inside of me more fuel. Identifying my emotions, with the aid of my dear wheel, has been a big help on my own mental health journey. If you’re someone who struggles with identifying emotions, I hope it’s a tool that can help you too.

Oftentimes, when someone is struggling with their mental health, they won’t come right out and say it. Some may hint at what they are feeling, hoping others pick up on the clues. Others may use language that means “I need help” without actually saying the words — because saying them can sometimes make it feel too real, or you might be afraid of how others will react. No matter what reason someone has for using “code words,” it’s important we talk about what kinds of phrases to look out for. Talking about these phrases can help us identify loved ones who are struggling and get them to the resources and support they need. To find out what people said when they were having a hard time with their mental health, we asked members of our Mighty community to share one thing they said that was really code for “I’m struggling today.” Here’s what our community shared with us: 1. “I’m not feeling well.” “It’s not untrue and I don’t have to explain myself. People automatically assume I have a cold or something.” — Mackenzie C. “It’s true. Majority of the time, depression keeps me exhausted and anxiety keeps me awake, so I get no respite from my brain. Top that with the stress of nursing school, and I literally don’t feel well.” — Bria M. 2. “Well, I’m alive!” “ I just realized that whenever people ask me how I’m doing, I say, ‘Well, I’m alive!’ or ‘Well, I’m here!’ It’s basically my way of saying that somehow, I am still alive and carrying on even though I am so exhausted and fight every day.” — Kellyann N. 3. “I didn’t sleep well last night.” “ It’s more acceptable to be tired from a bad night’s sleep than it is to be too exhausted to deal with life today.” — Ciara L. “It’s an immediate response I turn to because I’m just always tired of my depression, but I’m not the best at lying.” — Max W. 4. “Eh, you know.” “ No, they probably don’t. But are they still able to identify with you? One hundred percent. And that makes them think you’re OK.” — Josie S. 5. “It’s too much.” “I say this whenever all my thoughts overwhelm me and I have no way of truly telling anyone how bad I really feel.” — Erin R. 6. “I’m exhausted.” “Just not the kind that can be cured by sleep. Some days I get so tired of fighting to survive and don’t want to fight anymore.” — Alecia F. “It’s the truth, every illness I have exhausts me to the core, but they usually brush it off as mom exhaustion (which also plays a part).” — Joanna G. “‘I’m tired’ usually means a lot from not feeling well to being emotionally exhausted.” — Breeanna M. 7. “I’m just out of it today.” “Code for: I really don’t feel myself right now and it’s scaring me. Those days don’t happen often but when they do, I’m afraid I’m relapsing and I will need to readjust my medication.” — Christa M. 8. “I’m fine.” “‘I’m fine, honestly.’ There are many times I’ve been struggling and even though I’ve been asked if I’m OK, I just can’t always seem to be honest and explain that I’m not. Usually because I can’t even make sense of it myself to tell someone else. Then I kick myself afterwards for not saying something. Can’t win.” — Amy W. “[For me], fine never means fine. If I’m vague like that, then I’m hurting but won’t admit it. If I’m good, I’ll say that but won’t openly admit to struggling.” — Jackie S. 9. “I’m bored.” “ Meaning that I’m so sick and tired and I’ve had too many struggles today and I don’t feel very good.” — Denisa 10. “I’m having an ‘off day.’” “Code for I don’t feel like me today, today is harder than other days. I may not act like I need you checking in on me, but I actually really do.” — Jenna L. “‘Off’ means I need time off from any responsibilities and wait for the feeling to pass. Hopefully.” “I’m just a lil off. It’s my code for: ‘I feel like I’m imploding but I don’t want to burden you.’” — Jace P. 11. “I’m hanging in there.” “Usually said because I don’t want to bother anyone with the things that are going on in my head.” — Katie S. 12. “I’ve been listening to music a lot today.” “Music is how I get away from the nightmare in my head. And when I can’t listen to it, I’m just quiet. Unfortunately the people around me don’t recognize either of these. Ever.” — Megs G. 13. “I don’t want to be alone.” “That’s when it’s really bad and I really need someone. Otherwise I’m usually silent and not my bubbly self.” — Milly S. 14. “I’m all good, don’t worry about it.” “It’s just what I do. [I] don’t want others worrying about me — gotta help fix them before I fix me.” Alexis D. 15. “I just can’t today.” “ [When I’m] not feeling too good.” — Scarlett E. What would you add? If you or someone you know needs help, visit our suicide prevention resources page. If you need support right now, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text “START” to 741-741 . Unsplash photo via Timothy Paul Smith

Seeking a therapist can feel overwhelming, daunting and a little bit scary. What will they ask me? How will I feel? Do I need to tell them everything? What if I feel uncomfortable? The questions we ask ourselves are often what hold us back from making that first appointment. However, professional counseling is often the missing link when it comes to managing our mental health, and sometimes the best person for you might actually be online. Two therapists from Talkspace , Kate Rosenblatt LMHC, LPC, and Amy Cirbus  PhD, LMHC ,  answer some of the most common questions from The Mighty community regarding online therapy. Talkspace’s mission is to provide more people with convenient, affordable access to licensed providers who can help those in need to live a happier and healthier life. Talkspace aims to present more people with the opportunity to utilize and benefit from therapy in a stigma-free environment. Learn More See their answers to the community’s questions below: Is there a difference in treatments if I see someone online versus in person? Online therapy has similarities and differences to in-person therapy. The biggest difference is how you communicate with your therapist. In-person therapy typically involves meeting in an office for a 50-minute or 1-hour appointment (frequency can vary depending on your specific needs). With online therapy, you can often send a text, audio or video message to your therapist anytime you like. Depending on your plan and insurance, regular live video sessions can happen too and can conveniently take place from almost anywhere. One of the distinct advantages of online therapy is the ability to reach out to your therapist more frequently instead of waiting for your weekly in-office appointment. Being able to get support, work on your goals and check in with your therapist throughout the week can make a significant difference. How do I know if my therapist is a good fit for me, especially in a virtual setting? Therapists vary in their specialities and offer different types of treatment, regardless of whether you see them in person or online. The best way to understand what to expect with your therapist is to ask questions about their qualifications, approach and areas of expertise. Finding the right fit can be really hard; it can take some trial and error. Therapists are human too, which means they may not be aligned with your wants, needs and values. And that’s OK! It’s important to find someone who is possibly in a similar life phase (so they relate to some of the experiences you have) and specializes in treatments that are relevant to your needs. Having followers, reviewers or other clients attesting to their competence helps too. After the first few sessions, whether in-person or virtual, start to ask yourself some important questions. Does your therapist spend more time listening than talking? Is this a person who demonstrates empathy and tries to “walk in your shoes?” Do you feel like they are open-minded and fluid? In therapy sessions, clients should be encouraged to lead the way, so it’s important that your therapist is a gentle guide, mentor and facilitator to help you move toward your goals. If they seem to take over the conversation, lack empathy in their responses or appear close-minded to your life situation, they may not be the best fit. I’m not sure how to articulate my feelings. What if I can’t express myself? Everyone is different in how they express their feelings. Some find that activities like art, movement, music and spoken word are the best ways to convey emotions. One of the great things about online therapy is that it allows you to use these mediums (and more) to communicate your feelings to your therapist. Try breaking the ice by sending your therapist memes, videos and songs that resonate with you. It’s also important to always go at your own pace when it comes to sharing what’s on your mind. Will they be able to understand/read how you are feeling on just a computer screen? If you are writing to your therapist, you may need to be more direct about how you are feeling since your therapist won’t be able to hear your tone of voice or see your body language. Consider using other methods of communication, too, like leaving your therapist a video or audio message or sending them some photos of your life. This can help your therapist get to know and understand you better. I keep talking about the same things over and over in therapy — is this normal? It’s completely normal (and typical) to repeat conversations in therapy until you reach a resolution! Sometimes you find it right away, and other times disclosing details can reveal it’s way more complex than you thought and will require more time to work through. That being said, if you feel like you’ve spent too much time on one particular subject, and it’s taking away from your ability to work through other things, tell your therapist you’re feeling stuck. We love your feedback! I’m feeling OK (I’ve felt worse).  How do I know if I should start therapy or wait? Even if you are feeling OK overall, therapy can still be beneficial. It’s a great place to find non-judgmental support outside of your friends and family.  Being in a fairly stable place in your life, as opposed to being in crisis, is also the perfect time to focus on creating and maintaining healthy habits and coping skills. Your therapist should also support you in identifying and achieving personal goals. Therapy is a space where you can reflect on your core values and use those values to create a meaningful life. It’s not only for times of urgency (although that’s important too!). Can I choose my therapist? What if I want to change therapists? Online therapy is, in many ways, like in-person therapy,  so you can always choose your therapist. The client-provider relationship is an important factor to ensuring a successful outcome, so you’ll also be able to select a better match for you if it isn’t working out. However, it’s important to give your therapist a chance to work together for at least a few sessions before making the switch. Is an online therapist available nationwide? I plan to travel in the near future and wonder if it will allow me to get care on the go. Talkspace online therapy is available nationwide. If you are on a trip or traveling, you can stay in touch with your therapist and continue working on your mental health goals. Where can I go to try online therapy? Interested in trying online therapy? Talkspace partners with some insurance plans. Even if you don’t have an insurance plan that covers mental health services like Talksapce, online therapy is typically less expensive than traditional face-to-face therapy. You may find that it fits your budget even if you are paying out-of-pocket . To help you get started, T he Mighty has partnered with Talkspace to give Mighty members $100 off Talkspace services with code MIGHTY . Learn More

If I were to ask you to picture and describe a depressed person, what would you envision? Someone having trouble getting out of bed every day? Someone who’s calling into work sick because they can’t leave the house? Someone who’s isolated from friends and possibly sleeping 10 or 12 hours a day? Someone who can’t stop crying and who’s feeling hopeless? Or would you envision a popular, college-educated professional living it up in the big city with a great job, a good group of friends and a long list of accolades to her name, but who wakes up each morning with a gripping sense of anxiety and an internalized pressure to continue to be “perfect” and “keep it all together?” Would you picture a successful Millennial startup employee who you admire for his discipline and drive but who inwardly is devastatingly self-critical and relentlessly demanding on himself and who, after work, copes with his life with a drink or two and several hours of gaming? And would you picture that smiling, competent, friendly coworker of yours who always seems to be getting All The Things done but who secretly, inwardly feels like she’s a complete failure and fears time is flying by and she’s wasting it every day? Let’s face it: you’re probably not going to picture these folks. And yet each of them could be a perfect example of someone dealing with what’s come to be known as “high-functioning depression.” While high-functioning depression doesn’t look like the stereotype of depression most of us hold in our heads, this diagnosis nevertheless carries significant risks if left untreated. But the uniquely tricky thing about high-functioning depression is that it’s hard to spot precisely because the people dealing with it look, from the outside, like they’re holding it all together. This can lead to a lack of ability to self-identify (or have those around you identify you) as depressed and, moreover, a possible resistance to seeking treatment because of the stigma surrounding more “typical” depression. And this is a big problem. So in today’s blog post, I want to explain to you what high-functioning depression really is, walk you through 11 signs of high-functioning depression and how this may show up, explain the unique risks associated with high-functioning depression, and share more about how you or your loved ones can get the help you need if you identify with high-functioning depression. What is High-Functioning Depression? In my opinion as a psychotherapist, high-functioning depression is a pop psychology term for what’s clinically known as dysthymia. Dysthymia, according to the “Diagnostic And Statistical Manual of Mental Disorders 5th Edition”  (DSM 5), is a mental health disorder characterized by: “Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least two years,” and includes the presence of two or more of the following symptoms, “Poor appetite or overeating; insomnia or hypersomnia ; low energy or fatigue; low self-esteem; poor concentration or difficulty making decisions; feelings of hopelessness.” And yet, while these symptoms may look diagnostically similar to the symptoms we think of when we envision major depressive disorder (MDD), individuals dealing with dysthymia may not have the same severe levels of impaired biological and mental functioning that can make major depression easier and more obvious to spot. In other words, someone struggling with dysthymia may still be able to get up and go to their demanding, prestigious job, be in a romantic relationship, post the believable smiley photos on Instagram, regularly get together with their girlfriends for happy hour and generally handle all the logistical adulting stuff of their life — passing for someone who doesn’t “look depressed.” But inwardly, this same person may be gripped with a challenging set of symptoms invisible to those of us who love and know them. Symptoms that may greatly diminish their overall quality of life, their career, their relationships, and bloom into more challenging mental health concerns if left untreated. 11 Real-Life Ways High-Functioning Depression Can Manifest Above, I provided you with what the DSM-5’s clinically indicative dysthymic symptoms. Now let’s talk, in layman’s terms, about 11 ways that some of these symptoms may manifest in your real life. 1. Difficulty experiencing joy. With high-functioning depression, the things that used to bring you pleasure — whether this is a cherished yoga class or a monthly ritual of getting together with your girlfriends — these same things don’t bring you joy anymore. They may feel like burdens or events you want to avoid because it feels like more of an effort than a support. 2. Relentless criticality — of self and others. You may have a relentless and invasive internal narrative that’s critical of yourself, of others and of the world in general. You think you’re a failure, you think your boss is an idiot, your partner’s the most irritating person to have ever lived, and life’s just one big slog. This chronically negative thought pattern may feel like something you just can’t turn off. 3. Constant self-doubt. You may constantly doubt whether or not you’re on the right career path, whether you’re in the right relationship, doubt what you’re doing with your life and if you can even handle being an adult. This pattern of constant self-doubt may be situational or pervasive but it’s something that feels like you just can’t get over. 4. Diminished energy. If it feels like getting through each day is like walking up a mountain with a backpack of rocks, if you feel like you barely have the mental, emotional and physical energy to handle your life anymore, if your overall energy levels are greatly diminished, this could be a sign of high-functioning depression. 5. Irritability or excessive anger. If you find yourself blowing up over small things — your partner says something wrong, your co-worker messed up a project, your kid just broke your favorite coffee mug, if you find yourself exploding in a way that feels disproportionate to the event, if irritability and excessive anger are something you’re wrestling with, this may be a sign. 6. Small things feel like huge things. Similarly, if you find yourself feeling overwhelmed or greatly stressed by an event that happens that maybe wouldn’t have felt like such a huge deal in the past (a friend cancels weekend plans, the grocery bags break when you’re carrying them in, your darn trackpad stops working because you spilled some coffee on it) and it feels like the End Of The World instead of the annoyance that it is — if you find your stress responses disproportionate to the event itself, this may well be a sign of high-functioning depression. 7. Feelings of guilt and worry over the past and the future. You worry that you chose the wrong career in college, you question whether you’re in the right grad school program, you worry about paying off all those student loans, you worry your biological clock is running out, you worry that you married the wrong partner, you worry about who’s going to care for your folks when they get older, etc. We all have these worries from time to time, but if feelings of guilt and worry over your past and future feel pervasive and dominant, this may be more than “normal” worry. 8. Relying on your coping strategies more and more. If you find yourself needing extensive zone-out time after work and on the weekends, turning towards your coping mechanisms more often than not — such as substances or behaviors like using alcohol, drugs, excessive gaming, constant Netflix, etc. — all in an effort to escape your life, this could speak to underlying depression. 9. Generalized sadness. If you find yourself feeling a generalized sense of sadness you can’t seem to pinpoint the cause of, if you drop your mask and armors of smiling competency when you close your door behind you, if you feel a subtle sense of hopelessness, this could speak to high-functioning depression. 10. Seeking perfection. This one’s a tough one. In a way our society condones perfectionism — getting good grades, getting into the Ivies, landing that amazing tech job, striving, striving, striving. But perfectionism has a shadow side where striving turns into unrealistic demands of yourself and psychologically beating yourself up when you fall short of the bar you set for yourself. If you find yourself doing this and it’s causing you distress, be curious about whether this a sign of high-functioning depression. 11. Inability to rest and slow down. If you need to clean up, tidy and organize the house after you arrive home from an exhausting day of work before you even consider letting yourself rest, if you find yourself uncomfortable with slowness, stillness and fallow periods of time because of the uncomfortable thoughts and feelings you come into contact with when you do actually slow down, this could be a sign of high-functioning depression. The Unique Risks To Being Someone With High-Functioning Depression. Mental health struggles come in all shapes and sizes but, as we undo the stigmatization and globalization of mental health scripted over these past few decades, most of us likely still have an unconscious image in our heads of what a depressed person looks like. And while this internalized image of someone who can’t get out of bed, who can’t hold down a job, and who has constant suicidal ideations may be one form of depression, it doesn’t mean that someone who sees themselves in the list above or in the clinical descriptor of dysthymia isn’t also dealing with depression. But these folks may not be willing to see themselves as depressed. And this can be a big problem. Because, in my clinical opinion, there’s a unique set of risks to being someone with high-functioning depression. First, because you’re still “holding it all together” it may make it harder for both you and others to spot the very real mental and emotional strain you may be under because you pass. You fly under the radar. You and those around you doubt the seriousness of what you may internally wrestle with because, after all, your life still looks pretty great from the outside, right? Second, as someone who is high-functioning, you may grow up believing that with enough effort and willpower, you can achieve, gain or fix anything that life throws at you. Not so with high-functioning depression. High-functioning depression isn’t just a bad attitude, and you can’t just “will your way” out of it. High-functioning depression is a biological and psychological disorder that requires adequate and clinically appropriate treatment. Arguably, the more you push and “will yourself out of it” instead of seeking proper support, the worse your symptoms may get. For example, if left untreated, high-functioning depression, or dysthymia, can potentially bloom into major depression or major depressive episodes where your biological and psychological functioning is more severely impaired. Or, perhaps in your attempts to deal with your high-functioning depression on your own, comorbid disorders — such as eating disorders or substance use disorders — can develop from your attempts to manage your intolerable feeling states. Bottom line: Dysthymia, or high-functioning depression, requires adequate clinical treatment as much as the most stereotyped version of major depression does. And the good news is that with proper clinical treatment, dysthymia can be managed. Treatment and Supports for High-Functioning Depression. While there is no single reason why someone develops dysthymia or high-functioning depression and while there is not necessarily a way to prevent it, there are several evidence-based effective treatment modalities to help you manage and support yourself if you deal with it:  Psychotherapy  and/or medication. In fact, according to a paper from “ The Canadian Psychological Association ,” “Psychotherapy is as effective as medication in treating depression and is more effective than medication in preventing relapse. For some patients, the combination of psychotherapy and medication will be more beneficial than either treatment on its own.” So if you see yourself in this article today, I strongly encourage you to  seek out a therapist  and/or speak to your doctor or psychiatrist about what treatment options may be available to you. The reality with high-functioning depression and moving through your days is that it can often feel like you’re attempting to build a castle on a foundation of quicksand.  Get the help you need  to build a solid, stable foundation for yourself — whatever that takes! — so you can build and craft a life in a more sustainable way. You’re so worth it. Now I’d love to hear from you in the comments below: Did you see yourself in this article? What’s one piece of advice you would give someone resisting seeking out therapy or talking to their doctor about possibly being depressed because they’re afraid of the stigma, believe therapy doesn’t work or that they can just handle it on their own? Leave a message in the comments below so our community of readers can benefit from your wisdom. And until next time, take very good care of yourself. Warmly, Annie Additional Resources: 1. 5 Important Things to Remember If You’re Experiencing Depression. 2. Four Effective Tools For Managing Anxiety. 3. The Mindful Way Through Depression: Freeing Yourself from Chronic Unhappiness . 4. DBT Skills Training Handouts and Worksheets , by Marsha Linehan, Ph.D. Follow this journey on Annie Wright Psychotherapy We want to hear your story. Become a Mighty contributor here . Image via Death To Stock/Contributor