Traits of a perfectly hidden depression syndrome • Your perfectionism is fueled by a constant, critical inner voice of intense shame or fear. • You demonstrate an excessive sense of responsibility and look for solutions. • You are unable to accept and express painful emotions. • You dismiss or discount abuse or trauma. • You worry a lot and avoid situations where you're not in control. • You are highly focused on tasks and expectations and validate yourself with your accomplishments.

Depression is not a joke 

Learn to spot unhealthy perfectionism, understand its emotional sources and find a way to silence that self-critical voice

personaldevelopment

Personal Development

Learn to spot unhealthy perfectionism, understand its emotional sources and find a way to silence that self-critical voice

Torn advertising poster, New York, 1960. Photo by Ernst Haas/Getty

Margaret Rutherford has been a psychologist in private practice for more than 25 years. She hosts <a dir="ltr" href="https://drmargaretrutherford.com/selfwork/" rel="">The SelfWork Podcast </a>and is the author of <a dir="ltr" href="https://drmargaretrutherford.com/perfectlyhiddendepressionbook/" rel="">Perfectly Hidden Depression </a>(2019). She lives in Arkansas.

Edited by Christian Jarrett

‘If it’s worth doing, it’s worth doing well.’ How many times did I hear that growing up? My parents were attempting to teach me (just in case I hadn’t absorbed it from their actions) the importance of striving for excellence. They were encouraging what some psychologists call ‘constructive perfectionism’ or ‘healthy perfectionism’ – a personality trait that’s associated with finding enjoyment and even fulfilment in life from doing things as well as you possibly can. With constructive or ‘positive perfectionism’, the focus is process-oriented; you learn from mistakes or even failure. It’s generally considered a beneficial trait that’s linked with being more conscientious and self-disciplined.

Yet perfectionism can have a darker side. The American academic and author Brené Brown defined this kind of perfectionism in her first <a dir="ltr" href="https://www.hazelden.org/HAZ_MEDIA/2545_GiftsofImperfection.pdf" rel="noreferrer noopener">book </a>, The Gifts of Imperfection (2010), as ‘a self-destructive and addictive belief system that fuels this primary thought: if I look perfect, live perfectly, and do everything perfectly, I can avoid or minimise the painful feelings of shame, judgment and blame.’ This form of perfectionism, which is fuelled by inner shame that must be quelled, involves trying to constantly meet perceived expectations of what ‘perfect’ is. This perfectionism isn’t fulfilling and it’s far from enjoyable. Yet many people feel it’s mandatory to look as if all is perfect. They believe that not to do so would imply imperfection.

This is what’s <a dir="ltr" href="https://psycnet.apa.org/record/1996-14509-001" rel="noreferrer noopener">known </a>in the wider psychological literature as ‘unhealthy perfectionism’ or ‘destructive perfectionism’. In this case, the purpose has nothing to do with process. It’s goal-oriented. It’s driven. It’s pressured. And I believe it’s increasingly contributing to mental health problems.

Constructive perfectionists, let’s say if they’re swimmers, want to beat their personal best. That brings with it all kinds of positive vibes. Winning the race is great, if indeed they do.

But destructive perfectionists want to be the perfect swimmer. And winning every race is the goal; if not, shame says to them that they have little to no value or worth.

Many perfectionistic people will fall somewhere on a spectrum between the two poles. But in my clinical practice I’ve noticed another issue. Ironically, destructive perfectionists might not even recognise themselves as perfectionists, because they never believe their best is good enough. There’s always the next achievement. And then the next. And the next.

So, what are the roots of destructive perfectionism? I believe people often develop this way of thinking and being when they grow up without a sense of support, safety and nurturing. It can also be a reaction to childhood trauma or extreme cultural expectations, where appearing perfect becomes a mandatory strategy to emotionally survive, and where vulnerability is disdained.

Over the past decade, I’ve treated more and more people who didn’t quite know why they’d come to therapy. They’d erected huge barriers against revealing any kind of emotional pain; I wondered if they even had the capability of expressing such feelings. Outwardly, they didn’t seem depressed at all; the descriptions of their issues sounded more like the result of overwork, fatigue or mild anxiety.

My interpretation is that they were destructive perfectionists who were running out of steam, but not sure what, if anything, was wrong. Their emotional pain was expertly, and often unconsciously, hidden.

If I asked them if they were depressed, I’d hear a firm denial. ‘I have too many blessings in my life.’ If I questioned whether or not their childhood provided safety and security, they’d laugh and deny or discount any kind of problem. Or sometimes they’d become very quiet and look out the window, as if they wished they were anywhere but my office.

Yet as they returned for more sessions, they’d slowly risk sharing one shame-filled secret after another. Their seemingly impenetrable cloak of silence would slowly slip off, only to reveal tremendous loneliness and despair.

And in many cases, as they let down their guard, I found they could also understand that what was ‘wrong’ or unhealthy might not fit the rubric of classic depression. But it was just as real. And just as damaging.

I began researching the popular literature about perfectionism, shame and fear of vulnerability. I found a wealth of <a dir="ltr" href="https://www.guilford.com/books/Perfectionism/Hewitt-Flett-Mikail/9781462528721/authors" rel="noreferrer noopener">research </a>and writings about the importance of vulnerability and the cost of shame by the aforementioned Brown, the much earlier thoughts on ‘covert depression’ by the author and family therapist Terrence Real, and the <a dir="ltr" href="https://www.harpercollins.com/products/self-compassion-kristin-neff?variant=32205936885794" rel="noreferrer noopener">book </a>Self-Compassion (2015) by the psychologist Kristin Neff. But crucially I couldn’t find anything for the general public about the relationship between perfectionism and a form of potentially serious depression.

So, drawing on the experiences and stories of the many clients I’ve seen in my practice over 25 years, I formulated my own ideas about this distinct problem and how it can be addressed most effectively and compassionately. My work – laid out in my <a dir="ltr" href="https://drmargaretrutherford.com/perfectlyhiddendepressionbook/" rel="noreferrer noopener">book </a>Perfectly Hidden Depression (2019) – is based on how a dangerous kind of perfectionism-fuelled depression can affect someone’s life; how even if someone scores low on a standard depression inventory, they can be living with deep-seated emotional difficulties and unresolved traumatic experiences that might ultimately threaten their will to live. This is the syndrome I call ‘perfectly hidden depression’.

I’ve identified 10 traits that manifest in the daily decision-making and behaviour of people who exhibit signs of this syndrome:

<ul><li>You are highly perfectionistic, fuelled by a constant, critical inner voice of intense shame or fear. </li><li>You demonstrate a heightened or excessive sense of responsibility and look for solutions. </li><li>You have difficulty accepting and expressing painful emotions, remaining more analytical or ‘in your head’. </li><li>You discount, dismiss or deny abuse or trauma from the past, or the present. </li><li>You worry a great deal (but hide that habit) and avoid situations where you’re not in control. </li><li>You are highly focused on tasks and others’ expectations, using accomplishment as a way to feel validated. Yet as the last accomplishment fades, new pressure assumes itself, and any success is discounted. </li><li>You have an active and sincere concern for the wellbeing of others, while allowing few (if any) into your inner world. </li><li>You hold a strong belief in ‘counting your blessings’ and feel that any other stance reflects a lack of gratitude. </li><li>You have emotional difficulty with personal intimacy but demonstrate significant professional success. </li><li>You might have accompanying mental health issues that involve anxiety and control issues, such as obsessive-compulsive disorder (OCD), generalised anxiety disorder (GAD), panic and/or eating disorders. </li> </ul>

If you read these 10 traits and find that many or all of them match you, then hopefully this is in some sense reassuring – it might give you an inkling of why you feel the way you do, how you haven’t known what was wrong and have been ashamed to even consider it. If suddenly a light has come on – you recognise that you can’t bring yourself to share any vulnerability; or perhaps you recognise these traits in someone else, then first – breathe. And know this: I’ve found there is an antidote to perfectly hidden depression – self-acceptance.

If you believe that you are an unhealthy perfectionist and that it could be masking your own deep-rooted emotional problems, I propose five stages that can help you: consciousness, commitment, confrontation, connection and change.

The first stage: consciousness

This stage refers to the importance of becoming aware that your perfectionism is a problem in the first place. Although recognising one’s problems is a part of every emotional/mental healing process, this stage might be especially complicated for you because you’ve convinced yourself that your perfectionist traits are normal or not a problem. ‘Isn’t everyone like this?’ you might wonder. The answer to that is a resounding ‘no’. Yet giving up or tweaking a strategy that’s brought you external success is likely to be very difficult. In fact, the process of avoiding any painful feelings and memories might have become something you do unconsciously.

There are various ways to develop more insight into the role that destructive perfectionism is playing in your life, but one exercise that you can try on your own is mindfulness. Mindfulness authors teach that it’s not a process where you have to ensure you’re always focusing intently on something. Mindfulness is more about changing how you’re paying attention. Mindfulness deepens your experience of the present.

Here’s one simple mindfulness technique: sit somewhere comfortable and set a timer for three to five minutes. Breathe deeply and close your eyes. Stay as focused on your breaths as possible, even counting them from one to 10, and then starting over. If your mind wanders (which it will), gently let go of those thoughts and refocus on the breath. When the timer goes off, check in with your emotions, your eyes still closed. There could be irritation, relief, feeling silly. Simply notice and watch them dissipate.

Becoming conscious takes patience. The more you practise mindfulness, you’ll begin to notice more about how you’re interacting with both your external and internal worlds, including developing greater insight into how needing to seem perfect has seeped into almost all aspects of your life.

The second stage: commitment

As you become more aware of the problems perfectionism is causing you, you might still find that changing is hard. Ironically (and destructively) this can morph into another goal for you to reach perfectly. I’ve found that there are five major stumbling blocks to challenging perfectionism’s grasp on your mind and heart:

<ol><li>Adopting such a rigid commitment that when you falter or don’t do it perfectly, you’ll quit or simply want to stop thinking about it. </li><li>Beginning with a goal that’s too hard or too large. </li><li>Going it alone and not asking for help along the way. </li><li>Dealing with the fear and shame of giving up your persona with its familiar coping strategies – while stress increases. </li><li>Other mental difficulties you might have worsening due to the pressure, such as OCD or an eating disorder. </li> </ol>

One of the best strategies for overcoming the first two potential stumbling blocks is to alter the goal of ‘commitment’ to that of ‘intention’. It’s less autocratic and holds more grace and forgiveness. Zooming in now on the third stumbling block, try this writing exercise: reflect and write down instances that you can remember where you didn’t ask for help but, in hindsight, it would’ve been helpful to do so. Go back and replay what you could’ve said or asked for. Practise those sentences coming out of your mouth and hear yourself say the words. How does doing that make you feel? Try to think now of the present, and a situation where you could ask for help.

This will stretch your awareness of how needing to seem in control prevented you from asking for help. And when you begin to actually practise asking, it’s as if you’re an actor, going over your lines. The practice itself can help create a new sense of you – someone who can ask, and does ask, for help.

You might find the fourth stumbling block in the list to be the most difficult. Dropping your perfectionist tendencies will feel like shedding your armour while in the midst of battle – you’ve been using them as a coping mechanism for so long, albeit one that’s counterproductive. Journaling is one of the best ways to begin getting down on paper those times when, where and how you’re tempted to slam that mask back on. Then you can better predict the times you’re likely to falter. If that happens, remember the complex reasons behind this habitual behaviour and try to treat yourself compassionately.

The fifth block in the list is a reminder that addressing your perfectionism won’t be easy and you might need to stop this work for a bit and attend to any worsening clinical symptoms of anxiety or other disorder. If you’re worried this is the case, please seek the help of a mental health professional. But don’t be demoralised – remember that healing is a process, not a destination; you need to stay safe while healing.

The third stage: confrontation

Let’s talk about the difference between personal beliefs and rules. The rules you set yourself govern how you behave. Your beliefs are something you accept to be true. The two interact. Your beliefs likely influence the rules you set yourself. At the same time, the rules you follow can limit or expand your beliefs. For example, you might have the rule ‘I always put a smile on my face, no matter what.’ It’s connected with the belief ‘People won’t like me if I don’t smile.’

The confrontation stage involves identifying the rules you live by, possibly without even realising it – what you consider is allowed or disallowed, what you should do, must not do, always need to do, never should do. They’re in your head all the time. But are they still rules you want to follow? They could be spoken rules from your family, the culture you live in, the dangers surrounding you, what’s expected of you – or they could be unspoken yet understood.

If you decide a rule doesn’t serve you well, write one out that could take its place. The realisation that you could replace a rule with a new one can be liberating. You’re beginning to visualise a life that can be more freely lived. And that can be life-changing.

The fourth stage: connection

If you’re following these stages and beginning this journey, you might have become much more aware of your own vulnerability. It can be terrifying to consider connecting with feelings that you’ve long suppressed. Looking in control, pleasing others, keeping your foot on the accelerator at all times – you might feel that all these choices have protected you. To confront shame head on, to connect with anger, to admit fatigue – you can fear feeling far too exposed.

Think about a turtle. At any sign of danger, the turtle pulls its head back in and waits. Similarly, if you’re prone to destructive perfectionism born from a difficult past, it’s likely that you too tend to withdraw into whatever shell you can find when painful feelings get stirred up.

Real’s book I Don’t Want to Talk About It (1998) has a quote that’s apt. He’s talking to a patient about emotional vulnerability, and the guy, who was trying his best to understand why it was important to engage with one’s difficult emotions, finally says: ‘You either feel it or live it, right? The pain. Either feel it or live it. Isn’t that what you’re going to say to me?’

He got it. The point is that, if you don’t connect with and process your emotional hurt, anger or sadness, it will govern your life in ways that you can’t see – you’ll end up blindly living it.

If you are feeling safe and secure, and you have support on hand should you need it, here’s an exercise to help you better connect with your difficult emotions. (Please don’t do this alone if you have severe trauma in your past. You’ll need an expert’s guidance and support to safely connect with that pain.)

Carefully create a timeline, where you divide a horizontal line by years of age: write ‘2, 4, 8, 12, 20’ and so on. You’re going to go back to those years and write down both the good and the hurtful things that occurred to you. This is an exercise in acknowledgment. Not blame. Acknowledge the good, the bad, and the ugly. This will also take courage as you confront the denial that might still want to emerge and complain: ‘Oh… it wasn’t that bad.’ You’re not whining. You’re acknowledging the emotional consequences or charge of an event with the same compassion you’d show someone else. You’ll begin to see patterns and connections between events. And, hopefully, you will find self-compassion.

This exercise can be powerful, as you go back and acknowledge the things that made you who you are – both the positive gifts you received and how your talents and skills led to success. But you’re also honouring pain from your past that you’ve discounted or denied, forgotten or avoided. You’re allowing yourself to recognise that you are the sum of all of your experience. And self-compassion – recognising the impact of whatever pain was there and showing yourself the same kindness you’d freely give another – is empowering. There’s no more reason to hide. You can accept what’s there, all of it. And all of you.

The previous confrontation stage and this connection stage are where you’re going to find the reason ‘why’ you began needing to look perfect. To build on the exercises you’ve already completed, ask yourself what messages you received in the past about your value and safety within relationships. And begin to realise that you don’t have to live by those rules or avoid pain any longer. Connecting with pain teaches that you can tolerate it and that your vulnerabilities don’t define you any more than your successes do.

The fifth stage: change

In my years as a clinician, I’ve learned the benefits of insight (hopefully increased for you by working through the connection stage and by reading this Guide). It offers context and understanding. But where your hope comes from is through changing your behaviour – that is, seeing positive results from the efforts you’re making. This final stage is where you’ll find that hope.

So, one last exercise: go through the 10 traits I listed that are associated with perfectionism-fuelled depression and, with trusted friends, your partner, a parent or a therapist, think about specific ways you can begin to put your insight to work and actually risk behaviour change – living each day differently, making different decisions, treating yourself with greater kindness. Choose which is the simplest and give it a try. This isn’t something to do perfectly. Remember, you’re on a journey.

Often, someone will come into a therapy session and begin with: ‘Well, I tried something new, but it wasn’t a big deal.’ I tell them every change in a welcome and desired direction is a huge deal. This stage allows you to choose each small step you’re ready to take – whether it’s saying no, or allowing someone else to lead, or to risk confiding in a friend – and invites you to celebrate those changes.

<ul><li>If you’re someone with the trait of positive perfectionism, which is process-oriented and about striving for excellence, then use it. Enjoy it. And thrive. </li><li>In contrast, destructive perfectionism involves obsessive focus on unrealistic goals, and I’ve identified a syndrome that I call ‘perfectly hidden depression’ in which striving to appear perfect at all times is a counterproductive strategy that masks a difficult past and emotional vulnerability. If you identify with this description, please know there’s a way out. It’s not easy. But if you’re patient with yourself, you can do it. </li><li>My advice is based on five interactive stages: consciousness (recognising the problem); commitment (overcoming the obstacles to change); confrontation (changing the unhelpful rules that you live by); connection (processing the difficult feelings that fuel your perfectionism); and change (recognising and celebrating your progress). </li><li>You might need to reconsider unhelpful relationships that are preventing you from achieving positive change, for example by setting new boundaries. </li><li>You’re worth fighting for, not despite your imperfections, but because of them. You’re worth loving, not because of what you can do, but because of who you are. </li> </ul>

Researchers worldwide are <a dir="ltr" href="https://www.apa.org/pubs/journals/releases/bul-bul0000138.pdf" rel="noreferrer noopener">investigating </a>perfectionism’s causes, be they cultural, political, familial, social or an interaction of all four of these factors. There’s some <a dir="ltr" href="https://www.apa.org/monitor/nov03/manyfaces.html" rel="noreferrer noopener">disagreement </a>on whether or not perfectionism can be adaptive at all or if it’s almost always maladaptive.

Among the different kinds of destructive perfectionism described in the literature, there’s ‘self-oriented perfectionism’, which is pushing yourself to the extreme; ‘other-oriented perfectionism’, which is about expecting perfectionism from others; and ‘socially prescribed perfectionism’, characterised by feeling the need to meet the perceived high expectations of others. The most dangerous is the last because of its <a dir="ltr" href="https://link.springer.com/chapter/10.1007%2F978-981-10-4816-6_19" rel="noreferrer noopener">associations </a>with suicidality.

There’s other terminology out there. For example, in a <a dir="ltr" href="https://www.sciencedirect.com/science/article/pii/S0092656620300428" rel="noreferrer noopener">meta-analysis </a>published in 2020, the authors distinguished between ‘perfectionistic concerns’ (which includes trying to reach external goals/expectations set by others, similar to ‘socially prescribed perfectionism’) and ‘perfectionistic strivings’ (pushing yourself to perfection, similar to ‘self-oriented perfectionism’). They found that both forms of perfectionism were linked with depression and social disconnection, and that perfectionistic concern was further associated with greater stress.

In general, all types of destructive perfectionism appear to be <a dir="ltr" href="https://hbr.org/2018/01/perfectionism-is-increasing-and-thats-not-good-news" rel="noreferrer noopener">on the rise </a>and many findings point to links with suicidality. The rate of unhealthy perfectionism in younger generations is especially concerning, with studies showing it’s measurably out of hand.

Hopefully, I’ve helped you understand how perfectionism – which can sound like a virtue – can be harmful. If you believe you exhibit the signs of unhealthy perfectionism and especially ‘perfectly hidden depression’, I think the exercises in this Guide will begin to help you create another way of living and being.

However, the hardest work isn’t making a change; it’s maintaining it. There are so many pulls and tugs from that perfectionistic shaming voice that holding on to a fresh perspective and behaviour can be challenging. But it can happen; it simply takes practice. And lots of it.

Yet, sometimes people in your world don’t support the changes you’ve made. And you might want to reconsider relationships that are too damaging, and to set appropriate boundaries in the ones that remain.

For example, maybe your family is still expecting you to constantly do for them, without regard for your own needs. Maybe you spend hours on the phone with a friend who demands all of your attention and constantly says how she doesn’t know what she’d do without you. People in your world might have become far too accustomed to you working too hard, giving too much, and not asking for anything in return. Assess whether or not these relationships can nurture the ‘new’ you and try to establish new boundaries.

You’re worth fighting for, not despite your imperfections, but because of them. You’re worth loving, not because of what you can do, but because of who you are. You’re growing in true strength, not because you seem in control, but because you’ve found self-acceptance and can listen and respond to every part of you.

The material in this Guide is drawn from my own <a dir="ltr" href="https://drmargaretrutherford.com/perfectlyhiddendepressionbook/" rel="noreferrer noopener">book </a>, Perfectly Hidden Depression: How to Break Free from the Perfectionism that Masks Your Depression (2019).

In the Netflix <a dir="ltr" href="https://www.netflix.com/gb/title/81010166" rel="noreferrer noopener">documentary </a>Brené Brown: The Call to Courage (2019), the American academic and author eloquently describes the dangers of shame and the healthiness of vulnerability.

Brown’s Ted <a dir="ltr" href="https://www.ted.com/talks/brene_brown_the_power_of_vulnerability?language=en" rel="noreferrer noopener">talk </a>The Power of Vulnerability (2010) has had more than 50 million views, which makes it one of the most watched ever. She discusses her research into vulnerability and human connection.

The <a dir="ltr" href="https://podcasts.apple.com/us/podcast/middle-finger-to-perfection/id1123408201" rel="noreferrer noopener">podcast </a>Middle Finger to Perfection is hosted by two recovering perfectionists – the psychotherapist Jenna Teague and the life coach Ashley Looker – who share their own struggles with perfectionism and invite various guests who are working in this same area. I joined them for an <a dir="ltr" href="https://podcasts.apple.com/us/podcast/perfectly-hidden-depression-with-dr-margaret-rutherford/id1123408201?i=1000486940024" rel="noreferrer noopener">episode </a>in August 2020, and found them engaging and delightful.

In the short YouTube <a dir="ltr" href="https://www.youtube.com/watch?v=dVeTo03opu8" rel="noreferrer noopener">presentation </a>‘The Problem With Being Perfect’ (2018), the author and speaker Mel Robbins discusses perfectionism and how to address it.

How to get over ‘never good enough’ | Psyche Guides

Depression is not a joke

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