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10 Ways Perfectionism Can Mask Depression — Almost Perfectly

Margaret Rutherford, Ph.D.
Psychologist & author
By Margaret Rutherford, Ph.D.
Psychologist & author
Margaret Robinson Rutherford, Ph.D., is an author and psychologist. She received her Ph.D. in Clinical Psychology from The University Of Texas Southwestern Medical School.
Image by BONNINSTUDIO / Stocksy
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Mallory was a perfectionist. She'd created a very successful, very engaged life. She loved her family and friends. Her career was going great guns. Hidden away, however, lay secrets that were slowly eating away at her will to live. 

In a recent interview, she revealed her truth. "Five years ago, just before my 39th birthday, I was seconds away from driving my car into the path of a tractor-trailer. The only thing that stopped me was seeing the driver's face. I realized he would think he killed me, and I couldn't be responsible for that. The next day I went to my longtime doctor and, for the first time ever, spoke freely about what I learned later was depression. I remember the pain in her eyes as she said, 'I had no idea. Why didn't you say anything?'"

Mallory's depression was real all right. But her near-tragic story is an example of an overlooked presentation of the disorder that I've termed perfectly hidden depression (PHD).  

So, let's talk about how to recognize PHD in yourself. Or someone you love. Or someone you treat. 

First, perfectly hidden depression isn't a diagnosis. It's a syndrome or group of behaviors and beliefs that are found together, sort of like salt and pepper. Or red hair and freckles. Many of its 10 traits can be healthy in moderation; it's when they're tightly interwoven and lead to complete denial and avoidance that the actual depression hiding underneath can remain silent. 

Ten common traits of perfectly hidden depression.

If you identify with PHD...


You're highly perfectionistic, with a constant, critical inner voice of intense shame.

Striving for excellence is one thing. Your motto: "If it's worth doing, it's worth doing well." But striving fueled by an almost constant voice of shame isn't simple striving. Your eye is on the goal. Those shameful voices can viciously berate you if you're not the perfect parent, most accomplished lawyer, head of the class, or "best" best friend. You consistently measure and evaluate your status, and if you're not meeting perceived expectations, you ramp up the pressure. Even though perfection is unattainable, your shame can whisper differently, and your own critical beliefs can hold you hostage. 


You demonstrate a heightened or excessive sense of responsibility.

You honor duty, obligation, and loyalty. You're über-responsible, and you rarely say no. You may seem as if you simply "like to be busy" or "enjoy a challenge." And if given one more responsibility, you'll pile it on your plate with the rest. Yet the actual motivation for assuming that new task is that it provides further distraction from anything painful.


You have difficulty accepting and expressing painful emotions.

You may be able to describe your emotions. You can say, "My best friend's husband was diagnosed with cancer. We're all shocked." But you struggle to actually express any sadness or fear. You can feel it for an instant, but it disappears before any tears can come to your eyes. You may even believe that tears signify weakness rather than intensity. And with this emotional drought can come intense loneliness. 


You worry a great deal and avoid situations where control isn't possible. 

You aren't someone who can easily remain rooted in the present. If you do yoga, you may hate the final position, the suggestion being to breathe and relax. You love to cook but have a very hard time sitting with guests and enjoying the meal.

Your need for control is strong, and so a lot of time is spent worrying about the things that might occur to interrupt that control. Yet you must not seem as if you're worrying. People will shake their heads and wonder aloud: "You never seem to have a care in the world. You don't sweat the small stuff."


You intensely focus on tasks, using accomplishment as a way to feel valuable.

If you're having a bad day, it feels good to get something done that perhaps you've been putting off. There's value in purpose and effort.

But you carry it too far. You're struggling to feel an innate sense of self-worth, not one based on what you can do but based on who you are. Since you tend to believe that if anyone knew your vulnerabilities, you'd be judged or rejected, then you require the next accomplishment as a tangible sign of your value. 


You have an active and sincere concern about the well-being of others while allowing few, if any, into your inner world.

Caring for others is something you do very well. However, you don't reveal your own struggles or vulnerabilities. You don't reveal pain from your past or your present. Your spouse or best friend might know the facts, but they aren't discussed. There's a wall up against the revelation that you feel empty or overwhelmed.

This can be especially dangerous when suicidal ideation is present, and you can't let anyone in or ask for help. Devastatingly, even if you do, you may not be believed. "What, you? Depressed? You've got everything in the world going for you." 


You discount or dismiss 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 to put those feelings away until a time when you can more effectively deal with them. You can even compartmentalize joy; sometimes it's not the time to burst out singing.

However, if you identify with PHD, you rigidly over-compartmentalize. You've developed very strong boxes where you lock painful feelings away, either consciously or unconsciously, shoving them into a dark recess of your mind. This allows you to discount, deny, or dismiss the impact of difficult or even traumatic life experiences.


You have accompanying mental health issues, involving control or escape from anxiety.

You live your life in a very controlled, well-governed fashion. So, actual psychiatric diagnoses that might coexist with PHD are disorders having to do with control, such as eating disorders or anxiety disorders. Use of alcohol or sedative medications might also be a problem as you seek escape from pressure. 


You hold a strong belief in "counting your blessings" as the foundation of well-being.

Counting your blessings and expressing gratitude is healthy. But what's termed rigid positivity is a problem here, where expressing self-compassion is out of the question. Instead of acknowledging the reasonable and rational impact past struggles or abuse had on you–a gift you easily give to others–you don't choose to do it for yourself. That would be viewing yourself as a victim or being a whiner. And that's unacceptable. 


You have emotional difficulty in personal relationships but demonstrate significant professional success.

In the professional structure, you thrive. You know and follow the rules. You work hard and are successful. 

Yet true intimacy requires vulnerability. The rules, such as they are, are much looser; the roles less defined. And as we've already discussed, vulnerability is much more difficult for you. So, being a good giver, you may have attracted really good takers. Or you may have chosen a partner who isn't comfortable with vulnerability either. Your relationship may be based primarily on what you do rather than who you are for each other, with the emphasis staying on the kids, your careers, and being the perfect-looking couple to others. 

If you've woven an intricate façade of the perfect-looking life, it can be terrifying to reveal more of who you really "are." There are multiple mental and emotional hurdles; the perceived stakes can be very high; the strategy can be conscious or largely unconscious; the predicted loss of status or control can be frightening. Yet there are those who decide to risk the revelation of early trauma or childhood struggles, realizing if they do not, the lives that they'd fought so hard to create might end by their own hand.

If you identify with perfectly hidden depression, you can risk. You can learn to accept your vulnerability. You can confront shame. 

And you can begin to live more fully and freely, no longer silent in your struggle. 

Perfectly Hidden Depression® is a registered trademark. If you're wondering where you might stand on the spectrum that is PHD, take this questionnaire.  

Margaret Rutherford, Ph.D. author page.
Margaret Rutherford, Ph.D.
Psychologist & author

Margaret Robinson Rutherford, Ph.D., is an author and psychologist in private practice for over twenty-five years. She received her Ph.D. in Clinical Psychology from The University Of Texas Southwestern Medical School. She has written for a variety of outlets, including HuffPost, The Mighty, Psych Central, The Gottman Blog, Psychologies, StigmaFighters, The Good Men Project, and This Is My Brave. Her most recent book is called, Perfectly Hidden Depression: How to Break Free from the Perfectionism that Masks Your Depression.