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What Is Perfectly Hidden Depression?


hide photoWelcome to a new column on Psych Central! I’m Dr. Margaret Rutherford, and I’m a clinical psychologist whose practice has been based in Fayetteville, Arkansas for twenty-five years. I couldn’t be more excited to share with you what I’ve been researching and writing about for the last four years — Perfectly Hidden Depression ®.

In the spring of 2014, I wrote a blog post that I hoped would be interesting — even engaging. The title?  “The Perfectly Hidden Depressed Person — Are You One?”

I’d been blogging weekly for over a year by that time, something I’d come to love doing. As I sat in my sunroom, writing what was to become another offering, I was thinking about several patients I’d seen over the years — patients whose work differed from the classically depressed patient. Their emotional pain was difficult to reach, and if not paying attention, was easy to miss. They were smiling, talking about how funny they felt about coming in to see a therapist. They complained of anxiety, not being able to sleep, feeling as if something was wrong that they couldn’t put their finger on. They were highly engaged in the community, the church, or with their families, successful in almost everything they touched. They were do-ers. Go-getters.

Initially, they denied trauma or childhood problems. Or if they mentioned something, it was quickly discounted. “There are so many people that had it worse than me.” “It was all such a long time ago.” “I haven’t thought about those things in years.”

Yet as we began reframing their histories, couching their childhood experiences in terms of self-compassion and acceptance of potential anger, hurt or pain, a tear might appear suddenly. A look of poignant relief would emerge from what had been a carefully crafted persona of perfectionism. And these very courageous people would reveal a long ago rape, or a refrigerator that had been full of beer, instead of food.

So that spring of 2014, I termed this self-presentation, “Perfectly Hidden Depression.” PHD for short.

The post was interesting all right. It went viral.

Whatever had occurred, whatever paths had led to the survival strategy of detaching from or even dissociating from emotional pain — whether or not they were intentionally erecting this barrier, or whether it had become so deeply entrenched that it was mostly unconscious — people began reaching out. They couldn’t ignore their dramatic response to hearing themselves so accurately described.

Hundreds of emails poured into my inbox.

What you can expect here on Psych Central…

I am honored and delighted that, today, Psych Central will become a fresh place where we can further discuss and try to understand PHD. It’s similar to what’s been called “smiling depression” or “high-functioning depression.” Yet this new term, Perfectly Hidden Depression, will more specifically identify the interplay of efforts to remain unseen by others, and actual depression.

And we’ll go further, identifying the behaviors and belief systems that serve as the foundation of such an intricate and complex emotional survival strategy. We’ll review recent research on the relationship between perfectionism and depression, and pull resources from multiple writers, researchers and therapists, such as Drs. Brene Brown and Kristin Neff, whose work speaks directly to the power of vulnerability and self-compassion.

In the coming weeks, we’ll identify the ten characteristics of the syndrome of PHD — ten beliefs and accompanying behaviors that are found with one another. Basically, when you see one, you’re likely to see the others — like salt and pepper, or red hair and freckles.  There will be a questionnaire available for readers to take, to determine their score on the spectrum of PHD. We’ll further describe the many pathways to the development of PHD, and what can maintain its presence.

Healing Perfectly Hidden Depression through self-acceptance…

And of course, we’ll talk about healing.

If, as Andrew Solomon eloquently quotes, the opposite of (classic) depression is vitality, the opposite of Perfectly Hidden Depression is self-acceptance.

We’ll look at healing techniques and experiences, where someone with PHD can begin to carefully and safely begin to risk unveiling their true selves, one small but vitally important step at a time. They can do healing work around whatever trauma or loss occurred, and can begin to feel and express who they are in the moment, finally breathing a sigh of relief. They can begin to slowly connect with feelings of anger, fear or sadness that have been shut away or denied, but will be freeing to accept and work through. They can work with their loved ones in making whatever adjustments are needed to help them maintain this new emotional awareness and honesty. And they can confront their greatest fear that, if they show any vulnerability, that they will be seen as weak and incompetent.

Hiding will no longer be necessary. The need to appear perfect? All but a painful memory.

Yet it’s kind of like a game of Jenga. Whatever thought you risk challenging, whatever behavior you choose to tweak, or whatever emotion you begin to allow to surface has to be chosen with care. Or the fear of everything falling apart is too great. You’ll stop, and start hiding all over again.

There’s more than one reason to identify Perfectly Hidden Depression..

There’s more than one reason we need to shine a light on PHD. The suicide rate is dramatically increasing, both here in the United States and internationally. Studies showing a relationship between perfectionism and suicide are appearing. The pressure of social media seems to be having an effect, as teenagers report more depression, and their suicide rate is going up. Books on the topic are grabbing our attention, such as, “What Made Maddy Run,” a story of a young college athlete who admitted some struggles, while remaining at the top of her athletic and collegiate game. She tragically died by suicide.

No one should fall through the cracks. No one should be left to deal with hidden depression alone, no matter how perfectly it’s hidden.

Maybe if we talk about it — perhaps if we give permission to one another to reveal struggles more openly, we can curb this tide. Maybe if we alert mental health clinicians to think again before making an assumption that if someone doesn’t look anhedonic, they’re not depressed.

It could be Perfectly Hidden Depression.


Next week’s column will discuss the differences between healthy coping, depression and Perfectly Hidden Depression. I’d love to hear from you below or, more confidentially, on my email: Thanks so much!

You can hear more about PHD and many other topics by listening to Dr. Margaret’s new podcast, SelfWork with Dr. Margaret Rutherford or click here to read her other work.

Perfectly Hidden Depression® is a registered trademark.

Photo by A_Peach

Photo by A_Peach

Photo by A_Peach

Photo by A_Peach

What Is Perfectly Hidden Depression?

Dr. Margaret Rutherford

Dr. Margaret Rutherford is a clinical psychologist who's practiced in Fayetteville, Arkansas for twenty-five years. Her passion for researching Perfectly Hidden Depression began in 2014 and she's currently writing a book to be published next year by New Harbinger. Her work has been featured on Psychology Today, The Huffington Post, The Mighty and The Good Men Project, among others. She's the author of "Marriage Is Not For Chickens", a blogger (Https:// and podcaster (SelfWork with Dr. Margaret Rutherford). She welcomes your questions and comments --

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APA Reference
Rutherford, D. (2018). What Is Perfectly Hidden Depression?. Psych Central. Retrieved on November 27, 2020, from


Last updated: 15 Feb 2018
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