What may be intriguing by now in our exploration and discussion of Perfectly Hidden Depression® is this question: If someone isn’t going to reveal their depression or their pain, how in the world are we supposed to identify what’s going on? How is the mental health community able to recognize what’s not voiced or seen? How are family members or friends able to help someone with PHD — someone who doesn’t show the classic symptoms of depression? What if the person themselves hasn’t a clue that something like PHD exists?

Perhaps our best bet is to be able to identify what behaviors and what beliefs constitute the syndrome of Perfectly Hidden Depression itself. It’s like trying to determine when and where a tornado might be created. What are the precursors that are ultimate warning signs? What conditions have to be just right for a funnel cloud to form? Until all the signs are perfectly aligned, there’s no tornado. Yet suddenly, “out of nowhere,” destructive powers reveal themselves.

We need to know the early warning signs. We need to have systems in place to interpret data, and not take what can be easily viewed on the horizon as total reality. We need to add another lens to our camera, one that could predict problems before they surface.

The ten major characteristics of Perfectly Hidden Depression…

Below are the ten primary characteristics of PHD. They’re not all present in every person who might recognize themselves in PHD. But they’re fairly consistent. In later columns, we’ll travel deeper into each one. But for now, we’ll outline them quickly.

1. Is highly perfectionistic, 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 appear perfect. They’re the perfect mom, an accomplished lawyer, head of the class, or a fantastic best friend. They consistently measure and evaluate their status, and if not meeting expectations, they ramp up the pressure.

2. Demonstrates a heightened or excessive sense of responsibility.

People with PHD are very aware of duty, obligation, and loyalty. They can be counted on in a crunch. They’re the first ones to notice when something is going wrong, and look for solutions. They’re good leaders, although 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 tendency can be manipulated by those who rarely take responsibility.

3. Has difficulty with accepting and expressing painful emotions.

I know when I’m sitting across from someone who’s smiling brightly at me, and simultaneously describing a significant loss or disappointment, I may have tripped over someone else who’s hiding. Not always. But it’s a question I begin to ask myself as a therapist.

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

4) Worries a great deal, and avoids situations where control isn’t possible. 

The PHDP isn’t someone who can stay easily in the present. If she does yoga, she may hate the final position, where you breathe and relax. He may love to cook, but has a very hard time sitting with guests 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. Ironically, tt’s important to hide her worry. So it might not be obvious to others that anxiety exists. “You never seem to have a care in the world. You don’t sweat the small stuff.

Someone with PHD will look as if they do things easily and without effort.

The worry is hidden, right under the smile.

5) Intensely focuses on tasks, using accomplishment as a way to feel valuable.

You’re only as good as your last success.” People with PHD do, all the time, and count on activity and accomplishment to mask 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 carries 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) Has an active and sincere concern about the well-being of others, while allowing few if any into his inner world.

This isn’t fake concern. It’s not pretend or insincere. It’s real. 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 that they’re 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 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 that they habitually lock painful feelings in, and shove them back into 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 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 an actual diagnosis that might accompany PHD might likely be eating disorders and /or obsessive-compulsive traits . Alcohol or sedative medications could be used to escape anxiety as well.

9) Holds 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 okay to feel that.

10) Has emotional difficulty in personal relationships, but demonstrates significant 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 see yourself or a loved one in these characteristics, I hope this column will help you. If you’d like to take a questionnaire to see where you might be on the PHD spectrum, please click here.

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.