Depression’s Two-Way Mirror: High-performance depression is real, and getting recognition by specialists as a singular risk

Depression & Anxiety 594 views

Performing at a high level and “looking good” while doing so may mask a depression that warrants but also responds well to treatment.

Depression’s Two-Way Mirror: High-performance depression is real, and getting recognition by specialists as a singular risk

Mostly you see them at work—where you won’t see them. And for the most part, they’re good with that.

If the invisibility of depression makes it hard to get good statistics on the number of people living with it—statistics roil around 10 percent of most populations—an even more shadowy group are people with high-performance depression. It’s been hanging around the Diagnostic and Statistics Manual, the American Psychiatric Association’s “Bible” of diagnosable disorders, as dysthymia, one of those Greek-ish psych words unlikely to bringing much out of the shadows.

The latest, fifth edition of the DSM (2013) has renamed it “persistent depressive disorder” (PDD). The new name reflects the revised perception that this otherwise easily understandable (if not understood) thing, high-performance depression, is a combination—or is it cross?—between chronic major depressive disorder and dysthymia.

While it’s easy to poke jokes at professional nomenclatures, there may be something in a name. It may make it easier to recognize a phenomenon that actually would prefer to hide. And it may draw people who have it to see that there is such a thing. The reason is simple: most people with it “read”—if not literally the DSM-5. They’re basically the kinds of people who look into things, and they know how to search.

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If it’s so hard to see, what does it “look” like?

To back into the answer, it has most of the usual “psychological” symptoms of clinical depression but only some of the physical, or behavioral, ones. The problem for people with PDD isn’t not being able to get out of bed. Many of them all but jackknife out of bed in the wee, dark hours, racked with anxiety and needing to start burning it off.

It’s gender non-specific, but it hews to the stereotype of the supermom career woman. She starts dealing with the family’s needs before they’re up, is perfectly attentive to all of them, heads off for what is usually a more demanding than usual job, and then comes home to feed and bed the waiting family.

Oh, and as often as possible, she’s at the gym, or working out at home, because the only reliable way to keep the edge off is to do heavy aerobic exercise. What would she do without breaking an actual sweat?

She’s generally appreciated and often looked up to. But outside the rink where she does her figure-skating routine, the ice is always about to go out from under her. She lives in constant doubt of her performance—of her very abilities. Her self-esteem is as low as her esteem by others in the external world is high. Her mind runs on the brink of disaster and calamity, and, in her mind only, it’s forever running, late.

It’s fight or flight without the (temporary) release and relief of either. Some professionals would argue it is fight or flight carried out, exhaustingly, daily.

To speak more technically, the identifier symptoms are:

  • Poor appetite or overeating
  • Difficulty staying asleep or awake
  • Poor concentration
  • Feelings of fatigue
  • Low self-esteem

If you got her to talk about it, you’d likely find feelings of hopelessness. “It’s always been this way.” But it’s highly unlikely you’ll get her to talk about it. And the list of symptoms above is hardly specifically diagnostic of PDD.

If you’re looking for symptoms of high-performance depression in yourself, be on the alert for signs of being excessively self-critical. Being self-critical is a normal part of growth and the process of individuation. Finding yourself constantly lacking or in the wrong is not.

Perhaps the one good thing about being excessively self-critical is that it is, however distressingly to you, conspicuous to others. People may well point it out to you.

It’s a “safe” thing to say to someone else. If not quite the fully desired opposite of “you’re bad” (i.e., it's not always, "No, you're great"), it’s a clear “you’re being too hard on yourself.” Most people who are too hard on themselves have to hear it multiple times from many people in all areas of their lives before it rings true. If you keep hearing it, listen.

In some cases there may be subtle clues to others. Looking “down” when alone, for example, in front of the computer screen at work. Inattention to the more cosmetic aspects of hygiene, such as hair and fingernails. Tell-tale facial signs of exhaustion.

And if there’s copious evidence of high performance (holding down more than one job is not at all uncommon) “moderated” with alcohol and drug use—recreational, of course—signs of addiction and its cover-ups may appear. Also, substances used to cope compound other symptoms, and it's a popular area for denial.

That’s the central problem with the “how it looks” symptoms. Because most people with high-performance depression feel inadequate—let’s even say bad—in some fundamental way, they don’t want to be found out. Especially because “nothing will help anyway.”

So what is it? And is it treatable?

It’s not garden-variety depression, but it is the real thing. It’s “chronic” at its core. It’s always there. Perhaps only people with depression can understand what it’s like to have no plan to kill oneself but to be suicidal all the time. This is that, combined with the idea that “time is running out.”

You can see why professionals consider it a particularly dangerous form of depression. And why people who have it and the people they interact with—most of whom stand to benefit—as often as not deny it, and refuse to see/believe it when it is pointed out.

And here’s the thing. Hardly anyone who is diagnosed with depression the first time considers it the good news. It’s hard not to take personally something so profoundly personal, something so redolent of personal inadequacy.

For the high-performing type, being diagnosed as having depression is not to be recognized. It is to be found out. Busted. Shamed. At one and the same time to have one’s deepest, secret fears confirmed while feeling somehow incredulous and side-swiped at the same time.

Still, being recognized, and sometimes recognizing oneself in someone else's story, is key. The good news is, both men and women are speaking out, in print and in other public forums. Not just about the draining hopelessness of it all, but in recognition that the syndrome is depression at work in one of its more insidious disguises. These women and men both sound the alarm and point the way.

Perhaps the most important thing being acknowledged is that PDD isn’t “depression lite.” The gravity of the condition is written into its very persistence. Unrecognized for what it is, and untreated, it’s a recipe for increased social dysfunction, isolation, addiction, psychiatric hospitalizations, and actual suicide attempts.

The appropriate treatment with medication, and with which medication, is for a consulting professional to determine and prescribe or advise. For a more technical view of that matter for people with dysnthymia in particular, there is a helpful article in the Journal of the American Psychiatric Association that’s readable by lay people. The usual advisories about cleaning up diets and making exercise routine also apply.

But there’s general agreement that for high-performance depression, talk therapy is both the thing most needed and the thing most effective. People with PDD are, by and large, only too good at “looking in.” What they most need is help looking in constructively.

Being able to talk about “it” with the people closest to them is often a late feature of the “talk” part, though that proves profoundly therapeutic when the time is right. But naming something—recognizing it and calling it what it is—is often disruptive to family and social systems, many of which people with chronic depression have carefully engineered, however unconsciously, to avoid detection.

Perhaps especially for people with high-performance depression, talking to someone knowledgable but personally disinterested is the beginning of stepping away from the mirror and into life at its fullest.

Sources/Reading: (particularly helpful)


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