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I have written previously about high-functioning depression in an attempt to bring attention to the common occurrence of experiencing depression even in individuals who otherwise are highly functional.  I also hoped and continue to hope to normalize the experience of having depression as this mood difficulty truly does not only strike “weaker” individuals, but happens at one point, or more, for all of us.  Furthermore, this blog does not only apply to depression, but to psychological distress in general, including anxiety, irritability, and anger.  Many of these mood difficulties are highly related, if not overlapping.

Today, I want to focus on something that many patients have said to me over the years.  When discussing their psychological history, I often hear statements such as “I didn’t know I was depressed” (or, fill in the blank with anxiety, withdrawn, etc.) and “I thought what I was experiencing was normal” (yes it is normal, but these patients actually mean they did not recognize anything was wrong).  Despite how much it would seem that our general public is informed about common mood problems like depression and anxiety, or minimally that they would know when they are feeling sadness or intense worry, this is not always the case.

As a psychologist, I believe part of my responsibility to patients is educating them on their symptoms, and to the extent possible, helping them to understand their thought processes and behaviors.  When patients share such statements as above, it is typically accompanied by feelings of surprise and to some extent shame; shame that they were unable to recognize the severity of their problems beforehand.  The reality is that many otherwise “high-functioning” individuals may have trouble recognizing their emotional difficulties for several reasons.

  1. The most obvious is lack of education on symptoms and mental health disorders.  For example, while most individuals likely know that sadness is part of depression, there are other cognitive, emotional, and behavioral aspects to depression that might be present but overlooked.  This is understandable as unless a person has had previous exposure to the world of mental health, they would not be aware of the cluster of symptoms that are likely to co-occur.
  2. There is a term that us psychologists often like to use: ego-dystonic.  When something is ego-dystonic, this means that a person is experiencing thoughts, emotions, behaviors, or desires that are uncomfortable, unacceptable, distressing, and more precisely inconsistent with their self-concept.  For a person who has been otherwise “functional,” it can be incredibly ego-dystonic to experience any sort of mental health concern.  Such inconsistency with one’s self-concept could result in the person not at all recognizing signs and symptoms of distress, or, if able to identify the symptoms, may lead to denial or minimization of the problem.
  3. Most mental health issues do not follow a particular pattern; some may be more transient and circumstantial, others can result from a genetic loading, and still others (such as PTSD) can continue to intensify and worsen over time if left untreated.  When symptoms are transient, it is easier for a person to keep pushing forward without efforts to address the problem.  When issues are more consistent, a person may essentially “get used to” thinking, feeling, and behaving a certain way.  When issues are severe, persistent, but related to a distressing memory or experience, it is also often the case that the person will engage in efforts to deny or suppress their difficulties.  Moreover, in all of these cases, the person may try to minimize their distress to feel “normal” only to see an exacerbation or future recurrence of symptoms.

When otherwise “high-functioning” individuals finally present for therapy due to psychological distress, it is often after a significant negative event or enough commentary by loved ones.  The good news is that (1) seeking professional psychological help continues to become less and less stigmatized, thereby making the thought of seeking help more ‘acceptable’; and (2) once the person has accepted that “something” is wrong, and at least somewhat embraces the idea of seeking professional help, these conditions can be easier to treat.  This goes back to the ego-dystonic nature of having the mental pain present in the first place.  These people want to feel healthy and be free from distress, so they are more willing to actively engage in therapy in order to make changes.

It is amazing how the mind, which is a highly complex and formless continuum, can lead us down different paths.  It can create narratives for the self that lead to acceptance or denial, and such beliefs can significantly impact action and our quality of life.  There is no shame to be had over not immediately recognizing you are in need of help; there is only hope to be gained in recognizing you do.

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