When Is Perfectly Hidden Depression (PHD) Not All There Is?

The distinctions between OCD, GAD, BPD, Bipolar II, and PHD.

Posted Feb 18, 2020

Photo by Spencer Davis on Unsplash
Seeing the whole picture...
Source: Photo by Spencer Davis on Unsplash

Perfectly hidden depression may be tremendously vital, even life-saving, to understand. But in some cases, that term may not explain all of what is going on -- and an actual psychiatric disorder (other than depression) may be present. 

You may need to look at the whole picture of who you are -- your strengths and your struggles. 

In fact,  there are four psychiatric disorders that share several traits with perfectly hidden depression, other than depression itself. It’s important that you don’t minimize or discount these other psychiatric issues. Their presence could be essential to recognize and treat. Perfectly hidden depression isn’t a diagnosis—it’s a syndrome. Thus, mistakenly labeling these other psychiatric issues as solely “perfectly hidden depression” or underestimating their importance could hinder your growth and stability..

Those diagnoses are Bipolar II Disorder, Obsessive Compulsive Disorder, Generalized Anxiety Disorder and Borderline Personality Disorder

Let's go through each one. 

PHD versus Bipolar II Disorder

First let’s look briefly at bipolar II disorder. It’s a cyclic disorder, meaning that you can experience frequent unexplained mood shifts, moving from being hyped up and full of energy into a more depressive episode. These shifts can happen at various rates. (I haven’t included another form of bipolar disorder, bipolar I, due to the fact that its symptoms are more dramatic and thus not as likely to be discounted as due only to PHD). So if you’re someone who can get an incredible amount accomplished, have oodles of energy, have problems turning your mind off, and struggle with anxiety and don’t sleep much, is that perfectly hidden depression or the more energetic stage of bipolar II disorder?

Intensely focusing on tasks getting done is part of your nature, and you might appear to be in overdrive. There’s little relaxation or hang time in either perfectly hidden depression or the hypomanic stage of bipolar II. Yet, someone with bipolar II disorder may experience an over-the-top energy, tinged with anxiety and agitation, and then slide into sadness or depression. The swing is noticeable to others and affects that person’s daily functioning. Those with perfectly hidden depression don’t swing into obvious depression. Nor do they feel grandiose. Neither would be allowed. 

If you identify with this cycle, then you need to talk with a mental health professional to determine these distinctions. Remember as well that you could identify with perfectly hidden depression and still have some bipolar II traits.

PHD versus Anxiety Disorders, specifically GAD and OCD

Most of us can easily reveal minor worries or anxieties. Maybe you’re familiar with worries such as, “I’m nervous about this interview,” or, “I have to lose five pounds before we go to the beach.” Yet a true anxiety disorder is much more burdensome. There are many types of anxiety disorders, but there are two that are important to discuss in regard to PHD. One that shares a primary feature with perfectly hidden depression—worry—is generalized anxiety disorder (GAD)

People with severe generalized anxiety disorder can complain frequently of being able to visualize traumatic things happening. They actually may feel as if these visions are accurately predicting violence—that immense danger is not just a potential but a reality. It’s as if they’re watching a video they don’t know how to shut off. This very difficult problem is not part of the perfectly hidden depression syndrome.

What generalized anxiety disorder does share with perfectly hidden depression is the prevalence of worry. But the content of that worry varies distinctly. In PHD, your worry is much more likely to be centered on the fear of exposure and the loss of control. In GAD, you worry constantly your ability to handle stress or external pressures. And you can’t hide your anxiety from the world; you're known as worrier or may constantly advise your children of danger. Worry invades their thinking to the point that you can often struggle to function and may even isolate from the world. This isn't the portrait of someone who experiences PHD. Not at all. 

Perfectly hidden depression may also have traits of obsessive-compulsive disorder (OCD), another type of anxiety disorder.  

Obsessive-compulsive disorder reflects a compulsive need to do certain things in an attempt to control anxiety. If you have OCD, you may, for example, consistently need to make lists for everything, have repetitive rituals that you’re compelled to do, struggle with being flexible, count objects around you obsessively, or have to have your surroundings so scrupulously clean that you’re up at 2:00 am, mopping the kitchen floor. 

Brittany, who strongly identified with perfectly hidden depression but also had some OCD traits, felt compelled to keep a highly detailed daily calendar. It was so jam-packed, filled with Post-it notes and tabs, it was almost indecipherable to anyone else. 

Again, talking with a mental health professional about both generalized anxiety disorder and obsessive-compulsive disorder might clear these distinctions up for you. As with bipolar II, it may not be an either/or situation but an “and.” You’re not borrowing trouble. You’re making sure you understand and receive the help you need.  

PHD versus borderline personality disorder

One of the chief characteristics of borderline personality disorder (BPD) is a life ruled by intense, impulsive, and unstable emotions. Those who have untreated BPD may have lives filled with emotional chaos, lots of dramatic ups and downs, self-destructive tendencies, suicide attempts, and an immense fear of abandonment. 

So why would someone with borderline personality disorder identify with perfectly hidden depression? From my work with patients with BPD, they often describe feeling as if there’s a dark, very empty part of themselves, a part that’s ultimately filled with despair, loneliness, self-loathing, or rage. One patient called it “a black hole that tries to suck any goodness out of my life.” This dark, empty part of themselves can crossover with or seem similar to the “hidden self” of perfectly hidden depression. 

What drives behavior is quite different between them. In fact, the dynamics of perfectly hidden depression and borderline personality disorder could be considered as on opposing emotional poles. In PHD, intellectualization and overanalyzing tightly rule behavior, whereas dramatic emotions and impulsivity rule someone with BPD.  

Both sadly and happily, they’re not the same. If you see yourself in the criteria for borderline personality disorder, it’s essential that you seek help. There are specific treatment regimens, such as dialectical behavior therapy, that can be highly effective; with hard work, you can develop a more stable life.

So, if you feel it’s a good idea, if any of this strikes a chord in you, please make an appointment with your family doctor, a psychiatrist, or a therapist—someone with whom you can discuss your symptoms objectively. You don’t want to make the mistake of not paying attention.