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Is the Lens for Discovering Depression Overly Narrow?

The DSM's depression criteria is too limited when perfectionism is present.

Key points

  • Just as cardiology research widened its lens to detect potential signs of heart attacks, psychology needs to broaden its view of depression.
  • Academic researchers have found significant relationships between certain kinds of perfectionism and suicidal ideation.
  • When perfectionism or a heightened need for emotional self-control is present in a patient, providers can ask more detailed questions.
Source: Agence Olloweb/Unsplash
A lens needs the right focus.
Source: Agence Olloweb/Unsplash

Before 1987, if you were a woman or a minority and went to a doctor for symptoms of a potential heart attack, you might've been out of luck. Why? Because both groups were vastly under-recruited for research studies—and thus, your symptoms may not have fit the criteria.

After these groups began to be included in large research studies (albeit still underrepresented), research found that heart disease can manifest differently between groups. And important differences continue to be found.

Many women—even many healthcare providers—do not recognize that heart disease is the No. 1 killer of women around the world,” says Joseph A. Hill, M.D., Ph.D., chief of cardiology at the University of Texas Southwestern Medical Center in Dallas. “It is vitally important that we study females with or at risk for heart disease,” he says.

So, what happened? Cardiology's lens broadened when the data on women started coming in. And the symptom picture they responded to changed as a result.

Psychology needs to take note, as we can easily make a similar mistake when it comes to diagnosing depression. We're not looking through a wide enough lens.

What perfectionism researchers have been trying to point out...

Many well-meaning providers are over-relying on the official diagnostic criteria provided by the DSMV—now the DSMV-TR. And perfectionism researchers have been trying to warn the mental health community that perfectionism, depression, and suicidal ideation are increasing and can be significantly correlated.

But this form of depression may look quite different than what is described in classic symptom criteria.

Here's one woman's story—and how she felt.

Researchers divide perfectionism into three categories, those three being self-oriented (expecting perfection from yourself), other-oriented (expecting perfectionism from others), and socially-prescribed (needing to meet and exceed the expectations of others). Speaking of the latter’s higher correlation with the potential of suicide, premiere researcher Dr. Gordon Flett stated in an interview, “The reason for that … socially prescribed perfectionism has an element of pressure combined with a sense of helplessness and hopelessness … The better I do, the better I’m expected to do.” Ironically, this helplessness reflects that no one has control over the expectations of others; thus, socially-prescribed perfectionism is found by most studies to hold the most suicidal danger. It’s as if you’re on a treadmill that keeps going faster and faster. The pressure can be immense.

And yet, people are congratulating you on what a great life you have; the perfect family, the perfect attitude.

Flett and his colleagues, Paul Hewitt and Samuel Mikhail, go even further in their book on perfectionism published in 2017.

Clearly, the potential role of perfectionism in the chronicity of depression has not received sufficient empirical attention, but the association of perfectionism with persistent distress is clearly evident among individual perfectionists… there were also signs with these perfectionists that much of their despair was kept hidden and other people were not aware of it.” (Hewitt, P, Flett, G, & Mikhail, S. 2017. p 223-234. Perfectionism: A Relational Approach to Conceptualization, Assessment, and Treatment, The Guilford Press.)

So what questions should mental health clinicians be asking?

No one can read another person's mind. But clinicians can realize that there are a set of traits of a different presentation of depression—perfectly hidden depression. You can look for and recognize these traits which can provide a much-needed lens into seeing someone's struggle—someone who might not be able to express vulnerability easily and whose perfect-looking camouflage is well in place.

Currently, a clinician might ask, "Do you ever feel hopeless?" But if you see or hear some of the above traits, then ask another question. "If you felt hopeless, would you tell anyone?" The answer to the second question would be "no."

And that one answer could provide a vital window into saving that person's life.