• Dr. Nicole Amoyal Pensak

The Price of Perfection: High Functioning Depression and Anxiety

Updated: Feb 28, 2019

#highfunctioningdepression #highfunctioninganxiety #perfectionism #anxiety




Broadly speaking, perfectionism is a personality style where people set exceptionally high standards for themselves in order to achieve perfection (Harvey, Moore, and Koestner, 2016). However, the motive behind perfectionism is not achievement of perfection, but rather, the avoidance of failure. More simply speaking, perfectionism is really a type of anxiety. Anxiety is adaptive and evolutionarily speaking, protects us from danger. In cavemen days, anxiety helped our ancestors flee from predators. However, in modern days, rarely do we need to flee from predators. Consequently, maladaptive anxiety is increasingly common and acts as a faulty alarm system- alerting us to danger as if there were a predator chasing us, when actually we are not in real danger. In regards to perfectionism, those with this type of anxiety are so afraid to fail, they go to great lengths to avoid the possibility of failure. Underneath, an alarm system is going off, but usually it is difficult to make sense of the signal.


There are several subtypes of perfectionism, but for this post, I am going to focus on two subtypes; Self-Oriented Perfection- Striving (SOP-S) and Self-Oriented Perfection Critical (SOP-C). In a recent study by Harvey et al., (2016), investigators studied children ages 8-12 and found that SOP-S was adaptive and associated with better performance in school. SOP-C was maladaptive and associated with greater negative affect and being more self-critical of performance. Interestingly, while two subtypes of perfectionism were correlated with one another, when controlling for overlap between the two, SOP-S was associated with internalization of high parental expectations and SOP-C was correlated with internalization of high parental criticism. An example of SOP-S would be, “I worked for two weeks on my term project. It was really difficult. Of course, I would have been rather doing other things, but when I turned it in, I was satisfied with my project.” Alternatively, SOP-C would say “I worked on my project for the last three nights. Last night, I stayed up all night. My project is terrible. I knew I should have worked on it weeks ago.” In the latter case, procrastination is also evident as it is commonly associated with perfectionism. Perfectionists tend to procrastinate because they put so much pressure on themselves and set such unrealistic, high expectations, that the task ultimately becomes extremely burdensome.


As perfectionistic tendencies increase, there is greater likelihood that symptoms of depression and anxiety will be experienced. Depression can be experienced when the standards are so high that a pervasive sense of hopelessness occurs- because essentially individuals can’t keep up with their own benchmarks for success. In terms of anxiety, since perfectionism is a high-level avoidance strategy, ultimately when someone completes something “perfectly” by their own standards- it reduces their anxiety in the short term. Unfortunately, in the long term, it increases their anxiety because it reinforces the feedback loop and having to maintain a certain level of perfectionism. Usually, those with perfectionism experience ‘high functioning depression’ and/or ‘high functioning anxiety.’ These subtypes of depression and anxiety are different than classic forms of depression and anxiety.


In order to better understand high functioning depression and anxiety, I turned to the research. Unfortunately, after conducting a pubmed search of the terms- there were no studies on high functioning depression and anxiety. It is no wonder, as Carol Landeau, a Clinical Professor of Psychiatry of Human Behavior and Medicine at Brown University states “high functioning depression is not something you find in textbooks,” and it is often associated with perfectionism. Harvard School of Public Health labels high functioning depression as “low grade depression.” The dangers of high functioning depression and anxiety are summarized here, but the most critical point is that those with high functioning depression maintain a high level of functioning and are thus, less likely to seek help. If you want to learn more about high functioning depression and anxiety, this article gives you a nice summary of the conditions and how they relate to perfectionism. For this post, the focus will be on perfectionism and strategies to help manage perfectionism.


Strategies to help combat perfectionism:

In order to overcome perfectionistic tendencies, there are several strategies you can use. First, build a repertoire of coping skills. Broadly speaking, there are two types of coping strategies; emotion-focused coping and problem focused coping. Emotion-focused coping includes emotion regulation strategies such as meditation, relaxation, and distraction and should be used for everything that is notin your control. Problem-focused coping includes problem solving and coming up with practical solutions to the stressors at hand for everything that is in your control.


For example, if you are preparing for a presentation, you will prepare as much as you can before the presentation. This will likely consist of doing your research, put together an engaging deck of slides, and practicing beforehand (practical/ problem-focused coping strategies). A perfectionist however, will likely be stressed out trying to make the presentation perfect and will never be satisfied with the product. In addition, the perfectionist will likely work all night (perhaps sacrificing sleep or other important quality of life matters) and still not be happy with the presentation. All of the preparatory work isin your control. However, a perfectionist may ruminate or obsess over the types of questions that will be received from the audience. The perfectionist may replay scenarios of the presentation in their head. However, this is not productive. Furthermore, the presenter cannot control the types of questions that will be received. So, it’s actually best to engage in an emotion-focused coping strategy instead of obsessing and ruminating.



Here are some brief emotion-focused coping strategies to add to your coping repertoire:

1. Relaxation exercises: click here for free relaxation exercises to listen to on your smartphone, laptop, or computer.

2. Diaphragmatic breathing: Sit up straight with your feet flat on the floor. Place one hand on your stomach and one hand on your chest. Imagine you are filling up a balloon in your stomach with air. Breathe in for 5 seconds, breathe out for 3 seconds. Repeat. Repeat. Repeat.

3. Mindfulness meditation: Close your eyes. Pay attention to the sounds around you while taking some deep diaphragmatic breaths. Notice the distant sounds, the sounds of electrical appliances, or the traffic outside. Notice the sensations in your body as you breathe and listen. What is the most distant sound you can hear?

4. Distract for anxiety: Grab a magazine or a newspaper. Circle every other “A” on the page. Go line by line. It is really difficult to worry and concentrate on this activity at the same time.

Another coping strategy to combat perfectionism is to look for distorted thinking, also known as cognitive distortions. Cognitive distortions are irrational/ biased ways we think about ourselves, others, and our world. There are several types of cognitive distortions that are common, especially in those with perfectionistic tendencies. Some of the most common cognitive distortions include:

- Catastrophizing: imagining the worst case scenario (e.g., I will fail this test).

- All-or-Nothing Thinking: categorizing things as perfect or failure, right and wrong, bad and good (e.g., there is only one right way to do this task).

- Mind-reading: thinking you know what someone else is thinking (e.g. “My professor gave me a bad grade because he hates me”).


There are other types of cognitive distortions and for a more complete list with explanations click here. However, start with these common types of cognitive distortions and try to self-monitor your thoughts. Start to notice if you are having any of these types of thoughts. Try to think about the way you are thinking. Then, you can begin to challenge these irrational thoughts by asking yourself, what is the evidence for and against this thought? What proof (facts) do I have that make this thought true?

Finally, another helpful strategy to combat perfectionism is to look for the opportunities for ‘exposure’. The most effective treatment for anxiety is Cognitive Behavioral Therapy with Exposure. While I won’t go into a full description of the therapy here, I will offer a very simplistic definition of exposure (because that’s the active ingredient). Exposure is essentially gradually engaging in situations that elicit discomfort/ anxiety for long enough period of time such that your anxiety lowers. This is the process of desensitization. For perfectionists, exposure may look like doing something imperfectly and then sitting with the discomfort and anxiety that occurs from not doing something perfectly and then resisting the urge to check or correct the situation. For example, try setting a timer for a reasonable amount of time to complete a task (30 minutes for a homework assignment). Once the timer goes off, no matter what, stop the task and let it go unfinished or unchecked. Then, allow yourself to sit with the discomfort and imagine the worst possible scenarios of what will happen with that unfinished assignment (e.g., “I will fail.”). Do this for a long enough period of time that your anxiety comes down. Then, move on and do not go back to the assignment. Repeat as necessary. Allow yourself to experience whatever consequences occur (I assure you it will not be as terrible as you imagine). Over time, and when repeated enough, eventually you get desensitized from the “consequences” of not achieving perfection and thus may feel less compulsive (e.g. less of an urge to engage in perfectionistic behaviors).


This is a very simplified explanation of perfectionism and exposure techniques and is not meant to represent therapy with a licensed clinical psychologist. If you would like to learn more about how to manage perfectionism and if therapy is a good option for you, please contact Dr. Nicole Amoyal Pensak for a free, brief, telephone consult at 609-283-2056. You may also email her at drnicoleamoyalpensak@gmail.comfor more information.

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NICOLE AMOYAL PENSAK PHD

LICENSED CLINICAL PSYCHOLOGIST

609-283-2056

210 Broad Street
Red Bank, New Jersey 07701

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