A Case Study of Perfectly Hidden Depression By Margaret Rutherford, PhD on 11/25/19 - 1:12 PM

I watched one day as Brittany, a tall, stylishly dressed young woman, came into my office and wondered (as I always do in a first session) what problem or issue would she would present.

“I saw you on Facebook, talking about “perfectly hidden depression (PHD).” I’ve never been to therapy. But I know that you’re describing me, and I’ve got to get help, because things are getting worse.”

She stopped abruptly, seeming to immediately regret telling me even that much about herself. Smiling brightly, she sat a little sheepishly on the sofa, one of her legs nervously pumping up and down. She didn’t know what to do and waited for me to respond.

Like what you are reading? For more stimulating stories, thought-provoking articles and new video announcements, sign up for our monthly newsletter.

“Well, if you identify with PHD, you’re not used to openly talking about yourself. So, I bet being here is hard.” She nodded, looking down at her feet. “We can take all this very slowly. I’m here to listen, but you’re in charge of how fast or slow this goes. So, is there something that’s happened recently that made you more worried about yourself?”

Brittany didn’t tell me everything about her life in that session. In fact, it was months before I would know the whole story. As trust grew, she’d blurt out hurtful secrets that she’d been keeping, all the while very closely watching to see my reaction, as she gradually took more and more risks in sharing her real life. Still, her ability to openly express the emotions connected to those secrets was very limited; self-compassion was foreign to her. I’d see only an occasional tear, quickly covered by a blank look or a change of subject.

What was that story? It began with a childhood assault by her drugged-out father, with injuries that required multiple surgeries. It continued with a passion for ballet, which was sabotaged by a teacher who was demeaning and sharply critical of her body, contributing to anorexia. That was followed by intense pressure from her mother to marry someone who was “going to do well.” But the someone she attracted, her fiancé, was abusive and highly manipulative, frequently threatening to publicly humiliate her by telling “all he knew.”

Brittany wasn’t the first client I’d seen with this kind of emotional disconnect between the pain of what she was saying and the feelings she struggled to identify. Elizabeth found herself lying naked on a beach, having been drugged and raped. "I've never thought the story was all that important, it was a long time ago," she told me, smiling hesitantly. Linda hadn’t cried in years, even after her mother's sudden death. "Crying makes me uncomfortable,” she explained. “I think it’s a sign of weakness." Jackson talked about strange, secret impulses to drive off the road, then followed his confession with, “I have a good wife and family. I'm just a little stressed."

Like Elizabeth and Linda and Jackson, Brittany didn’t look depressed in the classic sense. She was highly organized, her planner stuffed with sticky notes and extensive to-do lists. She stayed very busy with dinners with girlfriends while she and her fiancé appeared to have the perfect relationship. She was successful in her job, although highly anxious about making the right decisions for her professional future. She didn’t look sad; in fact she was often quite jolly and funny. What she allowed others to see looked pretty perfect.

The more we worked together, the more she became aware of perfectionism’s grip on almost every aspect of her life. She realized the many barriers she put up to even consider living a more vulnerable life. She tackled her anorexia, confronting and discarding old irrational beliefs that she no longer wanted to live by, one of them being that she always had to seem in control. She said, “I cry now every time I eat dinner. But I know I’m growing.” She ended her silence, one emotion at a time, confronting her tendency to remain overly analytical and “in her head.” With huge trepidation, she broke things off with her fiancé and faced the wrath of their families. Much to her amazement, her mother backed her up. She could recognize that, all along, her emotional pain had been masked by her obsessively cheerful demeanor and incredibly high expectations of herself.

It was such an old strategy—she hadn’t been conscious of it. Until she was. And the light of that awareness couldn’t be turned off.

On the last day I saw her, she looked at me very directly. “I never told you that I planned to kill myself. I couldn’t see another way out. But I heard the term perfectly hidden depression, and something clicked. I didn’t know what I was doing but I knew I wanted it to stop.”


In suggesting the concept of perfectly hidden depression, I’m not offering the absolute, never-has-been-considered-by-anyone-else warning signal for depression or suicide. Perfectionism has been known to be correlated with depression. Yet an awareness of the presence of perfectionism might lead to us asking different questions. Instead of, “Do you feel hopeless?” the question becomes, “If you ever felt hopeless, would you tell anyone?”

I’m challenging mental health professionals to think outside classic depression’s diagnostic box. We know that depression can present as melancholy or anger and agitation. Another potent contender should be the virtual absence of spontaneous expression of any emotion but rigid positivity.

Perfect-looking is perfect-seeming. But seeming isn’t being. 

File under: The Art of Psychotherapy