High functioning anxiety: what it costs and what helps

Is high functioning anxiety a real diagnosis?

It is a real experience with no formal diagnosis behind it. No diagnostic manual contains the phrase. The nearest recognised term is generalised anxiety disorder, described as persistent and excessive worry about daily activities or events¹. Nothing in that description asks whether you are keeping up, and keeping up is the whole of what the informal phrase was invented to say.

Much of what people mean by it also sits below the line any formal category draws, and that ground is neither rare nor mild. Worry at that level is around twice as common as the full syndrome, and it persists rather than passing². Falling short of a category and being well are 2 different things. I would not try to place yourself on one side of that line from a list of criteria, and the line matters much less than what the worrying is costing you and who else is paying part of the bill.

What does the worrying feel like from the inside?

Nothing about this announces itself as fear. There is no moment of terror to point at, only a low braced feeling that is there before you are properly awake, a sense of something unfinished that stays half a step ahead of you all day. That forward lean has a name in my field, anticipatory anxiety: what you are afraid of is not what is happening, it is what has not happened yet.

The body keeps the record. A jaw that aches by Friday. Shoulders somewhere near your ears by the middle of a meeting. A stomach that has an opinion before you have decided anything is wrong. Sleep you technically get and do not benefit from, because you wake at three already composing. Sex, which asks you to stop monitoring, becomes one more thing you attend without quite being present for.

The thoughts arrive last, and they arrive dressed as responsibility. If I run through it once more I will not be caught out. If I stop checking, something will slip, and it will be mine. The worrying presents itself as the work, which is how it avoids ever having to argue its case.

Why does nobody notice?

Everybody watches for a drop in output, and output is the last thing to go. Anxiety gets spotted by what it stops: the cancelled plan, the missed deadline, the flight not taken. Nothing of yours has been cancelled.

• What they see. The work, arriving early.
• What they miss. The hours of rehearsal behind it, and that you have never once delivered anything without them.
• Praise. Each time the rehearsal pays off somebody thanks you for it, and the arrangement gets renewed for another year.
• You. You read the relief at the end of each deadline as proof that the system works, rather than as what the system costs.
• Abroad. Moving country hands you a ready explanation for being tired and on edge, and nobody around you knows what you were like before.

There is nothing unusual in carrying this unseen. Worldwide, only about 1 in 4 people who need treatment for an anxiety disorder receive any¹.

What is the worrying doing for you?

The worrying is doing a job, which is why being told to stop has never helped anybody. What follows is my clinical judgement rather than a research finding.

• Preparation. You run the meeting several times in your head so that nothing in it arrives unannounced.
• How the work got good. For the people I see, the rehearsal is what made the work good in the first place, which makes putting it down a real loss rather than an obvious improvement.
• No finishing line. There is always one more thing to check, so the worry has nowhere to stop.
• Caring. Worrying feels like caring. Setting it down feels like becoming the sort of person who lets people down.
• Rest that is not rest. You want an evening off, and you arrange the evening so that there is something in it to prepare for.

At home this is rarely read as fear. What I see is a partner who asks you to leave the laptop alone, an agreement, one more message answered, and then no more asking, which removes the only interruption that was working. They are not being unreasonable and you are not being dishonest, and the evening still ends with the 2 of you further apart. Read more about feeling disconnected from your partner.

Is this anxiety or am I simply conscientious?

Conscientiousness is a preference and anxiety is a requirement. The difference has nothing to do with how hard you work, and it shows in 3 places. None of them is a test, and they are aids to understanding rather than a score.

The first is what happens when you stop. A thorough person finishes early and feels pleased. Here, finishing opens a gap, and the gap fills immediately with the next thing, because the relief never lasts long enough to be enjoyed. The second is reach. Conscientiousness stays near the work, while this has moved into holidays, into text messages, into whether you offended somebody weeks ago. The third is choice. You can decide to do a careful job. Deciding to stop rehearsing is not available to you in the same way, and that is the part worth taking seriously.

None of that settles which formal description fits you, and I would not try to settle it from a list. It does show how much of your life the worry now has an opinion about.

How do you begin to change it?

You find out what the worrying is for, and you learn to set it down without lowering your standards.

• Name the decision. When you catch yourself rehearsing, write down the one decision the rehearsal is meant to produce.
• Decide and stop. Where there is a decision, make it, and stop there.
• Find the other kind. Where there is no decision to be made, the worry is doing something other than getting you ready, and that is the part worth understanding.
• Use paper. Your head sets no limit on rehearsal. A notebook does.
• Start with the body. A longer breath out, an unclenched jaw, a walk before the evening closes in. None of that reaches the fear, and it lowers the volume enough to think.
• Do nothing on purpose. Sit for a short while with nothing to prepare, and notice what arrives. This is a suggestion for noticing, not a measure of progress.
• Come early. Holding it together is no reason to wait.

The fear is that you lose your edge. What goes first is the cost, the rehearsing and the lost sleep, and in my experience the standards survive it. In the room I work on what the worrying keeps at a distance, and with the clients I see that is something about being found wanting.

These steps are not enough when putting the worry down feels like becoming careless, so you pick it up again within the hour; when the worry has been running since childhood and attaches itself to whatever is nearest; or when your sleep has gone and your body will not settle whatever you do. What holds worry in place is rarely information you are missing, and that is where individual work with a therapist becomes the next step.

Questions people ask

Will a therapist think I am wasting their time if I am coping?

No, and the coping is the part I most want to understand rather than a reason to send you away. Nothing has to have gone wrong in public before the work is worth doing.

What happens in a first session for something like this?

You describe how the worrying works, and I ask what it prepares you for and what it keeps at a distance. At the end we decide together whether to carry on and how often.

Will therapy take away the drive my work depends on?

The aim is to remove the cost rather than the standards, and what goes first is the rehearsing and the lost sleep. If your standards start to feel threatened, bring that into a session rather than acting on it alone.

Which kind of therapy suits high functioning anxiety?

Work that goes into what the worrying protects suits this better than work aimed only at quieting the symptoms, and that is what I do. Practical methods for managing worry help alongside it, though on their own they rarely shift the sense that putting it down would be careless.

Can I try something shorter before booking a session?

Yes, there is a free 30 minute call, and it is enough to tell whether this way of working suits you. If you spend your days preparing, there is something to be said for a conversation that asks for no preparation.

If your anxiety looks like success from the outside, I work with what it is costing you in anxiety therapy.

Sources

1. World Health Organization, Anxiety disorders, fact sheet
2. Haller, Cramer, Lauche, Gass and Dobos, The prevalence and burden of subthreshold generalized anxiety disorder: a systematic review, BMC Psychiatry, 2014

How this article was written: I choose the subject and the angle. An AI assistant researches and drafts. I read the draft, correct and improve it and stand behind every clinical statement. The professional and clinical judgement is mine.