High-Functioning Anxiety: Signs and What Helps

What is high-functioning anxiety?

“High-functioning anxiety” is a popular term, not a diagnosis. It describes someone who looks fine from the outside. They hold down the job, meet the deadlines and turn up on time. Inside, they are driven by worry, tension and a fear of falling short.

Because nothing is visibly going wrong, the anxiety is easy to miss, including by the person who has it.

Signs of high-functioning anxiety

What other people see:

• Organised, reliable and always prepared
• High standards, and often high achievement
• Busy, and finds it hard to say no

What is going on underneath:

• Worry about many different things that is hard to switch off¹
• Overthinking decisions and replaying conversations
• Over-preparing and checking, to head off any chance of failure
• Being often tired but unable to sleep properly¹
• A tense body: a sore jaw, neck or back from muscle tension¹
• Irritability, restlessness and trouble concentrating¹
• Difficulty relaxing, and guilt when resting

Is it an anxiety disorder?

It can be. Generalised anxiety disorder (GAD) is diagnosed when someone worries uncontrollably about many things, has symptoms on most days for six months or more, and finds that the worry makes everyday life harder.¹

Many people with high-functioning anxiety sit just under that line. Researchers call this subthreshold anxiety, and it is not trivial. A systematic review of studies covering more than 48,000 people found that:²

• It is about twice as common as full generalised anxiety disorder
• It tends to persist
• It causes more distress and more difficulty at work than people without anxiety experience
• It raises the risk of developing other mental health and pain conditions

In other words, coping well on paper doesn’t mean the anxiety isn’t costing you anything.

The link with perfectionism

Perfectionism and anxiety often travel together. A meta-analysis of 284 studies found that perfectionism, both striving for very high standards and worrying about mistakes, was linked with anxiety disorders, depression and other mental health problems.³

The pattern feeds itself. Anxiety drives the extra effort. The extra effort gets results and praise. The results seem to prove that the worry was necessary.

What it costs

• Sleep. A mind that won’t switch off keeps you awake. See insomnia
• Your body. Tension headaches, jaw clenching and gut symptoms are common. See teeth grinding and tension headache
• Energy. Running on adrenaline is tiring, and it is a path to burnout
• Enjoyment. Achievements bring relief, not pleasure, and then the next worry arrives

A quick self-check

Doctors often use a seven-question form called the GAD-7 to screen for anxiety. It asks how often over the past two weeks you have been bothered by things like feeling on edge, not being able to stop worrying, and trouble relaxing. In the study that developed it, a score of 10 or more picked up 89 per cent of people with generalised anxiety disorder.⁴

It is a screening tool, not a diagnosis. A high score is a reason to talk to your GP.

What helps

• Cognitive behavioural therapy (CBT). The best-studied psychological treatment for anxiety. In trials against placebo, some of its largest effects were in generalised anxiety disorder.⁵ It works on the beliefs that keep the pattern going, such as “if I don’t worry, things will go wrong”
• Contain the worry. Setting aside a fixed 30-minute “worry time” each day reduced worry, anxiety and insomnia in a randomised trial.⁶ See how to stop overthinking
• Exercise. Aerobic exercise reduces anxiety, and more vigorous sessions work better⁷
• Cut back on caffeine. It can increase anxiety and disturb sleep⁸
• Practise “good enough”. Deliberately do a small task to 80 per cent and notice that nothing bad follows
• Online programs. Structured CBT courses can be done from home⁹

See also how to calm anxiety.

When to see a doctor

• Worry is affecting your daily life, even if you are still getting everything done¹
• You can’t remember the last time you felt relaxed
• Sleep is poor most nights
• You rely on alcohol to wind down
• You have physical symptoms, such as palpitations or chest tightness, that haven’t been checked

Your GP can set up a mental health care plan and refer you to a psychologist.¹ If you are having thoughts of suicide, call Lifeline on 13 11 14.

References

1. healthdirect. Generalised anxiety disorder (GAD).
2. Haller H, Cramer H, Lauche R, et al. The prevalence and burden of subthreshold generalized anxiety disorder: a systematic review. BMC Psychiatry. 2014;14:128.
3. Limburg K, Watson HJ, Hagger MS, et al. The Relationship Between Perfectionism and Psychopathology: A Meta-Analysis. J Clin Psychol. 2017;73(10):1301-1326.
4. Spitzer RL, Kroenke K, Williams JB, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-7.
5. Carpenter JK, Andrews LA, Witcraft SM, et al. Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depress Anxiety. 2018;35(6):502-514.
6. McGowan SK, Behar E. A preliminary investigation of stimulus control training for worry: effects on anxiety and insomnia. Behav Modif. 2013;37(1):90-112.
7. Aylett E, Small N, Bower P. Exercise in the treatment of clinical anxiety in general practice - a systematic review and meta-analysis. BMC Health Serv Res. 2018;18(1):559.
8. healthdirect. Anxiety.
9. THIS WAY UP (St Vincent’s Hospital Sydney). THIS WAY UP online programs.