We hand the reins over to the clinical psychologist team from Therapy Partners, a HK-based provider of psychological therapies, evaluations and more, for a discussion and debate over a particular term that’s gaining resonance in the mental health sphere – high functioning anxiety.
What is High Functioning Anxiety?
A quick internet search for “high functioning anxiety” leads to pages and pages of results that include symptom lists, treatment options, personal stories and TED talks about the subject. The term has clearly made its way into the modern mental health lexicon.
Despite this, it’s a term that doesn’t appear in the most recent edition of Diagnostic and Statistical Manual of Mental Disorders (5th edition; “DSM-5”) nor in the International Classification of Diseases (11th revision; “ICD-11”) – the two most used manuals as a basis for diagnosing mental disorders. The closest thing in either of these two publications is “generalised anxiety disorder”; however, both publications make it clear that, for the diagnosis to be made, symptoms must result in significant distress or significant impairment in key areas of functioning. So, a diagnosis is typically made when functioning is low, not high.
Others have made compelling arguments that when it comes to another diagnosis – autism spectrum disorder – the term “high functioning” does more harm than good. When it comes to high functioning anxiety, would retiring the term be the best way forward, or would that potentially be “throwing the baby out with the bathwater”?
We asked two of our clinical psychologists – DR BRENT HORNER and DR ANDREW STOCK – just that question, and here’s how their conversation went:
Brent: So, this term we keep hearing, high functioning anxiety – might we be better off without it? There are already nearly 300 mental disorders listed in the DSM-5, do we really need more labels?
Andrew: You make a good point – I’m not sure an ever-expanding list of diagnoses is what we need when it comes to mental health. But these types of descriptions can really resonate with people. Is that enough to justify their widespread popularity and use, though?
Brent: I’m not convinced. As far as I can tell, the term is used to describe the experience of people with anxiety who still manage to function well. Or perhaps, who even function better in certain contexts because of their anxiety.
Andrew: Interesting; anxiety can be a strong motivator. Like feeling nervous before a big presentation. Or making sure our kids are safe when we worry about them. If we are anxious about things or people, it’s often closely connected to the fact that we care about them, and that they’re important to us.
Brent: But if anxiety is to fall into official diagnosis territory, that typically means someone is not functioning well anymore. I think the experience that high functioning anxiety is trying to describe is typically a highly driven, go-getter approach to an aspect of life like education or work, which does not really allow for the noticing of persistent anxiety or the possibility of addressing it.
Andrew: You’ve made an important distinction there. While it may be a term that resonates with people, it might also help to convince them that they really are highly functioning in every aspect of their lives. And it’s my personal and clinical experience that those who might identify with high functioning anxiety are not always so high functioning in every context.
Brent: High functioning at work, low functioning at home. I’ve seen that a fair bit, especially for individuals in high-pressure roles. In their work role, being constantly on edge is mostly adaptive – they keep on top of things and are really motivated to solve problems. But being constantly on edge at home, with your kids – that can be less helpful.
Andrew: For the sake of this discussion, though, let’s assume that someone can experience persistent, clinically significant anxiety and function well across different areas of their life… perhaps that’s where this term is helpful?
Brent: I’ve just revisited the exact wording in the DSM-5 and the ICD-11. They mention significant impairment in functioning, or significant distress. That “or” is important! I think it’s safe to say that when you sit down with someone who identifies with high functioning anxiety, it doesn’t take too long to realise that they are experiencing significant distress.
Andrew: Hold on, so what you’re saying is that when it comes to anxiety, you can be “high” or “low” functioning, and still be experiencing a clinically significant issue? Now I’m also wondering if we really need the term high functioning anxiety when there is already a diagnosis that aptly describes this experience – generalised anxiety disorder.
Brent: Our conversation has left me with more questions than answers. I guess that means it’s been healthy discussion! Having said that, I’m sure of one thing – anxiety is something that we all experience, regardless of our level of functioning. Once we recognise that we are experiencing it and that it is really affecting us – internally and/ or externally – it’s time to do something about it.
Andrew: And if you look at treatment recommendations for high functioning anxiety, guess what? They are identical to treatment options for anxiety: therapy, and perhaps a limited course of medication. So, Brent, you’re 100 percent right, if someone is experiencing anxiety that is really affecting them, it’s time to get support, and talking with a health professional about getting support can be a great place to start.
Has this conversation between Brent and Andrew left you with more questions than answers as well? That’s OK! If the term “high functioning anxiety” has helped you personally, continue to hold it lightly as a helpful description of your experience.
It’s important to keep asking questions, to be curious about our own experiences and challenges. One question that hopefully has been answered is what to do when you are struggling with anxiety – reach out. Whether that’s to a friend, a family member, a colleague, or a mental health professional is up to you.
If you are really struggling, please find help now. Listening to your anxiety – in body and in mind – could be one of the most important things you do for your health and wellbeing.
This article is about mental ill-health. If reading it triggers significant psychological and/or emotional distress for you, please seek appropriate support. For example, you might speak with a friend or family member that you trust, or a health professional, or contact a mental health helpline such as The Samaritans on 2389 2222 (Cantonese) or 2389 2223 (English). In an emergency, contact 999.
This article first appeared in the Autumn 2022 issue of Expat Living magazine. Subscribe now so you never miss an issue.