As our lives get busier and busier and more and more crises develop on the world stage, we are seeing reports of increasing incidences of mental health issues like anxiety (Xiong et al., 2021).
At the same time, the pressures associated with work and life demand that we conduct ourselves like the proverbial swan. Gliding along effortlessly while beneath the surface desperately flailing and paddling, we appear to be coping and doing well.
This creates the perfect storm for high-functioning anxiety.
But how does high-functioning anxiety differ from other types of anxiety?
To answer that, let’s delve into the concept, explore the symptoms, and present practical ways in which positive psychology can help and provide interventions you can use with clients.
OK, so let’s get this out there: High-functioning anxiety is not classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This means that there is limited research on the topic, but it does not mean that it does not exist. It is well recognized in practice (Hubbard, 2023) and is usually diagnosed as a subset of generalized anxiety disorder (Behar et al., 2009).
High-functioning anxiety describes individuals who experience anxiety but still manage to maintain high levels of performance in their personal and professional lives (Pandya, 2023). This means that unlike typical anxiety, which can be debilitating and outwardly observable, high-functioning anxiety often goes unnoticed by others.
People with high-functioning anxiety appear to have their lives together. They meet deadlines, excel at work, and appear to be highly organized, but beneath this seemingly calm exterior lies a constant state of worry and tension (Maenpaa, 2022).
How does it differ from other types of anxiety?
High-functioning anxiety differs from other types of anxiety in its manifestation and impact (Castañeda et al., 2008).
What does this mean? And what do you need to know as a therapist?
Anxiety and high-functioning anxiety are complex disorders that require nuanced and person-centered care, but here are the broad brushstrokes regarding the differences between the two.
If your client presents with traditional anxiety disorders, such as generalized anxiety disorder (GAD), panic disorder, or social anxiety disorder, you’ll know it can significantly impair their ability to function (Wolitzky-Taylor et al., 2010). This can often lead to avoidance behaviors, difficulties in daily tasks, and visible signs of distress (Wetherell et al., 2003).
In contrast, individuals with high-functioning anxiety manage to push through their symptoms and maintain a facade of competence and success (Maenpaa, 2022). This may come at a cost, as they often struggle internally with relentless self-doubt, perfectionism, and fear of failure.
Advances in neuroscience suggest that beyond manifestation and impact, there are also differences in the workings of the brains of those with high-functioning anxiety versus those who experience other forms of anxiety (Sylvester et al., 2012).
These findings have pinpointed the exact neural systems involved and suggest that high-functioning anxiety is associated with increased functioning of the cingulo-opercular and ventral attention networks and decreased functioning of the fronto-parietal and default mode networks (Sylvester et al., 2012).
Rethinking the term “high-functioning”
The term “high-functioning” can be misleading. It implies that the individual is coping well with their anxiety, but in reality, they are often struggling silently (Terlizzi & Villarroel, 2020). This silent struggle has some serious implications (Maenpaa, 2022).
It creates a very lonely environment for the person struggling with high-functioning anxiety, as they may not get the recognition and support they need.
It can discourage people from seeking help because their accomplishments mask their anxiety.
It’s essential to recognize that just because your client may be functioning at a high level, that does not mean they are mentally healthy. High-functioning anxiety can have serious implications, and those experiencing it need care, support, and potentially, therapeutic intervention.
Recognizing high-functioning anxiety involves looking beyond the surface. If your client has high-functioning anxiety, they may or may not present with the usual signs and symptoms of anxiety, such as (Terlizzi & Villarroel, 2020):
Excessive worry that is difficult to control
Restlessness
Being easily fatigued
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbance
Over and above these signs and symptoms, your high-functioning anxiety client may also be experiencing some or all of the following (Maenpaa, 2022):
As we can see from the list of signs and symptoms above, high-functioning anxiety can have profound effects on mental health and overall wellbeing (Hubbard, 2023).
Increased anxiety is also strongly associated with increased chances of having additional medical conditions like asthma, heart disease, back problems, ulcers, migraines, and eyesight difficulties (Niles et al., 2015).
The constant internal struggle experienced by high-functioning clients as they work so hard to “keep it together” can also lead to chronic stress (Weger & Sandi, 2018). This further negatively impacts both mental and physical health (Renna et al., 2018).
Your clients with type A personality may experience burnout, sleep disturbances, depression, and physical ailments due to prolonged stress (Mcgonagle & Kessler, 1990). In addition, the relentless pursuit of perfection and fear of failure can erode self-esteem and lead to feelings of inadequacy and dissatisfaction (Schiller et al., 2016).
Learn more about what it’s like to live with high-functioning anxiety from comedian and performer Jordan Raskopoulos in this TEDx talk.
Living with high functioning anxiety - Jordan Raskopoulos
Strengths & Weaknesses of High-Functioning Anxiety
Due to its complexity, high-functioning anxiety presents with a variety of strengths and weaknesses.
Strengths
It may seem counterintuitive to even think about mental health challenges such as high-functioning anxiety as having any kind of positive effect or strengths associated with it, but there may well be strengths that are associated with the experience. Let’s take a closer look.
As we’ve noted above, people with high-functioning anxiety often present a very organized and well-adjusted persona. It is likely that they are able to do this because they’ve developed internal strengths and anxiety coping skills, either on their own or with the help of a therapist (Abdelaziz, 2020).
Typical strengths that have been found to develop as a result of high-functioning anxiety may include (Abdelaziz, 2020):
Self-awareness
Self-compassion
Resilience
Acceptance
Positive outlook
Being goal oriented
Creativity
Caring
Spirituality
High-functioning anxiety clients may develop these strengths through self-management strategies such as:
Creating a routine
Establishing a structured daily schedule provides a sense of predictability and control, which may reduce anxiety.
Finding a distraction
Engaging in activities that divert attention from anxious thoughts can provide relief and promote relaxation.
Seeking therapy/professional help
Professional support can offer effective strategies and interventions tailored to individual needs, enhancing coping mechanisms.
Breathing exercises and physical activity
These practices aim to reduce physical symptoms of anxiety, promote relaxation, and improve overall mental health.
Though there is evidence that clients with high-functioning anxiety may develop these strengths and strategies as a natural and innate process, as therapists, we know that therapeutic support will make this more likely and potentially more successful (Abdelaziz, 2020).
Through a targeted strengths-based coaching approach, you can help your clients identify and build on their strengths so that they can maintain a balanced and productive life despite their challenges.
Weaknesses
The weaknesses associated with high-functioning anxiety mirror those attributed to GAD in many respects (Hubbard, 2023). Over and above these, clients with high-functioning anxiety may also experience (Pandya, 2023):
Burnout
The constant pressure to perform can lead to exhaustion and burnout.
Impaired relationships
People-pleasing and fear of conflict can strain personal and professional relationships.
Internal struggle
The external appearance of competence often hides significant internal distress and dissatisfaction.
High-Functioning Anxiety & Other Conditions
High-functioning anxiety often coexists with other conditions, such as autism and depression (Niles et al., 2015).
High-functioning anxiety and autism
High-functioning anxiety and autism can sometimes overlap, particularly in individuals with high-functioning autism (previously referred to as Asperger’s syndrome; Hollocks et al., 2018).
Both conditions can involve social difficulties, a need for routine, and heightened sensitivity to sensory stimuli (Steensel et al., 2011). It’s important to differentiate between the two to ensure appropriate support and intervention for your clients.
High-functioning anxiety and depression
High-functioning anxiety often co-occurs with depression (Lamers et al., 2011). The relentless pressure and self-criticism can lead to feelings of hopelessness and sadness (Dryman & Heimberg, 2018).
Individuals may appear outwardly successful but feel empty and unfulfilled inside. Recognizing the co-occurrence of these conditions is crucial for effective treatment.
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9 Ways Positive Psychology Can Help Your Clients
Positive psychology focuses on enhancing wellbeing and happiness rather than just treating mental illness (Duckworth et al., 2005). Here are some ways it can help manage high-functioning anxiety (Jeng et al., 2022).
1. Building positive emotions
Positive psychology helps clients cultivate positive emotions such as joy, gratitude, and hope (Franco, 2020). Experiencing these emotions can offset the negative emotions associated with anxiety, reducing overall stress and enhancing emotional resilience.
2. Strengthening resilience
Positive psychology encourages the development of resilience, which is the ability to bounce back from adversity (Franco, 2020). By encouraging a growth mindset and focusing on strengths, you can equip your clients to better handle themselves in anxiety-provoking situations.
3. Enhancing self-efficacy
Believing in our ability to manage and overcome challenges is a key aspect of positive psychology (Youssef & Luthans, 2007). Increased self-efficacy can reduce feelings of helplessness and improve the capacity to cope with anxiety.
4. Promoting meaning and purpose
Finding meaning and purpose in life can provide clients with a sense of direction and motivation, which can help mitigate anxiety (Pfund et al., 2023). When your clients feel that their actions are aligned with their values and goals, they are less likely to be overwhelmed by anxiety.
5. Encouraging positive relationships
Positive psychology highlights the importance of nurturing supportive relationships (Franco, 2020). Helping your clients to develop a strong social support network can provide emotional comfort, reduce feelings of isolation, and offer practical assistance in managing anxiety.
6. Cultivating optimism
Optimism, or the tendency to expect positive outcomes, can reduce anxiety by fostering a hopeful outlook (Franco, 2020). Encouraging your clients to develop an optimistic outlook can ensure they approach challenges with a problem-solving mindset rather than feel defeated by them.
7. Fostering gratitude
Practicing gratitude can shift focus away from anxious thoughts and toward appreciating positive aspects of life. This shift in focus can improve overall mood and reduce the intensity of anxiety (Cregg & Cheavens, 2020).
8. Developing mindfulness
While mindfulness itself is an intervention, the underlying mechanism involves staying present and fully engaging with the current moment. This awareness helps reduce overthinking and worrying about the future, common triggers for anxiety (Hoge et al., 2013).
9. Encouraging personal growth
Positive psychology encourages continuous personal growth and self-improvement (Franco, 2020). By striving to improve and recognizing personal achievements, individuals can boost their confidence and reduce anxiety related to self-doubt.
By leveraging these positive psychology mechanisms, you can provide a framework for clients to build a more positive, resilient, and fulfilling life, which can naturally alleviate anxiety and enhance their overall mental health.
6 Tools & Exercises for Managing High-Functioning Anxiety
Managing high-functioning anxiety requires a proactive approach that combines practical tools and exercises to form self-management strategies. These strategies can help alleviate symptoms, increase a sense of agency, and promote overall mental wellbeing.
Here are six effective tools and exercises to consider.
1. Mindfulness & meditation
Practicing mindfulness helps individuals stay present and reduces overthinking, a common trait in high-functioning anxiety (Hoge et al., 2013).
Regular meditation can promote relaxation and decrease stress levels. You can use our Creating a Mindfulness Anxiety Plan to help your clients create a mindfulness practice that will proactively address their anxiety symptoms.
2. Relaxation techniques
Techniques such as deep breathing, progressive muscle relaxation, and guided imagery help manage physical symptoms of anxiety, providing immediate relief and promoting a sense of calm. Square or box breathing is said to help relieve anxiety (Chen et al., 2017). You can see how to apply it in the video below.
Effective time management can reduce the stress of juggling multiple responsibilities. Prioritizing tasks and setting realistic deadlines prevent overwhelm and burnout.
4. Exercise
Regular physical activity is a powerful tool for reducing anxiety (Jayakody et al., 2013). Exercise releases endorphins, which enhance mood and reduce stress.
Activities such as walking, yoga, and qigong can be particularly beneficial (Chow et al., 2012; Smith et al., 2007). Arielle Schwartz’s trauma-informed yoga classes focus on relieving stress and anxiety. The Holden QiGong YouTube channel has several anxiety-focused qigong classes you can try.
7-Minute seated Qi Gong routine to relieve anxiety naturally
5. Journaling
Writing about thoughts and feelings provides an outlet for stress and helps identify triggers and patterns (Sohal et al., 2022).
Journaling can offer insights into managing anxiety more effectively. Try our Gratitude Journal Tool, which will prompt your clients to identify experiences and people to be grateful for, as well as lessons learned from their experiences.
6. Sleep hygiene
Establishing good sleep habits is crucial for overall wellbeing (Prasad & Pandey, 2012). Quality sleep reduces anxiety symptoms and improves cognitive function.
Implementing these tools and exercises can significantly alleviate the symptoms of high-functioning anxiety, leading to a more balanced and fulfilling life.
17 Exercises To Reduce Stress & Burnout
Help your clients prevent burnout, handle stressors, and achieve a healthy, sustainable work-life balance with these 17 Stress & Burnout Prevention Exercises [PDF].
You can also look at our Square Breathing Tool, which provides printable instructions.
Additional reading
20 Best Anxiety Tools for Helping Your Clients Cope — With over 20 helpful anxiety tools to help clients cope with and overcome anxiety difficulties, this article provides key information for practitioners caring for clients with anxiety.
Anxiety Therapy: Types, Techniques, and Worksheets — By shedding light on anxiety disorders and their treatment, this article aims to provide useful suggestions, tools, and above all, hope for individuals negatively impacted by these conditions.
The course will help you identify and implement positive psychology skills, build emotional intelligence, maximize strengths, balance life domains, develop positive relationships, find meaning and value, and more.
Delivered to your doorstep in a beautiful box set, it also provides the opportunity for 40 ICF continuing coach education points.
If you’re looking for more science-based ways to help others manage stress without spending hours on research and session prep, check out this collection of 17 validated stress management tools for practitioners. Use them to help others identify signs of burnout and create more balance in their lives.
A Take-Home Message
High-functioning anxiety is a complex and often misunderstood condition. While individuals may appear successful and in control, they may be struggling internally with significant anxiety and stress.
Recognizing the signs and symptoms of high-functioning anxiety is crucial for providing appropriate support and intervention. By leveraging positive psychology techniques and practical tools, individuals can manage their anxiety more effectively and enhance their overall wellbeing.
Remember, it’s essential to look beyond the surface and understand that high functioning does not mean being free from anxiety. Seeking help and implementing effective strategies can lead to a healthier, more balanced life.
People with high-functioning anxiety show little outward behavior to indicate their struggle, but inwardly they may struggle with perfectionism, severe worrying, shame, and more.
Are constant anxiety and high-functioning anxiety the same?
Not necessarily. Constant anxiety would indicate that the person is always anxious, but this does not mean that they are high functioning. A person with high-functioning anxiety may present with constant anxiety or more intermittent anxiety.
Is there a test for high-functioning anxiety?
As high-functioning anxiety is not yet listed in the DSM, there is no validated test for it. You can, however, test for other forms of anxiety and then assess the level of functioning separately. Together these two assessments would give you an indication of high-functioning anxiety.
References
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About the author
Susan McGarvie, Ph.D., is a writer, researcher, and therapist in private practice. With more than twenty years' experience working in the health and NPO sectors, her research, writing, and work have focused on supporting practitioners to better manage stress and create a balanced sense of wellbeing.
As our lives get busier and busier and more and more crises develop on the world stage, we are seeing reports of increasing incidences of mental health issues like anxiety (Xiong et al., 2021).
Recognizing high-functioning anxiety involves looking beyond the surface. If your client has high-functioning anxiety, they may or may not present with the usual signs and symptoms of anxiety, such as (Terlizzi & Villarroel, 2020):
Managing high-functioning anxiety requires a proactive approach that combines practical tools and exercises to form self-management strategies. These strategies can help alleviate symptoms, increase a sense of agency, and promote overall mental wellbeing.
