High-Functioning Anxiety: What It Is and How Can Therapy Help?
You meet every deadline... Colleagues think of you as calm, reliable and organised. Yet at 2am your mind is replaying a conversation from Tuesday, drafting tomorrow's to-do list, and wondering whether that email you sent at lunch time was worded OK.
In my clinic I meet many people who live like this, and in my 18 years as a qualified psychologist, working in both the NHS and independent practice, I've seen the number of people who have sought therapeutic support for high functioning anxiety grow. However, they rarely come in saying "I'm suffering with anxiety"... Instead I hear them describe problems with 'overthinking', burn out or feeling that nothing they do is ever quite enough. Often they're surprised to hear that what they're describing is in fact a sign of underlying anxiety, and that this responds very well to therapy.
This article explains what high-functioning anxiety is, why it so often goes unnoticed, and how evidence-based therapy can help.
What is high-functioning anxiety?
"High-functioning anxiety" isn't a formal diagnosis meaning that you won't find it in the psychiatric diagnostic manuals like the DSM-5 or ICD-11. Rather it's a term for the type of anxiety that sits underneath a life that looks, from the outside, to be going well (even enviously so).
High Functioning Anxiety is similar to Generalised Anxiety Disorder (GAD) but the difference is in the level of functioning. GAD is a psychiatric diagnosis which is diagnosed when high anxiety leads to impaired functionality (the anxiety prevents the individual from going about their normal day-to-day business), but in high-functioning anxiety the opposite occurs - the individual's high anxiety has lead them to over-functioning, by channelling their nervous energy into 'doing' and productivity (which is why burnout might also be present). Their worrying has driven their tendency to over-prepare, ruminate, spend long periods planning for problems or double checking. Whilst this masks the anxiety from others, it takes a toll on their wellbeing and self-care.
And this explains exactly why it's so easy for the sufferer to miss what's happening. Their anxiety is channelled into behaviours that look, on the surface, like good coping, and moreover, are often socially endorsed (such as taking more on, being prepared for all eventualities, being overly helpful or attentive to the needs of others, and so on).
Common signs of high-functioning anxiety
Everyone's experience is different, but these are the patterns I see most often:
Overthinking (AKA worrying) and rumination: replaying conversations, rehearsing what you'll say, analysing decisions you've made, 'what if...' thoughts.
Perfectionism: high standards that feel non-negotiable, and a sense that "good enough" isn't good enough or could lead to disapproval, problems or criticism.
Difficulty saying no: taking on more than you can manage because disappointing others feels intolerable.
Constant busyness: struggling to rest, or feeling guilty and fidgety when you do.
Needing reassurance: checking emails several times before sending, or seeking feedback due to high level of self doubt.
Physical symptoms of stress: tension in the jaw or shoulders, headaches, stomach problems, disrupted sleep, failure to tend to self-care like exercise or healthy eating.
Irritability or tearfulness that seems to come out of nowhere, often at home rather than at work because that's where it's safest to let it all out.
Imposter feelings: a sense that success is down to luck and you'll eventually be "found out".
If several of these feel familiar, you're far from alone, and this is something that you can break free from.
Why high-functioning anxiety can be missed
Over the years I've worked in therapy I've seen doctors, solicitors, managers, parents... all of whom were excellent at their jobs but were run ragged because high-functioning anxiety was hiding in plain sight. Because they manage to keep everything ticking over, they got used to thinking that their anxiety was normal and something that they just accepted. Friends and employers only seeing their conscientiousness and good results, unaware of the toll it's taken on their health and self-esteem.
There's also beliefs that can be subconsciously reinforcing high functioning anxiety: if I stop worrying I'll lose my edge, or things will fall apart. The anxiety feels like it's fuelled success, so letting go of it seems risky. In therapy, we often find the opposite is true. People tend to perform better, not worse, once fear isn't in the driving seat - freeing up capacity and a new found freedom.
If high functioning anxiety is left unaddressed for a long time the cost will build up. Common consequences include exhaustion and burnout, poor sleep, strained relationships, low mood, and over reliance on alcohol or overworking to 'switch off' or feel better. Many people also describe a more subtle loss: never feeling satisfied, and never being fully present in their own lives.
How therapy can help high-functioning anxiety
The good news is that anxiety is one of the most treatable psychological difficulties. As a HCPC psychologists, our Plum Psychology team are trained in several evidence-based approaches and tailor them to the individual.
Cognitive behavioural therapy (CBT) CBT is recommended by NICE for generalised anxiety disorder and has a strong evidence base. It helps you notice the thoughts and beliefs that fuel anxiety, such as "I must never make a mistake", and test them out. We also look at the behaviours that keep anxiety going, like over-preparing, checking and avoiding rest and experiment with alternatives.
Acceptance and commitment therapy (ACT) Rather than trying to get rid of anxious thoughts, ACT helps you relate to them differently which takes the power out of them. The focus is on living according to your values, not your fears. Many high-achievers find this a relief after years of trying to think their way out of worry.
Compassion-focused therapy (CFT) Behind high-functioning anxiety there's often a harsh inner critic. CFT helps you develop a kinder, steadier inner voice that motivates you through encouragement rather than threat.
Working with perfectionism and core beliefs For some people, anxiety is rooted in long-standing patterns, such as feeling that your worth depends on achievement. Therapy can explore where these beliefs came from and gently loosen their grip. Sometimes trauma-processing therapy can help with this, such as EMDR - particularly suitable for high-functioning anxiety where a difficult event from your past has caused your nervous system to be braced for the same event again and kept you on high alert.
There's no one-size-fits-all approach. Treatment is shaped around what's driving your anxiety and what you'd like to be different.
What therapy for high-functioning anxiety looks like in practice
Many people with high-functioning anxiety worry that therapy will be another thing to get "right". It isn't. It's a space where you don't have to perform.
A typical course of therapy might include:
An initial assessment: we talk about what's bringing you to therapy, how anxiety shows up for you, and what you'd like to change.
A shared understanding: together we map out what keeps your anxiety going, often called a formulation. Many people find this step alone brings real relief.
Active work: trying out new ways of thinking and responding, both in sessions and in everyday life between them.
Consolidating and ending: reviewing progress and building a plan to stay well after therapy finishes.
The number of sessions varies, but a focused piece of work for anxiety is often somewhere between 8 and 20 sessions. At Plum Psychology we work with the budget you have in mind by agreeing goals that are realistic within the time-frame that this allows us.
When to seek support for high-functioning anxiety
You don't need to be at breaking point to deserve help - if you push through this could take a toll on your physical and mental health, and impact on your ability to function. It may be time to speak to someone if:
anxiety is affecting your sleep, health or relationships (making you snappy or causing you to push others away)
you can't remember the last time you felt properly relaxed or had down time
you're relying on work, alcohol or constant busyness to keep worry at bay, if you pause for a moment the worries crowd in or anxiety feels overwhelming
self-help strategies haven't been enough on their own or haven't stuck
At Plum Psychology, we offer a calm, confidential space to understand your anxiety, where it came from and why it's so prevalent. We will help you to find a way out of it so you can feel freer and happier.
If you'd like to find out more, get in touch to arrange an initial consultation.
If you're struggling to keep yourself safe, please contact your GP, call NHS 111, or call Samaritans free on 116 123, any time of day or night. In an emergency, call 999.
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