The Problem of High Functioning Anxiety – Mad In America – Mad in America

High Functioning Anxiety (HFA) is not a diagnosis recognised by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Nor is it limited to the discrete behaviours commonly associated with generalised anxiety disorder (GAD), such as interpersonal avoidance, social paralysis, and persistent fatigue.

Instead, HFA has emerged as a nebulous, catch-all term to describe anyone who lives with anxiety but manages to function reasonably well on a day-to-day basis. Those characterised (or self-identified) as “high-functioning anxious” tend to be proactive, outgoing, successful, high-achieving, put-together, and reasonably calm—until they are not—the typical “type A personality” who excels at work and life.

A kaleidoscopic photograph depicting a busy street, reflected multiple times
Image courtesy of A.T. Kingsmith

Discussions of HFA have become more widespread in recent years because they emphasise a positive side to anxiety. According to Melanie Badali, it is for this reason very little research has been done by mental health professionals to scrutinize the term. Since nobody wants the social stigma that comes from acknowledging they have a problem, HFA allows sufferers and practitioners alike to stress the bustling and instrumental aspects of anxiousness—”anxiety can help push a person to perfect tasks at work, get all the chores done at home, to be a more attending partner, colleague, friend, etc.”

However, what someone thinks and feels can be very different from the outgoing, ambitious, proactive, detail-oriented, or self-sufficient exterior they present to the world. And when anxiety accumulates it can become immobilising, leaving a person unable to cope with the demanding routines and expectations it once enabled. While, in recent years, there has been a 25% surge in reports of anxiety worldwide, making it the most prevalent mental health challenge, in this productivity-driven age it is virtually impossible to know just how many people struggle with HFA. What is clear, is that there is an increasingly prevalent correlation between the relentless pressure to be “high-functioning” and the arresting guilt of feeling useless and unproductive.

The demands of HFA often drive people to try and ignore symptoms, or “power through” their struggles. This is done by fashioning false persona that conceal the need for constant reassurance, a fear of failure, tendency to compare oneself negatively to others, nervous habits, and the potential for substance abuse through an outward facade of confidence and levelheadedness. It is not until people are alone that they “crash.”

Anxiety and Productivity

Despite being celebrated as productive and even beneficial, HFA fuels a myriad of nervous habits in the body—racing thoughts, lost time, procrastination, cracking knuckles, lip and nail biting—that cannot be so easily separated out from the dominant narratives about productivity and efficiency within the current social and economic order.

As Joanna Moncrieff points out, capitalism has created a culture of relentless productivity by requiring people to produce enough surplus value to be employable. Whereas in pre-capitalist societies there were lots of opportunities for people contribute to their communities, in the capitalist system labour only has economic value if it generates sufficient profit. As Moncrieff continues, this process of exclusion from the productive workforce deprives people of a connection with and investment in their communities, thus contributing to individuals becoming marginalised and demoralised, which is then labelled (wrongly) as mental illness.

If we look at HFA through the lens of political economy—that is, how people’s preferences, opinions, and identities are shaped by their material conditions—unemployment and low productivity transform from a personal failing into a socio-political problem that extends beyond the horizon of any one individual and into the everyday norms, values, and contexts we inhabit, all of which are underpinned by the ways we perceive work and working life. After all, it is the unrelenting pressure for increased outputs that transform one’s toxic busyness and self-destructive overwork into “key strengths” that can shine on a résumé.

It is not that people are unable to take the occasional break from the unrelenting drive to produce. It is that they often struggle to understand what this break really means, for every thought of taking one triggers the question: “What have I done to deserve it?” Since value in a capitalist society is determined by the labour people produce and not by the ambitions and principles they hold, we have accepted that the busier we keep ourselves, the happier we can expect our lives to be.

This marks the problem of anxiety, or any other form of mental distress connected to larger social structures and processes, as one’s own fault and thus one’s responsibility to fix. Such a prioritisation of profit over participation inundates any practice or treatment that frames anxiety as something that is wrong with you—be it your own behavioural deficiencies or faulty coping mechanisms—by pushing people to internalise their health and wellbeing as synonymous with productivity and purchasing power.

HFA and the DSM

We are living in a context where it has become preferable to comprehend mental illness in the same way as physical illness—that is, with clear-cut categories and cures—without fully weighing the evidence against this position. Such a paradigmatic shift towards a sort of medicalisation of productivity is reflected mostly clearly in the changes made to the DSM from the publication of the first edition in 1952 (DSM-I) to the fifth edition in 2013 (DSM-5).

According to Bruce Cohen, whereas DSM-I and DSM-II make few references to the workplace, from DSM-III (1980) onwards there is a substantial jump in work-related terminology that mirrors productivity-driven reforms across society. In particular, the introduction of an emphasis on workplace performance in terms of “social phobia” and “social anxiety disorder” to DSM-III and DSM-IV coincides with the advent of a general tendency in people to entertain the use of drug treatments for their “failures” to be sociable and assertive at their jobs.

With the introduction of DSM-5 two decades later, many of the issues afflicting the previous manuals have only intensified. Allen Frances, chair of the DSM-IV task force, describes the fifth iteration as a “colossal waste” mismanaged by a “small, withering, cash strapped, and incompetent association that feels compelled to regard its bottom line as a higher priority than having a safe, scientifically sound, and widely accepted diagnostic system.” The resultant effect is a diagnostic process that further pathologizes what are often relatively commonplace behaviours and temperaments to serve the market-driven interests of employers.

As Susan Rosenthal observes, Cohen’s textual analysis reveals the increasing degree to which psychiatry has been positioned as an authority on “acceptable behavior” at work, at school, and at home—acceptable behavior being defined by increased productivity across all aspects of life. A person no longer needs to perceive their anxiety as excessive or longstanding to be instantly prescribed addictive, anti-anxiety drugs. Additionally, shyness and introversion become social phobias, hopelessness and despair related to the burden of precarity becomes depression, and restless or non-compliant employees are diagnosed with ADHD.

By encouraging sufferers to question their own feelings rather than the organisation of wider social, economic, gendered and cultural structures dominated by the ideals of individuated patient-centric Western health policies, tools like the DSM legitimate the extension of non-productive stigmatisation into job training, contract work and even unemployment. This aids in the proliferation of the neoliberal focus on the rational, self-serving actor as the primary site of mental health transformation which simultaneously depoliticises the rise of increasingly alienating work environments and the constant pressures to re-brand and up-skill they engender.

You Are Not the Problem

Widespread experiences of mental distress are far more than isolated instances of illness to be “cured” by psychotropic drugs or personalized treatments. They point to the ways structural deficiencies and imbalances are coded into our lived experiences, compelling us to make excuses for the system but never for ourselves. If a person cannot cope with this rigid, internalised understanding of mental health, they are likely to conclude that they are “abnormal,” unwell, or otherwise deviant—that they are “the problem.”

As David Smail traces out, this has created a situation whereby any symptoms arising within individuals are divorced from the cultural, political, and economic interactions between people and from the nature of the social world we have created. Yet anxious people everywhere are connected by a pervasive condition that has spread into our homes and workplaces, our dreams and desires—always tracking along the contours of exclusion and marginalisation. How else can we comprehend why racialised or queer people are, on average, more anxious than white or straight ones? That working-class children are more stressed than middle- and upper-class ones?

When we internalise the dominant capitalist narrative of productivity above all else, which portrays people who rest and take breaks as unworthy of amity and contentment, it becomes an ideological apparatus through which we make sense of the world. As a result, many of the supports on offer are eclipsed by market logics that have little interest in eradicating or even suppressing mental ill-health. All too often, what counts for “help” seeks to expand our capacities to continue producing while remaining unwell, exploiting possible every moment of time and spare resource for the purposes of “self-actualisation.”

Such trends are poised to continue with the release of the DSM-5-TR (TR for text revision) this year. As Sarah Fay makes clear, the architects of the DSM could have spent the past decade revaluating the intensified relationship between productivity and mental health. Instead, DSM’s invalid, unreliable, and suspect diagnoses have been further entrenched in an updated version through the same pathologizing logics and loosened diagnostic criteria.

Most treatments on offer today—from enduring psychiatric and pharmaceutical interventions pushed by the DSMs to mindfulness, CBT, and the other psychotherapeutics—put forward increasingly personalised and customised means to such ends. In the place of treating it as incumbent on individuals to resolve their own mental anguish, instead, that is, of accepting the vast personalization of stress that has taken place over the last thirty years, perhaps we should be asking: “Why has it become ‘normal’ that so many people today are anxious?”


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.