High-Functioning Anxiety, When You Are Successful and Still Not Okay

Dr. Georgine Nanos, MD, MPH. Founder, Kind Minds TMS. Physician-led brain health, Encinitas, CA.

The women I treat for anxiety are almost never the women who came in for anxiety.

They come in for the insomnia. Or the jaw pain, or the stomach thing that three specialists have now failed to find, or because a routine physical turned up a blood pressure number that did not match the rest of the chart. Anxiety is what we find. It is very rarely what they came in to say.

And when I do say the word out loud, most of them argue with me about it. Which I get. I actually think they're being reasonable, because the anxiety is the engine. It is the thing that gets the deck finished at midnight and the forms signed and the school emails answered and the whole operation standing up, and being told that your most reliable quality is a medical condition sounds a lot like being told to stop being good at your life.

So let me be careful about what I'm actually saying.

It Gets Treated Last Because It Works

Here's the part nobody will tell you. High-functioning anxiety goes untreated for years specifically because it is functioning.

You're producing. You're showing up. Nothing has visibly fallen over. And in a fifteen-minute appointment, the clinical picture that gets the attention is the one that is failing loudly, and yours is failing quietly and on schedule, so you get told you're doing great, maybe try to get some more rest, and how are the kids.

That's not your doctor being careless. That's a doctor trapped in a system that pays for fifteen minutes and rewards the absence of a crisis. But the effect on you is the same either way: you get to be the most capable person in every room and the last person in the building to get looked after.

I'd say roughly half the women who eventually sit in my office have been at this for a decade before anybody used the actual word. A lot of them arrive because of the nights, not the days, and if that's the part you recognise, the anxiety and sleep loop is worth understanding on its own.

What the Prescription Usually Is, and What It Is Not

Somewhere around year two or three, somebody writes for a benzodiazepine.

And it works. That's the whole problem, honestly. It works beautifully and immediately and it teaches you very quickly that relief is something you take rather than something you build.

A benzodiazepine is a fire extinguisher. It is genuinely excellent at the thing it does and I prescribe them, in the situations they're for. It is not a smoke detector. It is not the wiring. And nobody should be living for eight years in a building where the extinguisher is the only safety system anybody ever installed.

The question worth asking at that appointment is not "can I have something for this." It's "what is the plan that ends with me not needing this." If nobody has ever offered you a version of that conversation, that's the gap, and it's not because you didn't ask correctly.

What Anxiety Is Actually Doing

Anxiety is a prediction. That's the cleanest way I know to put it. Your brain is constantly running a model of what is about to happen, and an anxious brain is running a model that has been trained on far too much threat and not nearly enough evidence of safety, so it keeps returning the same answer regardless of the input.

Which is why reassurance does so little. You cannot argue a prediction model out of its training data. You already know the presentation is fine. Knowing has never once helped.

At Kind Minds we treat anxiety alongside depression and OCD, and every person starts identically: a physician-led brain health consultation with structured cognitive assessment as a baseline, which decides whether any of this is appropriate for you at all, and screens for the contraindications that make TMS the wrong choice for some people. Those are real and that screening is the reason a physician does it and not a form at a front desk.

The Part Where I Admit Something

I walk the beach every single afternoon. Thirty to forty miles a week, three blocks from my office, and I would love to tell you that's a disciplined cardiovascular routine undertaken by a physician who practices what she preaches.

It is not. It's regulation. It's the thing that keeps my own prediction model roughly honest, and on the weeks I skip it everybody at my Monday morning team meeting can tell, including me.

I say that because there is a version of this article where the doctor sounds like she solved it and is now reporting back. I didn't. I manage it, deliberately, with things that work, and that is available to you too.

What You Can Do Right Now

If you have been handling it for years and the handling has started to cost more than it returns, that is the signal. Not a breakdown. Not a crisis. The cost going up.

Go get evaluated by a physician who will look at the whole picture rather than the fifteen minutes of it that fit in the appointment. Ask what the plan is beyond a prescription. Ask what happens if the prescription stops being enough. Advocate for yourself here and be slightly rude about it if you need to be, because the women who get properly treated are almost always the ones who insisted.

And to every woman reading this who has decided that because she is coping, she doesn't qualify for help: coping is not the same as being well. You have been carrying something heavy so smoothly that nobody noticed, least of all you. You're allowed to put it down.

Frequently Asked Questions

Can TMS treat anxiety?

Kind Minds treats anxiety with TMS alongside depression and OCD. Whether it is appropriate for you specifically is determined at a physician-led consultation, which also screens for medical contraindications.

What is high-functioning anxiety?

It is not a separate diagnosis. It describes anxiety in someone who continues to perform well at work and at home, which is exactly why it is commonly missed, dismissed, or left untreated for years.

My anxiety medication works. Why would I change anything?

You might not. The question worth asking is whether there is a plan that ends with you needing less of it, and whether anyone has ever offered you one. Medication that manages symptoms indefinitely without a longer-term plan is worth revisiting with your physician.

Can you have anxiety and depression at the same time?

Yes, and it is extremely common. They frequently travel together, and treating only the one that is louder tends to leave the other in place.

How do I know if my anxiety needs treatment if I am still functioning?

A useful test is cost rather than collapse. If maintaining the same level of functioning takes more out of you each year, in sleep, in health, in what you have left over for the people you love, that is worth a proper evaluation. Waiting for something to break is not a diagnostic strategy.

Kind Minds TMS provides physician-led, longitudinal brain care in Encinitas, CA. To learn whether treatment is appropriate for you, book a Comprehensive Brain Health Consultation, a medical evaluation, not a sales call.