High Functioning Depression

High Functioning Depression

Authored by Pin Ng PhD

Edited by Hugh Soames

Reviewed by Michael Por, MD

High Functioning Depression

Understanding of mental health, both clinically and among the general population, has advanced dramatically in recent years. However, high functioning depression remains a hidden mental health condition1https://journals.sagepub.com/doi/abs/10.1177/1745691618769868. Those suffering from it can go for years without getting the help they need, while even those closest to them, can be unaware that every day is a struggle.

What is high functioning depression?

High functioning depression was originally known as dysthymia and is now frequently referred to as persistent depressive disorder (PDD)2https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719439/. Indeed, PDD provides a good description of what high-functioning depression is: a long-lasting depressed condition. However, the depression could be defined as relatively mild, meaning that they can continue leading what appears to be a normal life. Some clinicians prefer not to use any of those terms, instead viewing depression as a mental health condition that can present in a range, from mild to severe. In this view, PDD is not a discrete diagnosis, but instead just a different way of describing depression.

In fact high functioning depression, or PDD, is still a depression. However, unlike most depressive episodes, it might have little or no apparent impact on the sufferer’s life. Instead, the struggle is internal. Someone with PDD might have a successful career, but find it a difficult to achieve that success, or even just to go about their normal life. While most people imagine that depression comes in episodes, during which their lives will be severely impacted, PDD is different3https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3130974/. It is a chronic condition, and while its effects may seem small, their persistence means they can have a considerable impact.

Those with PDD are also at risk of suffering a major depressive episode, and it’s likely that, without treatment, most people with PDD will have at least one such episode. But for most of the time someone with PDD will carry a draining low-grade depression that lowers their quality of life. It’s also important to remember that high functioning does not mean fully functioning. Someone with PDD may appear to participate in normal daily activities, like work, school, social and family life, but it takes a heavier toll on them than it does for others.

How is high functioning depression diagnosed?

A difficulty with diagnosis of high-functioning depression is that for most mental health conditions, diagnosis is based on the impact they have on normal life. Almost by definition, high-functioning depression cannot be diagnosed in this way. Instead, the diagnosis criteria center on how the client feels and experiences life.

One important thing to note is that a diagnosis is of a chronic condition. The DSM-5 criteria require patients to have had symptoms for at least two years (or one year for adolescents) and to have experience symptoms that lasted for most of the day, on most of the days, for those two years.

They must also exhibit at least two depressive symptoms. These including feeling sad or hopeless for no apparent reason, having difficulties concentrating or in decision-making, having low self-esteem, and feeling fatigued. They can also include some behavioral changes, such as over- or under-eating, and changes in sleeping habits, like sleeping a lot more or less than usual. These must be sufficient to cause some impairment and distress in the individual, and cannot be better explained by anything else, such as a different mental health or physical condition.

It does not take much imagination to realize that although the symptoms of PDD may be mild in the moment, the cumulative effect of suffering them for years can be enormous.

What does high-functioning depression look like?

Despite the different name, high-functioning depression is still depression. And, therefore, some signs will be the same as any other depression. However, the high-functioning element means that others, even those closest to the sufferer, may not even realize that anything is wrong. Even when the symptoms are particularly bad, they may be attributed to something else, sleep problems, for example, could be blamed on laziness or just a bug. Changes in mood might be explained away as a bad day. Even the person with PDD might not realize, thinking the way they feel is normal and just the way everyone experiences life. However, those with PDD often share common thoughts and feelings.

One common feeling is a sense that they must put on a front. This might be pretending that things were easier, or took less effort, than they really did. This might result from a belief that peers at work, for example, appear to accomplish the same tasks with less effort. Or from a sense that, at a social event, others can engage in chat and meeting others effortlessly, without feeling emotionally drained.

They may also be aware of a mismatch between how they and others experience things. For someone with high-functioning depression, a great day might only qualify as a normal day for other people. Their normal days might be a struggle, which they can manage, but find difficult, while their bad days might seem unbearable.

And, finally, they might find that others simply don’t believe how much of a struggle they find things. They might, for example, have difficulty simply getting up in the morning. Others around them, who do not have PDD, won’t have the same problem.

The nature of PDD means that it’s much more likely that someone suffering it, rather than someone near them, will be the first to identify that it’s a possibility4https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3079189/. However, those close to the individual might notice behaviors that should be explored.

The depressive element of the PDD might be ascribed to personality in some people. The sense of hopelessness or low mood might, for example, be disregarded as a gloomy or pessimistic personality. However, if these are the dominant moods, and they do not bear relationship to objective reality — for example, the pessimism is about something most people expect to go well — it is worth exploring what causes these feelings.

Other symptoms can also be assigned the wrong causes. PDD can make even normal daily routines feel like an effort, but some might consider this laziness. Of course, an untidy home or failure to meet commitments might be the result of laziness or disorganization. But for someone with PDD it is more likely that it’s a direct consequence of the depression affecting their energy levels and motivation.

The way the possible sufferer relates to other people should also be considered. For someone with PDD it is often an effort to engage in social activities that others enjoy and look forward to. Again, some might ascribe this to a natural introversion and shyness, however, it’s worth exploring this to ensure that it is a personality trait, and not a symptom of PDD affecting their anticipation of social events.

Finally, the potential risk of other parts of life should be explored. Even a mild depressive state, like that experienced with PDD, can increase the risk of substance abuse. While the other symptoms might have effects at work or with relationships.

Like any mental health condition, it can only be diagnosed by a professional. So, any concerns should be discussed with a suitably qualified professional, who can help ensure that the patient gets the help they need.

How high-functioning depression is treated

There is no reason anyone should live with PDD. Many people who have experienced it just assume that it’s a natural part of life, or something they just have to get through. However, it is treatable, and because it is at the milder end of depression, can usually be treated successful, greatly improving the quality of life for the sufferer and for those around them.

The first step is to get a diagnosis. Once that is in place, the most appropriate form of treatment can be discussed with a medical professional.

Medication is often prescribed and can be highly effective. The most common prescription will be for anti-depressants. These work in different ways, depending on the type, but the main effect is to lift mood. They are not, however, an instant cure. Because of the way they work they can take time to be effective, sometimes weeks, and even then, the side effects may be undesirable, meaning that it can take time to find the right medication and dosage. However, when this is found it can make a huge difference, helping to stabilize a normal range of emotions.

Therapy is also highly effective in treating PDD. This may take the form of counselling, in which the client can explore their feelings, helping them to understand and deal with them. However, the most effective form of therapy is cognitive behavioral therapy. This is an active therapy, in which the client works with their feelings, understanding what causes them and how they can take practical steps to address them. This will include critically analyzing their thought patterns, identifying what causes their negative feelings, and ways they can break the negative cycle of thoughts to replace it with something more positive.

In-patient treatment for high functioning depression often works exceptionally well, with the multi-award winning Marbella Rehab® leading the field in affordable, luxury treatment for high functioning depression. In a depression rehab, your personalized treatment program grows with you, ensuring that your comfort and health are prioritized. In-patient rehab treatment for high functioning depression takes around 30 days of full immersion to achieve lasting recovery.

Treatment for high functioning depression can be highly successful, but that success can only start when the client seeks help.

Life with high functioning depression

References: High Functioning Depression

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  10. Staekenborg SS, Su T, van Straaten EC, et al. Behavioural and psychological symptoms in vascular dementia; differences between small- and large-vessel disease. Journal of Neurology, Neurosurgery and Psychiatry. 2010;81(5):547–551. []
  11. Folstein MF, Folstein SE, McHugh PR. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research. 1975;12(3):189–198.[]
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