Today we’re going to focus on high-functioning depression. What is it? What’s it not? Is it dangerous or is it not? And what does that mean anyway, ‘’high-functioning” depression”? It’s still depression, isn’t it? It’s the newer term for what’s “properly” called Persistent Depressive Disorder, which used to be called before that, Dysthymia. Maybe it’s a little sexier to call it ‘high-functioning depression” or “smiling depression.” But here’s my thought: if more people react to one label better than they do others, more power to that label. I don’t particularly care what we call it – and if more people can say, “Oh yeah, that’s me,” and recognize its validity or presence, then I’m all for it.
Let’s make sure we all understand that I can’t think of any mental illness or disorder that’s not on a spectrum.
You have depression. How you cope with it is based on myriad of factors. And there are millions of people who are coping every day around the world. I hope you’ll benefit from listening and sharing this episode about moderate depression, or high-functioning depression.
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What Cleveland Clinic says about PDD or Persistent Depressive Disorder
My TEDx talk that today has earned 60,000 views!
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This is SelfWork and I’m Dr. Margaret Rutherford. At SelfWork,we’ll discuss psychological and emotional issues common in today’s world and what to do about them. I’m Dr. Margaret and SelfWork is a podcast dedicated to you taking just a few minutes today for your own selfwork.
Welcome or welcome back to SelfWork. I’m Dr. Margaret Rutherford. I’m a clinical psychologist, and I started SelfWork almost seven years ago in order to extend the walls of my practice to those of you who might already be interested in psychotherapy or you’re in therapy, to some of you who may have just been diagnosed with something or you’re having a problem you can’t figure out and are looking for answers. But also to a third group of you who are very skeptical about mental health treatment, mental illness in general, or you just think psychologists and therapists are a little wacky <laugh>. Well, anyway, so here we are today. I wanna give a trigger alert to this episode because we are gonna be mentioning suicide. So just to trigger alert, to keep you safe. Today, we’re going to be focusing on high functioning depression. Now what is that and what is it not?
Is it dangerous or is it not? And what does that mean anyway? High functioning depression. It’s still depression, isn’t it? It’s actually the newer term for what’s properly called persistent depressive disorder, which used to be called before that dysthymia. Maybe it’s a little sexier to call it high functioning depression, or I’ve also heard it called smiling depression. But here’s my thought, if more people understand or respond to some label or another better than they do others, then more power to that label. I don’t particularly care what we call it, but if more people say, yeah, yeah, that’s me, and recognize its validity or presence, then I’m all for it. I want you to understand, however, that I can’t think of any mental illness or disorder that’s not on a spectrum. Everything from schizophrenia to bipolar disorder to phobias to anxieties. But the major reason I wanted to point out the distinctions between good old classic depression and high functioning depression is that it can be too easy to believe one is better than the other, or that somehow people who aren’t high functioning have some kind of innate weakness.
than they’re more high functioning counterparts. I don’t believe that at all. At all. You have depression. How you cope with it is based on a myriad of factors, and there are millions of people who are coping every day around the world. We’ll get more into that in the body of the episode. We don’t have a voicemail for today, <laugh>, as I got into writing this so much that I ran out of time, but we’ll feature that voicemail next week. It’s from a mom of two small children whose own mother she describes as borderline and is having huge problems in the past with alcohol. She’s in a tough spot with her mom. She’s trying to figure out how she can best, best keep her children safe. So I’ll do my best to answer. But again, that’s next week. Before we get started, let’s hear from one of our wonderful sponsors whose support really allows me to offer y’all self work. Let’s hear from AG1.
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It is always a bit embarrassing when you find out that what you’ve been saying about something isn’t quite accurate, especially when you’re supposed to be an expert. And that for me is with depression, or at least I’ve written a book about it. As I was researching for my book Perfectly Hidden Depression, I read several articles on what was termed “smiling” or “high functioning” depression. I never saw real symptom lists. What I read or what I thought I understood was that people who identified with high functioning depression knew they were depressed. They could see themselves in some, or a lot of the diagnostic markers of depression, foggy thinking, indecisiveness, fatigue, sleep or appetite issues, not enjoying the things they used to enjoy and an overall sense of being down a lot or most of the time. But these symptoms weren’t so severe that they weren’t able to slap a smile on their face, take their meds, go to therapy – or both – get in a couple of good walks, get the kids to school and get to work.
So I made the simple assumption that high functioning depression wasn’t as debilitating as someone with more severe symptoms or classic depression. So I was right, but I also didn’t understand the entire picture.
This week, I was interviewed for an article for Wonder Mind about high functioning depression, and the author asked what the symptoms were. I somewhat confusedly said, “wWell, it’s not a diagnosis, so it doesn’t have symptoms. It’s more a way of people talking like they know they have depression, but they developed really good coping skills, or they know what their triggers are and avoid them,” or some such language, and she seemed a little confused. So what did I do? The next morning? I looked more into the term high functioning depression. What I had not realized, even when I was writing the book, was that the term high functioning depression was the newer term for what used to be called the more moderate depressive state of dysthymia, and now it’s termed persistent depressive Disorder or PDD for short.
The Cleveland Clinic says about PDD, it’s mild or moderate depression. That doesn’t go away. A person with PDD has a sad, dark or low mood or two or more symptoms of depression. The symptoms last most of the day on most days over a long period of time. So it’s a change of nomenclature or what we call moderate depression. And as I said in the intro, I don’t really care what we call it. If a term is more meaningful now in 2023 than dysthymia or PDD was, it’s certainly far less jargonistic sounding. Let’s go with it. <laugh>. I emailed the author immediately and explained to her what I’d figured out felt a little silly, but we all have to sometimes say we make mistakes.
Let’s also make this point. All mental illness exists on a spectrum. I said this in the intro, as I suppose medical illnesses do.
You can have really severe bronchitis or you can have a much milder throat infection. So all that’s very simple. But depression has been and will always be on a spectrum.
So let’s first go through the pros of high functioning depression. Not that having depression is in any way a “pro” or some kind of benefit. A darkness still exists for you. Your emotions are difficult. You have physical symptoms and trouble with your thinking, and those things have been that way for quite a while by diagnostic standards, in fact, at least two years. But compared with more severe depression, this kind of depression doesn’t sabotage your life as much as a deeper depression can and often does.
So here are some of the pros of high functioning depression when we compare it to deeper, more severe depression. Obviously, most of the time you can work and get things done.
That’s the easiest pro to see. You may hate going to work or dislike your job, but perhaps you figured out how to maximize what you most like and minimize what you don’t. Maybe you have a hobby that you look forward to doing after work that brings you much more fulfillment and stands as a balance for what you don’t enjoy so much. Maybe you love your kids and being around them or doing for them is very meaningful for you. So you’re coping. There’s much research out there, for example, on resilience in times of war. By no means for anyone are things right, and certainly depression does exist. You may long for what used to be, but you’re going through a collective experience and that connection is what can sustain you. So resilience may be part of holding down a depression to a more moderate depression, but again, it’s multifaceted.
One of my other observations is that when a less severe depression is occurring, your connection with others mostly remains intact. Physical symptoms may not be as likely and meaningful connections are still possible, and that’s quite a feat. Really, it is. You may not see it that way. You may not give yourself credit for keeping on, keeping on, but it’s huge. You can admit some days are harder than others, but you can talk about it hopefully, or if you can’t talk about it, perhaps you journal or you exercise to get some of your anger or sadness out. I realize how much I’m saying the words “may” or “can” here. There’s not one picture of the moderately depressed person. I’m sure your culture, your gender or gender identification, your race, your age, all of these human characteristics are going to come into play when someone describes the moderately depressed person or the high functioning depressed person.
It’s the term. In fact, Chesley Kryst used about herself, at least her mother said she did after her suicidal, tragic death, who was Chesley Kryst? She was Miss U S A in 2019 and 2022 years due to the pandemic. She was the oldest Miss U S A at the ripe age of 28. She was shorter, more muscular, stunning, and brilliant. But I quote her when I’m teaching my class on perfectly hidden Depression to clinicians as she says that she only finds emptiness in achievements that her culture told her would bring fulfillment, and she jumped out of a New York City high-rise apartment building in January of 22. Obviously to her death. I don’t think that Chesley Kryst had high functioning depression. I think her depression had worsened in a major depression, which then she didn’t realize, or perhaps she would’ve identified with perfectly hidden depression. We’ll talk about that difference as well as other pitfalls of high functioning depression after this word from Better help.
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Let’s get back to talking about Chesley Kryst. I don’t want to oversimplify what Ms. Kryst went through or get into some kind of label dispute about what we call it. She thought of it as high functioning depression. That’s what she reportedly told her mother the day before she died. Perhaps even that’s what she and her therapist talked about. But moderate depression or high functioning depression can morph into major depression, and if she indeed experienced perfectly hidden depression or her perfectionism and high achieving life was really camouflaging even deeper despair than she wanted to reveal, she may not have had a way to talk about the extent of her suicidal plans or impulses. What matters is that she very purposefully fell to her death and the world lost a woman. Her family lost a daughter or a sister, and she was no longer alive to figure out that she could get better.
In my TEDx talk, I warn against just this kind of silence or fearing what might happen if you reveal suicidal thoughts. I also know as a clinician for 30 years just how common suicidal thinking is. It’s not weakness, it’s not a sin. It’s a human response to depression and abuse and whatever else has happened to you. I do wanna make the point here that no depression is easy. Not one kind of depression is better to have than another kind, but you can function better with what’s called smiling, depression, high functioning depression, whatever. You just can live your life. You’re still walking around having to cope with a sense of sadness and maybe even dread, but even high functioning depression has its pitfalls. So we’re gonna talk about that and as always, what you can do about it. This is in no way a complete list, but it’s what has come to me as I write this this afternoon, and I hope it’s helpful.
First, loneliness can creep up on you. With high functioning depression, you can easily tire of keeping up appearances, but you can get trapped in doing so and begin to have thoughts of being caged in by the life you’ve created into the depression that never seems to get better or worse. It’s just there. So let me say high functioning depression has a root cause, just like more severe depression. Let me repeat that. It has a root cause. So what could that be? The first cause could happen through learning. What I’m saying is that high functioning depression can become almost its own lifestyle. You absorb depressed thinking or behavior as a child. Basically, you learn it. Think about if your parents never praised you or rarely gave you the message of what they saw in you that was your power or talent or skill. You can grow up feeling less than maybe your parents also felt that they were less than, and so you learn that from them.
But it isn’t reality or it doesn’t have to be. The problem is you can absorb low self-esteem. You can be told you don’t wanna try too hard or show that you really want to work hard for something because that’s how you get hurt. That’s when you look stupid. So you don’t risk, you don’t try. You don’t even have a clue of what your potential is. You live your life very carefully or you avoid risk or you avoid the chance of others seeing whatever your real struggles are. Now, you might say, “Well, I was never abused as a child.” That’s good. In fact, that’s great. But damage can also be done by growing up in a vacuum where you were taught or it was modeled for you, that you just get through life. You settle, and guess what? That’s depressing. Life can seem just okay, not bad, not good, just okay, so maybe you do put that smile on your face every morning.
Maybe you clock in at work and remember it’s your colleague’s birthday and you wish them a good day. Maybe you love your daughter and she’s excited about a soccer game she’s going to play that day. You’ve tried to give her what you never had and good for you, but your own life seems pretty humdrum.
What I’m not saying is that there’s something inherently bad about normal. I think it’s sort of funny… normal has become a negative term. Why? I’m not sure – the only time I hear it used positively these days is when you get a test back and the results are normal or when your life has been chaotic and you’re glad to get back to normal. But I’ve seen on social media for example, that normal is simply not okay, and that can be a part of high, high-functioning depression. My life seems normal, but I’m telling myself that’s not good enough.
Really, that’s a setup for selfs sabotage. But humdrum is not normal. Now, there are days that are pretty humdrum <laugh>. We all have them, but if your life stays that way, that’s the point of high-functioning depression that you don’t get out of it. It’s only when you stigmatize normal, when you see it as not bright enough or shiny enough or not good enough, that normal becomes a message to yourself that you have failed somehow.
So let’s get back to the cause of high functioning depression. Maybe it’s not learned. Maybe your high functioning depression is the product of something else, a relationship that went sour that you’ve never gotten over, some loss of a dream that you’ve never recovered from. Maybe you stopped going to school, dropped out. Maybe you’ve got a learning disability that’s either never been diagnosed or you’ve not wanted to admit it.
Maybe you’ve grown up feeling that because of your race, you don’t have a chance because you’ve been bullied and you’ve absorbed that message that you’re less than, that you need to hide. You’ve got to look for what you believe about yourself or about life in general to determine what may be getting in your way of having a good life or what I like to say, a good enough life, which is not humdrum. It’s just good enough, and that can help you overcome depression that you don’t believe the messages you got from your neighborhood or your family or your culture. If not, your condition can devolve into feelings of self-loathing or self-doubt, the stuff of more severe depression. Now, I’m very aware as I’m talking that I’m a white financially secure woman. It may seem easy for me to say these things, but then I think of situations like the one I’m about to tell you the things I’ve learned from my own patients.
One day when I looked on my schedule, I saw something kind of interesting. One of the patients I was going to see that day was the mother of someone I’d actually seen years before. And that patient, the one I’d seen years before, had asked a special favor of me to see her mother. Let’s call her mom Emma. That was not typically my practice to see someone’s parents, but her mom had heard about me from her daughter and she knew I hadn’t thrown her under the bus, but had recommended instead that her daughter work through the legitimate feeling she had, while also have whatever compassion she could for her mom. Emma had had a really, really rough life and hadn’t been all that great of a mom. The daughter told me that she’d apologized a hundred times over, but she’d also told her daughter she wanted to share something with me she’d never shared before.
So I agreed to see her mom. Emma.
Also on my roster that day was a man who was one of the head honchos of the corporation where Emma worked. She worked on the chicken line, cutting up chicken parts. She’d never even finished elementary school. The other man I was about to see was a big wig in the chicken company. I smiled a little when I saw that and wondered what my day might bring.
Emma came in first. Sure enough, she got tears in her eyes when she talked about the damage she’d done to her daughter. Her feelings were very sincere. She thanked me for helping her daughter. But when I asked why she’d wanted to come in for herself, she said, “I’ve never told this to anyone, but I’ve never forgotten it and I know that I’ve been affected by it”. And there was a pause.
“I was sexually abused by my brother for years and I’ve never told anyone”, and she got tears in her eyes again. Of course, I asked, “How does it feel to tell me?” And she said, “Like a weight just dropped off my shoulders.” She went on to describe other things in her life. For example, she was taking care of her ex-husband who now was almost completely unable to care for himself, and he had been horribly abusive to her. She asked for no sympathy. She simply wanted to tell someone about the abuse and felt tremendous relief as she said. I admired her candor and continued to work with her for a few more sessions. ’cause she needed to help setting some boundaries. She needed to remember that she had to care for herself. That wasn’t through massages, but real self-care, some time to herself, some rest.
So that same day, as I said before, I saw the big wig as we’ll call him <laugh>, we’ll call him Pete.
Pete had had all the education and opportunities that life could offer, and those were many. He was smart, but as I like to say, he was his biggest fan and it wasn’t attractive. He came in with his wife and seemed to have the agenda that I tell her there was no reason for her to be depressed, that she had everything a woman might want. His wife looked at me and said, “I have everything except Pete’s love.” Pete scoffed at that and looked at me as if I’d agree with him. Some basic narcissism, of course, but what was so evident to me that Pete didn’t have a clue about what real connection was or could be.
The differences between Emma and Pete were many. I could have said back then that maybe both of them in their own very unique way were experiencing chronic but moderate depression or high functioning depression.
But Emma had found a way to stay connected, to seek forgiveness, to care, to choose to be transparent and allow her pain to lessen. Whereas Pete had very little to no empathy for the chaos of his marriage, nor did he understand what true connection was. I knew at the time that underneath what looks like narcissism, what looks like bravado is sadness, insecurity, and depression.
Now, whether we wanna call it high functioning depression or what, I don’t know. Pete only came in twice because he also didn’t know how to risk true connection with me.
I actually worry more about the Petes of the world than I do the Emmas. Emma has developed coping skills. Pete, not so much, except in the area of achievement. It was Pete’s life that was full of sadness. It was Pete that was caught. It was Pete whose life would stay chaotic until he could try to risk understanding what made him – him, what had happened to him.
High functioning depression, despite its name is still depression. That’s a point that I hope I’ve made clearly. But I hope that this episode has helped you realize that you can figure out where those feelings and thoughts came from, and you can begin to change them. Because life is worth living very fully. And if SelfWork has helped you do that or make changes in your life that are important to you, please let me know.
Thanks always for listening. You can let me know that by leaving a rating or review of wherever you listen to self work, it always means so much. Ratings are simply a quick, yes, I like this <laugh>, or a star rating. I guess it’s a 5, 4, 3, 2, 1. And of course, review is a little more detailed, but all of it means so much to me.
I just spoke last night to a small women’s caucus. I wanna remind you that I’m available to speak to your organization. I don’t care if it’s 20 people or 200 people. I can speak virtually or I can come to you given the appropriate circumstances. I’d love to do that so we can all share the wisdom that we all have.
You can also join my Facebook group at facebook.com/groups/ selfwork. We’re at about almost 3,600 people. Some people go and then some people come. It’s a great group. We’d love to have you there. And as always, you can buy my book Perfectly Hidden Depression@amazon.com or wherever you buy your books, and it gives you 60 exercises that you can follow along and learn how to get in touch with your own emotions very safely and securely.
Again, thank you. I’m always grateful you’re here. Please take care of yourself, your family, and your community. I’m Dr. Margaret, and this has been SelfWork.