High Functioning Depression:

The invisible suffering

December, 2019

Do you have the feeling that something is just not right? You can be happy, but you feel exhausted and down without any reason? Have you thought about depression but can't identify with the common symptoms?


Not everyone knows that there are many different forms of depression. We usually talk about Major Depressive Disorders, where the patient continuously feels sad and anxious and has no drive to do anything. But there's also a low-level form of Depression called High Functioning Depression.

What is High Functioning Depression?

High Functioning Depression, also called PDD - Persistent Depressive Disorder or Dysthymia, is a low-level chronic form of Depression. It's more than chronic unhappiness with life and negative thoughts. Patients with PDD function almost normally but struggle internally. Dysthymia can also have episodes of MDD - Major Depressive Disorder or Clinical Depression.

High Functioning Depression is also known as "Smiling Depression" because it often affects people who appear as strong individuals who manage well. If they open up about their condition, they often hear, "Come on, you're strong - get over it" or "You always made it; it will pass!". But it's not that easy.

Often, people don't know they suffer from High Functioning Depression. A study from Rudolf Uher, MUDr, Ph.D. shows, 3.3% of women suffer from Major Depressive disorders and 5% from PDD or High Functioning Depression (Men: MDD 2% and PDD 3.1%). Because PDD is so difficult to detect, the actual number is probably a lot higher.

What is the difference?

When we think about Depression, we think about the visible signs of a Major Depressive Disorder. Like negative thinking and inability to see positive solutions, withdrawing from loved ones and regular activities, increased sleeping, exhaustion and lethargy, suicidal thoughts, and weight loss or gain. But what about people who can manage careers and families but struggle invisibly inside?

I had to deal with PDD and MDD episodes nearly my whole life, and it took over 25 years to find out what it was. Despite happy episodes, the main symptoms have been constant sadness, followed by quick exhaustion.

At one point, I thought I was suffering from Chronic Fatigue Syndrome (CFS), but because I also had some Major Depression episodes, it was always diagnosed as MDD. It didn't feel right because the Major Depression phases always had a trigger event and usually didn't last longer than some months.

Until I learned that High Functioning Depression could easily lead to Major Depression if untreated. Because this is what it is: Just functioning. As long as everything went well and there were not too many problems, I could handle my life well.

To deal with one problem was okay, but if more happened simultaneously, I struggled and slipped into an acute Major Depression. Sometimes I was so exhausted from the chronic low-level Depression that even the slightest thing could push me over the edge. These episodes usually lasted only for a few days, and I got myself out quickly, but it was merely functioning. People with PDD have an overall lower quality of life.

What are the symptoms of High Functioning Depression?

The most common symptoms for PDD are:

  • eating habits (gaining or losing weight)
  • sleeping habits (sleeping more than usual, trouble falling asleep)
  • low self-esteem
  • fatigue
  • low-stress tolerance
  • hopelessness and sadness
  • difficulty concentrating

What are the risk factors for PDD?

The persistent depressive disorder often begins early — in childhood, the teen years, or young adult life — and is chronic. Certain factors appear to increase the risk of developing or triggering persistent depressive disorder, including:

  • Having a first-degree relative with major depressive disorder or other depressive disorders
  • Traumatic or stressful life events, such as the loss of a loved one or financial problems
  • Personality traits that include negativity, such as low self-esteem and being too dependent, self-critical or pessimistic
  • History of other mental health disorders, such as a personality disorder

The main difference to Clinical Depression is that patients usually don't have suicidal thoughts. They can see and acknowledge what they have, even though it doesn't make them happy. Many people suffering from PDD don't know what's wrong with them. They don't fit in the usual, more known depression pattern. But they need to know what it is to name it. Sometimes it helps to understand what's wrong.

Many High Functional Depressed patients feel like they are just lazy or physically ill and never thought of the possibility of low-level depression. Because PDD patients master their lives on the outside, it is so difficult to see and accept it. High Functioning Depression often happens to people we recognize and know as vital. I believe the number of patients suffering from PDD is very high.

Like every mental illness, it often doesn't come alone. Alcohol- and substance abuse usually goes hand in hand with Depression.

How can you tell if someone suffers from High Functioning Depression?

Detecting PDD isn't always easy. The patients usually live an everyday life, have a successful career, manage their family and home, have friends, and have many good episodes. This is why it's hard to diagnose as such. Only an experienced Psychologist can make specific tests to be sure. But some signs can point to PDD:

  1. Many High Functioning Depression patients suffer from anxiety. For example, someone close to you gets nervous in a room full of people. Or you and your partner have agreed to meet someone, and shortly before the appointment, he tells you he doesn't want to go or isn't feeling well.
  2. Low tolerance to stress and things going wrong, often without a real reason. It can be a sign something bigger is going on.
  3. Substance abuse, a drinking problem.
  4. Lack of self-care.
  5. Trying to keep busy all the time but getting burned out quickly.

If you suspect your partner or someone close to you could suffer from PDD, you can try to talk about it in an open, non-judgmental way. Make sure they don't feel like they are doing something wrong. Their self-esteem is already very low, and they might even beat themselves up for not "functioning as they should."

"I was so scared to give up Depression,

fearing that somehow the worst part of me was actually all of me." —Elizabeth Wurtzel, author

How can you treat High Functioning Depression?

The first and most crucial step is to accept it. A low-stress tolerance and quick exhaustion is the most common symptom of PDD, besides chronic unhappiness and sadness. It's essential to allow it and not to fight it. If possible, take a day or two off, allow yourself to charge your batteries, and don't have a bad consciousness doing anything. By ignoring the need for rest, it makes it worse.

In general, the following are tips, not necessarily treatments. 

  • Anti-Depressants
    Can be an effective form of treatment. Like every kind of Depression, PDD is also linked to brain chemistry.
  • Talk to a professional
    If that's a therapist, psychologist, or Life Coach, that's entirely up to you. But talk to someone.
  • Self-care
    Because patients with PDD can usually manage their lives better than MDD patients, you can start to create a self-care plan. Allow yourself time off, do more of what you like to do, and try not to take more responsibility than necessary.
  • Pets
    Ideally, a pet can help you relieve stress, stick to a routine, and feel loved again. You can read more about "Emotional Support Dog - Aren't they all?" here.
  • Avoid alcohol
    Even though it might be just a few glasses of wine in the evening, alcohol always worsens the emotional state. Put that bottle away and make yourself a nice cup of tea.
  • Limit distractions
    Try not to binge TV-Shows on Netflix or spend hours on Facebook or Youtube just to distract yourself. It's kind of a runaway from the real world. Do it for a limited time only, and be mindful.
  • Get enough sleep
    If your head is spinning around all these negative thoughts, as soon as you hit the pillow, try reading a good book or making up a daydream about something you like. If you can't stop the thoughts, try to write them down on paper and look at them from another angle. Think about the positive things which happened that day. There is always something, even if it's tiny. Have a hot bath before you go to bed and, a nice cup of tea, listen to soothing (but not sad) music.
  • Try mindfulness
    Mindfulness and Thankfulness can help you concentrate on your life's positive things.
  • Get physically active
    Take your dog out for a long walk, go to yoga, or have a run - whatever brings your body in motion and makes you physically tired. Not only that, you're not able to think about negative things so much; you also will have a better night's sleep.

And most important: Talk to someone, a professional and also someone you trust, ideally someone very close to you. Not even your partner may have a clue what's going on with you. To get help and heal, it's important to talk. You are not alone!

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