"High functioning depression"?

[futureapppsy2]

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Any thoughts on this concept? It's not an empirically based disorder but occasionally makes the rounds in popular media articles, where it basically means "depression but with very little to no functional impairment," The articles either try to describe it as mild MDD or as PDD (what used to be called dysthymic disorder). Some media examples:

This Is What High-Functioning Depression Looks Like

I'm a happy mom, wife, and professional. What you don't know is that I struggle with depression, too.

www.healthline.com

This Is What It's Like to Live With High-Functioning Depression

Sometimes, depression robs you of your best self quietly.

www.vice.com

 

[WisNeuro]

Any thoughts on this concept? It's not an empirically based disorder but occasionally makes the rounds in popular media articles, where it basically means "depression but with very little to no functional impairment," The articles either try to describe it as mild MDD or as PDD (what used to be called dysthymic disorder). Some media examples:

This Is What High-Functioning Depression Looks Like

I'm a happy mom, wife, and professional. What you don't know is that I struggle with depression, too.

www.healthline.com

This Is What It's Like to Live With High-Functioning Depression

Sometimes, depression robs you of your best self quietly.

www.vice.com

Well, this gets a little at taxonomy and the theories behind "disorder." Necessary, sufficient, and all that. I'm a little wary of "high functioning" diagnoses in general. Many seem to just be pathologizing normal variations in normal emotional states. If we ran the numbers epidemiologically, these "disorders" would encapsulate the majority of the population. Additionally, I'm curious if a good chunk of these people aren't technically better captured under a dysthymic disorder.

 

[representwitpixels]

Some people are adept at managing underlying depression, not showing functional impairment and would not on first glance meet criteria. Upon clinical interview or later after the alliance strengthens, the patient might reveal effortfully managed depressive features, for example. Coping does not imply absence of pathology. Sometimes you do see cases of MDD that certainly fail muster on usual diagnostics. Some "high-functioning" patients may be hiding suicidality. Of course the extent to which the presenting syndrome may be understood will depend in no small part to the clinician and patient achieving a degree of honesty in the assessment. I have been surprised how many struggling people pass by unseen and unmet by the mental health system.

My view on those popular articles - if they help someone feel even a sliver of validation in their particular kind of suffering and/or is a pathway for getting into treatment, then they are doing a public service.

I can understand wariness of "high functioning" diagnoses and conjecture in the public sphere. Though we also might and I would argue even have a duty to continually puzzle about how we are conceptualizing patient's problems.

 

[clausewitz2]

I have read these pieces and I honestly don't understand what aspect of this HFD concept is not captured by the pre-DSM-V idea of dysthymia or depressive personality. Maybe y'all can explain what is different about it (I get why it does not fit entirely within current definition of PDD).

 

[DynamicDidactic]

IMO, another example of over-pathologizing normal behavior. Life is not always sunshine and not all problems are worthy of being diagnostic mental disorders. Of course, the boundaries are fuzzy.

 

[DynamicDidactic]

depressive personality.

Did I miss something? Is this a disorder again?

 

[bostongal109]

This is an interesting debate, and a topic I’ve struggled with conceptualizing as a clinician. My concern is that the idea of functional impairment necessitating a diagnosis seems be biased toward those with privilege. For example, take a single parent who lives alone, if their depression impacts their functioning, they cannot afford rent or groceries or care for their child. So the bar for functional impairment is way higher for them than, say, someone who has paid sick days and/or help at home so if they call out of work or don’t get out of bed to grocery shop or make meals, this doesn’t have the same repercussions. So I don’t love the functional impairment piece. I try to examine how difficult those basic tasks become and the approach to those tasks rather than if they are being completed.

 

[Sanman]

IMO, another example of over-pathologizing normal behavior. Life is not always sunshine and not all problems are worthy of being diagnostic mental disorders. Of course, the boundaries are fuzzy.

I don't know if it is over pathologizing normal behavior as much as it is creating psychobabble. Depression is depression, high functioning or not. A lot of what these articles discuss is people being unhappy with their life choices and wanting to refer to that as depression. Some examples include suicidality, which clearly meets criteria for depression. However, the term seems to be U.S. centric and steeped in our unique cultural stupidity as there is less acceptance of the idea that chronic stress can lead to depression ( I work 70 hours a week in a high stress job, have a baby at home with cholic, sleep 3 hours a night and have no personal time..."I have it all" and am still unhappy; No you have a high stress lifestyle and need make some tough choices and probably get some sleep...the French would riot if given your schedule). But, we are a pull yourselves up by your bootstraps (physically impossible FYI) country that has now created a new term to try and distance depression from laziness, as if laziness is always a bad thing (almost as bad as Socialism). As I write this, I have decided Francophobia is likely co-morbid with High functioning depression.

 

[R. Matey]

I think the issue is labeling an experience so it can be understood well enough to treat it. I think malaise or ennui aren't bad terms, speaking of the French. Some folks really want to have a term for their experience because it legitimizes it to them.

 

[clausewitz2]

Did I miss something? Is this a disorder again?

As far as the DSM is concerned? No, obviously not, although there are alternative taxonomies that do embrace the idea (PDM comes to mind). My point was more that the concept has been around since Kraeplin and is one of the more common complaints of the species 'why doesn't the DSM recognize this obvious clinical thing).

Old wine, new bottle.

 

[super.ego]

High functioning depression? I thought we called that, "life."

 

[erg923]

Most people already think the field overpathologizes. So...maybe we don’t do something as stupid as saying that there is a High functioning major depressive disorder. just a thought, ya know...

 

[foreverbull]

I rarely meet clients who fit the criteria for MDD - mild as a primary diagnosis, because by the time they seek help, it’s usually slipped into moderate with some substantial impairments like isolating socially, etc. (unless anxiety or something else is their primary diagnosis and depression is comorbid but a low level), but my thinking is that if the symptoms are enough to cause distress, maybe MDD - mild is appropriate here. Or PDD as @futureapppsy2 mentioned if it’s chronic, low level.

I think this criterion is key: causes impairment OR distress in areas of functioning. I’m guessing the people described in the articles have distress and some symptoms but not impairment? That is still MDD, diagnostically, if they have enough symptoms.

Or their depressive symptoms are situational/lifestyle-related/adjustment (one woman mentioned in the first article has a ridiculous schedule, and burnout from running ragged and lack of downtime can certainly cause depression), similar to what @Sanman was talking about.

As others mentioned in this thread, I am also very leery of expanding diagnoses any further or creating new diagnostic categories given that the DSM just keeps expanding with each edition to capture more and more of the population. And I wonder about the use of the label of “high functioning” with depression; I’m just not seeing any benefit to a new label when an adjustment disorder, PDD, or MDD - mild probably already capture it just fine.

 

[Sanman]

I rarely meet clients who fit the criteria for MDD - mild as a primary diagnosis, because by the time they seek help, it’s usually slipped into moderate with some substantial impairments like isolating socially, etc. (unless anxiety or something else is their primary diagnosis and depression is comorbid but a low level), but my thinking is that if the symptoms are enough to cause distress, maybe MDD - mild is appropriate here. Or PDD as @futureapppsy2 mentioned if it’s chronic, low level.

I think this criterion is key: causes impairment OR distress in areas of functioning. I’m guessing the people described in the articles have distress and some symptoms but not impairment? That is still MDD, diagnostically, if they have enough symptoms

Or their depressive symptoms are situational/lifestyle-related/adjustment (one woman mentioned in the first article has a ridiculous schedule, and burnout from running ragged and lack of downtime can certainly cause depression), similar to what @Sanman was talking about.

As others mentioned in this thread, I am also very leery of expanding diagnoses any further or creating new diagnostic categories given that the DSM just keeps expanding with each edition to capture more and more of the population. And I wonder about the use of the label of “high functioning” with depression; I’m just not seeing any benefit to a new label when an adjustment disorder, PDD, or MDD - mild probably already capture it just fine.

I would question that they do not have impairment. Going to work, but sleeping the rest of the time is impairment in social functioning. I think the key here is that impairment really needs to be relative to the functioning of the individual. "High functioning" depression seems to suggest that there is some static definition of functioning (similar to the term functional alcoholic). However, I would challenge that all of these people are not suffering impairment relative to their level of functioning prior to having mood issues ( a cashier and a physician clearly have different baselines). Given that and what I think are a large group with adjustment disorders due to life issues, you likely have most people covered. If you can remove something like a stressful job and symptoms dissipate, I would argue that they are suffering from a chronic adjustment issue and not "high functioning" depression.

 

[foreverbull]

I would question that they do not have impairment. Going to work, but sleeping the rest of the time is impairment in social functioning. I think the key here is that impairment really needs to be relative to the functioning of the individual. "High functioning" depression seems to suggest that there is some static definition of functioning (similar to the term functional alcoholic). However, I would challenge that all of these people are not suffering impairment relative to their level of functioning prior to having mood issues ( a cashier and a physician clearly have different baselines). Given that and what I think are a large group with adjustment disorders due to life issues, you likely have most people covered. If you can remove something like a stressful job and symptoms dissipate, I would argue that they are suffering from a chronic adjustment issue and not "high functioning" depression.

This is a fair point; I only skimmed the first article, but certainly if their individual baseline/pre-symptom experience is a different level of functioning, then that is impairment, and I’ve never worked with someone with zero impairment but just distress, although clinically it’s possible via the criteria.

I think that one point in the first article (perhaps?) is that depression doesn’t always look like depressed paralysis/inactivity (the movie depiction of the person with the dirty bathrobe sitting on the couch with a tub of ice cream, ignoring phone calls and not going to work). But we all already know this isn’t the only face of depression, so it’s odd that some feel the need for a new label for it, even though, as you say, and as discussed, most if not all of this phenomenon is captured by available diagnoses.

 

[Mad Jack]

You only need clinically significant distress OR impairment of functioning if you hit all the criteria. Plenty of people can be in significant distress while functioning appropriately

 

[Sanman]

You only need clinically significant distress OR impairment of functioning if you hit all the criteria. Plenty of people can be in significant distress while functioning appropriately

This is true and both terms are rather vague and subjective (likely on purpose). I would argue that if you are in distress , you are not functioning completely appropriately.

Hell, given the year that was 2020, I can say that I functioned appropriately in that I went to work, got myself food, did all my ADLs and IADLS, etc. I would not come close to saying I did all those things with the ease and expertise I did prior to 2020. Just because I was not fired, my bills are paid, and no one is evicting or repossessing my stuff does not mean I did not screw up a few times (forget stuff ,etc) and that I did not gain a few pounds eating junk food and not keeping my regular exercise routine.

Working in quality and compliance a bit previously, I have joked I could justify an adjustment d/o or mild depression dx for any patient in an LTC/ALF with whatever treatment plan I wanted. However, there is some truth to it.

 

[parametric]

Agreed that there’s a tendency to overpathologize and apply psychobabble terms to an overly broad range of human experience. But I think people with psychological disorders do vary in their ability to compensate. I’ve seen some clients with very severe eating disorders still appear to “function” and maintain a high level of performance at work and school. (That said, often they’re not functioning well at all in other domains of life like relationships, and/or “functioning” starts serving as an avoidance strategy in their life.) I’ve definitely seen a spectrum of how people experience and respond to depression and anxiety - some people are more willing or able to compartmentalize/tolerate distress in order to “do what needs to be done”. Guessing traits like self-efficacy and conscientiousness probably play a role here...As well as coping skill repertoire and access to material resources like mentioned above.

 

[foreverbull]

Agreed that there’s a tendency to overpathologize and apply psychobabble terms to an overly broad range of human experience. But I think people with psychological disorders do vary in their ability to compensate. I’ve seen some clients with very severe eating disorders still appear to “function” and maintain a high level of performance at work and school. (That said, often they’re not functioning well at all in other domains of life like relationships, and/or “functioning” starts serving as an avoidance strategy in their life.) I’ve definitely seen a spectrum of how people experience and respond to depression and anxiety - some people are more willing or able to compartmentalize/tolerate distress in order to “do what needs to be done”. Guessing traits like self-efficacy and conscientiousness probably play a role here...As well as coping skill repertoire and access to material resources like mentioned above.

My next question would then be, are we now ascribing a sort of arbitrary judgment of how well people are coping with their disorder as part of the diagnosis? Is “high functioning” then a value label that we think they’re doing better than those with more paralyzing and severe depression because of the former’s personality traits?

I am not trying to put you on the spot in particular, but it occurred to me as I skimmed the first article that “high functioning” can carry certain biases in a diagnosis that may make it seem like the people with lower levels of depression or who aren’t paralyzed to the point of not getting out of bed are somehow more motivated by innate traits rather than perhaps the severity of the features of the disorder itself.

Any thoughts? Interesting topic.

 

[parametric]

My next question would then be, are we now ascribing a sort of arbitrary judgment of how well people are coping with their disorder as part of the diagnosis? Is “high functioning” then a value label that we think they’re doing better than those with more paralyzing and severe depression because of the former’s personality traits?

I am not trying to put you on the spot in particular, but it occurred to me as I skimmed the first article that “high functioning” can carry certain biases in a diagnosis that may make it seem like the people with lower levels of depression or who aren’t paralyzed to the point of not getting out of bed are somehow more motivated by innate traits rather than perhaps the severity of the features of the disorder itself.

Any thoughts? Interesting topic.

That’s a good question! Your point is well taken. I’m not totally convinced high vs. low fxn is a useful subtyping and is probably very confounded by the severity of features of the disorder. Maybe that’s why EDs came to mind first - since those conditions provide a more quantifiable frequency and severity of behaviors/symptoms/medical problems. I guess I think of “high functioning” as the folks for whom, when the GAF was still in use, you’d get a 20-40 point discrepancy in their GAF score depending on what you used to rate it (e.g., someone with “no more than slight impairment” at work/school, but relationships very impaired and behaviors would warrant a higher level of care, inpatient hospitalization, etc.) These ironically tend to be some of the tougher cases to help develop consistent motivation for treatment...

After reading the first article in the OP though, I’m not convinced that’s “high functioning depression”, does seem more captured by PDD/dysthymia as something chronic but low-severity and not overtly impairing.

 

[DynamicDidactic]

My concern is that the idea of functional impairment necessitating a diagnosis seems be biased toward those with privilege. For example, take a single parent who lives alone, if their depression impacts their functioning, they cannot afford rent or groceries or care for their child. So the bar for functional impairment is way higher for them than, say, someone who has paid sick days and/or help at home so if they call out of work or don’t get out of bed to grocery shop or make meals, this doesn’t have the same repercussions.

As mentioned already, this is a moot point since clinically significant distress is enough. But... (unless I’m misunderstanding)

How is the bar higher? If anything it is lower, meaning that the single mom will meet criteria for depression easier than someone with sick days (or more clearly it is easier to identify the impairment). If you tell a clinician I cannot make the rent due to depression that is more likely to warrant a Dx than someone that has all the same symptoms but it does not interfere with rent (all else being even). So, the bar to reach criteria for functional impairment is lower for people with less means. Technically, someone with less means has the privilege of more quickly and simpler identification of functional impairment (of course many other obstacles).

My concern here is reinforcement of a belief that people with means somehow are seen as less sympathetic if they have depression. Like the single mom’s depression is more warranted than a rich and beautiful person. This is why we tend to ignore individuals that are depressed or suicidal but are rich/famous. It’s the belief that money is a solution to problems or that having means should be enough to help people. It’s a double standard. A shiny exterior doesn’t mean that the engine is fine.

 

[DynamicDidactic]

Let me add a other example. If a regular person shows up to work wasted on a regular bases, it is much more obvious that there is a problem (especially if you lose your job). If you are a rock star and you get on stage drunk all the time then it is part of the lifestyle (even if the tour gets canceled). Both people have a problem but it’s much harder to see the impairment in the rock star (in this small window of presentations). Yes, being a heroin addict when you are Keith Richards is easier. But assessing impairment is harder. Heroin use is definitely a problem either way.

 

[MAClinician]

I definitely did NOT have Keith Richards as an example of functional impairment on my SDN Bingo card for 2021