HIGH-FUNCTIONING DEPRESSION: A MASK or CLINICAL DIAGNOSIS?

Think of an individual that is depressed. How do we imagine this individual to be? 

A typical image would look like them lying wide awake on an untidy bed looking at the ceiling, irritable and withdrawn, a plate of food kept beside them, their surroundings a mess, ruminating inside a dimly lit room.

As quoted by Martin Seligman, “The depressed person is caught in a cycle of negative thoughts and feelings that reinforce one another. Energy levels fall, motivation drops, and the individual withdraws from life, leading to further isolation and worsening mood.” A clinically diagnosed Major Depressive Disorder (MDD) looks like the above image, with symptoms including depressed mood, anhedonia or loss of interest, social withdrawal, changes in appetite, sleep disturbances, feelings of worthlessness, and diminished ability to concentrate. 

High-functioning depression is an informal term for a form of depression that isn’t always visible externally. Individuals may appear to manage daily responsibilities well but internally struggle with persistent low mood, fatigue, and other depressive symptoms. Though not a clinical diagnosis, it shares features with Major Depressive Disorder and often goes unnoticed due to the person's ability to maintain outward functionality. A phone that appears to be in good condition but has hidden cracks and a damaged battery is an example of a high-functioning depression. It requires more effort to keep running because it is always on low power, even though it runs apps and maintains connectivity. Unless you look closely, the glitches are not visible.

High-functioning depression often overlaps with Persistent Depressive Disorder (PDD), a

clinically recognized condition also known as dysthymia. PDD is defined in the DSM-5 as a

chronic form of depression lasting at least two years in adults or one year in children and

adolescents. It involves a persistently low mood most of the day, more days than not, along with at least two symptoms such as low energy, poor appetite or overeating, sleep disturbances, low self-esteem, poor concentration, or hopelessness. Though typically less severe than Major Depressive Disorder, its long-lasting nature can significantly impair daily life. High-functioning depression is often seen as a modern-day mask for this condition.

Why is Persistent Depressive Disorder (PDD) or High Functioning Depression hard to

diagnose?  

1. No clear onset - Gradual, Not Sudden: Unlike Major Depressive Disorder, which often

begins with a clear shift in mood or function, PDD develops gradually, often starting in

adolescence or early adulthood. Many can't pinpoint when symptoms began, leading

them to underreport or believe it's just “how they've always felt.” The lack of a clear onset makes the symptoms easy to overlook or misattribute.

2. Symptoms are less Severe - but more Persistent: Depression is often stereotyped as

severe dysfunction extreme sadness, immobility, or loss of interest, typical of Major

Depressive Disorder (MDD). MDD symptoms like suicidal thoughts or total breakdown

are usually more intense than those of Persistent Depressive Disorder (PDD). PDD’s

chronic symptoms low energy, self-esteem, and pessimism, may not seem severe

enough for medical attention. As daily functioning is less affected, individuals often

continue life as usual, masking the disorder.

3. Normalization of Suffering: “This is just my personality”: Individuals with PDD often

see their chronic low mood as part of their personality, saying things like, “I’ve always

been negative” or “I thought everyone felt this way.” This mindset leads them to

normalize emotional pain, delaying treatment and making it harder for professionals to

recognize it as a clinical issue rather than personality trait.

4. No Major Episodes, Fewer Crisis Points: PDD lacks the intense episodes seen in MDD,

like sudden job loss, social withdrawal, or self-harm, which often prompt urgent care. As

a result, many with PDD go undiagnosed for years, never reaching a clear "breaking

point".

5. Mask of Productivity, High Functioning on the Outside: Many individuals with PDD,

especially those with high-functioning depression, appear to manage jobs, relationships,

and responsibilities normally. This outward functioning often misleads even

professionals, who may overlook the underlying mood disorder, mistaking it for

introversion, stress, or anxiety.

For example, A has Major Depressive Disorder. Her symptoms came on suddenly after a

breakup, she struggles to get out of bed, has stopped going to work, and feels overwhelmed by sadness and hopelessness. Her daily life has come to a standstill. On the other hand, B shows signs of high-functioning depression, likely Persistent Depressive Disorder. She goes to work, meets deadlines, and appears fine to others, but inside she feels constantly tired, unmotivated, and emotionally numb. While A depression is visible and disruptive, B is quiet, long-lasting, and easily overlooked.

To summarize, it may be preferable to think of high-functioning depression as a potential

manifestation of PDD, especially the milder kind. The primary distinction is in terminology:

high-functioning depression is more of a descriptive phrase that describes the distinct experience of those who live with depression while retaining their ability to function in society, whereas PDD is a clinical term used for diagnosis and treatment. This distinction is significant because the label "high-functioning" can occasionally cause the person and those around them to fail to recognize or intervene because the outward manifestations of struggle are either nonexistent or very subtle.

About the author:

Siddhi Chaubey is a Counseling Psychologist