High Functioning Depression

High Functioning Depression: An Invisible Illness

Depression is one of the most common mental health conditions in the world. For loved ones, recognizing the symptoms of depression can be difficult, and this can even be with severe cases of the disorder. But when it comes to high-functioning depression, the disease is truly invisible. In clinical terms, high-functioning depression is often called dysthymia and presents a dilemma for doctors, patients, and their loved ones. Dysthymia symptoms are typically subtle, and those with the condition will sometimes appear driven and successful. But beneath the surface are common depression symptoms, like pervasive sadness, feelings of guilt, and low self-worth.

What is high-functioning depression?

Dysthymia is sometimes referred to as persistent depressive disorder or high-functioning depression, and it is a continuous and long-term form of depression. Most of the other depression subtypes tend to come and go, with symptoms peaking for many weeks or months before subsiding and then triggering again. 

With dysthymia, the symptoms of depression may be lower-grade than in major depression, but they are persistent. People with dysthymia may have trouble with motivation, energy, and lack self-esteem or feel otherwise hopeless and cynical. These symptoms can last for years and will severely impact a person’s quality of life, work, schooling, and relationships. Depression symptoms can also influence a person’s physical state, and those with dysthymia may feel a range of somatic symptoms. 

How do people with high-functioning depression often appear to others?

People with persistent, high-functioning depression may not exhibit the severe symptoms present in major depressive disorder, like extreme, sudden weight loss or gain. Instead, people with dysthymia may appear to simply have a “gloomy” personality, when in fact, their problems go much deeper than that.

For those with this disorder, they may have a difficult time appearing enthusiastic or upbeat during happy occasions or when they hear good news. They may struggle with negativity, complaining, and finding it tough to have fun. People with dysthymia may exhibit a depressed mood that could be described as mild, moderate, or severe. Although treating depression may be difficult, it’s not impossible. People with dysthymia can make a full recovery with a combination of medication, talk therapy, and deep-brain stimulation techniques for more stubborn symptoms.

What are the symptoms of high-functioning depression?

Pinpointing major depressive disorder is difficult enough. But when it comes to dysthymia, this condition may be even more challenging to realize. The people who live with dysthymia often appear as high-achievers and lead others to believe they are “okay,” and nothing is bothering them. For loved ones, it’s essential to recognize the symptoms of dysthymia. The sooner someone gets the help they need, the easier it will be to put the symptoms in remission. 

Usually, the symptoms of dysthymia will ebb and flow for many years, and intensity can drastically change from one season to the next. In most instances of dysthymia, symptoms will not dissipate for more than two months at a time. Unfortunately, people with dysthymia are at risk of experience episodes of major depression before or during a bout of dysthymia, and this is called “double depression”. The most common symptoms of high-functioning depression are:

  • Feeling low, empty, sad, or hopeless
  • Feeling tired and lacking energy
  • Not being interested in daily activities
  • Being self-critical 
  • Trouble focusing and making decisions
  • Irritability, easily angered
  • Decreased productivity
  • Social withdrawal
  • Feelings of guilt and worry
  • Lack of appetite or overeating
  • Difficulty sleeping, either too much or too little

Children can also experience dysthymia. Their symptoms are mostly manifested as irritability and mood swings. Children and teens with depressive disorders are also more likely to exhibit somatic complaints than adults, such as upset stomachs or headaches.

Persistent Depressive Disorder vs. Major Depressive Disorder

The Diagnostic and Statistical Manual of Mental Disorders (5th Edition) has determined the official label for high-functioning depression: persistent depressive disorder. To understand the ins and outs of this condition, it is important to differentiate it from major depressive disorder, which is a separate diagnosis. 

 

According to the Diagnostic and Statistical Manual, to meet the diagnostic criteria for persistent depressive disorder, a person must have a depressed mood throughout most of the day, on most days for a period of at least two years. To be classified as a “depressed mood,” the symptoms must be observable by others or present according to the patient. These symptoms include:

 

  • Either lack of appetite or overeating
  • Changes in sleep habits, in the form of oversleeping or insomnia 
  • Lack of energy
  • Poor self-esteem
  • Feeling hopeless 

 

A person with persistent depressive disorder may have periods during which symptoms subside, but symptoms cannot be absent for more than two consecutive months to reach diagnostic criteria. 

 

On the other hand, major depressive disorder diagnostic criteria require a person to display five or more of the following symptoms:

 

  • Depressed mood
  • Loss of interest in usual activities 
  • Change in appetite, or a 5% or more weight gain or weight loss in a period of a month
  • Either sleeping too much or too little
  • Noticeable psychomotor agitation (purposeless activities like tapping feet, etc.) or psychomotor retardation (slowed thinking and reduced activity level)
  • Fatigue and low energy levels 
  • Feelings of worthlessness or inappropriate guilt
  • Difficulty thinking and making decisions
  • Thoughts of death/suicide or suicide attempts

While five criteria are needed for a diagnosis of major depressive disorder, at least one of the criteria must be depressed mood or loss of interest in activities. Symptoms have to be present most of the day, every day, for at least two consecutive weeks. 

Given the differences in diagnostic criteria, it is evident that major depressive disorder is a more severe form of depression, since a diagnosis requires a person to demonstrate more symptoms. Therefore, it may be more difficult to recognize when someone is suffering from persistent depressive disorder, but treatment is needed nonetheless. 

It is worth noting that some people may meet diagnostic criteria for both persistent depressive disorder and major depressive disorder. If someone suffers from major depression for two or more years, they are diagnosed with both that condition and persistent depressive disorder. In this case, depression is no longer considered high functioning. 

What are the risks and complications of high-functioning depression?

Most instances of high-functioning depression begin when someone is a child, teen, or young adult. The disease is chronic. There are also a few risk factors that can increase someone’s chances of developing dysthymia at some point in their life:

  • A parent or sibling has a form of depression
  • Chronic stress and traumatic events
  • Inherent personality traits such as negativity or low-self esteem
  • Having a personality disorder, anxiety disorder or other mood disorder

These risk factors do not predict beyond a shadow of a doubt that someone will develop dysthymia. It’s possible to have all the factors and not get the condition, or have no risk factors and deal with high-functioning depression. But the complications of untreated dysthymia can be dire:

  • Poor quality of life
  • Experiencing other severe mood disorders 
  • Becoming addicted to drugs or alcohol
  • Difficulty forming and maintaining close relationships
  • Decreased productivity leading to work and school problems
  • Chronic pain and other somatic issues
  • Suicidal thoughts and attempts
  • Developing a personality disorder

While dysthymia may be challenging to pinpoint, it is treatable. The right therapy and medication can often help people with high-functioning depression find relief from painful and persistent symptoms. But in some cases, medication and therapy alone won’t be able to alleviate more stubborn depression symptoms.

Can TMS alleviate high-functioning depression?

Depression can be a stubborn illness, with up to 60% of people with chronic disorders unable to find adequate relief from medications alone. While medication can help a large number of people with depression, sometimes patients will need more help. Deep brain stimulation techniques are useful for treating resistant depression symptoms. TMS is the most non-invasive of these techniques, enabling up to one-third of depression patients to achieve a total remission of symptoms. For people with stubborn dysthymia that is severely impacting their quality of life, TMS is worth considering. 

In 2014, The Journal of Clinical Psychology published a report reviewing 18 different studies that assessed the effects of TMS on treatment-resistant depression. Results of the review showed that TMS was effective for reducing depression severity, and patients who received TMS were 5 times more likely than patients in a control group to achieve remission of their depression symptoms. For persistent depressive disorder, which may be treatment-resistant given that symptoms last two years or more, TMS is a strong treatment option.

Patients are awake to receive TMS treatment, and it is a completely painless procedure with few side effects. Patients can return to work or school after treatment sessions, and won’t experience short-term memory loss that is a risk with other deep brain stimulation techniques. If you or a loved one have tried depression medication and it didn’t work, there is hope. Contact the clinicians at Pulse TMS today to see if you’ rea candidate for non-invasive TMS therapy.

Updated 7/25/21