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Updated 21 September 2020

Behind the fake smile: What is higher-functioning depression and anxiety?

Some people are very good at hiding their mental health issues.

  • Higher-functioning depression and anxiety are difficult to spot
  • People can appear to be doing well in society while struggling internally
  • Two clinical psychologist explain to Health24 how to better understand the condition

You're outperforming everyone else at work, your friends think you're the life of the party, and to the world you're a well-polished, well put together human being.

But inside, you're constantly at war with your brain, negative thoughts and the constant urge to give up and disappear.

In some people, mental health issues aren't as obvious as in others. This hidden condition is colloquially known as higher-functioning depression or anxiety. 

"Individuals that are diagnosed with depression and/or anxiety or present with prominent symptoms of depression and/or anxiety but fail to show a significant amount of distress in interpersonal contexts such as their working or social environments," is how Dr Erica Munnik, clinical psychologist in the Department of Psychology at the University of the Western Cape, defines the condition.

"They thus appear to be functioning well at work or are able to relate socially, although they are feeling a significant amount of intrapsychic distress – feelings of depression or anxiety."

This makes it hard for others – and the individuals themselves – to spot the signs and get professional help. 

READ | 10 mental health apps to get you through 2020 

Persistent depressive disorder

It's generally considered a problem if you have a persistent low mood for about two years, where there are no breaks in symptoms for two months at a time. You'll then be diagnosed with persistent depressive disorder (PDD), also known as dysthymia. 

The symptoms are similar to major depression and anxiety disorders, i.e. interrupted sleep, chronic fatigue, feelings of worthlessness, irritability, fear, anxiousness in social situations and so on. You're just more apt at suppressing your impulses to retreat from society and hiding your true feelings from those around you.

There's also a constant feeling that no one understands you, and that they never could understand what you're going through.

This can lead to destructive and obsessive coping mechanisms according to Munnik, like substance abuse, excessive exercising or overeating. It can also negatively affect your health, like increase your inflammation markers that can lead to disease. 

In the worst-case scenario, if it remains untreated, it could lead to suicide. 

READ MORE | Magic mushrooms and LSD can help depression sufferers deal with emotions, according to two studies 

What to look out for

Here are a few more things to look out for according to Dr Colinda Linde, another clinical psychologist and member of the South African Depression and Anxiety Group.

  • You feel a little down most of the time. Other people may notice this and refer to you as gloomy, cynical, or a downer.
  • Your low mood is almost always present, and it feels like you will never get relief. When you do feel happy, it doesn’t last long.
  • You may feel tired all the time, even if you get enough or too much sleep.
  • It may seem like you are lazy, but you just can’t summon the energy to do more than is necessary to function at a normal level.
  • You feel bad about yourself, unworthy, and as if you don’t deserve to be happy or to be liked by others.
  • You do everything you’re supposed to do, like go to school, or keep the house clean, but it always seems like a monumental effort.
  • You gain or lose weight without meaning to, because you either have no appetite or overeat without thinking about it.
  • You may feel hopeless often, or cry a lot without any real, concrete reason.
  • You do well enough at work or school, but it is a challenge and focusing on tasks is difficult.
  • You have to force yourself to engage in social activities, when you would rather stay withdrawn.

"Recognising the signs of high-functioning depression isn’t always easy. It is an insidious mental illness, because it hides behind the ability to function. Even for the person struggling with these feelings, it isn’t easy to realise that there is a real, underlying mental illness."

READ | Lockdown got you feeling low? Yoga may help 

How does it differ from major depression?

Linde says duration and severity are some of the key differences. PDD is a slow-burn over a long period, while major depression is more intense, and episodes take place over a shorter period of about two weeks. 

However, PDD can also lead to a major depressive episode, and higher-functioning individuals may experience it at least once in their lives. 

"It is important to remember that high-functioning is not the same as fully-functioning," says Linde.

"While PDD may not be as severe or debilitating as major depression, it still causes impairment in function and diminished ability to enjoy life. There is no reason that anyone should have to live with a constant low mood when effective treatments are available."

These treatments are the same as for general depression and anxiety, which can include cognitive behavioural therapy, psychotherapy, medication or a combination of all according to both experts.

READ MORE | Mom's depression can lead to behaviour problems in kids

How prevalent is it?

Around the world, it's estimated that almost 2% of people suffer from higher-functioning depression.

In South Africa, a 2018 study found that black women were disproportionately prone to higher-functioning depression, most likely due to prevalent low socioeconomic status, increased exposure to personal and community violence and heading single mother households. 

"South African studies on depressive disorders and anxiety disorders are well documented," says Munnik.

"Depressive and anxiety disorders are among the most prevalent category of disorders in the South African context. However, there are limited studies on the prevalence of higher functioning depression and anxiety in South Africa. It might be underreported and more prevalent than we anticipate."

"The South African context is dynamic and constantly changing. Individuals are faced with various challenges and need to be able to find a balance and or adapt to these changes. An inability to adapt to change personally (intra-psychically) or interpersonally (socially) may result in signs and symptoms recognisable as high functioning depression and anxiety. "

If you want to seek professional help, contact the SA Depression and Anxiety Group hotline on 0800 567 567 or Lifeline on 0800 121 314. These free services are available 24/7 to anyone and are confidential. 

Image credit: Pixabay

 
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