Avoiding your problems with work? You might have ‘high-functioning’ depression

Judith Joseph has spent most of her life building an impressive résumé. She is a board-certified psychiatrist, chair of the Women in Medicine Initiative for Columbia University’s Vagelos College of Physicians & Surgeons, a clinical assistant professor of psychiatry at NYU Langone Medical Center, the principal investigator of her own research lab — and a mom.

But despite her accolades, once the COVID-19 pandemic hit, Joseph couldn’t shake the sense that something was off. With the world on lockdown, Joseph began sharing skits related to her research on social media, many of which went viral. It was only then that she landed on a name to what she, and many others, had been experiencing: high-functioning depression.

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“I wanted to make sure that we weren’t just thinking about depression in the way that our grandmothers think of depression, not being able to get out of bed, crying,” Joseph said.

Instead, with high-functioning depression “you push through and you don’t deal with your pain because too many people depend on you,” she said. “You know something’s off, but you can’t quite put your finger on it. And you don’t slow down because you don’t know how to.”

To Joseph’s surprise, high-functioning depression was absent in medical literature. So she set out to design and execute the first research study on the topic, which published in February. Her first book, “High Functioning: Overcome Your Hidden Depression and Find Your Joy” (Little, Brown Spark), relies on findings from the study, anecdotes from patients from her private practice and lessons from her life to teach people how to understand the science of their sadness, so they can understand the science of their happiness.

The Times spoke with Joseph about her book’s findings and why it’s just as important to practice preventative care in mental health as it is in physical health.

This interview has been condensed and edited for clarity.

Dr. Judith Joseph is the author of “High Functioning: Overcome Your Hidden Depression and Reclaim Your Joy.” (Little, Brown Spark) (Photo by Anthony Steverson)

How would you define high-functioning depression?

With clinical depression, you have five or more symptoms, like low appetite, change in appetite, poor sleep, low energy, feeling restless, guilt, hopelessness, suicidal ideation. But you also have to meet criteria for having a low mood, or anhedonia. And on top of all that, you have to have lower functioning or significant distress.

People with high-functioning depression will have the symptoms of depression, but they’re not low-functioning. In fact, they cope by over-functioning, and they don’t acknowledge having significant distress. In fact, they’re muted. They don’t feel anything.

One of the symptoms of trauma is avoidance. So people think, “OK, I don’t want to go to this place or see this person or be in this situation because it triggers me.” But with high-functioning depression, people are avoiding by busying themselves so they don’t have time to feel, and when they sit still, they feel restless and empty.

A big part of high-functioning depression is being defined by your achievements or what you do for others. Why is it so hard to build identity outside of our external achievements?

Many of us have this coping mechanism of forgetting, and that’s one of the 30-plus symptoms of the trauma inventory. We outrun because we don’t remember what it was like to derive a sense of pleasure from things that truly bring us joy, because our past hides them.

Children, if there’s a conflict, they internalize it and they’ll say, “Well, if I only got straight A’s, Daddy wouldn’t have left.” Or “If I only did my homework, the dog wouldn’t have died.” Children use that magical thinking, but adults use it too. They focus on things like work, a role, on what they can do. In the short run, that’s a positive coping skill, but in the long run, when you continue to intellectualize and you don’t feel, that can show in different ways like binge drinking, excessive shopping, excessive doomscrolling, physical breakdowns or even dipping into low-function depression.

The bottom line is that there is a real value in acknowledging and processing your trauma and healing, because then you can actually experience a change.

In the first part of your book, you introduce two key terms: anhedonia and masochism. What is anhedonia and why is it important for people to know what it is?

There’s a real disconnect between the research and the real world, because in research, anhedonia is all over our rating scales. It’s a term that has been around in the medical literature for hundreds of years. “An” is a lack, “hed” is pleasure, and “onia” is a symptom. “Anhedonia” is a lack of pleasure and joy, and it’s a lack of pleasure and joy in things you were once interested in.

So imagine you’re eating your favorite meal and you’re not even tasting it, you’re not savoring it. Or if you are listening to your favorite song, and it doesn’t move your body the way it used to, it doesn’t light you up. Or if you’re looking at a beautiful part of nature, like the sun is setting and it’s exquisite, and you’re just checked out. Or if you’re with your partner, and you’re being intimate and you just want to rush through it; you’re not even in the moment. These are all the simple joys that make life worth living.

In research, you will rarely see the word “happy” on our rating scales, but what you do see are points of joy. Whereas in the real world, the patient will come in and say, “I just want to be happy.” But we’re like, “No, we’re just trying to eradicate your depression by increasing your points of joy.”

Happiness is an idea, whereas joy is an experience. If you can reframe that and think about it as: Anhedonia is robbing [me] of my joy; it’s not that I have to be depressed and weepy and sad, but if my points of joy are low, then that’s an indication that something is off.

It’s a really important shift because people can search and try to be happy all their lives and never get it. And even if you get the thing you think will make you happy, you’re still not happy. If you shift it, and you’re like, I can increase my points of joy every day, then it’s attainable. There’s hope. Today, you may get two points, but tomorrow maybe you get three.

How does masochism contribute to high-functioning depression?

When people think of masochism in the real world, they think of sex, which is not what we’re talking about. We’re talking about masochistic personality disorder. Masochistic traits are ones where people tend to bend over backward for others. They tend to sacrifice their joy for the sake of others. It’s almost like self-sabotaging. In today’s speak, it’s called people-pleasing.

What I found in my study was that a lot of people who are caregivers have high rates of anhedonia. Well, that makes sense. These are people who are not thinking about themselves. They’re putting others first, often at the expense of their own happiness. Because high-functioning depression is closely tied to trauma, and because a symptom of trauma is low self-worth and shame and self-blame, that may be a part of the reason why people with high-functioning depression can’t relax: They’re constantly doing for others.

If you’re someone who knows your self-worth and you know that your role doesn’t define you, you’re not going to bend over backward. You’re not going to keep going, even though you feel off and you feel burned out. You’re going to take care of yourself.

The second half of the book gives the reader concrete steps to reclaim their joy using what you call the Five V’s: validation, venting, values, vitals and vision. How did you develop these five Vs?

If you think about it, there’s been this renaissance in physical health, but there’s nothing for us in mental health. Why do we wait to check that box of low-functioning? We need to show people how to increase their points of joy and prevent these breakdowns on their own.

So, I came up with the five Vs based on what I learned about happiness and research, and derived them based off of things that I felt that people needed to do in order to overcome trauma and how to find sustainable joy.

Validation is the first step. Because many people, again, don’t acknowledge how they feel. They push through pain, they just get through life, and that’s how they cope. But if you can acknowledge how you feel, and accept how you feel, then you could actually do something about it.

Venting is expressing your emotions. Some of my clients are neurodivergent, so they’re not the most verbally expressive. But there are other ways you can vent. You can draw, you can write, you can pray, you can sing. You could talk about your feelings, if that’s how you want to express it. You can cry. Venting has different ways of getting that emotion out and decreasing your stress.

Values are things that, when you tap into them, you feel a sense of purpose and meaning. I would say that values are things that are priceless. Many of us with high-functioning depression, we’re chasing the accolades, and we’re chasing the things that look good on the outside but don’t really give us true meaning.

With Vitals, I wanted to put in the traditional things like sleep, movement and diet, which are all important. But I also wanted to add things like our relationship to technology, our relationships with other people and work-life balance, because the quality of our relationships with people in our lives is the No. 1 predictor of long-term happiness and health.

Vision is how do you plan joy so that you keep moving forward instead of getting stuck in the past? Celebrating your wins so you don’t have to live for tomorrow’s. Start planning joy today. That’s the whole point. Don’t hold your breath for happiness for the future.

(Maggie Chiang / For The Times)

For someone who’s avoidant, it can be really scary to slow down enough to really examine your interior life. What do you say to that person who doesn’t know how to broach the five Vs?

I always say don’t do the five Vs all at once, because people who are intense like myself will want to do everything at once. The goal is not to use all five at once; use one or two. I would say start with validation. It doesn’t have to be this big, grand thing. It could be as simple as looking in the mirror every day and just reflecting on how you feel. Or, if that’s too intense for you, there’s sensory tools like a 5-4-3-2-1 method that is a grounding tool that allows you to be present in your body. Just practice that every day for one to two minutes and, slowly, you should be able to start to self-reflect and acknowledge and accept what you’re feeling and move from there.

You directly tied the idea of “vision” to fostering joy and combating anhedonia. What’s the relationship between vision and anhedonia?

People with high-functioning depression want to keep doing what they’re good at. But it’s important to retrain your brain and slowly reintroduce yourself to the things that you once enjoyed.

For example, in the book I talk about a patient who forgot that they actually enjoyed nature. When they were a child, their parents used to take them camping and when the parents got divorced, they stopped going camping, and they forgot that that’s what they love doing. Now they live in a big city and what they usually do for fun is go see a show or something that is more accessible in a city. But when we identified that trauma, we started to challenge them to go back into nature again. By slowly introducing the person back to the things that they used to like, their anhedonia in relation to nature got better.

At the end of the book you break down the various types of therapy and drug interventions for someone struggling with their mental health. For someone who has your book in hand and is looking for next steps, what would you recommend them?

I’d recommend for them to take the quizzes [throughout the book] and to see where they are in terms of the levels of anhedonia, depression and trauma and then move from there.

Let’s say, biologically, you’re healthy and psychologically you don’t have very many risk factors. Then you have to work on the social aspect. What is it about you that’s keeping you in that toxic environment? What’s hindering you from leaving there? Because that’s where you’re losing joy.

For another individual, it could be that the social bucket is fine. The psychological bucket is fine. But biologically, maybe there’s an untreated autoimmune issue, or maybe you’re going through perimenopause. Well, then that’s where you need to focus on the science of your happiness.

For others who have trauma that’s never been processed, and they’re constantly in fight or flight, but biologically and socially, things are not as draining for them, then that’s where we need to focus.

There is only ever going to be one you in the history of the universe and in the future of the universe. That, to me, is so powerful because then you know that you’re here for a reason.

So I want people who read this book to really try to understand the science of your happiness, because there’s only one you. And then when you fully understand what’s draining from your happiness, then you can work on those efforts to increase your joy, using the book as a guide.

Shelf Help is a wellness column where we interview researchers, thinkers and writers about their latest books — all with the aim of learning how to live a more complete life. Want to pitch us? Email alyssa.bereznak@latimes.com.