I often wonder what people who knew me years ago would think if they saw my posts and articles, if they were to meet me again today and hear how casually I discuss my mental illness. I like to think they would be surprised, but who knows?

Because I seemed fine, I seemed more than fine, you could have easily thought I was thriving and having a great time. But behind every excellent grade was self-loathing and pushing myself past my limits. Behind every smile in a photo, were the thighs I had to hide in long trousers. I walked through the party with a drink in my hand, greeting people cheerfully, until I locked myself in the bathroom and cried for no reason. Mascara hastily wiped away, fake smile painted on bitten lips, and then back out as if nothing happened.

I played the role of someone who was doing well, who was happy, even though I barely knew what happy felt like anymore. I was consumed by the need to harm myself, starve myself, punish myself. I didn’t know what was happening to my mind, it was no longer my own. But from the outside, no one could tell. I was doing so well in all of my classes, I had friends and I even did volunteer work. I was miserable, and the worst part was knowing that no one would even believe me if I told them.

Because I didn’t deserve to be depressed when everything was going so well. I didn’t deserve to call myself depressed because I was out of bed and doing everything that I needed to. I was ashamed that I was feeling so bad, and this only made it worse. It made living so much harder.

What is Persistent Depressive Disorder

Officially, high functioning depression is called Persistent Depressive Disorder, or PDD for short. It means that someone experiences many of the symptoms of depression but to a level with which they can function seemingly normal. They can go to work or school, perform well and even engage in social activities.

PDD or high functioning depression is recognised as a mental health condition, and should be diagnosed by a psychiatrist or other mental health professional. It can be found in the DSM 5, and the symptoms are similar to those of major depression. It was previously known as Dysthymia, and is still sometimes referred to by this term.

The issue with high functioning depression

While PDD may not seem as serious as major depression, it can be just as harmful. Perhaps even more, as it can go undetected easily and thus untreated. Many will not realise someone is suffering from depression when they appear high functioning, but there is a cost to maintaining such an appearance. Life with PDD is still a struggle and nothing an individual should go through alone.

High functioning depression is worsened by the doubt. Externally, as individuals will not take their issue seriously or provide as much sympathy and compassion. They will struggle to get referred to the correct professionals and given adequate treatment. But also internally, as they may doubt themselves.

I felt that I didn’t deserve the label of depression, despite the self-harming thoughts and behaviours I was struggling through daily. That label and diagnosis seemed a luxury out of my reach. Even when I shared my struggle finally, three years on, they claimed that I couldn’t have depression as I was doing so well in all facets of my life. I was studious and getting good grades, I had friends and went on dates. I even did extracurriculars, giving up my time to organise charity events or theatre performances. But this was all part of my depression, not a reason that I don’t have it. This was me pushing myself too hard as I didn’t think I was worth anything without that. In my friendships I suffered from doubt and anxiety, and still felt lonelier than ever. Being high functioning was a symptom of my depression.

The symptoms of high functioning depression

The first criteria of PDD/ high functioning depression is to ensure that this is not a period of depression or poor mental health, and is long-term. Their depressed mood must occur on most days, for the majority of the day, for a minimum period of two years. The depressed mood must include at least two of the following symptoms:

1. Lack of energy and fatigue

2. A low sense of self-esteem

3. Decreased appetite or overeating

4. Issues with concentrating or making decisions

5. Insomnia or excessive sleeping

6. Feeling low, sad and hopeless.

Does this mean that you cannot seek help before this two year mark? Certainly not! If you are experiencing such symptoms, then something is going on, whether that is PDD, a different mental illness or a difficult period of mental health. Mental health is important enough to address with professional help, as it can affect you adversely. Always get help.

Part of the diagnosis process also involves ruling out another cause. If any of the following apply, then PDD may not be diagnosed.

1. There cannot be over two months of no symptoms in this two year period.

2. There cannot be a period of mania or hypomania. This consists of an unusually energetic period of euphoria, and is indicative of other mood disorders.

3. There can not be a medical condition or substance abuse that explains the symptoms.

4. There cannot be a different mental illness that fits the symptoms better.

How it feels to have PDD

This is a generalised description of having high functioning depression, but it can vary from each individual and is extremely subjective. Take a minute to enter their mind.

You feel low almost all of the time, with no relief or bouts of euphoria. Sometimes you feel happy, but it never lasts long and feels as satisfying as you would hope. People might refer to you as gloomy, cynical or a party pooper. You sleep enough, or even more than usual, but it never feels like enough, you’re always tired. Doing the smallest things feels like the biggest effort. You do everything required, but it feels like simply going through the motions, you’re not quite present. Focusing is so difficult, and takes a lot of effort to maintain. Your memory feels like it is getting worse. Sometimes you cry, for no reason at all, and everything just hurts.

My high functioning depression is linked to my BPD, as I have a need to please others and push myself too hard. I felt like I was always waiting for the thing that would make me happy. When I graduate high school, then I’ll feel good. When I start university, the new environment will make everything easier. When I get a boyfriend, then I’ll like myself more and eat properly again. But none of it works. One of the clearest memories that I just can’t shake is standing onstage, after a musical that I organised. Everyone is clapping, someone is handing me flowers, people are crying of happiness, and I feel...nothing. I feel empty. I feel like I should be happy but I’m not. Everyone found our graduation from university to be the happiest day ever, surrounded by friends and family, celebrating our achievement. I wasn’t happy, I wasn’t anything. I was just present, but barely that.

Can high functioning depression be a form of coping?

It’s almost funny that we think that being high functioning means someone isn’t depressed, when actually it can be their reaction to depression. It’s almost like a mask of denial that you can put on, you go through all the motions and then you’ll be fine. It’s a chance to pretend you’re not depressed, or to grapple for a way to feel better.

It can even be a form of survival. When I lost someone two years ago, I went straight back into my high functioning mentality. I went back to work two days after the funeral, even though I didn’t have to. I went through all the motions as I was scared to stop. If I stopped working long hours, going to social events and working out daily, I didn’t think that I would ever leave my bed. I was scared that if I didn’t revert to my high functioning mode, that I wouldn’t survive. It was almost a strength when I felt weak, an evolutionary mechanism for survival. I used it to push my grief aside, as it felt too big to even confront, it still feels that way many days. I’m not saying that this is a healthy form of coping at all, I’m just saying that it was my form of coping, and many others may react similarly.

Not showing the emotions doesn’t mean they don’t exist. Not being the visible image of someone struggling doesn’t mean you’re not. You don’t have to fit the stereotype or accepted idea of pain or mental illness. Whatever keeps you going while you get help is the best foot forward.

How to help someone with high functioning depression

It can be really easy to miss high functioning depression, to allow yourself to be fooled by their facade, but now that you know the traits, you can keep an eye out for it. How you react to their depression can make all the difference, so here is some advice for helping an individual with PDD.

1. Don’t wait for them to approach you. Don’t be the person that will later tell them that you always suspected, or noticed something, but didn’t want to intrude. Intrude. Intrude right now. When you think something is wrong with someone, there is no harm in sharing your concern. It is not offensive, the worst possible scenario is that you’re wrong and you can both brush it off. But if they don’t seem well, something is up. Maybe not a mental illness, but certainly a period of poor mental health. People love to know someone is looking out for them, so be that person.

2. If you approach, do it in private and take the time to address it in a non-judgemental manner. Allow them to be the one speaking, you are here to listen and help.

3. Whether you approach them or they come to you, don’t be shocked, and certainly don’t let them know if you are. Surprise feels like failure to someone with PDD, as it consumes them with guilt. Saying that you never would have guessed can diminish their experience. You can honestly admit that you had no idea, but leave it at that.

4. Don’t be afraid to ask questions, gauge the scope of this. Are they self-harming? Are they having suicidal thoughts? These questions can be hard to ask or answer, but what is harder is when they go unsaid and brew within the individual.

5. Be there for them. Check in on them, even just casual messages, ensure that a communication line is always open. You have your own life and that is fine, but just make sure there is always a spot for them when they need it. This is not a burden on you, they are the ones carrying the burden.

6. Encourage them to seek professional help. This can be scary for them, and with high-functioning depression it is easy to feel like you don’t need or deserve help. Pass some research over to them, and accompany them to the appointment if that is what they need.

7. Take some weight off their shoulders. This can be physically through tasks, so that they can stop running so fast and check in with themselves more. This can also be emotionally, by giving them care and reassurance. You’re not going anywhere, make sure that they know that. Tell them that they are not a burden, that you want to be here for them. It can sound obvious to you, but in the dark thoughts of depression the opposite is often believed.

8. It can feel like betrayal to tell someone else. You should definitely not do this lightly or as gossip. But if you think that they are really in trouble, you need to say something. To a family member or to a professional. If they refuse to seek treatment and you are concerned for their wellbeing or even life, you are doing them a favour by telling someone. They may not thank you right now, or even in a few weeks, but one day they will.

9. Look after yourself. It can be difficult to care for someone with depression, and be sure to check in with yourself as well. Open up to someone if you need to, perhaps keeping the individuals anonymity.

It is so easy to miss PDD, to label the person as an overachiever instead. We have this set image of depression, as someone who can’t leave bed or cries all day long. This is an outdated model, we need to stop holding mental illnesses to their picture perfect version that is easy to swallow. Depression has so many faces. They say that one in four people will suffer from a mental illness. You know one of these people, you know many of them. Maybe you are one.

You can make the change by being someone who is there for others, and open for their truth. You can stop mislabelling depression, and especially using it as a joke. You can recognise that depression can appear in someone who seems fine. So much happens behind closed doors, you have no idea what they are actually going through. So approach people with compassion, and believe them. Why would someone lie about having depression? Why would someone self-harm if they were not struggling? Even the act of ‘doing it for attention’ (I am not condoning this phrase, just replicating something I hear too often) is enough cause for concern and is a mental health issue in itself.

So what can you do?

Be the change that you want to see in the world - Gandhi.