588: You may have high-functioning depression & not even know it | Judith Joseph, M.D., M.B.A.
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What if the signs of depression weren't what you thought they were? What if instead of feeling stuck in bed or overwhelmed by sadness, you were constantly achieving, pushing forward, and over-functioning without ever realizing something was wrong? Today's guest, Dr. Judith Joseph, is here to help us rethink how we understand mental health. Dr. Joseph is a board-certified psychiatrist, clinical researcher, and a leading voice in the conversation around women's mental health.

She's the chair of the Women in Medicine Initiative at Columbia University, a clinical professor at NYU Langone, and the founder of Manhattan Behavioral Medicine, where she's conducting groundbreaking research on high-functioning depression. In today's show, we're diving deep into a topic that affects so many people but often goes unnoticed, high-functioning depression. Dr. Joseph will explain how this form of depression manifests, not through the traditional signs we expect, but through anhedonia,

Wes, we're going to talk about that because I didn't know what that term was either. Restlessness and an endless chase for external achievements. We'll also talk about the science of joy, why so many of us feel numb despite having it all, and how trauma often disguises itself as busyness. If you've ever felt stuck or in a cycle of stress or performance, or your emotions aren't matching your reality, you're not alone. Today's episode is for you.

So how do you define high-functioning depression? That's a great question. I get asked that all the time. Clinical depression happens when you have symptoms of depression, such as low mood, poor sleep or changes in sleep, changes in your appetite, energy level, concentration issues, guilt, hopelessness, all of these symptoms. And then when you check the box at the bottom of that list in the DSM-5, which is the Bible of Psychiatry,

you have to have those symptoms cause a lack of functioning or significant distress.

But what happens if someone comes to your office like mine or to your lab like my lab and you're checking the boxes, but then when you get down to the functioning box, they say, no, I actually overfunction. Or they don't acknowledge distress because they just don't have the tools to or they don't. That's culturally not how they express it. Or they just numb themselves. Then it's, you know, come back when you're broken down. Come back when the symptoms have caused significant impairment.

Well, as a doctor and a researcher, I thought, why are we thinking about things this way? You know, you see this renaissance in medical health, in longevity science, in menopause health, where everyone's saying, catch the cancer before it starts. Diagnose the heart issues before the heart disease. Don't wait for osteoporosis in women. Let's give them HRT. But where is this excitement for mental health? We still wait. We wait for people to break down. I thought that was a broken model.

And after 2020, and when all of my colleagues who are therapists are like, we're not taking more patients. There's just too, there's just, we can't right now. We're at capacity. And they were asking psychiatrists in retirement to come out of retirement. I just thought, well, look, this is what happens when you wait for people to break down. We're reactive. We're not proactive. So why don't we prevent mental health conditions that cause breakdown? Let's not wait for people to break down who are functioning. Let's shore them up. Let's give them the tools to prevent a breakdown.

So high functioning depression is when you have these symptoms of depression, but you're over functioning. Instead of staying in bed or crying, which people classically think depression looks like, there are some people who actually over function. And it could be because they're busying themselves to distract from the pain, or it could be that's how they were taught culturally or how they were raised. But there's a subset of people who over function despite these symptoms of depression.

So what are some of those subtle signs? How does this show up in our everyday lives? Usually what gets people on my couch or in my lab is anhedonia. And when I first started saying that term, people were like, anhedonia? But in research, I use that all the time. And there is not one study that I've conducted where you don't talk about anhedonia. But there is a disconnect between the real world and the research world.

Anhedonia is when you lack interest and pleasure in things that once lit you up, that once interested you, but now you're like, meh, bleh. And people think that that's like life. They think, oh, you're supposed to be that way. Uh-uh. Anhedonia is like a red flag. It's the sneaky sign that something is wrong, but we ignore it. Because why? It's not glaring. It's not a crisis.

You know, we look for things like crying and staying in bed. We don't look for a lack of joy. In fact, in medical culture, us doctors, we derive our ego from fixing things. So if you come to us and you're like, I lack joy and I lack pleasure and interest, we're like, okay, well, what do you want us to do with that? And a lot of doctors say,

They have anhedonia. They lack joy and pleasure. If you've ever been to a busy clinic and you've seen that doctor, you're like, oh, I don't think they like what they do, right? So anhedonia is what really brings people to my office. And it's a sign that people should look for. The other thing is this emptiness, this restlessness when you're sitting still. You have to be busy all the time. That is another thing people come to me and I'm like, okay, let's talk about high functioning depression.

It's so interesting. And I love, I don't love the concept of, I'm fascinated by the concept of anhedonia. When I picked up your book, which everyone should go read, I said, wow, this is really interesting. And I think you also estimate 75% of people experiencing high function depression have anhedonia. And I couldn't help but think reading it about the hedonic treadmill. And is there a relation where our

What we're looking to experience in life to bring us joy or happiness is perhaps misplaced. And there's this need for some people to do, you know, the bigger thing, the bigger vacation, this, you know, more extravagant experience, if you will, rather than these small, subtle moments of joy. I couldn't help it. You almost become numb to the everyday. Are these things related?

They are. You know, when people come to me for the private practice, they say, Dr. Judith, I just want to be happy.

But in the research practice, we're like, we don't even use that word in our rating scales. We use points of joy. So the questions that add up to happiness or what people think happiness is are, when you were sitting with your loved one, did you feel connected? When you were eating your food, did you savor it? When you took a nap, did you feel refreshed? All of those points, when you add them up, that is what we see as happiness, right?

But outside of research, people are like, well, I just want to be happy. So what do they do? They busy themselves. They're like trying to get that home or the second home. They're trying to get their kid into college. They're trying to, you know, get these things or these careers because that idea of happiness is what they're chasing.

And if you're so busy and you're chasing these things that you think will bring you happiness, you're missing out on joy. So I reframe it with my patients and I say happiness is the idea, the ideal. Joy is the experience. And for many of them, it's like a game changer. It's like, oh, my gosh, like I can try all my life and try to be happy today.

But that's not attainable. Experiencing joy a little bit every day, that is more within reach for them. Especially for my patients who've been trying so hard to be happy for years. It's like that reframe is so powerful. I can get points of joy and experience joy, whereas happy or that idea is out of reach. Complete change and they feel more hopeful. Well, it makes so much sense. I feel like we often get caught in that trap where you say,

you know, I'll be, you know, I'll be happy when, you know, insert X, my kid just gets accepted to, you know, Y school, or I just get through this painful moment at work, or, oh, if we could just close on that house or, oh, like, and you just find it's just never ending. Never ending. And the research shows it. I'm sure, you know, like those studies that look at I'll be happy when you still, you get it and you're still not happy. It's on to the next. I experienced that personally, you know, as someone who's an immigrant,

come from, came from very little, you know, and not processing my trauma and busying myself by getting straight A's, becoming a valedictorian, getting into prestigious schools, then medical school, then dual degree, then awards. You know, I live that I'll be happy one. I think a lot of people do and they don't even realize it. And then they're like, never happy, right? They're always on to the next.

Whereas when I was doing this research and I found myself with high functioning depression and anhedonia, I had to like, you know, reframe the way that I accessed my daily joy. So how does that look? When I get home, there's no laptop. I have to sit with my kid.

and I have to sit on the floor with her and look at her eyes and let her lead play and be in that moment, even if I feel restless, right? Just be present. When I'm eating my meals, I have to like taste the food, you know, look at the notes in the Caesar salad, crunch the croutons, you know, really experience the basic human experiences of joy. And it sounds so silly and like

primitive, but that's what we are. We're human beings. We're primitive. We have neural synapses. We have taste buds. We need to see beautiful things, not look at screens. All of these basic experiences are

release dopamine in a healthy, well-rounded way that uses the senses. But when we're not aware of that and we get so busy that we forget that this is what life is about, that's when we're chasing that idea of happiness and we're actually not experiencing joy. And that's why many of us feel so numb and blah and we're experiencing anhedonia. It feels like our inability to stay in the present moment

And all the distractions and things around us is a contributing factor here. It is. And, you know, it took me all these fancy Ivy League degrees and everything.

and research lab experiences to get me to what most people in other countries, when they're sitting on a mountain, they know the answers. They know the reasons, right? But it is rooted in science. When you're able to sit still and get back into your body, that is so powerful. And many of us have unprocessed trauma. I do a lot of PTSD studies, and there are over 30 symptoms of trauma that we're not aware of. And many people don't know that trauma

One of the avoidance symptoms of trauma is busying yourself. One of the other symptoms of trauma is feeling like you're not worthy. You have low self-worth. So what do you do? You keep doing, right? You keep people pleasing. If people knew that that was related to trauma,

then they may actually reflect and say, well, what is it in my past that's not processed that's causing me to constantly be on the move, that causes me to seek this role of being pathologically productive, that I'm not enough unless I'm doing, that I'm a human doing instead of a human being. If they had those tools to reflect and to really get to the roots of what's causing this behavior,

It allows them more clarity to then make better decisions about what they want to do in life, right? But if you're not aware, then you're just going to keep busying yourself. You know on a deep level, I have to stop, but you can't. You just keep taking on more. You keep piling on more to your kid's schedule. And eventually, it is contagious. The people who are busy, look around them. Their teams are busy. Their kids are busy. Their partner's busy. Their pets are busy. It

it becomes a way of life. But also slowing down, that can be contagious too. Joy can be contagious too. And that's why I get so passionate about this work, because I know that when you prioritize joy and the experience of joy, it spreads and people's lives, their communities can change. But when you're chasing being pathologically productive,

And those values shift. You know, the communities change for the negative as well. Here we go. Steve's got a trunk full of groceries and no one to help him. Oh, that's tough, Jim. Looks like a five trip load at least. He grabs the first bag. The second. Bob, it looks like he's trying to do it on one trip. He shimmies the door open, steps over the dog. Oh,

Oh, and he stumbles. Oh, right into the kitchen without missing a beat. Jim, now that's a man who eats his protein-packed Oikos. With 15 grams of complete protein in each cup, Oikos Triple Zero can help build strength for every day. Oikos, stronger makes everything better. So you mentioned pathologically productive. What a great alliteration. And the people pleaser.

And I can't help but make two huge generalizations and think about the differences between men and women here. I'm going to go out on a limb and say men maybe have a tendency to be more

insanely busy and productive and women maybe have a tendency to be the people pleaser. But what's your take? I think that culturally, men tend to have that burden of being pathologically productive in a way that's traditionally masculine, right? Providing financially, being strong and being unwavering.

when things are tough, versus women, you know, culturally are pressured to be pathologically productive as caretakers, as givers, as people who sacrifice their own joy for others. And

There's a term called masochism that used to be in the Bible of psychiatry, DSM-5. When people think masochism, they think of it the sexual term, but this is the masochistic personality disorder. You know, the tendency to bend over backwards, the tendency to sacrifice your joy for others. But there's also like the dark side of masochism in the DSM where it's you're inciting others to treat you poorly, right?

which is victim blaming. And that's why it was largely removed from the DSM version 3 when they were making the DSM version 4. They felt as if, you know, that masochistic personal disorder was being assigned to women who were survivors or victims of domestic violence. However, in the psychiatry world, we still use that term all the time behind closed doors. We use masochistic traits.

And what we found is that in layman's term, it's called people pleasing. You know, you bend over backwards for people who don't always deserve it. You know, like say there's that parent that's always like, can you pick up my kid or can you do this for me? And you're just like, okay, sure. And you know, it's an inconvenience, but you still do it. Or, you know, your boss is demanding and you know that they're going to ask you for something you can't possibly do, but they still ask you and you can't say no, right? You just have poor boundaries.

And you sacrifice your own joy for others. So that is what we tend to see with women a lot. And it's for many reasons, you know, society-wise. In many cultures, girls and women are taught to be givers and to think about the whole collective family versus their own personal happiness. Whereas in those same cultures, men are not given that same expectation. And then, you know, in terms of capitalism, you know,

Men are, they tend to be treated better in terms of how they're compensated versus women. So there are different ways that people pleasing can show up, but I tend to see the masochism more in women, the masochistic people pleasing traits that I talked about in women. But yeah, both men and women have a hard time showing who they are, how they're really feeling when they've coped for years being pathologically productive. Men may be more irritable,

But women tend to be, you know, more inwards. They tend to blame, self-blame more. And that's a generalization. There are men who self-blame as well. But, you know, in the work, both men and women can have high functioning depression. If you're someone who has a hard time slowing down, who just needs to do and lives by their role and doesn't want to let others down, if you're the rock,

you know, then you should be thinking about whether or not you're processing your emotions and you're just doing instead of being. And on that note, I can't help but think of purpose. And, you know, if you're doing and being and you're motivated every morning to get up and whatever you're doing is so meaningful to you, whether it's doing great work in the world, whether it's you, you're seeing patients, you're helping people or you're volunteering or your purpose is so many varieties of purpose.

Versus like, you know, I'll go back. I'm older than you. Like the old Dunkin' Donuts commercial. Like, you know, it's time to make the donuts. Like I got to get up. I got to do the thing. I just got to keep going. It feels like purpose can play a significant role here for people. Purpose and values. In my book, I talk about the five V's and values is one of those. And I just had a happiness lab demonstration with a group of people here. And

I brought out a beaker and in the beaker there was water. And I asked everyone in the lab to hold a rock and to put their rocks in the beaker. And then, you know, as the rock is supposed to symbolize what really anchors you in life, what gives you a sense of purpose and meaning. And then I diluted the water and I muddied the water with dye. And these are things that are the external. So I said, imagine the things in your life that have price tags versus the things that are priceless.

When we're focused on the things with the price tags, we don't see that rock. We're starting to lose sight of the things that are priceless, things that when you're on your deathbed, you wish you had more time doing, right? Spending time with your family or tapping into your community and these causes that give you a sense of purpose.

But we get so distracted, and I'm guilty of this too, chasing the things with the price tags, the things that are surface level, the things that like accolades and all of the above. It takes away from what really gives us meaning in life. And so I use that analogy because I find these visual tools very helpful, especially for my neurodivergent clients to

Really put them back in a mindset where they can stay focused on what really matters. You know, if people are busy and they come back, they're like, Dr. Judith, I'm busy again. I'm finding myself in this pattern. And I said, where's your rock? You know, some of them keep a rock in their purse or their briefcase and pull out that rock.

How can we hold on to this rock and not lose sight of it? And then that it's such a powerful tool, you know, because we don't use our hands and we don't use these sensory components as much as we used to because we're on so much technology. But having that physical rock in your hand allows people to be like, OK, I need to hold on to my rocks because I'm getting distracted by everything else. So, you know, if you're listening to this, think about if you had that jar, that beaker, right?

you know, what are the rocks you're going to put into that beaker and what keeps you from really holding onto those rocks. And that allows you to stay focused on the things that give you meaning and purpose versus the things with the price tags. Beautiful. I'm curious, you know, you have a tremendous personal story and I encourage everyone to pick up the book. I'm curious, what's been most meaningful for you in your journey? I,

I come from a family of four siblings. And whenever I look back in my life and whenever I felt the most empty and restless, I wasn't connected to people. And same with my team. I have this research team. And whenever I was, I got so busy chasing the studies. Oh, there's a new psychedelic study. I want it. I want this study. I want this new IV study. And it's like you lose sight of what really matters. You know, the work is really to help people not to have the shiny, bright study.

But whenever I let myself get clouded, my vision is clouded by these things that look bright and shiny that are not the things that I'm going to wish I did more on my deathbed.

that's when I was less connected to people. So I clearly wasn't connected to my team because they were saying, we can't do another study. We're tired. We have enough. We're the highest enroller in this area. Calm down. When I wasn't listening to the people around me and I wasn't connected to them, that's when I felt the most restless. And

When I wasn't connected to them, I was making worse decisions. Why? Because I was chasing things that don't give me meaning and purpose. Right.

And, you know, same with my daughter. If I feel as if I'm not connected to her, it's because I'm too busy. I'm chasing other things. But she's really one of the things that matters the most to me. Right. Same with my siblings. And so we all have our things. It may not be connection to people, but it could be, you know, nature for some of my clients. Nature is so important, but they chase the clout and the fame and they went to the big city and they haven't been able to walk in grass for a while. Right. And

And so they know that if they're not having access to nature, they don't feel purposeful. They don't feel as if they're fully fed, you know, spiritually. So you know what it is. You know what your rock is. And if you're not spending enough time holding that rock and being grounded in that rock, then you're likely being distracted by things that are surface level, you know, that are

They look great to others, but they're not leading you full and fed spiritually. So for everyone, including myself, it's a process. Do you have a go-to practice where you catch yourself up?

It's creeping up. What am I doing? And I need to do a reset. And is there something you do when that happens that's like your go-to to kind of reset yourself? Yes. You know, I do these weekly meetings with my team, but I also just check in with my one or two of my teammates regularly.

One is a marathon runner and she I consider her to be my my shero. So I'm always like, hey, Teresa, how am I doing? I thought I saw everyone. She's the real boss of my lab, because if Teresa says, nope, slow down, I have to slow down. She knows me. I check in with my my sister, Nikki. She is in my family. She is the one that knows, like, listen, what's happening here?

I haven't seen you. You know, you're looking a little ragged. And then I check in with my daughter. You know, I say to her, I'm like, baby girl, how's it going? You have been busy. You know, like you have to have these ways of reflecting. I have a therapist and I've had her for quite a while. I've been in therapy for over 10 years.

And she can always tell, you know, but many people, that's not their, their tell, right? That that's not how they check in. They can't verbally do it with people. So in my book, I talk about different ways, right? Like if you're someone who tends to carry the tension in your shoulder, I teach some of my clients who keep a lot of what they're feeling in their body will have a tension check. So I'll ask them throughout the week, you know,

Try and pay attention to that shoulder. How is it? Is it tensing? Because if you know how to tense your muscles, you also know how to relax them. And that's where the mind-body is so important. I'll ask them to, as they're tensing, to relax. Tense and relax. And also try and breathe because our body has these unique mechanisms to naturally calm our fight or flight.

And if you're able to control your breathing and tense and relax your muscle, that is what we do in our work. It's called progressive muscle relaxation and diaphragmatic breathing. Those are ways to check in with yourself physically. For others in my practice, they tend to break out or experience skin issues. So they may have to look at their bodies and figure out what's happening. But there's no right or wrong way. That's why I give so many tools to

for checking in and doing these vital checks. For my marathon runners, they tend to have a slow heart rate. But then if their beat's going above 60, that's a problem for them. Whereas other people who don't, they're not very athletic or muscular,

going above a heart rate of 90, you know, a resting heart rate of 90, that's their tell. So everyone has a different way to check in to see how much they're, you know, they're, they're busying themselves and, and a reminder to slow down. In my experience, we all have our weak spots. And in my life, whenever I've been extraordinarily stressed, it'll show up in that weak spot. It's

So maybe it's my gut. Maybe it's if I had an injury, it would be like my lower back. That was a big thing for me for a while. And everyone's kind of got their weak spots. And what's key is just kind of identifying what they are and taking a pause. And it's difficult. Very easy to say.

difficult IRL process. It is difficult. And, you know, it sounds so easy if people listen and say, oh, yeah, it's so easy to do. It's not. Try checking in. Try reminding yourself. It is a constant thing. You have to really be intentional in breaking these cycles and these patterns because you will fall back into it. That is

That is human psychology. It's human behavior. And how old is your daughter, by the way? She's eight. She's eight. So we also have an eight-year-old daughter and a five-and-a-half-year-old daughter. And in my experience, one, they're amazing, but they're very tuned in. Kids are attuned to this. You don't have to teach a child, a toddler, how to play. You know, you give a toddler a box and a spoon, and they're going to go to town, right? Yeah.

They know joy. It is in their DNA. And even when, you know, you look at a child in nature, they'll put the dirt in their mouth. They'll do all these things that as adults we cringe. But over time, we've become so busy with all the other things that we forget how to access basic joy.

And in my practice, I treat children, adolescents, and adults. And it's just so interesting to see the wide range of developmental stages and how differently they approach joy and how it becomes full circle, really. In some of my dementia studies, some of the patients are 89 approaching 90. And then in some of my pediatric ADHD studies, some of the children are as young as four.

And the four-year-old and the dementia patient, they're approaching joy very similarly. They're looking at the basics, right? They want to get good sleep. They want to enjoy, they want to taste a good meal, right? They love connection and cuddling. But in the middle of this, in the middle of the developmental extremes, we get distracted by all the things that make us busy, right?

And we think they're making us happy, but what they're doing is they're actually taking away our capacity to access joy. So all these things that we think are making us happy are actually distracting from joy. Well said. So what is your hope with this book? What's your one takeaway you want everyone to have? Understand the science of your happiness.

There's only ever going to be one Jason in the history of the universe and the future of the universe. There's only going to be one Judah. So let's understand the science of what is making us unhappy, right? How do you understand your happiness if you don't know what's detracting from it? And be real with yourself. And when you start to examine the science of your happiness, you'll see that a lot of the things that

you thought were supposed to make you happy are not. And also, you know, in my book, I have these tools for dissecting what I call the biopsychosocial model. It's a tool that I want to democratize. I want everyone to have access to it, to understand the biological risk factors, the psychological risk factors, the social things that are happening in your life.

And when you use the methods in my book, The Five Vs to Thriving, you can tap into things that are adding to your happiness because you finally understood the science of what's taking away from your unhappiness. I constantly get people who come to me who are saying, I've tried everything. I've read this book. I've tried this method. It's not working for me. And I'm saying, well, do you even understand happiness?

your basic science. And they're like, huh, what do you mean by that? That's not for me to understand. That's for the doctor to understand. No, because if we're going to empower people to arm them with the tools necessary for preventing mental health breakdowns, we're taking the approach of the longevity doctors here, right? We're saying, let's prevent that cancer. Let's prevent this breakdown. Let's prevent this unhappiness. We're giving them the tools to understand what actually

adds to their happiness. And I hope people read the book and they finally see themselves better. They see themselves clearer. They understand themselves better. And then they have the tools.

to support their joy. Being comfortable in the uncomfortable goes a long way. It does. It's not easy, but it's so simple to uncover, but we avoid it. We don't want to do it. So in closing, we covered a lot. I know you're short on time. Is there anything we didn't cover that you want to touch on before we close? I often use my hand to demonstrate joy because most of us have five fingers, right? Most of us do. And

The five Vs in my book allow you to access joy and to hold on to it. So you imagine your palm is open and each of the fingers represents one of the Vs. And I start with validation. So acknowledge what you're going through no matter what. Acknowledge and accept your emotions, the good and the bad.

If you were to walk into a dark room and someone closed the door and something fell, you'd be like, well, what's going on? Some of us would be swinging. Some of us would be running to get out. If the human brain does not know what's happening, if there's so much uncertainty in how we feel, we act in ways we don't understand. Acknowledge and accept your emotions. Validate them. The second fee is fear.

venting, express your emotion. So that could be through prayer. That could be through crying. That could be through writing them down. That could be through talking about them. That could be through art, but express them. And then in my lab, I show this demonstration of like this balloon full with air and it's tight. And as you vent, it, it,

it gets softer and it collapses. Well, that's how we are as humans. If we don't express how we feel, we'll burst. We're under a lot of pressure. And then the third is values. These are the things that really matter in life. And I talked to you about that exercise with the rock, but anchor yourself as much as you can to things that really bring life purpose and meaning. And then the fifth is vision. How do you plan joy? And I'm not just talking about planning it in 10 years, like for retirement, but

Plan it today. So today I had a very chaotic day with my internet in my lab. I'm going to treat myself to some good old-fashioned rest later. And I'm looking forward to that. I'm planning my joy and I'm going to celebrate my wins because today was a difficult day for me. And I'm going to acknowledge that. Listen, I'm going to see all my patients eventually today. I'm going to do everything I need to do. And I'm going to celebrate that one today in my own way.

And I encourage people to do that. You know, I do that every morning when I get my kid to school on time. Her school is very strict. But after I get her to school on time, I sit in my living room and I enjoy my coffee that I bought in St. Martin because it's rum flavored. It's not rum, but it's delicious. And I celebrate my wins.

And I encourage people to do that. Don't delay your happiness. Access your joy today because tomorrow is not promised. And it's very tempting for high-functioning people to want to do all five. I say pick one or two and tap into them because you can get one or two points today, maybe get one more tomorrow.

But really try to savor the joy, which is the experience today instead of delaying your happiness for tomorrow. Amen. Judith, thank you so much. Thank you so much. This was such an honor. Thank you for having me. I appreciate you.