It’s not uncommon to hear the term high-functioning getting tossed around to describe people’s mental health conditions. But is it a term that’s meaningful or useful?
To clarify, I’m not referring to people describing their own level of functioning in a way that feels right for them. I’m all for people using whatever language they choose to describe themselves. This post is about labels as constraints. The labels may be applied by others, or they may also be self-applied as a form of judgment or self-limiting.
For most mental illness diagnoses, one of the diagnostic criteria is that the symptoms cause clinically significant distress or impairment in social, occupational, or other domains of functioning. So just by virtue of having a diagnosis, someone isn’t at their best, unless the illness happens to be in full or partial remission.
What is high-functioning?
If someone is deemed to be high-functioning, we’re considering that high relative to what? Their own highest level of functioning? Other people with the same diagnosis? Other people in general? That evaluation could look very different depending on the “normal” used for comparison.
What the illness happens to be doing at a particular time matters quite a lot. While it’s possible that the level of functioning may remain relatively stable over time, it’s also very possible that there could be significant fluctuations in functional ability. Some illnesses in particular, such as psychotic disorders, tend to have a downward trajectory in functioning over time, on average. However, the fact that someone is relatively high or low functioning at one point in time doesn’t mean they could be the exact opposite within the space of not all that much time.
Different domains of functioning may be affected differently. Someone might function very well in the online world, but be unable to maintain social or work functioning “in real life.” So is that person high or low functioning, or somewhere in the middle? That would probably depend on the level of importance you placed on each of those domains.
Global Assessment of Functioning
The DSM used to use a 5-axis system of diagnosis, which was done away with in the DSM-5. Axis 5 was for the Global Assessment of Functioning (GAF) scale. A score from 0 to 100 was given to quantify the level of functioning at the time of assessment. The GAF was anchored using the descriptors in the image below.
The GAF considers functioning in terms of both functional domains and symptoms. Someone may be functioning well at work and thus appear overtly to be functioning well, but if they’re feeling highly suicidal, their functionality would rate low on the GAF.
Because the overt appearance of functioning doesn’t account for the level of inner distress, it only says so much about the current severity of the illness. Sure, functionality can be an important part of gauging someone’s illness severity; however, it’s not the be all and end all.
So, what’s in good for?
Personally, I think “high-functioning” is too vague to be all that useful clinically to describe other people’s illnesses. You would probably need to get a lot more specific than that before it actually becomes meaningful.
In terms of my own functioning, it’s been steadily declining “in real life,” yet I’m able to function in the blogosphere at a far higher level than IRL. I functioned at quite a high level when I was well, so the contrast to that is significant. I used to use that as my reference point, but that no longer seems useful. Now I consider my own functioning in terms of the level of difficulty involved in accomplishing basic day-to-day tasks.
What do you think of the high-functioning label?
This is a model that I put together to show how different domains of functioning and symptoms can range on a spectrum from low to high. You can read more about the rainbow model here.