Mental health

Is High Functioning a Useful Descriptor for Mental Illness?

High functioning: A useful descriptor for mental illness? - image of workplace team meeting

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 being constrained by labels.  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.

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 on the “normal” that’s being compared to.

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.

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 on the descriptors in the image below.

global assessment of functioning scale (GAF)

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, but it’s not the be all and end all.

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?

 

 

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54 thoughts on “Is High Functioning a Useful Descriptor for Mental Illness?”

  1. It is tricky. I can appear high functioning at work… and then crash the minute I get home and stay that way for twenty-four hours (hence trying to work part-time only). I can function in some situations more than others, I can function on some days better than others and the causes aren’t always clear or consistent (which may mean that there are too many factors to really notice easily). I was pretty functional yesterday, but not at all today, perhaps from doing too much yesterday.

    Although it’s not a mental illness, I have mixed feelings about describing myself as ‘high functioning autistic.’ I feel I shouldn’t just say ‘autistic’ because that makes people think of seriously autistic non-verbal people, or savants (although ‘high functioning’ could mean savant too). But I think people often don’t grasp ‘high functioning autistic’ either. Asperger’s Syndrome was a more useful term in some ways, but DSM5 got rid of it, plus I don’t feel comfortable using it any more now it looks that Hans Asperger collaborated with the Nazis.

    1. I would guess that the average person has just as limited an idea of what “high functioning autism” is as they do of what autism is in general.

  2. I’ve been assessed to be high functioning but never really liked it. It meant my struggles were dismissed by professionals, and it meant some people were outright jealous of me being “lucky” about my level of functioning. While I was jealous of them (I feel bad) because they got a lot of practical support from their family and a lot of emotional and professional support from mental health professionals.

    According to GAF, even when I was at my highest functioning in a highly stressful job with a lot of responsibility, I had serious symptoms. Eg self harm, suicidality, no friends, By that metric, I actually have higher functioning now even though I’m not working and living off my savings.

    1. I think that idea of having problems dismissed is where the idea of “high functioning” can be most problematic. And that whole competitiveness thing is really not good.

      1. Yup, the competitiveness thing sucks. I’ve been guilty of it myself. Like I used to be judgy, feeling I was somehow superior when actually it was my own Shit (eg me wishing I had supportive family) and nothing to do with them at all<3

    1. Now that GAF included in the DSM-5 diagnostic system many doctors don’t use it anymore. Even when it was used, some doctors placed more emphasis on it than others.

  3. Very interesting topic!! I love the concept of the GAF. I’m kind of sad they did away with it. My dad is hovering close to a hundred, unlike anyone else I’ve ever met. It’s amazing. His mental health is just…. off the charts.

    I’d give myself a 63. I’m pleased with how well I function, but when you consider that I can’t go near the workplace with a ten-foot pole, and I have energetic pollution issues, and that I sometimes do crazy stuff locally (like steal candy), I think altogether, I’d give myself a 63. And I’m fine with that. Oddly enough, I think 63 was the number they gave me when I was hospitalized way back in 2000 (after college).

    As for the concept of high-functioning, I agree that it should only be used if someone lays claim to it, or if it could NOT sound pejorative. I think of a friend of mine who struggles with OCD but doesn’t take any meds, and instead, she forces herself to live with it. To me, high-functioning sort of implies that you CAN go to work, but that you still struggle. (Although I’m sure “high-functioning” can vary from person to person.) I mean, I see myself as being high-functioning but limited, you know? I can be “normal” in a lot of contexts, but I struggle with some things in a day-to-day sense, and other things in a permanent sense. Interesting topic!!

    1. They did it away with because it wasn’t actually as useful as it was initially thought to be. And like you mentioned, function can vary a lot from context to context, so it’s more useful to describe that rather than give an overall score.

      1. I see what you mean. You could be really high in one area and really low in another, and what to do, average them out somehow?

  4. High functioning why with Mental Health? I am Learning Disable and have often been told I am High functioning. Which means that in some book that I am higher then the norms, really some days I have to wonder. Mental Health is a careful balance to just get though that day.

  5. When you’ve battled a mental illness for so long, you learn to function well enough to get by. People have mentioned that I am very high functioning because I look like i have it all together but they don’t see the days where I go home and crash, or sit up at night contemplating if I should end my life or the effort it takes to pull myself out of bed to function. So I often get told by family and friends who know about my MI “you’re strong, you’ll get through it” or “I know I don’t have to worry about you because you handle your depression well.”

  6. I’ve the usage of the GAF score but not so many. It was always very interesting to me because it told you something besides the individual symptoms. It was the only possibility to score something more on a social level with the DSM (if I recall correctly). On the other hand, it was scored on assessment so a moment in time.
    I think ‘high functioning’ is thrown left and right – I’ve heard about high functioning depression a lot in popular psychology – and for me (personally) high functioning ment high suffering because it can be hard to suffer in silence while on the outside everything seems hunky dory. For me it feel like something one would need to use with care and with a clear understanding and consensus about what it means.

  7. What a great post! You’ve hit upon several very important issues. First off, I am familiar with GAF, and my GAF scores usually indicate “medium” functioning as I recall. My doctor said in the early years of this diagnosis that I was high functioning then he changed it to medium functioning. But, you’ve raised so many issues, that I don’t know what I am supposed to think on the subject anymore! Ha. Oh well… :/

  8. I feel pretty much the same way about it as being called “high functioning autistic” – that it can be used to minimize the struggles many of us really have. That is why I’m not a huge fan of the term.

  9. This whole thing is so blurred… I have dysthymia, which is often called high-functioning depression, and I’m sure I am high-functioning compared to people with major depression, even just because I can manage without meds that would be specifically for depression, sometimes better, sometimes worse, and the great majority of my suicidal thoughts are passive even if they are there most of the time. I am also pretty good at masking myy symptoms, which I suppose is part of what makes one high-functioning in other people’s eyes, and the level of my depressive symptoms fluctuates a whole lot. But like for so many people context is key and while I can be high-functioning in some situations, I’m basically non-functional in others, and it just depends on so many things that I don’t even fully realise I guess. Some things about my depression are not high-functioning at all, like that I still self-harm quite regularly or wouldn’t be able to keep a job position unless it’s highly flexible and pretty much completely adjusted to me as is the case right now. Also I’ve had several major depressive episodes over the years, but still managed to mask quite well and do most things that I was supposed to do, with no meds, because I didn’t feel like there was any other option for me to do anything else, I was in a lot of denial and not really knowing what was going on, so would that mean I was still high-functioning then, because I kept on going as normal outwardly and didn’t kill myself despite I felt suicidal and not functional at all but just simply had to function? I’m sure there are many people like that, for example those who have no regular access to mental health care, and also children and adolescents, and I wonder how such people would be classified.
    Right now my life is really stable, happy and good and not very stressful compared with what it used to be like, and I think that the level of my functioning is also largely dependent on the amount of stress I experience and my environment, I’m pretty sure that if my life were to change a lot in terms of amount of stress, I would spiral down and be far less functional, so I am always a little doubtful if it’s seriously so that I myself am so high functioning, or am I simply in a good time in my life right now and a more or less favourable environment so I can manage it well.
    Then on the other hand I’m very low-functioning in terms of anxiety so yeah, the whole thing is really strange, especially now that I’m thinking more of it, and I guess only useful as a way of describing yourself, perhaps to get a brief idea of what your condition is like to people who don’t know, or as a way of comparing two people with different functioning levels and the same condition, but then I wonder what would be the benefit of such a comparison supposed to be.

    1. I think that idea of dysthymia as high-functioning depression also sets up a comparison as to whose illness is somehow more valid. That kind of thing ends up silencing people, and that’s definitely not good.

  10. Interesting topic! I agree that “high functioning” is too vague a term to be meaningful. I had a therapist who liked to describe me as “high functioning,” but I felt very frustrated by that since I was in therapy for issues that were negatively affecting my behavior and my communication. I didn’t feel like I was functioning well at all.

  11. Thank you for writing this. I was discharged from the ED clinic as it was explained to me that while my weight was really low, I was still going to uni and had a partner whe all the other patients had to stop everything. It took everything I had to keep going, sleeping where I could. My relationship was in tatters because of my health, and I was very suicidal. But because I was still doing things people assumed I must be better than what I was telling them. I personally think this label is dangerous and the people who are given this label are often assumed to need support less than others, and this isn’t always the case.

  12. I shall share the information you provided here. That’s so interesting! Who knew that mental illness and degree of function had much in common? It’s glaringly obvious, but until you see it that way, it never occurs (to some of us). Thanks Ashleyleia for another winning post!

    On another subject, I have a friend who is an ’emerging blogger’. I wondered if you might like her information to include in your ’emerging blogger’ series? She’s brand new, and it might be a bit early to do that, but I wanted to inquire. Thanks!

  13. I absolutely love how in depth you get with the subjects you use for mental health blogs. As a new blogger, it makes me feel good to read it and also I totally look up to your blogs!

  14. I agree with you that level of functioning is vague. According to the image, my level of functioning changes with in hours. It’s based on what is happening and how I am feeling. It can change even at work. It depends on what is happening and how I feel while at work too.

    I have always functioned the best while writing. It is an escape as well as a tool for my thoughts. I become a better person when I take the time to write about any topic.

  15. I also love how informative these blogs are, thanks for sharing, especially as someone new to the whole mental health topic, you’re sharing very interesting things!💞💞

  16. It’s not something I’ve seen in use in the UK but I’m led to believe it’s widely used in the States. My thought is that it was intended only for newly discharged patients or for new outpatients?

    As you’ve said Ashley, we can be high functioning in some areas at one point and that might change over time, depending on other multidimensional info. about us.

    I personally would question the outcome’s validity as it’s done in one moment and would have to be conducted at regular intervals to get an accurate picture of one’s ‘functioning’ levels.

    1. I think ithe GAF was only intended to be a cross-sectional measure, and would be done at key times like hospital admission and discharge. The term “high functioning” seems to be used more in a colloquial sense from what I can gather, as it wasn’t something that I often heard in a clinical context.

  17. I’m always told I’m high functioning and switched on. It annoys me because most of the time it’s a well you don’t need ya because you are switched on and high functioning etc etc yes and?? Sometimes I’m not?? It’s just that by the time I have any mental health help in place I’ve generally gone through my crisis and I’m coming out of it! Plus.. I hide it very very well. Doesn’t mean it’s not there. Xx

  18. Great article! I suffer from Schizoaffective Disorder, which involves psychotic symptoms as well as a mood disorder, and was labeled as high functioning by my psychiatrist; yet I never fully understood how that could be an accurate description as my functionality seemed to dip when I my psychotic symptoms would arise. Does this mean I’m only high functioning when I’m asymptomatic? If that’s the case then the term must only be used independent of the illness it’s labeling as it no longer address the symptoms but rather those periods of time when the symptoms have abated.

    1. I think because there isn’t a universally agreed upon delineation of what high functioning is, it ends up meaning whatever the person using the label decides they think it means.

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