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March 3, 2026
Margit Hiebl
Perfect facade, inner emptiness: What high-functioning depression means, who it affects, and what treatment looks like – explained by psychiatrist Prof. Dr. Andreas Menke
With
Prof. Dr. med. Andreas Menke
They seem like their life is absolutely perfect. Everything runs smoothly. One career step after another. Everything succeeds effortlessly – outwardly. Success follows success. Exemplary. No one would suspect that something might be wrong. Not even the affected person themselves. Even though, despite all the success, an inner emptiness and apathy spreads.
An exhaustion that is often explained away: It's all just stress. Really? Not necessarily. “Everyone has a stressful week now and then. The question must be: When is the limit exceeded?” says Prof. Dr. Andreas Menke, specialist in psychiatry and psychotherapy at Medical Park Chiemseeblick. “When you don't feel restored after a regeneration phase – and feel like there's no land in sight.”
This is a clear warning sign. Such symptoms often conceal high-functioning depression: functioning and performing despite inner emptiness. The fatal thing about it: “It is often not recognized at first, because the people affected function very well,” says the professor. He illustrates this with the example of a cold that you don't show and continue to work anyway – until the body says it can't go on.
Functioning until total standstill. “It's similar with depression,” he explains, “only here it's not just the body that strikes, but especially the psyche.” High-functioning depression is not an independent diagnosis in the usual classification. The term describes this atypical form of depression because it is difficult to grasp, yet illustrative.
“The symptoms are not yet visible externally, but intensify internally,” says Prof. Dr. Menke. Because under the surface, a system is working at full capacity – in multiple ways: On one hand, the constant striving for performance on all levels takes effort; on the other hand, maintaining the facade requires additional energy. Some also speak of “smiling depression,” because the affected always seem “in a good mood.”
But at some point, hiding becomes so exhausting that they can barely manage to do other things or handle small tasks alongside work. The point at which the drive completely dries up comes gradually. Many realize only late how blocked they are. For perfectionists, this is almost unbearable – their self-image starts to waver: because work no longer flows easily to produce an acceptable result.
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Perhaps mistakes also creep in because concentration deteriorates. The fuse gets shorter, self-doubt and feelings of guilt increase. And eventually, it leads to a sadness that can no longer be compensated. It particularly affects performance-oriented people, academics, athletes, artists, and leaders – people who are used to having everything under control.
Many affected individuals learn their functional pattern early and not necessarily out of their own motivation: they want to please or fight for recognition – at home, at school, or on the sports field.
The modern working world encourages this development: constant availability, digital acceleration – those who are always "on" lose the sense of boundaries and separation. Studies indicate that women are more often affected, but men are less likely to seek help.
They compensate longer, says Prof. Dr. Menke – on one hand, because naturally, they do not want to admit to being depressed – on the other hand, out of fear of stigmatization, which might lead to loss of reputation or job. And because perfectionists are drilled to convince with performance, they try unconsciously or consciously to fill the void with even more work – a vicious cycle begins.
It is not uncommon for the illness to manifest itself on a somatic level: back pain is the classic example – triggered by tension resulting from psychological pressure. Likewise, migraines or stomach problems can occur. And because the high performer always solves everything themselves, they try to tackle this case as well and in the worst case, numb themselves with alcohol, drugs, or tablets.
New is not the phenomenon. In retrospect, there are historical figures who, from today's perspective, suffered from a high-functioning depression. One of the probably most famous examples is Winston Churchill, who fought his "black dog," a metaphor for his dark phases, with even more work and alcohol. Or Empress Elisabeth, who reacted to the pressures of the monarchy by imposing even more pressure on herself through excessive dieting and extreme sports.
But how can such a vicious cycle be broken? The first step is to admit one's own exhaustion. Not so easy for high performers. It is fortunate when people around are attentive and gently reflect what they perceive. Sometimes a coach can also give the impulse to seek further professional help.
"A central component is psychotherapy," says Prof. Dr. Menke. "The treatment, however, depends on the severity and symptomatology." Cognitive behavioral therapy can help recognize and gradually change toxic behavior patterns or beliefs. The tendency towards overperformance is thus reflected upon, which can also release internal pressure.
Further measures help to better cope with stress and reconnect with oneself – for example, mindfulness and relaxation techniques such as progressive muscle relaxation, autogenic training, Qi Gong, or yoga.
Depending on the severity of the illness, medication treatment with antidepressants may also be useful in acute phases. They help to reduce symptoms such as brooding or sleep disorders and promote stability. Therapy is usually outpatient - in severe cases, inpatient treatment may be considered. "The advantage," says Menke, "is that you get out of the environment and gain distance." This can also have a significant impact or set things in motion.
After professional intervention, the crucial question arises: How do I deal with it in my new everyday life? "It is important that those affected change their attitude towards work and performance – that is, create different structures, make new schedules, plan more breaks or compensation," says Prof. Dr. Menke. Learning such strategies is part of the therapy.
But also establishing an overall healthier lifestyle with enough sleep and regular physical activity – to clear the mind. Mindful nutrition is also part of stabilizing mental health. And not to forget: maintaining the social network, consciously planning small joys.
But the most important lesson – and this applies to all of us: You should take your psyche seriously. "Many people tend to rationalize everything, recognize and focus on the stressors. They always look for external reasons when they are sad. However, this is not the basic principle of the psyche," explains Prof. Dr. Menke.
"You don't need a reason for depression – it's a symptom of the disease." One should learn to understand that the psyche is vulnerable and resilience can be built. It deserves as much attention as the body. And if it needs help, it is not a sign of weakness to accept it – but of courage.
