| Occupational burn-out | |
|---|---|
| Other names | Burn-out |
 | |
| A person who is experiencing psychological stress | |
| Specialty | Psychology |
According to the World Health Organization (WHO), occupational burnout is a syndrome resulting from chronic work-related stress, with symptoms characterized by "feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; and reduced professional efficacy." While burnout may influence health and can be a reason for people contacting health services, it is not itself classified by the WHO as a medical condition.
In 1974, Herbert Freudenberger became the first researcher to publish in a psychology-related journal a paper that used the term "burnout." The paper was based on his observations of the volunteer staff (including himself) at a free clinic for drug addicts. He characterized burnout by a set of symptoms that includes exhaustion resulting from work's excessive demands as well as physical symptoms such as headaches and sleeplessness, "quickness to anger," and closed thinking. He observed that the burned-out worker "looks, acts, and seems depressed." After the publication of Freudenberger's original paper, interest in occupational burnout grew. Because the phrase "burnt-out" was part of the title of a 1961 Graham Greene novel A Burnt-Out Case, which dealt with a doctor working in the Belgian Congo with patients who had leprosy, the phrase may have been in use outside the psychology literature before Freudenberger employed it. Wolfgang Kaskcha has written on the early documentation of the subject.
Christina Maslach described burnout in terms of emotional exhaustion, depersonalization (treating clients, students, and/or colleagues in a cynical way), and reduced feelings of work-related personal accomplishment. In 1981, Maslach and Susan Jackson published the first widely used instrument for assessing burnout, the Maslach Burnout Inventory. Originally focused on the human service professions (e.g., teachers, social workers), its application broadened to many other occupations. The WHO adopted a conceptualization of burnout that is consistent with Maslach's.
Today, there is robust evidence that burnout reflects a depressive condition.
Diagnosis
Classification
Burnout is not recognized as a distinct disorder in the current revision (dating from 2013) of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It's definitions for Adjustment Disorders, and Unspecified Trauma- and Stressor-Related Disorder in some cases reflect the condition.
The Royal Dutch Medical Association treats "burnout" as a defined subtype of adjustment disorder. In The Netherlands burnout is included in handbooks and medical staff are trained in its diagnosis and treatment.
Regarding the International Statistical Classification of Diseases and Related Health Problems
(ICD), the ICD-10 edition (current 1994-2021) classifies "burn-out" as a
type of non-medical life-management difficulty under code Z73.0.
It is considered to be one of the "factors influencing health status
and contact with health services" and "should not be used" for "primary
mortality coding". It is also considered one of the "problems related to life-management difficulty". The condition is only further defined as being a "state of vital exhaustion".
The ICD-10 also contains a medical condition category of "F43.8 Other reactions to severe stress" (sometimes known as neurasthenia), which some (including the Swedish National Board of Health and Welfare)
believe defines the more serious cases of burnout. Swedish sufferers of
severe burnout are treated as having this medical condition. This category is in the same group as adjustment disorder and posttraumatic stress disorder, other conditions caused by excessive stress that continue once the stressors have been removed.
A new version of the ICD, ICD-11, was released in June 2018, for first use in January 2022. It has an entry coded and titled "QD85 Burn-out". This describes the condition in this way:
Burn-out is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: 1) feelings of energy depletion or exhaustion; 2) increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; and 3) reduced professional efficacy. Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.
This condition is classified under "Problems associated with
employment or unemployment" in the section on "Factors influencing
health status or contact with health services." The section is devoted
to reasons other than recognized diseases or health conditions for which
people contact health services.
In a statement made in May 2019, the WHO said "Burn-out is included in
the 11th Revision of the International Classification of Diseases
(ICD-11) as an occupational phenomenon. It is not classified as a
medical condition."
The ICD's browser and coding tool both attach the term "caregiver
burnout" to category "QF27 Difficulty or need for assistance at home
and no other household member able to render care". This acknowledges that burnout can occur in this context.
The ICD-11 also has the medical condition "6B4Y Other specified disorders specifically associated with stress", which is the equivalent of the ICD-10's F43.8.
The American Psychiatric Association
says "it is estimated that 2 out of 5 psychiatrists have professional
burnout," and believes that "addressing this problem has become one of
the most pressing issues for medicine."
Instruments
In 1981, Maslach and Jackson developed the first widely used instrument for assessing burnout, namely, the Maslach Burnout Inventory (MBI).
Consistent with Maslach's conceptualization, the MBI operationalizes
burnout as a three-dimensional syndrome consisting of emotional
exhaustion, depersonalization, and reduced personal accomplishment. Other researchers have argued that burnout should be limited to fatigue and exhaustion. Exhaustion is considered to be burnout's core.
There are, however, other conceptualizations of burnout that
differ from the conceptualization adopted by the WHO. Shirom and Melamed
with their Shirom-Melamed Burnout Measure conceptualize burnout in
terms of physical exhaustion, cognitive weariness, and emotional
exhaustion;
however, an examination of Shirom and Melamed's emotional exhaustion
subscale indicates that the subscale looks more like a measure of
Maslach's concept of depersonalization. Demerouti and Bakker (with their Oldenburg Burnout Inventory) conceptualize burnout in terms of exhaustion and disengagement. There are other conceptualizations as well that are embodied in these instruments: the Copenhagen Burnout Inventory, the Hamburg Burnout Inventory, Malach-Pines's Burnout Measure, and more. Kristensen et al. and Malach-Pines (who also published as Pines) advanced the view that burnout can also occur in non-work roles such as that of spouse.
The Utrecht Work Engagement Scale (UWES), was released by
Wilmar Schaufeli and Arnold Bakker in 1999. It measures vigour,
dedication and absorption; positive counterparts to the values measured
by the BMI.
In 2010, researchers from Mayo Clinic used portions of the MBI, along with other comprehensive assessments, to develop the Well-Being Index,
a brief nine-item self-assessment tool designed to measure burnout and
other dimensions of distress in health care workers specifically.
The core of all of these conceptualizations, including that of
Freudenberger, is exhaustion. Alternatively, burnout is also now seen as
involving the full array of depressive symptoms (e.g., low mood, cognitive alterations, sleep disturbance). Marked differences in understanding of what constitutes burnout have highlighted the need for consensus definition.
Subtypes
In 1991, Barry A. Farber proposed that there are three types of burnout:
- "wearout" and "brown-out," where someone gives up having had too much stress and/or too little reward
- "classic/frenetic burnout," where someone works harder and harder, trying to resolve the stressful situation and/or seek suitable reward for their work
- "underchallenged burnout," where someone has low stress, but the work is unrewarding.
Caregiver burnout
Bodies such as the US government's Centers for Disease Control and Prevention, the American Diabetes Association, and Diabetes Singapore
identify and promote the phenomenon of "diabetes burnout." This relates
to the self-care of people with diabetes, particularly those with
type-2 diabetes. "Diabetes burnout speaks to the physical and emotional
exhaustion that people with diabetes experience when they have to deal
with caring for themselves on a day-to-day basis. When you have to do so
many things to stay in control then it does take a toll on your
emotions... Once they get frustrated, some of them give up and stop
(maintaining) a healthy diet, taking their medications regularly, going
for exercises and this will result in poor diabetes control."
Autistic burnout
"Autistic burnout" is a term used to describe burnout when it occurs in people with Autistic Spectrum Disorder (ASD).
In this population, in addition to the typical symptoms it can cause
"autistic regression," an increase of autistic symptoms. It is
"regression" in the sense that the afflicted has typically had a
similarly high level of symptoms in the distant past, and the burnout is
perceived to be regressing them to this earlier state. It is also known
as "decompensation", because the compensations the person usually makes
are no longer being made.
Such burnout sometimes leads to permanent disability or suicidal behavior. It need not be caused by workplace stress, but can also be caused by the stress of social interaction or other sources. Spoon theory is sometimes used to understand people in this situation.
Relationship with other conditions
A growing body of evidence suggests that burnout is etiologically, clinically, and nosologically similar to depression.
In a study that directly compared depressive symptoms in burned out
workers and clinically depressed patients, no diagnostically significant
differences were found between the two groups; burned out workers
reported as many depressive symptoms as clinically depressed patients.
Moreover, a study by Bianchi, Schonfeld, and Laurent (2014) showed that
about 90% of workers with full-blown burnout meet diagnostic criteria
for depression. The view that burnout is a form of depression has found support in several recent studies.
Some authors have recommended that the nosological concept of burnout
be revised or even abandoned entirely given that it is not a distinct
disorder and that there is no agreement on burnout diagnostic criteria.
Postpartum depression
is a form of depression recognised by the DSM that differs mainly from
major depressive disorder in that it has a specific trigger.
Liu and van Liew wrote that "the term burnout is used so
frequently that it has lost much of its original meaning. As originally
used, burnout meant a mild degree of stress-induced unhappiness. The
solutions ranged from a vacation to a sabbatical. Ultimately, it was
used to describe everything from fatigue to a major depression and now
seems to have become an alternative word for depression, but with a less
serious significance" (p. 434).
They also argue that burning out can trigger four distinct kinds of
depression, each with their own recommended treatment. These are adjustment disorder with depressed mood, major depressive disorder, dysthymia, and bipolar disorder.
Tamar Kakiashvili et al. however argued that while there are
significant overlaps in symptoms between burnout and major depressive
disorder (aka "depression"), there is much endocrine evidence to suggest
that the biological basis of burnout is vastly different to typical
depression. They argued that antidepressants should not be used by
people with burnout as they make the underlying hypothalamic–pituitary–adrenal axis dysfunction worse.
Despite its name, atypical depression, which is seen in the above
table, is not a rare form of depression; the cortisol profile of
atypical depression is similar to the cortisol profile in burnout.
Commentators advanced the view that burnout differs from depression
because the cortisol profile of burnout differs from that of melancholic
depression; however, as the above table indicates, burnout's cortisol
profile is similar to that of atypical depression.
It has also been hypothesised that chronic fatigue syndrome is caused by burnout.
It is suggested that the "burning out" of the body's stress symptom (by
any of a wide range of causes) can lead to chronic fatigue.
"Occupational burnout" is known for its exhausting effect on sufferers. Overtraining syndrome, a similar but lesser exhausting condition to CFS has been conceptualised as adjustment disorder, a common diagnosis for those burnt out.
Risk factors
Evidence
suggests that the etiology of burnout is multifactorial, with
dispositional factors playing an important, long-overlooked role. Cognitive dispositional factors implicated in depression have also been found to be implicated in burnout. One cause of burnout includes stressors that a person is unable to cope with fully.
Burnout is thought to occur when a mismatch is present between
the nature of the job and the job the person is actually doing. A common
indication of this mismatch is work overload, which sometimes involves a
worker who survives a round of layoffs, but after the layoffs the
worker finds that he or she is doing too much with too few resources.
Overload may occur in the context of downsizing, which often does not
narrow an organization's goals, but requires fewer employees to meet
those goals.
The research on downsizing, however, indicates that downsizing has more
destructive effects on the health of the workers who survive the
layoffs than mere burnout; these health effects include increased levels
of sickness and greater risk of mortality.
The job demands-resources model
has implications for burnout, as measured by the Oldenburg Burnout
Inventory (OLBI). Physical and psychological job demands were
concurrently associated with the exhaustion, as measured by the OLBI. Lack of job resources was associated with the disengagement component of the OLBI.
Maslach, Schaufeli and Leiter identified six risk factors for
burnout: mismatch in workload, mismatch in control, lack of appropriate
awards, loss of a sense of positive connection with others in the
workplace, perceived lack of fairness, and conflict between values.
Effects
Some research indicates that burnout is associated with reduced job performance, coronary heart disease, and mental health problems.
Examples of emotional symptoms of occupational burnout include a lack
of interest in the work being done, a decrease in work performance
levels, feelings of helplessness, and trouble sleeping. With regard to mental health problems, research on dentists and physicians
suggests that what is meant by burnout is a depressive syndrome. Thus
reduced job performance and cardiovascular risk could be related to
burnout because of burnout's tie to depression. Behavioral signs of
occupational burnout are demonstrated through cynicism within work
relationships, such as coworkers, clients, and the organization.
Other effects of burnout can manifest as lowered energy and
productivity levels, with workers observed to be consistently late for
work and feeling a sense of dread upon arriving. They can suffer
decreased concentration, forgetfulness, increased frustration, or
feelings of being overwhelmed. They may complain and feel negative, or
feel apathetic and believe they have little impact on their coworkers
and environment. Occupational burnout is also associated with absences, time missed from work, and thoughts of quitting.
There is a growing amount of research suggesting that burnout can
manifest differently between genders, with greater incidence of
depersonalisation among men and higher emotional exhaustion among women.
Treatment and prevention
Health
condition treatment and prevention methods are often classified as
"primary prevention" (stopping the condition occurring), "secondary
prevention" (removing the condition that has occurred) and "tertiary
prevention" (helping people live with the condition).
Primary prevention
Maslach
believes that the only way to truly prevent burnout is through a
combination of organizational change and education for the individual.
Maslach and Leiter postulated that burnout occurs when there is a
disconnection between the organization and the individual with regard
to what they called the six areas of worklife: workload, control,
reward, community, fairness, and values. Resolving these discrepancies requires integrated action on the part of both the individual and the organization. With regard to workload, assuring that a worker has adequate resources to meet demands as well as ensuring a satisfactory work–life balance could help revitalize employees' energy. With regard to values, clearly stated ethical organizational values are important for ensuring employee commitment. Supportive leadership and relationships with colleagues are also helpful.
One approach for addressing these discrepancies focuses
specifically on the fairness area. In one study employees met weekly to
discuss and attempt to resolve perceived inequities in their job.
The intervention was associated with decreases in exhaustion over time
but not cynicism or inefficacy, suggesting that a broader approach is
required.
Hätinen et al. suggest "improving job-person fit by focusing
attention on the relationship between the person and the job situation,
rather than either of these in isolation, seems to be the most promising
way of dealing with burnout.". They also note that "at the individual level, cognitive-behavioural strategies have the best potential for success."
Burnout prevention programs have traditionally focused on cognitive-behavioral therapy (CBT), cognitive restructuring, didactic stress management, and relaxation. CBT, relaxation techniques
(including physical techniques and mental techniques), and schedule
changes are the best-supported techniques for reducing or preventing
burnout in a health-care setting. Mindfulness therapy has been shown to
be an effective preventative for occupational burnout in medical
practitioners.
Combining both organizational and individual-level activities may be
the most beneficial approach to reducing symptoms. A Cochrane review,
however, reported that evidence for the efficacy of CBT in healthcare
workers is of low quality, indicating that it is no better than
alternative interventions.
For the purpose of preventing occupational burnout, various
stress management interventions have been shown to help improve employee
health and well-being in the workplace and lower stress levels.
Training employees in ways to manage stress in the workplace have also
been shown to be effective in preventing burnout. One study suggests that social-cognitive processes such as commitment to work, self-efficacy, learned resourcefulness, and hope may insulate individuals from experiencing occupational burnout. Increasing a worker's control over his or her job is another intervention has been shown to help counteract exhaustion and cynicism in the workplace.
Additional prevention methods include: starting the day with a
relaxing ritual; yoga; adopting healthy eating, exercising, and sleeping
habits; setting boundaries; taking breaks from technology; nourishing
one's creative side, and learning how to manage stress.
Barry A. Farber suggests strategies like setting more achievable
goals, focusing on the value of the work, and finding better ways of
doing the job, can all be helpful ways of helping the stressed. People
who don't mind the stress but want more reward can benefit from
reassessing their work-life balance
and implementing stress reduction techniques like meditation and
exercise. Others with low stress, but are underwhelmed and bored with
work, can benefit from seeking greater challenge.
Secondary and tertiary prevention (aka treatment)
Hätinen et al. list a number of common treatments, including treatment of any outstanding medical conditions, stress management, time management, depression treatment, psychotherapies, ergonomic improvement and other physiological and occupational therapy, physical exercise and relaxation.
They have found that is more effective to have a greater focus on
"group discussions on work related issues", and discussion about "work
and private life interface" and other personal needs with psychologists
and workplace representatives.
Jac JL van der Klink and Frank JH van Dijk suggest stress inoculation training, cognitive restructuring, graded activity and "time contingency" (progressing based on a timeline rather than patient's comfort) are effective methods of treatment.
Kakiashvili et al. say that "medical treatment of burnout is
mostly symptomatic: it involves measures to prevent and treat the
symptoms." They say the use of anxiolytics and sedatives
to treat burnout related stress is effective, but does nothing to
change the sources of stress. They say the poor sleep often caused by
burnout (and the subsequent fatigue) is best treated with hypnotics
and CBT (within which they include "sleep hygiene, education,
relaxation training, stimulus control, and cognitive therapy"). They
advise against the use of antidepressants as they worsen the hypothalamic–pituitary–adrenal axis
dysfunction at the core of burnout. They also believe "vitamins and
minerals are crucial in addressing adrenal and HPA axis dysfunction",
noting the importance of specific nutrients.
Light therapy (similar to that used for Seasonal Affective Disorder) may be effective.
Burnout also often causes a decline in the ability to update information in working memory. This is not easily treated with CBT.
One reason it is difficult to treat the three standard symptoms
of burnout (exhaustion, cynicism, and inefficacy), is because they
respond to the same preventive or treatment activities in different
ways.
Exhaustion is more easily treated than cynicism and professional
inefficacy, which tend to be more resistant to treatment. Research
suggests that intervention actually may worsen the professional efficacy
of a person who originally exhibited low professional efficacy.
Employee rehabilitation is a tertiary preventive intervention
which means the strategies used in rehabilitation are meant to alleviate
burnout symptoms in individuals who are already affected without curing
them.
Such rehabilitation of the working population includes
multidisciplinary activities with the intent of maintaining and
improving employees' working ability and ensuring a supply of skilled
and capable labor in society.
