Occupational burnout

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."[1] 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.[1]

Occupational burn-out
Other namesBurn-out
A person who is experiencing psychological stress
SpecialtyPsychology 

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.[2] 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 was likely in use outside the psychology literature before Freudenberger employed it.[3] Wolfgang Kaskcha has written on the early documentation of the subject.[4]

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.[5][6] In 1981, Maslach and Susan Jackson published the first widely used instrument for assessing burnout, the Maslach Burnout Inventory (MBI).[7] Originally focused on human service professionals (e.g., teachers, social workers),[7] the MBI's application has been broadened; the instrument or variants of the instrument are now employed with job incumbents working in many other occupations.[5] The WHO adopted a conceptualization of burnout that is consistent with Maslach's.[8]

Today, there is robust evidence that burnout reflects a depressive condition.[9][10][11][12]

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).[13] Its definitions for Adjustment Disorders,[14][15][16] 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.[17] In The Netherlands burnout is included in handbooks and medical staff are trained in its diagnosis and treatment.[18]

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.[19] 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".[20] It is also considered one of the "problems related to life-management difficulty".[21] The condition is only further defined as being a "state of vital exhaustion".[22]

The ICD-10 also contains a medical condition category of "F43.8 Other reactions to severe stress"[23] (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.[18] 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.[24]

A new version of the ICD, ICD-11, was released in June 2018, for first use in January 2022.[25] The new version has an entry coded and titled "QD85 Burn-out". The ICD-11 describes the condition 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.[26]

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.[1][27] 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."[28]

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".[29][30] QF27 thus acknowledges that burnout can occur outside the work context.

The ICD-11 also has the medical condition "6B4Y Other specified disorders specifically associated with stress",[31] 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."[32]

Instruments

In 1981, Maslach and Jackson developed the first widely used instrument for assessing burnout, namely, the Maslach Burnout Inventory (MBI).[7] Consistent with Maslach's conceptualization, the MBI operationalizes burnout as a three-dimensional syndrome consisting of emotional exhaustion, depersonalization, and reduced personal accomplishment.[7][5] Other researchers have argued that burnout should be limited to fatigue and exhaustion.[33] Exhaustion is considered to be burnout's core.[8][34]

There are, however, other conceptualizations of burnout that differ from the conceptualization suggested by Maslach and adopted by the WHO. Shirom and Melamed with their Shirom-Melamed Burnout Measure (SMBM) conceptualize burnout in terms of physical exhaustion, cognitive weariness, and emotional exhaustion.[35][36] An examination of the SMBM's emotional exhaustion subscale, however, indicates that the subscale more clearly embodies Maslach's[8] concept of depersonalization than her concept of emotional exhaustion.[9] Demerouti and Bakker, with their Oldenburg Burnout Inventory, conceptualize burnout in terms of exhaustion and disengagement.[37] There are still other conceptualizations as well that are embodied in these instruments: the Copenhagen Burnout Inventory,[38] the Hamburg Burnout Inventory,[39] Malach-Pines's Burnout Measure,[40] and more. Kristensen et al.[38] and Malach-Pines (who also published as Pines)[41] advanced the view that burnout can also occur in connection to life outside of work. For example, Malach-Pines developed a burnout measure keyed the role of spouse.[42][43]

In 1999, Wilmar Schaufeli and Arnold Bakker released the Utrecht Work Engagement Scale (UWES). The UWES measures vigour, dedication and absorption; positive counterparts to the values measured by the MBI.[44]

In 2010, researchers from Mayo Clinic used portions of the MBI, along with other comprehensive assessments, to develop the Well-Being Index, a nine-item self-assessment tool designed to measure burnout and other dimensions of distress in healthcare workers specifically.[45]

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).[46][47] Marked differences among researchers' conceptualizations of what constitutes burnout have underlined the need for a consensus definition.[12][48]

Subtypes

In 1991, Barry A. Farber[49] in his research on teachers 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.

Farber found evidence that the most idealistic teachers who enter the profession are the most likely to suffer burnout.

Caregiver burnout
Main article: Caregiver stress

Bodies such as the United States government's Centers for Disease Control and Prevention,[50] the American Diabetes Association,[51] and Diabetes Singapore[52] 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."[52]

Autistic burnout

"Autistic burnout" is a term used to describe burnout when it occurs in people with Autistic Spectrum Disorder (ASD).[53] 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.[54][55][56][57][58] Spoon theory is sometimes used to understand people in this situation.[59]

Relationship with other conditions

A growing body of evidence suggests that burnout is etiologically, clinically, and nosologically similar to depression.[60][61][62][63][64][65][66][12] 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.[67] Moreover, a study by Bianchi, Schonfeld, and Laurent (2014) showed that about 90% of workers with full-blown burnout meet diagnostic criteria for depression.[63] The view that burnout is a form of depression has found support in several recent studies.[61][62][64][65][66][68][34] 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's diagnostic criteria.[12][69]

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[16] 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.[70] 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.

TestMajor depressive disorderAtypical depressionPTSDChronic Fatigue SyndromeBurnout
Cortisol awakening response↑↓ [71]↓↓ [72][73]- or ↓
Adrenocorticotropic hormone (ACTH)↑- [74]- or ↓
Dehydroepiandrosterone sulphate (DHEA-S)↓↑ or ↓↓ [75]↑

[70][76][77][78][79][80][81][82]

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.[63] 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.[63]

It has also been hypothesised that chronic fatigue syndrome is caused by burnout.[83][84] 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.[85]

Risk factors

Evidence suggests that the etiology of burnout is multifactorial, with dispositional factors playing an important, long-overlooked role.[86][87] Cognitive dispositional factors implicated in depression have also been found to be implicated in burnout.[88] One cause of burnout includes stressors that a person is unable to cope with fully.[89]

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.[90] 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.[91]

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.[92] 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.[8]

Effects

Some research indicates that burnout is associated with reduced job performance, coronary heart disease,[93] 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.[94] With regard to mental health problems, research on dentists[61] and physicians[39] 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 workplace relationships with coworkers, clients, and the organization itself.

Other effects of burnout can manifest as lower energy and productivity levels, with workers observed to be consistently late for work and feeling a sense of dread upon arriving. They can suffer concentration problems, forgetfulness, increased frustration, and/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.[94] Occupational burnout is also associated with absenteeism, other time missed from work, and thoughts of quitting.[95]

Chronic burnout is also associated with cognitive impairments in memory and attention.[96] (See also Effects of stress on memory.)

Research suggests that burnout can manifest differently between genders, with higher levels of depersonalisation among men and increased emotional exhaustion among women.[97][98]

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.[90]

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.[8] Resolving these discrepancies requires integrated action on the part of both the individual and the organization.[8] 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.[8] With regard to values, clearly stated ethical organizational values are important for ensuring employee commitment.[8] Supportive leadership and relationships with colleagues are also helpful.[8]

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.[99] The intervention was associated with decreases in exhaustion over time but not cynicism or inefficacy, suggesting that a broader approach is required.[8]

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.".[100] 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.[101] 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.[6]

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.[102] 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.[95] 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.[103]

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.[104][105][106]

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.[107]

See also Occupational stress, Caregiver stress, Stress management.

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.[103]

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.[17]

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.[70]

Light therapy (similar to that used for Seasonal Affective Disorder) may be effective.[108]

Burnout also often causes a decline in the ability to update information in working memory. This is not easily treated with CBT.[109]

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.[103]

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.[110]

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.[103] 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.

See also Management of depression, Treatments for PTSD and Chronic fatigue syndrome treatment.

See also

Stress and the workplace:

Medical:

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Further reading
  • Bianchi, R.; Schonfeld, I.S.; Laurent, E. (2014). "Is burnout a depressive disorder? A reexamination with special focus on atypical depression". International Journal of Stress Management. 21 (4): 307–324. doi:10.1037/a0037906.
  • Caputo, Janette S. (1991). Stress and Burnout in Library Service, Phoenix, AZ: Oryx Press.
  • Cordes, C.; Dougherty, T. (1996). "A review and integration of research on job burnout". Academy of Management Review. 18 (4): 621–656. doi:10.5465/AMR.1993.9402210153.
  • Freudenberger, Herbert J (1974). "Staff burnout". Journal of Social Issues. 30: 159–165. doi:10.1111/j.1540-4560.1974.tb00706.x.
  • Freudenberger, Herbert J. (1980). Burn-Out: The High Cost of High Achievement. Anchor Press
  • Freudenberger, Herbert J. and North, Gail. (1985). Women's Burnout: How to Spot It, How to Reverse It, and How to Prevent It, Doubleday
  • Heinemann, L.V.; Heinemann, T. (2017). "Burnout Research: Emergence and Scientific Investigation of a Contested Diagnosis". Sage Open. 7: 215824401769715. doi:10.1177/2158244017697154.
  • Kristensen, T.S.; Borritz, M.; Villadsen, E.; Christensen, K.B. (2005). "The Copenhagen Burnout Inventory: A new tool for the assessment of burnout". Work & Stress. 19 (3): 192–207. doi:10.1080/02678370500297720.
  • Maslach, C., Jackson, S. E, & Leiter, M. P. MBI: The Maslach Burnout Inventory: Manual. Palo Alto: Consulting Psychologists Press, 1996.
  • Maslach, C.; Leiter, M. P. (2008). "Early predictors of job burnout and engagement". Journal of Applied Psychology. 93 (3): 498–512. CiteSeerX 10.1.1.607.4751. doi:10.1037/0021-9010.93.3.498. PMID 18457483.
  • Maslach, C. & Leiter, M. P. (1997). The truth about burnout. San Francisco: Jossey Bass.
  • Maslach, C.; Schaufeli, W. B.; Leiter, M. P. (2001). "Job burnout". Annual Review of Psychology. 52: 397–422. doi:10.1146/annurev.psych.52.1.397. PMID 11148311. S2CID 42874270.
  • Ray, Bernice (2002). An assessment of burnout in academic librarians in America using the Maslach Burnout Inventor. New Brunswick, NJ: Rutgers University Press.
  • Shaufeli, W. B.; Leiter, M. P.; Maslach, C. (2009). "Burnout: Thirty-five years of research and practice". Career Development International. 14 (3): 204–220. doi:10.1108/13620430910966406.
  • Shaw, Craig S (1992). "A Scientific Solution To Librarian Burnout". New Library World Year. 93 (5). doi:10.1108/eum0000000002428.
  • Shirom, A. & Melamed, S. (2005). Does burnout affect physical health? A review of the evidence. In A.S.G. Antoniou & C.L. Cooper (Eds.), Research companion to organizational health psychology (pp. 599–622). Cheltenham, UK: Edward Elgar.
  • van Dierendonck, D.; Schaufeli, W. B.; Buunk, B. P. (1998). "The evaluation of an individual burnout intervention program: the role of in- equity and social support". J. Appl. Psychol. 83 (3): 392–407. doi:10.1037/0021-9010.83.3.392. S2CID 53132933.
  • Wang, Yang; Ramos, Aaron; Wu, Hui; Liu, Li; Yang, Xiaoshi; Wang, Jiana; Wang, Lie (2014). "Relationship between occupational stress and burnout among Chinese teachers: a cross-sectional survey in Liaoning, China". International Archives of Occupational and Environmental Health. 88 (5): 589–597. doi:10.1007/s00420-014-0987-9. PMID 25256806.
  • Warr, Peter. (1999). Psychology at Work, 4th ed. London: Penguin.
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