BURNOUT SYNDROME

Online dictionaries provide a suggestive translation for the burnout concept: „The tubes burned out easily and had to be constantly replaced…”.This is the sequence of events that leads to the syndrome: the depletion of one’s own intellectual energy, usually directly tied to the profession one has, presumably exerted with great passion and dedication, after a long lasting effort.
The most accurate definition, including the eventual prophylactic actions to be taken, is based on the context in which this syndrome manifests: the surpassing of one’s resistance to professional effort and of one’s capability to recuperate (1,17). Its manifestation, perceived by others and by the affected individual consists of behaviors and feelings, more or less subjective, noticed by the individual and/or those around him/her. The most common symptoms overlap those found in various types of depression: fatigue, insomnia, difficulty concentrating, irritability, depressed mood, lack of pleasure and motivation for daily activities concerning – surprisingly – those linked to professional activity. Other symptoms are included in the psychosomatic category: headaches, lumbago, gastrointestinal problems, breathing difficulties, loss of appetite, various cenesthetic complaints.
If we use the word symptoms we must include our description in the biological model, which is not necessary the case here. Official psychiatric classifications do not recognize burnout as a form of depression. International Classification of Diseases (ICD 10, 1992) (2) includes this syndrome in the last chapter (amongst “Factors influencing health status and contact with health services” codes Z00-Z99, in “Problems related to life management difficulty” code Z73.0 together with other “problems”, such as “Accentuation of personality traits” including type A behavior pattern, “Lack of relaxation and leisure”, “ Stress, not elsewhere classified”, “Inadequate social skills, not elsewhere classified”, “Social role conflict, not elsewhere classified”, ranging from Z73.1 to Z73.5), all of which do not refer to nosological entities, but to particularities varying with context and eventually with the individual’s psycho-social vulnerability.
We can thus define burnout as a cumulation of psychological symptoms, more or less interchangeable with the psychiatric equivalents, already indexed among the diagnostic criteria of some psychiatric disorders (exhaustion depression, stress disorders etc.) (3). It is true that, given time, these psychological symptoms and disfunctions can translate to actual depressive symptoms. Because burnout is, in fact, a surpassed work-related state, it is wise to be aware that the onset of the symptoms might show a change in the individual’s professional life. This means that the professional act, which one performs with degree of satisfaction, is disrupted by something unpleasant or disappointing that later becomes stressful. Oftentimes, work-related stress can be induced by an unsatisfied expectation that later becomes frustration. The intensity of this frustration depends on one’s narcissism regarding one’s value in relation to professional success. This psychological selfishness, as it is named by some psychologists and philosophers, may be the starting point of workaholism as a gratification for a creative but hedonistic individual who sees professional success as the payoff for the effort invested in it, but also overlaps with the pleasure of feeling it subjectively, contemplating the success from the height of one’s vanity. This is why using the term burnout is often excessive: it should be limited only to those individuals who manifest these symptoms in the context of an intense professional activity (some call it work-related stress) with high stakes (researchers, top positions that require a lot of personal, emotional and intellectual involvement). In some professions the risk of burnout is a priori accepted, and thus these professionals benefit from financial gratification or prolonged recreation leaves (psychiatrists have salary increments and prolonged recreation leave, the so called “dangerous conditions bonuses”, and so do coroners, pilots, train operators etc.).
Due to burnout, the individual experiences a decrease in the capability to cope usual work-related requirements and situations, which he/she easily and pleasurably resolved before, followed by an increasing lack of interest for these activities, despondency and loss of motivation to further pursue them. Finally, the individual begins to question whether one’s professional pursue, so personally and intellectually invested upon, has any meaning at all. Trying to quantify the subjective disturbances burnout casts upon the individual, authors write about “exhaustion, cynicism, lack of personal accomplishment” as defining dimensions from a social psychology point of view, in contrast to the “energy, involvement, efficiency” prior to the onset of burnout (4).
Recent arguments stand for the extension and equalization of the burnout concept to chronic stress that can appear in various circumstances, not only work- related (5). These authors believe that “unresolved stress” cannot be taken in consideration only when it comes to professional activity and thus, this disorder should be considered as a multidimensional one, with positive consequences in the research of chronic stress in general and especially regarding prevention. Many branches of medicine and psycho-sociology are, indeed, connected to this syndrome even if it isn’t a nosological entity in the official classification, which in change contains many formulations of clinical symptoms as consequences of chronic stress, be it work-related stress or any other form. We can, therefore, deduce that, what we often call burnout can, in some situations, be reinterpreted as chronic stress/acute stress disorder/posttraumatic stress disorder/depressive reaction to stress or other concepts from the official or unofficial medical or psychiatric jargon.
However one may call this aggregate of psychological symptoms, which, in time, becomes (or not) characteristic of psychiatric/psychosomatic disorders, it is often accompanied by biological findings (an increase in serum level of stress hormones, linked to major clinical consequences), negative functional outcome (a decrease in working efficiency), somatic comorbidities, some with severe or even fatal consequences (cardiovascular disease, myocardial infarction), psychiatric comorbidities or complications (depression, suicide, transient cognitive impairment), worsening of some psychosomatic disorders (respiratory, cardiovascular, immune, dermatological issues). New research is showing just how devastating this kind of occupational stress can be to the brain, causing changes both in the structure and function of this organ. The emotional and cognitive turmoil of burnout leaves a signature mark in specific brain areas associated with cognition, memory, attention and emotional response, MRI results showing a reduction in gray matter in the medial prefrontal cortex, hipoccampus, caudate and putamen and an enlargement of the amygdala (6). Burnout can alter neural circuits, R-fMRI showing weaker connections between the amygdala and areas linked to emotional distress (anterior cingulate cortex) and executive function (medial prefrontal cortex) (7). Data from animal experiments show that stress causes an enhanced release of glutamate, neurotoxicity affecting regions such as the medial prefrontral cortex, the anterior cingulate, and the basal ganglia. These results are consistent with neuroimaging findings in subjects who have experienced severe early-life trauma. In addition to dysregulation in brain function, emerging evidence suggests that burnout also leads to stress-related changes within the regulation of the body’s neuroendocrine system, especially the hypothalamic–pituitary–adrenal axis. Chronically elevated cortisol levels eventually lead to the down-regulation of this stress hormone to abnormally low levels, a state called hypocortisolism. Hypocortisolism induces low-grade inflammation throughout the body, arteries responding with a buildup in plaque over time, leading to cardiovascular disease (8).
Like all psychiatric/psychosomatic disorders, the importance of stress depends on the subjective significance of the traumatizing/stressful event every individual perceives, according to the classical model given by German psychiatrists of the mid-20th century (9) o f “ k e y m o m e n t ” / ” f o r m a t i v e e x p e r i e n c e ” (Schlusserlebnis). Just like a key (the acute or chronic stress event) fits to the subjective “lock” (the specific vulnerability given by the personal significance of the stressor for the individual), the stressor becomes more severe if it “fits” to the area of maximal personal motivation of the individual. Kurt Schneider underlined the importance of immediate subjective context (Hintergrund) and that of the background affect and mood (Untergrund) and the role these play in the moment facing the stressor (10). These authors have plastically described this mechanism as an “Achilles heel” that is responsible for the vulnerability permitting the event (or a sum of events) to create the subjective experience of burnout, reactive depression, exhaustion depression etc.
We find this mechanism in the list of possible work-related circumstances and situations, as a premonition of burnout onset, as the term was first coined by Herbert F r e u d e n b e r g e r ( 1 9 7 4 ) ( 1 1 ) : p r o f e s s i o n a l dissatisfaction/even that of personal life, which appears as a daily useless waste of energy, the onset of fatigability then exhaustion, perceiving all daily activities as pointless, onerous, as if slowing down one’s thinking, the activity lacks drive, all of this being perceived by the individual and those around him/her, including superiors. This setting takes shape when work seems to lose its motivation, when it is not longer recognized by those significant for the individual, when there is a lack of results or when positive results are assumed by others etc. Therefore, the person afflicted by burnout goes trough f e e l i n g s o f d i s e n g a g e m e n t , h o p e l e s s n e s s , s e l f depreciation, detachment and abandonment from others.
It is useful for those who are active and competitive to know the alternative to burnout so they can take precautions: avoiding chaotic activity under the self imposed pressure of being performant at any cost, avoiding unrealistic expectations, avoiding losing control over the rhythm of one’s work, avoiding the workaholic defective lifestyle which involves the lack of necessary periods of relaxation, rest and sufficient recovering sleep, avoiding perfectionism and learning how to delegate tasks. In type A personality (12), characterized by hipercompetitivity-ostility, ambition, eagerness to complete the set professional objective (by means of total professional implications which leads to work- dependence known as workaholism), all of these behaviors developing under the pressure of time, the situation must be recognized by others or by oneself in order to take the appropriate measures to adapt it to reality: the potential pessimistic view of the world must be replaced by a positive, constructive one, the social support system must be used in order to socialize when one feels overwhelmed, so does the “trusted-confident” system to depressurize moments of decision over one’s own choices.
Once installed, burnout can be counteracted with coping and self-care strategies. The Resilience Development Model defines resiliency as a cyclical process of uncovering, using, and developing the innate self, motivating life force, human spirit, or strength that lies within (13). Yoder suggested strategies which include taking vacations, changing assignments, developing supports, developing personal awareness, having rituals, and changing jobs. Other self-care strategies included maintaining adequate sleep patterns, good nutrition, regular exercise, and relaxation (14). Developing techniques such as meditation, mindfulness, deep breathing, self-reflection, and humor and massage could also be therapeutic (15). As for health care professionals it is important to be able to set boundaries to maintain personal/professional balance (16, 17).
References
1.Attwel KC, Physician and medical student mental health. In: Sadock BJ, Sadock VA, Ruiz P (Eds). Kaplan&Sadock’s Comprehensive Textbook of Psychiatry. Philadelphia, PA: Wolter Kluwer Lippincott Williams&Wilkins, 2009, 2703-2716.
2.WHO (1992), ICD – 10. Clasificarea tulburărilor mentale și de comportament. Simptomatologie și diagnostic clinic. Bucureşti: All, 1998, 365-370.
3.Wilson JL (2015, March). Burnout questionnaire (adapted from “Symptoms of Burnout” (Freudenberger, H. Burnout. P18; Bantum, NY, NY; 1981)). Retrieved from https://adrenalfatigue.org/burnout- questionnaire/.
4. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory. Manual(3rd ed.). Palo Alto, CA: Consulting Psychologists Press, 1996.
5.Bianchi R, Truchot D, Laurent E, Brisson R, Schonfeld IS. Is burnout solely job-related? A critical comment. Scandinavian Journal of Psychology, 2014; 55(4):357-361.
6.Golkar A, Johansson E, Kasahara M, Osika W, Perski A, Savic I. The influence of work-related chronic stress on the regulation of emotion and on functional connectivity in the brain. 2014;PLOS ONE 9: e104550.
7.Liston C, McEwen BS, Casey BJ. Psychosocial stress reversibly disrupts prefrontal processing and attentional control. Proceedings of the National Academy of Sciences, 2009;106:912–917.
8.Oosterholt BG, Maes JH, Van der Linden D, Verbraak MJ, Kompier MA. Burnout and cortisol: Evidence for a lower cortisol awakening response in both clinical and nonclinical burnout. Journal of Psychosomatic Research, 2015;78:445–451.
9.Kretschmer E. Der Senzitive Beziehungswahn (4th ed.). Berlin: Springer, 1966.
10.Schneider K. Klinische Psychopathologie (7th ed.). Stuttgart: Georg Thieme Verlag KG, 1947.
11. Freudenberger HJ. Staff Burn-Out. Journal of Social Issues, 1974;30:159–165.
12. Friedman M, Rosenman R. Type A behavior and your heart. New York: Knopf, 1974.
13. Grafton E, Gillespie B, Henderson S. Resilience: the power within. Oncol Nurs Forum. 2010;37(6):698–705.
14. Yoder E. Compassion fatigue in nurses. Appl Nurs Res. 2010;23(4):191–197.
15. Swetz K, Harrington S, Matsuyama R, Shanafelt T, Lyckholm L. Strategies for avoiding burnout in hospice and palliative medicine: peer advice for physicians on achieving longevity and fulfillment. J Palliat Med. 2009;12(9):773–777.
16. Showalter S. Compassion fatigue: what is it? Why does it matter? Recognizing the symptoms, acknowledging the impact, developing the tools to prevent compassion fatigue, and strengthen the professional already suffering from the effects. Am J Hosp Palliat Med.
2010;27(4):239–242.
17. Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry, 2016; 15:103-11.

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