“…in trying to keep his ideal world as upright as possible,

it is terminated… inevitably leading to a collapse, Ben is diagnosed with burnout…

Now the battle begins, against depression, self-doubt and prejudice.

But also, the path to independent life begins…”

 

These words are from the play, “Das Burnout”, which premiered last year in Berlin. It is a brave attempt of authors to address the acutest societal problem today in a very unusual way – by means of the musical genre. Skillfully orchestrated music, lights, and decorations underline the contrasting sensations and let the viewer merge emotionally with the characters on stage. “It is the disease of our time, and thus a piece of history,” says Sabine Haydn, main author of the play, explaining her motive.

Omnipresent burnout

This both touching and entertaining story illustrates what happens often nowadays. To be precise, Gallop, Inc., the polling organization found that about “30%” and “25%” (4.1 million) German employees reported being “stressed” or “burned out”, whereas there were only 2.7 million in the previous period (2016 and 2015 respectively). Although, the Wall Street Journal referred to this as “an epidemic in Germany”, this problem is not local. For example, more than 3.4 million employees in the UK suffer regularly from exorbitant workload. Japan and South Korea have even coined a special term for death from overwork, as they encounter a high level of suicide from burnout.

This disease pervades most of occupational domains, from top-executives to the working class, including client-service specialists. It is believed, that those who work directly with people are more susceptible. Thereby, health and social workers, teachers and academic staff are admittedly considered as a high risk group.

For me as person, who only started my career as a young scientist, the latter group is of particular interest. It is a known fact that academics are overworked: researching, teaching, grant writing, bureaucracy. They are literally swamped with excessive paper work. The looming menace of project funding cuts can easily damp down enthusiasm. The Science Daily even refers to this situation as “A lost generation of young scientists”. Under such gloomy circumstances it’s very difficult to avoid burnout. Incidence among university’s dwellers can vary between 10 and 85% depending on the burnout measurement method and sphere of education. For example, the level of burnout among medical students may reach up to 50%.

 What is Burnout?

The above numbers are alarming, to say the least. Moreover, the statistic is potentially misjudged due to the lack of the clear diagnostic criteria for burnout as a full-fledged disease. This sends a clear message on the necessity to rethink and revise the whole concept of Burnout syndrome.

The notion of ‘burnout’ was coined to explain work-associated disorders. Accumulating empirical evidence states that ‘burnout’ rests on three main pillars – exhaustion, depersonalization and reduced professional efficacy, resulting from exposure to prolonged stress. To put it in other words, an ongoing imbalance in triadic relations between one’s expectations, inner resources and job/life demands induces chronic stress which in turn leads to the emotional, physical and mental exhaustion. This is tightly connected with social withdrawal, de-motivation and reduced self-confidence and with time develops into burnout. However, recent facts speak strongly against the work-related nature of burnout and attest its penetration into all life spheres.

In addition, some personality traits are stress-amplifying factors for burnout, e.g. neuroticism (negatively biased person) and narcissism (admiration of one’s own attributes). Perfectionist traits which are particularly pronounced among students and scientists, also are leading to burnout.

Burnout has been related to many health consequences. Apart from affective impairment (anxiety, depression), it is reported to be linked to cognitive dysfunction (working memory, episodic memory and executive functions). Similarly, there are physiological repercussions, such as coronary heart disease, vascular dementia, reduced life expectancy, and even suicide. Recovery usually takes months, rather than weeks.

Burnout or Depression?

One of the urgent problem is the absence of an agreement on a medical diagnostic toolkit for burnout which could help with the early detection and the development of a valid treatment. To date in most cases it is treated as depression or not treated at all.

For the record, the International Classification of Diseases has recognized burnout as a “state of vital exhaustion” under “Problems related to life-management difficulty”. In contrast, burnout is not present in the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification.

The problem, which came first or caused the other to happen, burnout or depression, is a matter of an ongoing debate. It was long believed that depression is one of the symptoms of burnout or should be treated as a synonym for burnout. Later these statements were supplanted by the dominant opinion that depression and burnout are part of the same continuum, in which burnout develops over time into a depression. This is also reflected in the discussion about the autonomous status of burnout.

Those, who advocate the separation of both, persistently claim that burnout manifests in a different way over the course of the disease, although they also acknowledge some common aspects. These differences are apparent on a physiological level – the cardiovascular, immune and endocrine system, inflammation, cortisole level (see details in the coming paragraph). And to top it all off, factor analysis (statistical way to find hidden patterns and their overlap) in most cases hints at a distinct nature of burnout that separates depressive from burnout patients.

Other studies cast doubt on the separation. They point to the compelling facts of similarities in the overall causation. They stress that 50% of the symptoms of burned out people are similar to those in depressed patients (namely fatigue, sleep disturbance, loss of energy). Based on this fact they assert that burnout is a part of depression (e.g. Study 1, 2, 3, 4, 5).

Allostatic load?

Although at the moment there is no officially accepted biomarker for burnout, however some experimental data reveal a perspective for the autonomous status of burnout and for its reliable biological measurement.

For example, one EEG study found a correlation between burnout score and power of alpha band originating from the higher activity of an ensemble of neurons, but not for depression. Another group of studies were focused on the so-called ‘inflammatory’ indicators of burnout. They measured the heart-rate variability which corresponds with changes in cardiac vagal tone (vagal tone is a process occurring within the parasympathetic nervous system, resulting in changes to the heart rate. The vagus nerve, is a part of autonomic nervous system (ANS), controls the heartbeat to keep it within a safe range; interested reader can read more about vagus nerve in our previous post) and compared it with work-stress scores. The more we are exposed to stress at work, the more drastic is the decrease in cardiac vagal tone. These findings suggest that burnout causes changes in ANS and it likewise leads to the dysregulation of the immune function.

Along the same lines, long exposure to work-related stress diminishes cortisol (a stress hormone) level (Hypocortisolism), whereas depression is linked to elevated level (Hypercortisolism). Contrary, the Dresden burnout study tested the same correlation between burnout and cortisol level. They found that “significantly elevated level of cortisol” was associated with high levels of burnout. Furthermore, they also revealed substantial positive correlation between burnout and blood based indicators (i.e. leukocytes, hemoglobin, and platelets). Importantly, they were not correlated with depression. The contradiction in these findings may originate primarily from the heterogeneity in experimental settings, e.g. the extent of the burnout disease, type of measurement of burnout, sampling method (i.e. cortisol).

Although the above mentioned lines of research are quite promising and have shown encouraging results, it is important to admit that there is currently no definitive answer on whether depression and burnout should be considered as two separate diseases.

Closing statements

How great would it be to perceive burnout-related emotions only at the theater or cinema, follow the struggles, defeats and triumphs of the main character without real-life implications! But this is far from real life. On the basis of the above, a rather grim picture emerges. An ordinary person who lives in an erratic modern world full of inordinate demands and competition faces an acute need to accumulate all available inner resources to cope with perpetually growing challenges. Over time, this could result in burnout.

It is apparent, that in such situation, avoidance is not an optimal strategy. It is impossible to skillfully circumvent all of life challenges. Studies testify that so called ‘psychological capital’ may be more efficient here. Specifically, how individuals perceive stress, what coping strategy they apply, how effectively they adapt to and recover from exposure to the stressful situations. In other words, preparedness and the capacity of an organism to adapt on the cognitive, emotional and physiological level to the constantly changing environment – could constitute a new ‘equilibrium’ of the healthy mind and body of individuals in the modern society.

PS.

And, by the way, the main character of the play “Das Burnout”, at the end came up with the conclusion that even when facing the most hopeless situation, the best thing you can do with your own life is to live it.