Occupational burnout

Occupational burnout
Other names	Burn-out, exhaustion disorder, neurasthenia
A person who is experiencing psychological stress
Specialty	Psychology
Symptoms	Emotional exhaustion, depersonalization, reduced personal accomplishment,[1][2] fatigue[3]
Differential diagnosis	Major depressive disorder

The ICD-11 of the World Health Organization (WHO) describes occupational burnout as an occupational phenomenon resulting from chronic workplace stress that has not been successfully managed, 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."^[4] It is classified as an occupational phenomenon, but is not recognized by the WHO as a medical condition.^[5]

The business world is in grave danger due to the rising number of employee burnout instances; ongoing stress eventually wears people out physically, emotionally, and mentally. Employee turnover, job satisfaction, and organizational productivity are all impacted in addition to individuals, which lowers organizational stability and efficiency. Burnout and other mental health issues have a substantial financial impact on the world economy, with annual expenses estimated at about USD 1 trillion. ^[6] National health bodies in some European countries do recognise it as such however,^[7] and it is also independently recognised by some health practitioners.^[8]

According to Kaschka, Korczak and Broich, "Burnout as a phenomenon has probably existed at all times and in all cultures."^[9] These authors note that the condition is described in the Book of Exodus (18:17–18).^[9]

Gordon Parker believes the ancient European concept of acedia refers to burnout, and not depression as many others believe.^[10][11]

By 1834, the German concept of Berufskrankheiten (occupational diseases) had become established. This covered all negative health effects of employment, both mental and physical.^[12]

In 1869, New York neurologist George Beard used the term "neurasthenia" to describe a very broad condition caused by the exhaustion of the nervous system, which was thought to be particularly found in "civilized, intellectual communities."^[13] The concept soon became popular, and many in the United States believed themselves to have it. Some came to call it "Americanitis".^[14] The rest cure was a commonly prescribed treatment (though there were many others). Beard yet further broadened the potential symptoms of neurasthenia over time, so that almost any symptom or behaviour could be deemed to be caused by it.^[15] Don R Lipsitt would later wonder if the term "burnout" was similarly too broadly defined to be useful.^[16] In 2017 the psychologist Wilmar Schaufeli pointed out similarities between Beard's concept of neurasthenia and that of contemporary burnout.^[17]

In 1888, the English neurologist William Gowers coined the term occupation neurosis to describe nerve damage caused by repetitive strain injury, translating the German concept of Beschäftigungsneurosen (occupational diseases affecting the nerves).^[18] The related term occupational neurosis came to include a wide range of work-caused anxieties and other mental problems. By the late 1930s, this condition was well known by American health professionals.^[19] It became known as berufsneurose in German.^[20]

In 1936,^[21] the Austrohungarian-Canadian endocrinologist Hans Selye first published about the concept of the general adaptation syndrome. This posits that in response to continuing stress, the human body goes into a physiological state of alarm, followed by resistance, followed by either recovery or exhaustion.^[22]

In 1957, Swiss psychiatrist Paul Kielholz coined the term Erschöpfungsdepression - 'exhaustion-depression'.^[23][24][25] The concept was one of a number of new depression-subtypes that gained traction in France and Germany during the 1960s.^[26]

In 1961, British author Graham Greene published the novel A Burnt-Out Case, the story of an architect who became greatly fatigued by his work, and who took much time to recover.^[27]

In 1968, the WHO's DSM-II replaced "psychophysiologic nervous system reaction" with the condition neurasthenic neurosis (neurasthenia).^[28] This condition was "characterized by complaints of chronic weakness, easy fatigability, and sometimes exhaustion." Another condition added to this edition was the similar asthenic personality, which was "characterized by easy fatigability, low energy level, lack of enthusiasm, marked incapacity for enjoyment, and oversensitivity to physical and emotional stress."

In 1969, American prison official Harold B Bradley used the term burnout in a criminology paper to describe the fatigued staff at a centre for treating young adult offenders.^[29] This has been cited as the first known academic work to use the term for this concept.^[30]

By 1970, the concept of hypasthenia in Russia was characterized by "fatigue, depression, tearfulness, anorexia, and work inefficiency."^[31]

In 1971, Paul Kielholz further publicised the idea of Erschöpfungsdepression in the German-speaking world through his book Diagnose und Therapie der Depressionen für den Praktiker.^[32] His work inspired further writing on the topic by Volker Faust (de).^[33]

In 1973, Canadian psychiatrist David M Berger proposed that "neurasthenia is a stress-intolerance syndrome".^[34]

In 1974, Herbert Freudenberger, a German-born American psychologist, used the term "burn-out" in his academic paper "Staff Burn-Out."^[35] The paper was based on his qualitative observations of the volunteer staff (including himself) at a free clinic for drug addicts.^[35] 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 paper, interest in the concept grew.

The American psychologist Christina Maslach described in a magazine article^[36] the impact of interpersonal stress on human service workers (e.g., social workers, psychiatrists, poverty lawyers, etc.). The impact manifested itself in symptoms such as fatigue, quickness to anger, cynical attitudes toward the people the service workers were supposed to help.

Also in 1976, Israeli-American psychologist Ayala Pines^[37] and American psychologist Elliot Aronson began treating burnout through group workshops.^[38] Pines collaborated with Maslach in writing essentially data-free papers about burnout in individuals who worked in day care centers^[39] and mental health facilities.^[40] By 1981, Pines's research on burnout took a different direction; she collaborated with Elliot Aronson.^[41]

In January 1978, Soviet endocrinologists LA Lavrova (ЛА Лаврова) and MS Bilyalov (МШ Билялов) found that in 125 patients with neurasthenia, there were substantial hormonal differences from normal.^[42]

In June 1978, a team led by Australian psychiatrist Gavin Andrews found that neurasthenic neurosis was defined by two features, "anxiety proneness" and "inability to cope with stress."^[43]

In 1980, the DSM-III was released. It abolished the concepts of neurasthenia and asthenic personality, both with the explanation "This DSM-II category was rarely used." Neither was directly replaced, although the DSM-III index refers people looking for the former to "dysthymic disorder" (a long-term and relatively mild form of depression), and the latter to "dependent personality disorder".

Also in 1980, the popular book Staff Burnout: Job Stress in the Human Services was published by American psychologist Cary Cherniss.^[44][45]

In April 1981, Maslach and fellow American psychologist Susan E. Jackson published an instrument for assessing occupational burnout, the Maslach Burnout Inventory (MBI).^[2] It was the first such instrument of its kind, and soon became the most widely used occupational burnout instrument.^[46] The two researchers described occupational burnout in terms of emotional exhaustion, depersonalization (feeling low-empathy towards other people in an occupational setting), and reduced feelings of work-related personal accomplishment.^[1][47]

In 1988, Pines and Aronson wrote the popular book Career Burnout: Causes and Cures,^[38] an updated version of a book they had published in April 1981 with fellow American psychologist Ditsa Kafry. They found that "marriage burnout" was just as prevalent as "job burnout".

The WHO's ICD-10 began being used in 1994. The classification removed the condition of asthenic personality, however continued to include neurasthenia (F48.0). Two overlapping types were defined, in one "the main feature is a complaint of increased fatigue after mental effort, often associated with some decrease in occupational performance or coping efficiency in daily tasks. The mental fatiguability is typically described as an unpleasant intrusion of distracting associations or recollections, difficulty in concentrating, and generally inefficient thinking."^[48] This category specifically excluded cases of "burn-out" (Z73.0), defined only as "State of vital exhaustion."^[49]

In 1998, Swedish psychiatrists Marie Åsberg and Åke Nygren^[50] investigated a surge of depression health insurance claims in Sweden. They found that the symptoms of many cases did not match the typical presentation of depression. Complaints like fatigue and decreased cognitive ability dominated, and many believed their working conditions to be the cause.^[51]: 16

In 2005, the Swedish Board of Health and Welfare adopted a refined conceptualisation of severe burnout it described as "exhaustion disorder."^[52] This led to the development of a number of treatment programs in that country.

In December 2007, the Swiss Expert Network on Burnout (SEB) was established.^[53] It has since held a number of symposia, and published treatment recommendations.^[54]

In March 2015, French psychologist Renzo Bianchi^[55] and his colleagues provided a literature review on the burnout–depression overlap (based on 92 studies) and concluded that the studies fail to prove consistently the nosological distinctiveness of the burnout phenomenon.^[56]

In May 2015, the WHO adopted a new conceptualisation of "occupational burnout". It was consistent with Maslach's.^{[citation needed]} However, occupational burnout was "not itself classified by the WHO as a medical condition or mental disorder."^[57]

As of 2017, nine European countries (Denmark, Estonia, France, Hungary, Latvia, Netherlands, Portugal, Slovakia and Sweden) legally recognized burnout syndrome as an occupational disorder, for example, by awarding workers' compensation payments to affected people.^[7]

The WHO's ICD-11 began official use in 2022. Within this categorisation, the concept of neurasthenia became part of the new condition of bodily distress disorder (6C20).^[58][59] The WHO also modified their definition of burnout that year.^[60]

The two main classification systems of psychological disorders are the Diagnostic and Statistical Manual of Mental Disorders (DSM, used in North America and elsewhere) from the American Psychiatric Association (APA), and the International Classification of Diseases (ICD, used in Europe and elsewhere) from the World Health Organisation (WHO).

Burnout is not recognized as a distinct mental disorder in the DSM-5 (published in 2013).^[61] Its definitions for Adjustment Disorders,^[62][63][64] and Unspecified Trauma- and Stressor-Related Disorder^[65] in some cases reflect the condition. 2022's update, the DSM-5-TR, did not add a definition of burnout.^[66]

As of 2017, nine European countries may legally recognise burnout in some way, such as by providing workers' compensation payments.^[7] (Legal recognition for financial purposes is not the same as medical recognition as a discrete disease.)

The ICD-10 (current 1994–2021) classified "burn-out" as a type of non-medical life-management difficulty under code Z73.0.^[67] It was considered to be one of the "factors influencing health status and contact with health services" and "should not be used" for "primary mortality coding".^[68] It was also considered one of the "problems related to life-management difficulty".^[69] The condition is further defined as being a "state of vital exhaustion," which historically had been called neurasthenia.^[70] The ICD-10 also contained a medical condition category of "F43.8 Other reactions to severe stress."^[71]

In 2005, the Swedish Board of Health and Welfare added “exhaustion disorder” (ED; F43.8A) to the Swedish version of the ICD-10, the ICD-10-SE, representing what is typically called "burnout" in English.^[72][73] Swedish sufferers of severe burnout had earlier been treated as having neurasthenia.^[74] According to Lindsäter et al., "The diagnosis has become almost as prevalent as major depression in Swedish health care settings, and currently accounts for more instances of long-term sick-leave reimbursement than any other single diagnosis in the country."^[75]

The Royal Dutch Medical Association defined "burnout" as a subtype of adjustment disorder^[76] as part of the ICD-10 system. In the Netherlands, overspannenheid (overstrain) is a condition that leads to burn-out.^[77] In that country, burnout is included in handbooks and medical staff are trained in its diagnosis and treatment.^[74] A reform of Dutch health insurance resulted in adjustment disorder treatment being removed from the compulsory basic package in 2012. Practitioners were told that more serious cases of the condition may qualify for classification as depression or anxiety disorder.^[78]

According to the Dutch College of General Practitioners, there is overstrain if these four criteria are met:

1. At least three of the following complaints are present:
   • fatigue
   • disturbed or restless sleep
   • irritability
   • inability to tolerate crowds or noise
   • emotional lability
   • worry
   • feeling rushed
   • concentration problems and/or forgetfulness
2. feelings of loss of control and/or powerlessness
3. significant limitations in occupational and/or social functioning
4. the aforementioned phenomena are not exclusively the direct result of a psychiatric disorder^[79]

"Burnout" is deemed to be when overstrain persists for more than six months and fatigue is prominent.^[79]

A new version of the ICD, ICD-11, was released in June 2018, for first use in January 2022.^[80] The new version has an entry coded and titled "QD85 Burn-out". The ICD-11 describes the condition as follows:

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.^[81]

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.^[57][82] 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."^[83]

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."^[84][85] 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",^[86] which is the equivalent of the ICD-10's F43.8.

If, after treatment, a person with burnout continues to have persistent physical symptoms triggered by the condition, in Iceland they may be considered to have "somatic symptom disorder" (DSM-5) and "bodily distress disorder" (ICD-11).^[87]

Further detail about the varied ways clinicians and others used the then-current ICD and DSM classifications with burnout was published by Dutch psychologist Arno Van Dam in 2021.^[8]

The US government's National Institutes of Health includes the condition as "psychological burnout" in its index of the National Library of Medicine,^[88] and provides a number of synonyms. It defines the condition as "An excessive reaction to stress caused by one's environment that may be characterized by feelings of emotional and physical exhaustion, coupled with a sense of frustration and failure."^[88]

SNOMED CT includes the term "burnout" as a synonym for its defined condition of "Physical AND emotional exhaustion state," which is a subtype of anxiety disorder.^[89] The Diseases Database defines the condition as "professional burnout."^[90]

A 2023 Future Forum study found that 42% of the global workforce reported burnout.^[91] A 2019 study by the World Economic Forum found that 30% of German employees, 37% of Spanish employees, 50% of U.S. employees, and 57% of UK employees had experienced workplace burnout.^[92]

In 1981, Maslach and Jackson developed the first widely used instrument for assessing burnout, the Maslach Burnout Inventory (MBI).^[2] It remains by far the most commonly used instrument to assess the condition. Consistent with Maslach's conceptualization, the MBI operationalizes burnout as a three-dimensional syndrome consisting of emotional exhaustion, depersonalization (an unfeeling and impersonal response toward recipients of one's service, care, treatment, or instruction),^[a] and reduced personal accomplishment.^[1][2]

The MBI originally focused on human service professionals (e.g., teachers, social workers).^[2] Since that time, the MBI has been used for a wider variety of workers (e.g., healthcare workers). The instrument or its variants are now employed with job incumbents working in many other occupations.^[1]

There are other conceptualizations of burnout that differ from that suggested by Maslach and adopted by the WHO.

In 1999, Demerouti and Bakker, with their Oldenburg Burnout Inventory (OLBI), conceptualized burnout in terms of exhaustion and disengagement,^[93] linking it to the job demands-resources model. This instrument is used mainly in the United States.

Also that year, Wilmar Schaufeli and Arnold Bakker released the Utrecht Work Engagement Scale (UWES). It uses a similar conceptualisation to the MBI. However the UWES measures vigour, dedication and absorption; positive counterparts to the values measured by the MBI.^[94] It is used mainly in Germany.

In 2005, TS Kristensen et al. released the public domain Copenhagen Burnout Inventory (CBI).^[3] They argued that the definition of burnout should be limited to fatigue and exhaustion.^[3] The CBI has had some use in Germany.

In 2006, Shirom and Melamed with their Shirom-Melamed Burnout Measure (SMBM) conceptualized burnout in terms of physical exhaustion, cognitive weariness, and emotional exhaustion.^[95][96] An examination of the SMBM's emotional exhaustion subscale, however, indicates that the subscale more clearly embodies Maslach's^[97] concept of depersonalization than her concept of emotional exhaustion.^[46] This measure has seen some use in Sweden.

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.^[98] It has been mainly used in the United States.

In 2014, Aniella Besèr et al. developed the Karolinska Exhaustion Disorder Scale (KEDS),^[52][99] which is used mainly in Sweden. It was designed to measure the symptoms defined by the ICD-10-SE's category for exhaustion disorder. The authors believed that those with the disorder were often initially depressed, but that this soon passed. The core symptoms of the disorder were deemed to be "exhaustion, cognitive problems, sleep disturbance". The authors also believed that the condition was clearly differentiated from both depression and anxiety.

In 2020, the Occupational Depression Inventory (ODI),^[100] was developed to quantify the severity of work-attributed depressive symptoms and establish provisional diagnoses of job-ascribed depression.^[101][102] The ODI covers nine symptoms, including exhaustion (burnout's putative core). The instrument exhibits robust psychometric properties. The ODI is the only instrument that assesses work-related suicidal thoughts, a particularly important symptom calling for immediate attention. Available evidence indicates that burnout scales have very high correlations with the ODI, correlations that cannot be explained by item overlap,^[101] suggesting that the ODI is a suitable replacement for burnout scales like the MBI.^[103]

In 2021, the Sydney Burnout Measure (SBM) was released by Gordon Parker et al., which "captures domains of exhaustion, cognitive impairment, loss of empathy, withdrawal and insularity, and impaired work performance, as well as several anxiety, depression and irritability symptoms."^[104]

There are still other conceptualizations as well that are embodied in other instruments, including the Hamburg Burnout Inventory,^[105] and Malach-Pines's Burnout Measure.^[106]

Kristensen et al.^[3] and Malach-Pines (who also published as Pines)^[107] 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.^[108][109]

The core of all of these conceptualizations, including that of Freudenberger, is exhaustion.^[97][110]

Maslach^[97] advanced the idea that burnout should not be viewed as a depressive condition. Recent evidence, based on factor-analytic and meta-analytic findings, calls into question this supposition.^{[111][112][46]} Burnout is also now often seen as involving the full array of depressive symptoms (e.g., low mood, cognitive alterations, sleep disturbance).^[113][114]

Marked differences among researchers' conceptualizations of what constitutes burnout have underlined the need for a consensus definition.^[115][116]

In 1991, Barry A. Farber 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.^[117]

"Underchallenged burnout" later came to be known as boreout.

Burnout affects caregivers; in the ICD-11 classification, in the description for code QF27 "Difficulty or need for assistance at home and no other household member able to render care" the term "caregiver burnout" is given as a synonym.^[86]

Burnout affects teachers.

Athlete burnout

A type of occupational burnout which burdens athletes young and old. Relatively little research has been conducted on this phenomenon, but it affects the mental health and overall well-being of countless athletes across the world. It may lead to athletes feeling immensely stressed out and in extreme cases terminating their participation in an activity they once enjoyed.^[118] Further impacts are unknown, but various other detriments to mental health are possible as well.

Causes

A host of factors could contribute to athlete burnout, but most notably, extended time participating in one sport with large amounts of stress accompanying this participation. Pressure from oneself, parents, coaches, or other figures can cause the stress that leads to a case of burnout.^{[citation needed]}

Prevention

Although no medical treatments or preventions are currently available, avoiding unnecessary, harmful stress can be beneficial for those suffering from this phenomenon. Creating a strong support system for athletes helps avoid these stressors and mental health challenges.

Future Research

Little research has currently been documented on this phenomenon. More research conducted could lead to more knowledge of its causes, treatments, and symptoms.^[119] Through use of models already in place such as Smith’s Cognitive-Affective Model of Athletic Burnout as well as new measures, researchers can hope to discover more information on this specific subtype of burnout.

A growing body of evidence suggests that burnout is etiologically, clinically, and nosologically similar to depression.^{[120][121][122][123][124][125][126][115]} 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.^[127] Moreover, a study by Bianchi, Schonfeld, and Laurent (2014) showed that about 90% of workers with very high scores on the MBI meet diagnostic criteria for depression.^[123] The view that burnout is a form of depression has found support in several recent studies.^{[110][121][122][124][125][126][105]} 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 little agreement on burnout's diagnostic criteria.^[115][128] A newer generation of studies indicates that burnout, particularly its exhaustion dimension, problematically overlaps with depression; these studies have relied on more sophisticated statistical techniques, for example, exploratory structural equation modeling (ESEM) bifactor analysis, than earlier studies of the topic.^[129][110] The advantage of ESEM bifactor analysis, which combines the best features of exploratory and confirmatory factor analysis, is that it provides a granular look at item-construct relationships, without falling into traps earlier burnout researchers fell into.^[130]

Liu and van Liew^[64] 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). The authors equate burnout with adjustment disorder with depressed mood.

Kakiashvili et al.,^[131] however, argued that although burnout and depression have overlapping symptoms, endocrine evidence suggests that the disorders' biological bases are different. They argued that antidepressants should not be used by people with burnout because the medications can make the underlying hypothalamic–pituitary–adrenal axis dysfunction worse.

Test	Major depressive disorder (typically melancholic depression)	Atypical depression	PTSD	Burnout
Cortisol awakening response	↑[131]	↓[132]	↓[131]	↓[131][133]
Adrenocorticotropic hormone (ACTH)	↑[131]	-[134] or ↓[133]	- or ↓[131]	- or ↓[131] or ↑[133]
Dehydroepiandrosterone sulphate (DHEA-S)	↓[131]		↑ or ↓[131]	↑[131]
Low dose dexamethasone suppression test effect on cortisol	no suppression[131]			hypersuppression[131]

^{[131][135][136][137]}

Despite its name, depression with atypical features, which is seen in the above table, is not a rare form of depression.^[138] The cortisol profile in atypical depression, in contrast to that of melancholic depression, is similar to the cortisol profile found in burnout.^[123] 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.^[123]

Autistic people are known to experience a state of mental, emotional, or physical exhaustion referred to as autistic burnout^[139][140] caused by masking of autistic traits and behavior and the general stress associated with living in an unaccommodating environment.^{[139][140][141]} Autistic burnout is considered to be distinct from occupational burnout in both etiology and presentation.^[140][142] In contrast to "occupational burnout", autistic burnout does not necessarily have to relate to employment^[143] and goes along with increased sensory sensitivity.^[144]: 186

According to a 2018 Gallup study, burned-out employees are at a 23% increased risk of going to the emergency room.^[145]

Evidence suggests that the etiology of burnout is multifactorial, with personality factors playing an important, long-overlooked role.^[146][147] Cognitive dispositional factors implicated in depression have also been found to be implicated in burnout.^[148] One cause of burnout includes stressors that a person is unable to cope with fully.^[149] A 2019 survey by Cartridge People concluded that workload was the main cause of workplace stress.^[150]

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.^[151] 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.^[152]

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.^[153] Lack of job resources was associated with the disengagement component of the OLBI.

Maslach, Schaufeli and Leiter identified six risk factors for burnout in 2001: 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.^[97]

Although job stress has long been viewed as the main determinant of burnout, recent meta-analytic findings indicate that job stress is a weak predictor of burnout.^[154] These findings question one of the most central assumptions of burnout research.

In a systematic literature review in 2014, the Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) found that a number of work environment factors could affect the risk of developing exhaustion disorder or depressive symptoms:

• People who experience a work situation with little opportunity to influence, in combination with too high demands, develop more depressive symptoms.
• People who experience a lack of compassionate support in the work environment develop more symptoms of depression and exhaustion disorder than others. Those who experience bullying or conflict in their work develop more depressive symptoms than others, but it is not possible to determine whether there is a corresponding connection for symptoms of exhaustion disorder.
• People who feel that they have urgent work or a work situation where the reward is perceived as small in relation to the effort develops more symptoms of depression and exhaustion disorder than others. This also applies to those who experience insecurity in the employment, for example concerns that the workplace will be closed down.
• In some work environments, people have less trouble. People who experience good opportunities for control in their own work and those who feel that they are treated fairly develop less symptoms of depression and exhaustion disorder than others.
• Women and men with similar working conditions develop symptoms of depression as much as exhaustion disorder.^[155]

The Stressmottagningen stress clinic believes "A certain type of person is considered to be at an increased risk of suffering from exhaustion disorder. The type includes creative, ambitious, perfectionist and emotionally committed individuals with a great need for appreciation, who find it difficult to delegate, find it difficult to say no to extra work and who find themselves in hierarchical organizations such as found in the healthcare, social care and education fields. Women aged between 35 and 50 are overrepresented in this category."^[156] Swedish worker health organisation Suntarbetsliv quoted statistics in 2017 showing that "women in their 30s are most affected."^[157]

The Gothenburg Institute of Stress Medicine's Kristina Glise wrote about a number of risk factors in February 2023.^[158]

Negative consequences of burnout on both the employee and the organization call for preventive measures in order to reduce the impact of the risk factors. Burnout prevention strategies, either addressing to the general working population (primary prevention) or the occupational groups which are more vulnerable (secondary prevention), are focused on reducing the impact of risk factors. Reviews of healthcare professionals‟ burnout focusing on identifying risk factors have been conducted previously.^[159]

A 2020 LinkedIn survey based on over 2.9 million responses concluded that employees struggling with work-life balance were 4.4 times more likely to show symptoms of occupational burnout.^[160]

The World Health Organisation has defined the effects of burnout as consisting of:

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
3. reduced professional efficacy.^[161]

This is in line with Christina Maslach and Susan E. Jackson's earlier findings that the syndrome is defined by emotional exhaustion, depersonalization (feeling low-empathy towards other people in an occupational setting), and reduced feelings of work-related personal accomplishment.^[1][47]

The Swedish health department has defined the effects of exhaustion disorder as being:

1. Concentration difficulties or impaired memory
2. Markedly reduced capacity to tolerate demands or to work under time pressure
3. Emotional instability or irritability
4. Sleep disturbance
5. Marked fatigability or physical weakness
6. Physical symptoms such as aches and pains, palpitations, gastrointestinal problems, vertigo or increased sensitivity to sound.^[162]

A 2023 study by Elin Lindsäter et al. found a wide range of symptoms had by people formally diagnosed with exhaustion disorder. The most common symptoms reported by people currently suffering with the condition were tiredness (48%), lack of energy (41%), difficulty recovering from exertion (33%), poor general cognitive functioning (33%), memory issues (32%) and difficulty coping with perceived stressors and demands (31%).^[163]

Some research indicates that burnout is associated with reduced job performance,^[164] coronary heart disease,^[96] and mental health problems.^[165] 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.^[166]

There is research on dentists^[121] and physicians^[105] that suggests that 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.

Forced overtime, heavy workloads, and frenetic work paces give rise to debilitating repetitive stress injuries, on-the-job accidents, over-exposure to toxic substances, and other dangerous work conditions.^[167] Williams and Strasser suggested that healthcare workers have focused much attention on the workplace risk factors for heart disease and other illnesses, but have underemphasized work-related depression risk.^[168]

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.^[166] Occupational burnout is also associated with absenteeism, other time missed from work, and thoughts of quitting.^[169]

Chronic burnout is also associated with cognitive impairments in memory and attention.^[170] (See also Effects of stress on memory.)

Studies by Agneta Sandström have shown that people diagnosed with exhaustion disorder had lower activity in the brain's frontal lobe than in control groups. They also had sleep problems caused by hormonal disturbances in the pituitary gland.^[171]

Research suggests that burnout can manifest differently between genders, with higher levels of depersonalisation among men and increased emotional exhaustion among women.^[172][173] Other research suggests that people revealing a history of occupational burnout face future hiring discrimination.^[174]

When it happens in the context of volunteering, burnout can often lead to volunteers significantly reducing their activities or stopping volunteering altogether.^[175] Likewise, academic stress, as it has been called, or academic burnout is a process originated from the inciting element, which implies the subjection to events that from the student's perspective can be considered as stressors.^[176]

Burnout might result in learned helplessness.^[8]

Burnout has been found to be associated with spiritual health.^[177]

Drozdstoj Stoyanov et al. believe burnout has three stages:

1. Flame out - trying to deal with excessive stress, causing depression and anxiety.
2. Genuine burn out - a process of increasing emotional exhaustion.
3. Rust out - being completely alienated from other people, cynical and ineffective.^[178]

A number of other researchers have also divided the burning-out process into stages.^[179]

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).^[180]

Maslach believes that the only way to truly prevent burnout is through a combination of organizational change and education for the individual.^[151]

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.^[97] Resolving these discrepancies requires integrated action on the part of both the individual and the organization.^[97] 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.^[97] With regard to values, clearly stated ethical organizational values are important for ensuring employee commitment.^[97] Supportive leadership and relationships with colleagues are also helpful.^[97]

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."^[181] They also note that "at the individual level, cognitive-behavioural strategies have the best potential for success."^[181]

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.^[182] The intervention was associated with decreases in exhaustion over time but not cynicism or inefficacy, suggesting that a broader approach is required.^[97]

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 do not 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.^[183]

In addition to interventions that can address and improve conditions on the work side of work-life balance, the ways in which people spend their non-work time can help to prevent burnout and improve health and well-being.^[184]

Corporate Social Responsibility (CSR) initiatives are considered a resource which counteracts the stress effects of job demands, lowering employee burnout by boosting happiness, resilience and capitalizing altruism.^[185]

Establishing a sense of psychological safety (the belief that it is safe to speak up) in an organisation helps prevent burnout.^{[186][187][188][189]} Similarly, feeling heard may also help.^[186]

Mindfulness therapy has been shown to be an effective preventative for occupational burnout in medical practitioners.^[190]

Training employees in ways to manage stress in the workplace is effective in preventing burnout.^[191] 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.^[169] 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.^[181]

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.^{[192][193][194]}

In one trial, workers taking a high-dose Vitamin B complex "reported significantly lower personal strain and a reduction in confusion and depressed/dejected mood after 12 weeks."^[195]

In another trial, doctors undertaking a program involving "mindfulness, reflection, shared experience, and small-group learning" for 9 months had a much lessened propensity to burn out.^[196] Another trial with medical interns found a ten-week mindfulness program reduced the incidence of burnout.^[197]

Burnout prevention programs have often focused on cognitive-behavioral therapy (CBT).^[198][199] 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.^[47]

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.^{[citation needed]}

Work-related factors can also impact workers in their non-work time. Authors from the University of Utah found the increased incidence of boundary violations influenced reports of burnout in healthcare workers during the COVID-19 pandemic. The authors detailed specific patterns within the broader context of boundary violations whereby intrusion events are associated with increased job-related demands, and distancing events are associated with reduced job-related resources. In response, healthcare workers utilized specific boundary work tactics in response to specific types of boundary violations to redefine boundaries and forestall burnout.^[200]

A 2020 survey by FlexJobs and Mental Health America found that no more than 21% of the 1500 people surveyed were able to have a constructive conversation with HR about burnout. 56% of respondents claimed that HR did nothing to encourage speaking out about burnout. 76% of respondents claimed that workplace stress was negatively impacting their mental health.^[201] According to Clockify, four out of ten people clocking 50+ hours state their company does not have a burnout program. Employees also claimed that only 31% of colleagues and 27% of bosses react to burnout.^[202] In a 2020 survey by Eagle Hill Consulting, 36% of employees said that their organization was not doing anything about employee burnout.^[203]

Research in the fields of organisational psychology, group dynamics and team performance amongst others, have built a body of evidence around the role of psychological safety in the work place.^[204] Psychological safety is an interpersonal construct which is experienced at the team or group level. It is an environment where people feel comfortable sharing concerns and mistakes without fear of embarrassment or retribution.^[205] This safe environment enables inclusion and for team members to bring their full selves to work. Through this process, a broader variety of information is shared in the organisation, allowing for creativity, innovation and learning, but also providing a better basis on which to make decisions, in turn leading to better outcomes and performance. Engagement and satisfaction at work are also described outcomes of psychological safety, which in turn are seen to be protective against burn out.^[206][186]

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.^[181]

van der Klink and 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.^[76]

Kakiashvili et al. said 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. Omega-3 fatty acids may be helpful. DHA supplementation may also be useful for moderating norepinephrine. 11 beta-hydroxysteroid dehydrogenase (and potentially other metabolites of liquorice root extract) may help with lowered cortisol response.^[131]

Salomonsson et al. found that for workers with exhaustion disorder, CBT was better than a Return to Work Intervention (RTW-I) for reducing stress; and that people whose symptoms were primarily depression, anxiety or insomnia had reduced total time away from work after a RTW-I than for CBT.^[207] van Dam et al. had also earlier found that CBT was an effective treatment.^[208]

Ybe Meesters found that light therapy (similar to that used for Seasonal Affective Disorder) may be effective.^[209]

Gordon Parker et al. found that the most useful treatment strategies appear to be talking to someone and seeking support, walking or other exercise, mindfulness and meditation, improving sleep, and leaving work completely or taking time off work.^[10][11]

The Swedish national health information service 1177 notes that "It is common for treatment and rehabilitation [of exhaustion disorder] to include several of the following parts:

• Information and education about how stress affects the body.
• Counseling and education on lifestyle and on methods to reduce daily stress. It can be done individually or in a group.
• Treatment with CBT.
• Conversation with a counsellor, psychologist or occupational therapist.
• Physiotherapy to work with the body in different ways.
• Medicines for sleep difficulties or depression."^[210]

The Royal Dutch College of General Practiconers recommends a three-stage treatment process, made up of a crisis phase, a problem and solution stage, and an application stage.^[79]

The Gothenburg regional government's Institute for Stress Medicine believes that "Recovery [from exhaustion disorder] is found in what is undemanding and joyful, and what that is varies greatly between individuals. Sleep and physical exercise are the basis of recovery and should be prioritized initially."^[211] According to a survey of their patients in 2018, the two most important drivers of recovery were "the sick leave itself" and "advice on physical activity."^[212] The institute's Kristina Glise (with others) has also twice detailed the institute's treatment practices in papers.^{[213][214][215]} Glise also wrote a series of diagnostic and treatment recommendations for doctors in February 2023.^[158]

The Stressmottagningen stress clinic believes that Focussed - Acceptance and Commitment Therapy (F-ACT, a form of CBT) is a useful component of exhaustion disorder treatment.^[216] Their treatment includes "psychotherapy, physiotherapy, as well as occupational therapy and work-life planning."^[156] They also note that there is "still no established treatment method" for the condition.^[156]

The Swiss Expert Network on Burnout in 2016 recommended mindfulness training, physical exercise, nature therapy, whole-body cryotherapy and whole-body hyperthermia.^[217]

Swiss doctor Barbara Hochstrasser^[218] released a book containing her treatment recommendations in 2023.^[219]

Korczac et al. in a 2012 literature review found that "only for cognitive behavioural therapy (CBT) exists an adequate number of studies which prove its efficacy."^[220]

Ahola et al. in a 2014 literature review found that less than 1% of 4430 papers reviewed contained scientifically rigorous data, and that the 14 well-designed studies collectively "showed that such [randomised control trial] interventions did not succeed in alleviating burnout symptoms."^[221]

Grossi et al. in a 2015 literature review found that "cognitive impairments seen in clinical burnout are partially reversible through treatment, [typically CBT] but patients are still cognitively impaired at follow-up."^[72]

Perski et al. in a 2017 literature review found that "tertiary interventions for individuals with clinical burnout may be effective in facilitating RTW [return to work]. Successful interventions included advice from labor experts and enabled patients to initiate a workplace dialogue with their employers."^[222]

Wallensten et al. in 2019 literature review found that CBT and workplace dialogue were effective, and that treating sleep and cognitive function issues were also important.^[223]

Lindsäter et al. in a 2022 literature review note the reported success of CBT, acceptance and commitment therapy (ACT), a multimodal rehabilitation program (MMR) program (involving group CBT, applied relaxation in a group, individual psychotherapy, physiotherapy, lectures, and medical treatment), physical exercise, cognitive training, consuming rhodiola rosea extract, and participating in an African dance program. However, overall they noted that "a multitude of interventions have been investigated for exhaustion disorder, but the evidence for any one type of intervention is limited."^[75]

Burnout also often causes a decline in the ability to update information in working memory. This is not easily treated with CBT.^[224]

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.^[181]

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.^[182]

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.^[181] 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 labour in society.

In a study conducted by Andrea Meluch,^[225] they studied how Communication Privacy Management can be applied to discussions about burnout across a diverse amount of sectors and industries. They found that discussing job burnout makes employees feel vulnerable and due to that feeling apply core and catalyst privacy rule criteria to help them make a decision about if they should disclose their job burnout. Core criteria is stable factors used to make choices about privacy rules while catalyst criteria refers to circumstantial influences that can cause a change in privacy rules. Meluch found the factors that contribute to if an employee discloses their feelings of burnout are if they feel that others in the company share the experience of burnout, the perceived judgment towards burnout, and the severity of the burnout they are feeling. Additionally the quality of the relationship they had and the level of trust they attributed to their coworkers and supervisors affected an employee's decision to disclose information. Meluch found that employees will conceal that they are burned out due to the level of risk and the worry about how they will be perceived in the workplace and how their work will be perceived.  

Another study by Debbie Dougherty and Kristina Drumheller^[226] explored how organizations manage the rationality/emotionality duality in the workplace. They found that in organizations that promote norms of rationality, organization members support the rationality/emotionality duality and accept and reinforce this duality by only focusing on emotions when they cause a disruption or rational practices and otherwise control their emotions. To privilege rationality over emotionality they usually recalled emotions in instances where their work was disrupted and rarely mentioned interpersonal conflict as emotional experiences. Additionally they would deny emotions, reframe emotions, rationally recite emotional experiences, and segment emotions “to a proper place and time”.^[226] Organizational members would rationalize their emotions and emotional expression as well as take emotions out of their sense making to fit the expectation of being rational. Dougherty and Drumheller expressed how only privileging rationality and not also privileging emotionality can inspire extreme emotional control that can lead to explosive forms of emotional expression such as organizational violence. They propose that organizational members need to be more aware of “the complex and necessary role of emotions”, promote healthy emotional expression, and recognize that organizations are locations of both emotional and rational sense making.

Katie Kim and Yeunjae Lee^[227] in their research on emotional exhaustion studied how emotional exhaustion is affected by organizations using transparent communication. They found when an employee feels emotionally exhausted, they have negative or cynical feelings towards their company and engage in negative communication behavior, such as complaining to external sources about their company. Kim and Lee express how this can affect organizations as their employees’ communication with external stakeholders can help with creating or losing an opportunity to build or maintain the organizations reputation. Employees can either share supportive views and Kim and Lee describe transparent communication as “an organization’s communication to make available all legally releasable information to employees whether positive or negative in nature”.^[227] It involves sustainability, accountability, and participation. Sustainability is the timely, accurate and unambiguous information provided to employees. Accountability is the organization's responsibility to provide objective and balanced information on activities and policies whether negative or positive. Participation is that stakeholders are involved in identifying the information that needs to be provided. Through this means of communication, Kim and Lee, found that transparent communication provides employees with the resources they feel they lack and creates a more positive relationship with the organization. Transparent communication helped alleviate emotional exhaustion and helped employees cope with burnout symptoms.

• Wikidata: Q327988 (Scholia)