This article is about our generation’s tendency to “work hard and play hard”, to do it all, to do it all NOW, and the most prevalent health issue associated with it:
BURNOUT – The Plague of Our Times
What inspired me to write about this subject was a recent Factory Berlin Fireside Chat event with the founders of SoundCloud. It was actually one of them, Eric, who brought up the issue of burnout. He said that a while ago, his girlfriend, sensing he was under a lot of stress and not responding very well to it, sent him on a “forced holiday” to an exotic island in Asia where he wasn’t allowed to use his phone at all for the entire period. He was supposed to just chill and disconnect, something that doesn’t come naturally to anyone determined to make their startup a success.
What does Eric’s story tell us about burnout?
- That burnout can just creep up on you unawares, often requiring another person to “diagnose” you with it after noticing changes in your behaviour, sleep patterns etc.
- That burnout can strike even the most successful & dedicated of entrepreneurs who enjoy what they do (in other words, burnout is not solely connected to “job dissatisfaction”, “low personal accomplishment” or being a victim of “poor leadership” at work)
- That it often requires taking immediate and rather radical therapeutic action…
So what exactly is burnout and how do you know you’re at risk?
Burnout is a state of mental and physical exhaustion that shares many characteristics with depression, and also, surprisingly, with post-traumatic stress disorder, according to Dr. Geri Puleo’s research on the subject.
But that is a broad, generous definition. According to my research, the term appears to change its meaning depending on the social and cultural context in which it occurs and also on the intentions of those using the term: who’s talking about burnout, matters (psychologists and medical practitioners have different definitions of burnout).
So before we discuss what burnout is, it’s worth taking a dive into its fascinating history…
A SHORT HISTORY OF BURNOUT
The term “burnout” entered the research lexicon in 1974, having been coined by the psychologist Herbert Freudenberger who defined it as the loss of motivation, growing sense of emotional depletion and cynicism that he observed among mental health workers volunteering at a free clinic in New York City: formerly idealistic, they were now depleted and weary, resenting patients and the clinic.Ironically, Freudenberger borrowed the term from the illicit drug scene where it colloquially referred to the devastating effect of chronic drug abuse.
This literature review about burnout reveals that it is prevalent in medical students (28%–45%), residents (27%–75%, depending on specialty), as well as practicing physicians.
Today, however, burnout is no longer confined to those studying or practising medicine: it is now recognised as a legitimate health issue affecting people from all walks of life. So is burnout an illness of modern life? And where does it stem from?
This research article, a collaboration between universities in Netherlands, Canada & Berkley, California, associates burnout with the rapid transformation from an industrial society into a service economy and the psychological pressures that may arise from that. From this viewpoint, a striking parallel exists with neurasthenia (literally, weakness of the nervous system) that was first observed at the end of the 19th century, a period that saw the transition from an agricultural into an industrial society.
Is it possible that burnout is just a maladapted response to change? And who is most at risk of suffering from it?
While at the outset burnout was identified with the medical profession, by the late 1980s researchers began to recognise that burnout can also occur among managers, entrepreneurs, as well as white- and blue-collar workers.
In a further expansion of the term, burnout can also be considered as a context-free phenomenon, in other words, burnout may occur outside work since work is not the only source of stress, or change, in our lives. For instance, the researchers behind The Copenhagen Burnout Inventory distinguish between work-related burnout, client-related burnout and personal burnout, the latter including people who do not work (students, the unemployed, retired people, housewives, etc). And since the sources of stress are many in our lives, should we also consider the notions of relationship-related burnout or family-induced burnout? Just an idea…
In general, the medical profession favours a very narrow definition since a medical diagnosis of burnout opens the possibility on behalf of the “sufferer” to benefit, or profit, from financial compensation arrangements. Thus, while in some countries (Sweden, Netherlands), burnout is considered a medical diagnosis, in other countries (U.S) it is a non-medical, socially accepted label that carries a minimum stigma in terms of a psychiatric diagnosis.
But going back to its roots, burnout was initially defined as “…a state of exhaustion in which one is cynical about the value of one’s occupation and doubtful of one’s capacity to perform” (Maslach et al., 1996, p. 20). Therefore, to qualify for a diagnosis of burnout, one has to not only display symptoms of exhaustion or inefficacy but also show a change in attitude towards cynicism. From this perspective, this diagnosis seems to be reserved exclusively for those idealistic people whose values have been gravely frustrated in the modern corporate environment (corporate hypocrisy?).
Burnout is a syndrome characterised by chronic exhaustion, cynicism, and a lack of personal accomplishment.
As you might have gathered by now, the more we dig into the concept of burnout, the more politicised it appears to be.
After looking at many definitions and diagnostic assessments of burnout, the practice guidelines issued by the Royal Dutch Medical Association in 2000 seem to be the most nuanced as they distinguish between three levels of stress-related disorders:
(1) distress (i.e. relatively mild symptoms that lead to only partly impaired occupational functioning);
(2) nervous breakdown (i.e. serious distress symptoms and temporal loss of occupational role); and
(3) burnout (i.e. work-related neurasthenia and long-term loss of the occupational role).
This classification recognises the fact that burnout is not a black or white diagnosis, it is the end stage of a process of stress accumulation over time. In other words, we’re always on a continuum between wellbeing and total loss of wellbeing, there is a lot of grey area between these two poles, something that conventional medicine doesn’t take into account.
And since I mentioned the fancy notion of wellbeing, I should also say that with the emergence of Positive Psychology in 2000, the focus in burnout research has changed from an exclusively negative approach to the erosion of a positive psychological state: simply put, burnout has now been rephrased as an “erosion of engagement with the job”, being regarded as the antithesis of work engagement, in the same way that cynicism is seen as a lack of dedication.
Burnout is an erosion of engagement with the job.
Since today’s organisations have shifted their emphasis from economic principles to the management of human capital, employee wellbeing should be a matter of concern to all of them, at least theoretically. In order to thrive, companies need employees who not only “show up” and “do their job”, but who go the extra mile by staying motivated, dedicated, enthusiastic, proactive and involved. Preventing burnout is not enough anymore, companies should actively promote work engagement and employee wellbeing.
But unfortunately theory is sometimes very far removed from reality and few companies take actual steps to enhance employee wellbeing. In which case, your wellbeing becomes your responsibility…
Before we tackle the complex issue of prevention or recovery from burnout, let’s first consider…
WHY (AND WHEN) WE GET BURNOUT
Burnout is a medical phenomenon that develops cumulatively over an extended time period. It is the last stage of what is colloquially called “adrenal fatigue” or “allostatic load”, a stress-induced condition that occurs when your adrenal glands, hypothalamus and pituitary gland (together – the HPA axis) are not working optimally anymore.
According to some studies, burnout is also associated with inherent personality traits such as introversion and neuroticism, which may explain why certain people are more prone to burnout than others. It is also associated with mood fluctuation, recent family stress and being unmarried/single/divorced.
The adrenals perform several vital roles in maintaining your health, most importantly, they control your body’s response to stress by releasing hormones like cortisol, DHEA and adrenaline, which are used to regulate your heart rate, immune system, energy storage and more. When the adrenal glands are overstimulated for a long period of time, they begin to weaken.
Unfortunately, adrenal dysfunction is not recognised by conventional medicine until it becomes life-threatening. This is when the adrenal glands virtually cease to function in an autoimmune condition named Addison’s disease. But what doctors fail to consider is that the transition from health to disease does not happen overnight, it sometimes takes many years for the body to succumb to chronic illness. This makes those early warning signs very important as they give you a wonderful opportunity to intervene and prevent bad things from happening.
So when should you start suspecting you’re heading towards burnout?
WARNING SIGNS OF BURNOUT
Here’s some warning signs you’re in trouble:
- a feeling of constant tiredness that is not ameliorated by sleep
- mild depression or a general lack of enthusiasm, difficulty ‘lifting’ yourself for important occasions
- irritability, low mood, cynicism and depersonalisation
- appetite changes
- frequent colds and flu
- gastrointestinal distress
- inability to focus
- becoming over-reliant on coffee, sugary sodas or other stimulants to get you through the day
- a craving for salty or sugary foods
- respiratory complaints, allergies
- low libido
- weight gain or weight loss
- increased alcohol or drug use
- getting a boost in energy late in the evening (this is due to disrupted cortisol cycle which usually happens in the “wired and tired” phase of adrenal fatigue, just before you succumb into burnout)
Historically, adrenal fatigue and burnout were recognised and defined by their symptoms. These days, thanks to modern lab tests, we can pinpoint exactly what happens when someone is suffering from these conditions. If you’re not sure your symptoms are caused by stress, this Genova Diagnostics adrenal function test will tell you exactly how your adrenals are performing and if there are any issues with your stress response (I offer this test in my clinic so please get in touch if you’d like to know more).
So why is everyone so concerned about burnout? Well, apart from making you feel really bad in the present, it also predisposes you to many other health problems in the future. Evidence is mounting that supports several potential mechanisms linking burnout with ill health, including metabolic syndrome, dysregulation of the hypothalamic-pituitary-adrenal axis along with sympathetic nervous system activation, sleep disturbances, systemic inflammation, impaired immunity functions, blood coagulation and fibrinolysis, and poor health behaviours (the more ill you are, the less likely to take care of your health).
So let’s take a quick look at what the medical literature says.
BURNOUT AND RISK OF CARDIOVASCULAR DISEASE
On a biochemical level, burnout is associated with several risk factors for cardiovascular disease due to the presence of microinflammation as indicated by high levels of C-reactive protein (hs-CRP) and fibrinogen concentrations, 2 nasty pro0inflammatory molecules. This study examined 630 women and 933 men, all apparently “healthy”, who underwent periodic health examinations. The authors controlled for possible confounders including 2 other negative affective states: depression and anxiety. In women, burnout was positively associated with hs-CRP and fibrinogen concentrations, and anxiety was negatively associated with them. In men, depression was positively associated with hs-CRP and fibrinogen concentrations, but not with burnout or anxiety. Although this study seems to suggest that burnout, depression, and anxiety are differentially associated with microinflammation biomarkers, dependent on gender (with burnout affecting predominantly more women and depression affecting predominantly more men), it is not easy to make a clearcut distinction among these negative affective states.
BURNOUT AND RISK OF TYPE 2 DIABETES
In this prospective study published in the Journal of Biobehavioural Medicine, 677 employed men and women were followed up for 3 to 5 years. The results indicated that burnout is associated with a 1.84-fold increased risk of diabetes even after adjusting for age, sex, body mass index, smoking, alcohol use, leisure time physical activity, initial job category, and follow-up duration.
As you probably guessed, burnout isn’t good for you:) In Part 2 of this article I will outline some basic preventive strategies you can take to keep burnout at bay. In the meantime, if you have any questions, please contact me at