Is burnout simply a stress reaction?

Abstract

Whether burnout is synonymous with stress is a question of clinical importance when considering the nosological status and management of both states. The biological changes associated with both stress and burnout suggest considerable overlap. However, we argue that the widespread acceptance by the lay community of burnout as a distinct and relatable syndrome suggests it is worthy of independent designation.

The term ‘burnout’ was coined by psychologist Herbert Freudenberger (1974). Subsequently, Maslach and Jackson (1981) developed the Maslach Burnout Inventory or MBI, with its three scales assessing emotional exhaustion, depersonalization and reduced personal accomplishment. That triadic symptom model is evidenced in the World Health Organization’s International Classification of Diseases, 11th Revision (ICD-11) definition of burnout which lists three criteria: (1) energy depletion or exhaustion; (2) increased mental disturbance from one’s job, or feelings of negativism and cynicism related to one’s job; and (3) reduced professional efficacy.

In our own research (Tavella et al., 2020, 2021), findings have supported exhaustion and reduced performance as key features (with the latter perhaps more a consequence than a symptom), but broadened the term depersonalization (described by other researchers as a loss of empathy or compassion fatigue) to capture a general loss of feeling often associated with social withdrawal and insularity, and added cognitive impairment (with individuals reporting problems with concentration and memory), with the last symptom supported in other studies (e.g. Schaufeli et al., 2020). Our findings also showed burnout to be commonly accompanied by a set of secondary psychological problems such as insomnia, depression and anxiety, as might be anticipated for any psychological state.

In light of its many psychological symptoms, questions remain as to whether burnout should be considered a nosological entity or whether is it is merely a misnomer for other formally recognized psychological states. A key question is whether burnout is simply synonymous with a ‘stress reaction’. While contemplated by others (e.g. Pines and Keinan, 2005), here we add some further observations. Concerning phenomenology, ‘stress’ can be induced by any number of ‘stressors’ and across a range of contexts. While usually a negative experience, some stress can be pleasurable and even positively exhilarating (Cavanaugh et al., 2000). Furthermore, acute stress can, in some instances, enhance performance, such as in sport (Bali, 2015). By contrast, ‘burnout’ is invariably linked with work pressures, initially positioned in the literature as ones associated with paid/formal employment (Maslach et al., 2001), but subsequently expanded to recognize burnout in contexts outside of formal/paid employment, such as in the contexts of parenting and volunteering, albeit with the commonality of cause still being an ‘informal’ type of work (Schaufeli et al., 2020). Furthermore, burnout is invariably a negative experience without redeeming features, resulting from chronic stress exposure and compromising performance.

Concerning biology, if burnout and stress are synonymous, we would expect comparable biological changes. There are multiple complex systems impacted by stress, as well detailed by Godoy et al. (2018). In summary, acute stress activates the autonomic nervous system (ANS), which activates the sympathetic-adrenal-medullary (SAM) axis, leading to alertness, an increased heart rate and rise in blood pressure as well as release of adrenaline and noradrenaline, while it may also downregulate the parasympathetic system. Stress also impacts (albeit more slowly) on the limbic system (the amygdala and hippocampus, in particular) and activates the hypothalamic-pituitary-adrenal (HPA) axis, stimulating the release of corticotropin-releasing hormone which subsequently triggers adrenocorticotropic hormone release and the secretion of cortisol (which can suppress or activate the immune system).

A three-stage General Adaptation Syndrome was put forward by Selye (1936) to explain the physiological changes of the body when it is under stress. First, there is an alarm phase with acute features. Second, a resistance phase occurs when acute features settle. Third, an exhaustion phase, in which cortisol levels may be increased, normal or decreased (Hannibal and Bishop, 2014). Burnout would appear intuitively to correspond to the third phase, and it might then be expected that there would be no evidence of any acute phase hypercortisolemia. In a review, Bayes et al. (2021) noted that, while most studies studying cortisol levels in those with burnout have demonstrated a hypocortisolemic state, some studies have quantified hypercortisolemia. While varying results may reflect complexities in measuring cortisol (e.g. diurnal variation in its levels, and whether it is best measured in blood, urine or saliva), the most parsimonious explanation is that some study subjects may have been tested during an activating ‘burning out’ phase (when cortisol levels would be expected to be elevated) and not when in a more definitive state of exhaustion (and thus experiencing true burnout) and when hypocortisolemic.

Yaribeygi et al. (2017) detailed the multiple structural brain changes associated with stress, in particular involving the hippocampus, amygdala and pre-frontal cortex. The impact on the hippocampus includes atrophy, reduction in dendritic branches and neuronal numbers, as well as decreased neurogenesis, being mediated by cortisol and noradrenalin. Such changes (often experienced by individuals as ‘brain fog’) are associated with compromised declarative, spatial and verbal memory as well as compromising cognition (perception and interpretation of stimuli) and learning. They may also be associated with decreased levels of brain-derived neurotrophic factor (BDNF) and increased concentrations of inflammatory cytokines. The review by those authors also considered the impact of stress on the gastrointestinal, endocrine and cardiovascular systems, and in relation to the last, its myriad effects including increased blood pressure, disordered blood clotting, atherogenesis and an increased risk of ischemic events and myocardial infarction.

Bayes et al. (2021) overviewed reported biological changes in those with burnout. The reports included structural brain studies (demonstrating decreased functional connectivity between the amygdala and the anterior cingulate cortex or dorsolateral prefrontal cortex), detailed deficits in non-verbal memory, and in visual and auditory attention, lower serum BDNF levels, increased cardiovascular disease and evidence of microinflammation. Their authors noted study limitations in defining burnout and the limited number of salient studies. Nevertheless, the similarity of symptoms and the findings that many of such brain and bodily changes occurring in chronic stress are reversible (Yaribeygi et al., 2017), as may be the case for those with burnout (Harvey, 2020), and with the most commonly nominated therapeutic interventions for burnout being destressing strategies (e.g. holiday breaks, exercise, meditation, mindfulness strategies), again argue for commonality across the two syndromes.

While Selye (1936) offered a three-stage model for stress, as noted earlier, multiple staging models have been proposed for burnout (Maslach and Leiter, 2017). While many staging models for burnout do not readily relate to Selye’s General Adaptation Syndrome, a staging model in which burnout is equated with Seyle’s third phase of exhaustion may be appropriate (Zastrow, 1984).

Mapping burnout onto this last exhaustion phase appears salient when considering that there are likely differences (both biologically and phenomenologically) between those who are ‘burning out’ as against those who are in a more finite stage of being completely ‘burnt out’. Indeed, Schonfeld and Bianchi (2016) emphasized that burnout should only be considered as the ‘end stage’ of a gradual process of psychological depletion rather than as a transient response to a stressor. Hooke’s Law may serve as a useful metaphor here, in suggesting that if stress is removed from an elastic body (in this case, a human) the individual may or should return to its natural state. However, if its yield strength point is exceeded, there will be a rupture (i.e. stress fracture), elasticity lost and return to natural state compromised. Research would be advanced if the boundary between those two states of elasticity/inelasticity could be demarcated for those who are burning out versus completely burnt out, and then examined against those experiencing stress that is not work related. While the optimal strategy for measuring cortisol levels is unclear, the change in a stressed or burning out individual from evidencing hypercortisolemia to hypocortisolemia may mark that change, and with any validated boundary then applied to symptom-based burnout measures to generate more specific cut-off scores than currently exist. Such a development would advance studies determining whether burnout is synonymous with stress or has some points of distinction.

Without such conclusive studies, we make the provisional suggestion that burnout is likely a nuanced stress reaction, nuanced in that it has a specific cause (over-demanding work, whether such work is ‘formal’ or ‘informal’), is negative and without any positive attributes, and that its key symptoms position it as of some severity along the third exhaustion phase of the stress spectrum.

Such a conclusion invites a predictable query. Why the use of the term burnout as against simply using a ‘stress reaction’ phase or condition? One of the key researchers in the field, Christina Maslach, reported that, in their early field studies, several interviewees related strongly to the word ‘burnout’ (Schaufeli et al., 2009). Heinemann and Heinemann (2017) more recently reiterated that, although empirically the distinction between burnout and other psychological states remains ambiguous, for the lay community ‘there seems to be no doubt that burnout is a real and serious phenomenon’. Thus, it has appeal as a descriptor – as it does as a metaphor (as illustrated by so many books on the topic having a cover with matches being extinguished). ‘I’m feeling burnt out’ has more impact and a narrower meaning in general conversation than ‘I’m feeling stressed’. The impact emerges from its relatively categorical pathological state, in that while everyone experiences stress (it is normative) not everyone experiences burnout (it is a dysfunctional state). The connotations of the burnout label depict it as a period of crisis with severe negative consequences for both sufferers and usually their employers (Schaufeli et al., 2009), therefore encouraging organizations to introduce preventive and corrective strategies, as well as health practitioners to provide counselling and introduce effective destressing strategies.

This brief overview therefore positions burnout as a nuanced stress reaction (in terms of its staging and key syndromal features), but we argue for the retention of the burnout label rather than for its repeal or return to a generic ‘stress’ domain at this stage. More precise differentiation first requires studies evaluating biological changes in ‘burning out’ and ‘burnout’ phases and then comparing end-stage burnout induced by work with end-stage stress reactions experienced in other contexts. While such questions remain open, we argue against viewing burnout and stress as synonymous and for preserving burnout as a state worthy of independent designated status that is in need of further investigation and particularly of staging.