Burnout seems to be affecting so many people right now it is surprising the experience is not officially recognised in Australia as a medical or mental health condition.
That may be about to change. Australian researchers are building a case to change the status of burnout so it ranks alongside psychological illnesses like anxiety or depression, with which burnout is frequently confused.
Clinical psychologist Dr Rebekah Doley has no doubt burnout is real.
She regularly sees clients with a "constellation of symptoms”, she says, that include emotional exhaustion, responsibility overload, lethargy and social withdrawal. Burnout sufferers can become quickly irritated, less productive and have trouble concentrating. It is a scenario that impacts all areas of life.
“It can look like depression or anxiety but the problem with that is too often burnout goes on to be treated in the same way as anxiety or depression,” Doley says.
Yet burnout is not yet included in the Diagnostic and Statistical Manual used in Australia and the US to enshrine mental health conditions. This means that while a burnout diagnosis is based on emerging research it isn't an official condition.
By contrast, in Europe and the UK burnout is viewed as an "occupational phenomenon" as described in the World Health Organisation’s Classification of Diseases. That gives it official recognition in some European countries but it’s still not officially a mental health condition.
As a result it is difficult to know how many are suffering, the long term impact, and how to treat it.
That's where Gabriela Tavella comes in. Her PhD research aims to change how the world diagnoses burnout.
She's completing a PhD on burnout at the University of NSW and is co-author of a book on the subject that includes a 34-point checklist for measuring burnout known as the Sydney Burnout Measure.
Tavella's research aims to isolate symptoms specific to burnout and come up with a definition that will allow it to be viewed as a disorder in its own right. Tavella also wants to understand whether burnout is a red flag along the path to other mental health conditions, such as depression.
Research suggests up to 30 per cent of people experience burnout at some point in life. During the COVID-19 pandemic frontline healthcare workers were hit even harder with almost 70 per cent in some studies saying they felt burned out.
So, what exactly is it? How does burnout differ from depression or fatigue? And importantly, how do you know if you have it?
Burnout's three red flags
Tavella was working as a research assistant with high-profile psychiatrist Gordon Parker, founder of the Black Dog Institute that investigates mental health across the life span, when the idea to research burnout took hold.
Parker was seeing more and more patients who had been referred for depression yet didn’t fit the typical patterns of this mental illness.
Parker and Tavella made a decision: Tavella’s PhD dissertation would attempt to define the condition, with a goal to elevate its status within the medical community.
She was not starting from scratch.
Researchers around the world have identified and attempted to define burnout, notably US social psychologist Christina Maslach. The Maslach Burnout Inventory is a three-part questionnaire that rates symptoms on a scale from "everyday" to "never".
Maslach has identified three components to burnout: exhaustion, de-personalisation and a sense of reduced professional efficacy.
Exhaustion is pretty self-explanatory, but de-personalisation means an absence of empathy, feelings of cynicism and disconnection, Tavella explains. And reduced professional efficacy reflects a belief that you are not effective at work and your contributions have little impact.
These facets of burnout typically manifest in three phases:
- Job stress, an imbalance between demands and resources;
- Individual strain which refers to an emotional response of exhaustion and anxiety;
- Defensive coping when attitudes such as cynicism take hold.
Academic debate is raging over whether these three components are sufficient to capture the scope of what burnout really is.
Tavella's work hopes to answer some important questions: is depression part of the burnout picture? Or should it be recognised as a step along the pathway to a depression diagnosis and act as a warning sign?
“Research is unclear to what degree suicidal thinking is associated with burnout and clarifying that is a huge, huge concern,” she says. “If it turns out that suicide is substantially linked to burnout then we might be missing some very important indicators.”
And two new symptoms
To find out more, Tavella has interviewed 600 people for her PhD research who report experiencing burnout and compared their responses with a second group diagnosed with clinical depression.
Each participant in the burnout group was given a series of different symptoms and asked to nominate which ones they experience. From there, Tavella created a list of five burnout symptoms – two more than Maslach.
This research – some published and some undergoing peer review – suggests social withdrawal and alsocognitive issues including focusing, concentrating and memory problems are additional and significant symptoms affecting those with burnout.
Social withdrawal marks the point where burnout begins to blur with the official symptoms of depression.
“Being insular, lack of pleasure and just a general lack of interest in the world around you is what we are finding coming up as important to burnout as well as Maslach’s three symptoms that have been featuring in the research literature since the 1970s,” Tavella says.
How does burnout differ from depression?
While depression and burnout seem to share some overlapping symptoms, key differences are emerging in Tavella’s research.
Lack of empathy is more common in those with burnout, for example. But the issue of what causes one person to become depressed and another to experience burnout is also likely to be important.
Burnout is most likely to be a structural problem. The way modern lifestyles trigger the body to be on constant alert, for example, is definitely part of the story.
“That means being overloaded at work or in other areas of life,” Tavella says.
Depression, on the other hand, has a different core trigger: “Your self-esteem or self-worth is being affected,” she says.
This matches the evidence Doley has gathered from 30 years of working with burned out patients. "You've got to begin by looking for external factors and these are generally out of the person's control," she says. "Next you look for aspects of personality."
What is burnout doing to your body?
Two key areas of the body are likely to be central to the burnout experience.
First is the autonomic nervous system that regulates heart rate, blood pressure, breathing, digestion and sex drive.
Doley says it's easy for most people to understand how stress is related to these central bodily functions: A thumping heartbeat or stomach pains are commonly reported symptoms in those experiencing emotional distress.
But prolonged exposure to stress can dysregulate the autonomic nervous system. In a healthy person this system knows when to rev up in response to threat and calm down again. But in a person with burnout these messages become confused.
“It means the body is never functioning in a normal range because it’s reacting as if you are constantly stressed all the time,” Doley says.
The impact shows up in the heart with existing research demonstrating burnout causes fluctuations in the time between each heartbeat, known as heart rate variability.
In response the brain’s hypothalamus, pituitary and adrenal glands – known as the HPA axis – release hormones in response to acute stress or danger. One of these is the stress hormone cortisol which is supposed to peak in the morning and decrease throughout the day.
The HPA system was designed to be used only occasionally as a "fight or flight” response. During burnout the body has too lower levels of cortisol circulating.
"This seems counterintuitive. Many people think less cortisol equals less stress but in fact it means overaction of the HPA axis in chronic stress/burnout affects the day-to-day functioning of cortisol leading to abnormalities," Tavella says.
This finding may be specific to burnout and differs from depression, Tavella says, when the body remains in a heightened cortisol state.
Research is now exploring whether a simple test for the presence of cortisol in saliva could be one way to distinguish between depression and burnout.
Are you at risk?
Why do we see one person rally in times of crisis and another with seemingly less on their plate succumb?
Personality type is a key risk factor for burnout, according to Doley and Tavella.
Psychologists rate human personality according to five categories and we all fit somewhere from low to high on a scale designed to measure each of these areas:
- Openness - imaginative, tolerant and prone to seek out new experiences
- Conscientiousness - competent, self-disciplined and motivated to achieve
- Extroversion - gregarious, assertive and an excitement-seeker
- Agreeableness - cooperative, modest and tender minded
- Neuroticism - anxious, self-conscious, impulsive and vulnerable.
So who is most likely to burn out?
Emotionally sensitive people who rank highly on neuroticism, and also goal-directed, detail-orientated Type A personalities who receive a high score on conscientiousness, are most at risk of burnout.
Doley says those concerned about how they are judged by others and those who struggle to feel control over the events of their lives are also more likely to burn out.
Tavella says, many participants in her research who were part of the burnout category volunteered that they were also perfectionists – a trait linked to both conscientiousness and neuroticism. Perfectionists set high standards and suffer a hit to their self-esteem and self-worth when these expectations are not reached, Tavella argues, setting up this personality type for burnout.
But personality can also be protective against burnout - particularly for those who show high scores on the extraversion scale.
“If you're extroverted, you're probably more likely to have support networks, as well as being more likely to collaborate to overcome problems,” Tavella suggests.
Doley says it's important not to see particular personality types as good or bad. Instead she says personality traits act like "frenemies".
For example, someone who might be a doer, always in control, the one who organises everything, might be high on conscientiousness. Yet too much conscientiousness can start to look like stubbornness if that person won't adjust to changing circumstances. What starts out as dynamism or resilience ultimately becomes dysfunctional.
"So we actually persist beyond what is reasonable and beyond what is good for our well-being," Doley says.
What can you do if you are high risk for burnout?
If you have a personality that's high risk for burnout don't lose hope. Methods that are effective against stress can also assist in reducing burnout risk, Tavella says.
The top four recommendations include talking to a supportive person — whether that's family, friend or a trained therapist — as well as learning meditation, mindfulness and also upping daily exercise.
Meditation, and also mindfulness, help regulate the HPA axis, heart rate variability and the cortisol response.
“It might sound a bit airy-fairy but the research shows those practises do modify the physiological changes that occur after exposure to chronic stress,” Tavella says. “Meditation has been shown to lead to changing the brain morphology in some of the regions implicated in burnout.”
How long does recovery take?
The answer to this urgent question is "it depends".
While self-care practises are vital, if you do not remove yourself from the source of the burnout then it makes healing more difficult.
“If there's a lifestyle reason you're burnout then how effective can meditation exercises really be?,” says Tavella, explaining that while meditation may have an impact it may not be enough without a lifestyle change.
The search for these changes is likely to be behind current phenomena such as the Great Resignation and Quiet Quitting, she adds.
And just as the same stressors may give one person burnout and leave another unaffected, the solution is "very, very individualised”, Tavella says.