Burnout Syndrome and neurofeedback

Background
Many changes have occurred in today’s working environment. Machines and computers have taken over much of the physical labour and due to the growing trend of job specialisation and the 24-hour economy, work has become more repetitive and has to be done more efficiently. More than before, employees are subjected to daily stress on the work floor. Since the 1970's one word has repeatedly shown up in relation to job-stress related psychopathology: “burnout”, or “burnout syndrome”.
Since the first description of burnout syndrome in 1969 by Bradley (Bradley, 1969), this metaphor for a state of psychological exhaustion, has gained greatly in popularity. A recent study in the Netherlands has shown that 4 percent of the total working population is showing serious symptoms of burnout and should seek professional help (Houtman et al., 2000). Thus, burnout seems to become a problem in today’s world to be dealt with.
What exactly are the symptoms of burnout syndrome? Freudenberger described the burnout syndrome among volunteers with whom he was working in a so-called ‘free clinic’ for drug-abusers. They changed from idealistic volunteers to disillusioned, indifferent care givers who were also suffering from exhaustion, headaches, sleeplessness, high irritability, depressive symptoms and social fear (Freudenberger, 1974). Many studies have been conducted since then, but the construct is still based on roughly the same symptoms. Although several definitions have been developed, most authors describe burnout syndrome as a response to prolonged emotional and interpersonal stressors on the job.
 The syndrome is generally defined by three dimensions: emotional exhaustion, depersonalization and reduced personal accomplishment (Schaufeli et al., 1993; Maslach et al., 2001). Using these three generally accepted components of the burnout syndrome, the Maslach Burnout Inventory (MBI) has been developed. A high score on exhaustion and depersonalization and a low score on personal accomplishment is an indication for burnout. The MBI is used world-wide as a diagnostic tool for burnout (Maslach et al., 1996).
 
Diagnosis
Interestingly, there is no official diagnosis for burnout syndrome in the DSM-IV (American Psychiatric Association, 1994), the most often used psychiatric diagnostic manual. In the Netherlands, patients showing symptoms common to burnout syndrome, are often classified by their primary symptom: fatigue, under undifferentiated somatoform disorder.

Table 1 DSM-IV Diagnostic criteria for 300.81 Undifferentiated Somatoform Disorder

1. One or more physical complaints (e.g. fatigue, loss of appetite, gastrointestinal or urinary complaints).
2. Either (1) or (2):
   (1) after appropriate investigation, the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication)
   (2) when there is a related general medical condition, the physical complaints or resulting social or occupational impairment is in excess of what would be expected from the history, physical examination, or laboratory findings
3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
4. The duration of the disturbance is at least 6 months.
5. The disturbance is not better accounted for by another mental disorder (e.g., another somatoform Disorder, Sexual Dysfunction, Mood Disorder, Anxiety Disorder, Sleep Disorder, or Psychotic Disorder).
6. The symptom is not intentionally produced or feigned (as in Factitious Disorder or Malingering).

Hoogduin et al. (Hoogduin et al., 2001) argue that the diagnosis “neurasthenia”, which is not present in the DSM-IV but does appear in the ICD-10 (World Health Organization, 1992), the second most used diagnostic manual, is more fit. This diagnosis is more specific to burnout, as undifferentiated somatoform disorder can encompass physical complaints other than fatigue.
 
Table 2 ICD-10 Diagnostic criteria for F48.0 Neurasthenia

1. Persistent and distressing symptoms of exhaustion after minor mental or physical effort including general feeling of malaise, combined with a mixed state of excitement and depression.
2. Accompanied by two or more of these symptoms: muscular aches and pains, dizziness, tension headache, sleep disturbance, inability to relax and irritability.
3. Accompanied by two or more of these symptoms: increased cynicism or depersonalization, diminished feelings of efficacy and emotional exhaustion.
4. Inability to recover through rest, relaxation or enjoyment.
5. Disturbed and restless, unrefreshing sleep, often troubled with dreams.
6. Duration of over one year.
7. Complaints are job-related.
8. Does not occur in the presence of organic mental disorders, affective disorder, panic or generalized anxiety disorder.

As we can see from these diagnostic criteria, burnout syndrome can best be described as an exhaustion syndrome accompanied by affective symptoms (general feeling of malaise, irritability, cynicism and depersonalization). There are, however, psychiatric disorders, which are not adequately distinguishable from burnout syndrome. These disorders are (atypical) depression and chronic fatigue syndrome (CFS) (Hoogduin et al., 2001).

Research with burnout  patients
The  presence of burnout syndrome as a social problem in many human services professions was the impetus for the research that is now taking place in many countries.

Causes and risk factors
Originally, burnout was thought of as a problem only experienced by those who are working in the human services sector. Such jobs include teachers, police officers, doctors, nurses, psychologists, lawyers, store clerks, customer representatives, receptionists, and so on. The symptoms were believed to be a result of the interaction between the person giving, and the person receiving help (Maslach, 2001)
 
Later research, however, showed that burnout does not only occur within these situations, but is also experienced in other stressful jobs. In fact, symptoms of burnout were found not to vary across different occupational groups (Demerouti et al., 2001).
The burnout construct, consisting of emotional exhaustion, depersonalization and reduced personal accomplishment, can be viewed as a vicious circle. When workload is high, burnout symptoms increase, especially the emotional exhaustion component (Bakker et al., 2003).
Emotional exhaustion is the experience of feeling drained of all energy.
When experiencing this emotional exhaustion, people tend to minimalize distress by detaching from others. They maintain an emotional distance from others. This detachment can manifest itself by an indifferent attitude toward others. Also, people experiencing burnout often develop hostile interactions with others.
Another common response to emotional exhaustion is to reduce workload. Burnout patients are known to avoid work, display a large amount of absenteeism, doing the bare minimum at work and not doing certain tasks that are experienced as more stressful, while doing more tasks that are considered less stressful.
These reactions result in a decline of job performance, both qualitative and quantitative. The person then feels guilty about his poor performance and a self-critical attitude develops. Deteriorated relationships with others and the acquired self-criticism then further contributes to emotional exhaustion, which in turn will worsen these maladaptive responses (Maslach, 2001).
Thus, the burnout construct itself consists of a vicious circle, beginning with emotional exhaustion.

But when exactly does a high workload lead to burnout symptoms? A number of studies have been dedicated to answer this question. A number of other factors were found to relate to high levels of burnout, these are:

• Traumatic events on the job (Van der Ploeg et al., 2003)
• Confusion, conflict and ambiguity to job role (Posig et al., 2003)
• Risk and safety factors (Leiter et al., 1997)
• Being undermined by a superior, or the belief that one is undermined by a superior (Westman et al., 1999)
• Low levels of social support (Brown et al., 1998)
• Inadequate job resources (Lee et al., 1996)

Reducing the risk for burnout thus constitutes minimalizing these risk factors. Also, healthy coping strategies help prevent burnout symptoms. Less burnout is experienced by those who are confident in their ability to handle problems and to tolerate stress. The belief that one’s stressful situation has meaning and is of value has been found to relate to low levels of burnout (Pines, 2004).

Burnout and cortisol
Burnout syndrome is seen as a response to chronic stress on the job, therefore, much research on burnout syndrome has been dedicated to examine disturbances in the biological system that controls the body’s response to stress. Ever since the studies of Seyle (1936), stress has been associated with activation of the hypothalamic pituitary adrenal (HPA) axis, ultimately resulting in an increased secretion of the hormone cortisol.
Acute stress activates the “flight or flight” mechanism, which enables the organism to fight or flee possible threats. This is expressed by an increase in the activity of the sympathetic nervous system, raising blood-sugar levels, blood pressure, heart rate and metabolism. This gives the organism a boost of alertness and energy, thus allowing it to escape the perilous situation.
 
Prolonged stress occurs when continuous stress responses keep the body on alert continuously. The ongoing stress response causes the hypothalamus to excrete cortino-trophin releasing hormone (CRH) which signals the pituitary gland to release adrenocorticothrophic hormone (ACTH). This stimulates the adrenal gland to produce the hormone cortisol. The normal function of cortisol is to help the body respond to stress and change. It mobilizes nutrients, modifies the body's response to inflammation, stimulates the liver to raise the blood sugar, and it helps to control the amount of water in the body. Through negative feedback loops cortisol inhibits its own release, thus regulating itself.  The physiological effects of cortisol help the organism to maintain homeostasis under conditions of prolonged stress. Cortisol is also associated with waking and sleeping. Levels of cortisol naturally fluctuate during the day. Cortisol levels are highest in the morning and lowest at night.

While stress under normal circumstances leads to a temporarily increase of cortisol, Heim et al. (2000) argue that chronic stress will eventually lead to chronically lower levels of cortisol (hypocortisolism). Heim et al. base these findings on research with persons with stress related bodily disorders as well as on animal models of chronic stress. The mechanisms underlying the development of hypocortisolism, he further argues, may be complex and heterogeneous between and within patients with stress-related disorders.
Due to the fact that cortisol helps the body cope in situations of prolonged stress, a state of hypocortisolism could play a role in the development of burnout symptoms, especially exhaustion.
In a study examining cortisol levels in burnout syndrome patients, a group of teachers was split into a high-burnout and a low-burnout group and  levels of cortisol were measured during three working days. The high-burnout group had significant lower basal levels of cortisol as compared with the low-burnout group (Pruessner et al., 1999). This is what you would expect based on of Heim et al’s conclusion that chronic stress leads to lower levels of cortisol.
However, in another study, where blue-collar workers were divided into three groups: “no burnout”, “burnout - not chronic” and “chronic burnout”, cortisol samples were taken in the morning and in the afternoon. Highest cortisol levels were found in the “chronic burnout” group and lowest cortisol levels were measured in the “no burnout” group. Cortisol levels of the “burnout - not chronic” group were in between (Melamed et al., 1999).
It is reasoned by van Doornen (2001) that conflicting results are largely due to different definitions of burnout. According to him, chronic stress on the job is associated with heightened basal cortisol levels during the day. But as subjects progress to the burnout stage, with exhaustion as its main component, these heightened levels of cortisol make room for lowered basal cortisol levels during the day.
 
This view is supported by another study (Schmidt-Reinwald et al. ,1999), in which the authors conclude that chronic psychosocial stress is associated with heightened basal cortisol levels, but that severe and prolonged burnout is associated by lowered basal cortisol levels. It is argued that these low levels of cortisol are due to a hyperregulated cortisol-feedback.
Burnout thus, neuroendocrinologically, seems to consist of a state of hypocortisolism following a period of chronic stress, which is accompanied by chronic high levels of cortisol. This hypocortisolism can be attributed to hyperregulation of cortisol on one or more levels of the HPA-axis, but the exact mechanism is complex and heterogeneous across patients.