Occup. Med. Vol. 50, No. 7, pp.

512-517, 2000
Copyright © 2000 Lippincott Williams & Wilkins for SOM
Printed in Great Britain. All rights reserved
0962-7480/00

Burnout syndrome: a disease of

modern societies?
A. Weber and A. Jaekel-Reinhard
Institute and Outpatient Clinic for Occupational, Social and Environmental
Medicine of the University of Erlangen-Nuremberg, Germany

In the light of social change and a transformation in the work situation, interest in the

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problem of burnout has grown over the past decade. There is a conspicuous
discrepancy, however, between what is regarded as certain knowledge and what is
published opinion. To date, there is no generally accepted definition of burnout, or
binding diagnostic criteria. According to the most common description at present,
burnout syndrome is characterized by exhaustion, depersonalization and reduced
satisfaction in performance. Because of its aetiopathogenesis, burnout is today mainly
regarded as the result of chronic stress which has not been successfully dealt with. This
paper gives an overview of the current definition for burnout syndrome and states
possible contemporary hypotheses for its aetiology. By examining diagnostic criteria
and possible therapies, methods of prevention are discussed. There is an urgent need
for further investigations to determine whether burnout syndrome is a work-related
disease.

Key words: Burnout; disability management; person-environment misfit; stress at the

workplace; work-related diseases.

Occup. Med. Vol. 50, 512-517, 2000

Received 15 March 2000; accepted in final form 21 June 2000.

INTRODUCTION and what is regarded as certain knowledge. In the last

decades burnout was a subject of scientific research
'... I'm under a lot of stress, ... completely burned out mainly among psychologists and sociologists. Major
..., I'd like to pack it in ..., my battery is flat...!'. Who contributions for identifying and classifying burnout
has not heard similar comments when people are talking syndrome have been published by psychologists.3'4
about their work? Are such statements, which are as Recently, the subject has caught the attention of
much part of a modern service society as the mobile doctors of social and occupational medicine. The central
phone and computer, just everyday phrases, excuses for problems for science and practice result from the fact
a lack of performance, or are they symptoms of a disease that there is no generally accepted definition of burnout.
which can be summarized by the term 'burnout The separation from other health disorders is difficult
syndrome'? and potential causal factors are still the subject of much
The term 'burnout' was coined in the USA a good 25 controversy.2'5 ~8 Nevertheless, burnout syndrome is an
years ago. The psychoanalyst Freudenberger, for exam- important problem in modern working environments
ple, published one of the first scientific descriptions of and is addressed in this paper from the point of view of
the burnout syndrome as psychiatric and physical occupational medicine. By considering the important
breakdown.1 In 1981, Maslach introduced a further- work published by psychologists an interdisciplinary
reaching definition and an instrument for measuring approach would facilitate the understanding of burnout
burnout which is still the most frequently used today, the syndrome in the field of occupational health.
Maslach Burnout Inventory.2'3
In industrialized countries, public interest in the
problem of burnout has increased over the last few DEFINITION: THE CURRENT SCIENTIFIC
years. The subject has enjoyed a boom in the media, but CONSENSUS OF OPINION
there is a great discrepancy between published opinion
According to one of the first more extensive character-
izations by Maslach and Jackson, burnout is the result of
chronic stress (at the workplace) which has not been
Correspondence to: Priv.-Doz. Dr. med. Andreas Weber, Schillerstr. 25 + successfully dealt with. It is characterized by exhaustion
29, 91054 Ertangen, Germany. Tel: +49 9131 8526118; fax: +49 9131 85
22317 and depersonalization (negativism/cynicism) and is
 A. Weber and A. Jaekel-Reinhard: Burnout syndrome 513

found predominantly in caring and social professions Contrary to earlier observations regarding the epide-
(e.g. social workers, teachers, nurses, doctors, dentists).3 miology of burnout, it has been noted that the syndrome
A later definition based on the MBI and which is in is not associated with certain workplaces, circumstances,
widespread use today, describes exhaustion, depersona- sex or age. The occurrence of burnout syndrome has
lization, and reduced satisfaction in performance as the been described in diverse occupations, e.g. in social
decisive elements of burnout syndrome.2'9 In the 10th workers, advisors, teachers, nurses, laboratory workers,
revision of the International Classification of Diseases speech therapists, ergo therapists, doctors and dentists,
(ICD 10) the term 'burnout' was described under Z.73.0 police and prison officers, stewardesses, managers, and
as 'Burnout-state of total exhaustion'.10 In addition to even in housewives, students and unemployed peo-
the question of a uniform, generally accepted definition, ple. 2 ' 11 ' 13 " 18 Psychological explanations assume that in
aetiological and pathogenetic aspects are the subjects of most of these occupations the combination of caring,
much controversy. It is generally believed today that advising, healing or protecting, coupled with the
'negative stress' (distress) probably represents a key demands of showing that one cares, is of central
importance.4'8

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phenomenon in the aetiopathogenesis of burnout. Other
important pathogenetic factors are thought to be 'being The prevalence rates published in the literature for
swamped by daily routine' and 'disappointed expecta- individual occupations must be regarded sceptically, as
tions'.2'5'6'8'11'12 Most of the theories and models for the the definitions and diagnostic criteria used are not
development of burnout syndrome are published in the uniform. Depending on the evaluation instruments and
psychological, psychosomatic and psychiatric litera- classification systems used, an incidence of burnout in
ture.3'4 This paper will focus on three main models from teachers of up to 30% has been given.17'19 For doctors
a social-medical point of view (Box 1). and dentists more recent studies give prevalence rates of
up to 10%.5>11'13-15
BOX 1. Burnout syndrome: important
aetiopathogenetic concepts from the social-medical
point of view IMPORTANT ASPECTS IN THE
AETIOPATHOGENESIS OF BURNOUT
A. Result of stress that has not been successfully
dealt with. Despite numerous new discoveries regarding the devel-
Emphasis on strain and society-the 'macrolevel'. opment of burnout syndrome, many questions still remain
unanswered. Is burnout merely high-level stress at the
B. Person-environment-misfit. workplace or the result of the complex interaction of social
Emphasis on interaction between society and the factors (circumstances) and individual factors (beha-
individual-the 'mesolevel'. viour)? Without a doubt, the changes in society and work
have led not only to changed demands, but also to a
generally undisputed increase in heterogenic psycho-
C. Discrepancy between expectations and reality.
mental and psychosocial stress.20"22 Occupational psy-
Emphasis on strain and the individual-the
cho-mental/psycho-social stress factors are illustrated in
'microlevel'.
Fig. 1 and include pressure of time, overtime and shift

Figure 1. Burnout: an interaction between society and the working environment.

Society Work environment

individualization • mechanization
loss of traditional • globalization/competition
support systems
• increased work complexity
anonymity
• job uncertainty ('hire and
educational fire')
expectations
• mobility/flexibility
lack of time Economization • specialization
multiple stress factors

Increase of psychosocial/psychomental stress

Higher burnout risk

514 Occup. Med. Vol. 50, 2000

work, as well as mobbing, economic pressures, and Figure 2. Burnout: a dynamic process ('burnout cascade').
multiple tasks such as job, family and leisure activities. In
addition, the importance of personal competence, parti-
1. Hyperactivity
cularly in the so-called tertiary sector, is continually
increasing (e.g. communicability, being able to work in a
team, frustration tolerance, service orientation, flexibility). 2. Exhaustion - chronic fatigue, loss of energy
According to the job-strain model, which has been
established for many years in occupational medicine as a 3. - withdrawal, resignation
Reduced
stress - strain concept, a high level of strain can result activity
from the cumulation of psycho-mental/psycho-social
stress and a lower level of stress tolerance, which in this 4. Emotional - aggression
reactions - negativity
context is to be regarded as 'negative stress'. When - cynicism
'negative stress' becomes chronic and is not dealt with
5. Breakdown - cognitive function

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adequately it leads to adverse effects on the health. Not - motivation
only do psychological and social factors play a role, but - creativity
so also do biological and biochemical factors. Above all,
6. Degradation - emotional distress
hormonal and endocrinological changes, particularly a - loss of social contacts
permanent increase in the cortisol level and disturbances
in the hypothalamic - pituitary -adrenal control system, 7. Psychosomatic - sleep disturbances
are under discussion.23"28 reactions - gastro-intestinal disorders

Recent research suggests that such influences are - susceptibility to infection

- sexual disorders
possibly not only relevant for the development of - intake of alcohol and drugs
burnout syndrome, but also in the pathogenesis of
occupation-related psychiatric/psychosomatic dis-
eases.17'29'30 According to the 'person-environment- 8. Despair - psychosomatic disorders
- suicide
misfit' concept, an imbalance between psycho-mental/
psycho-social stress and individual stress tolerance is
decisive for the development of burnout syndrome. The
risk of burnout is influenced not only by the extent of the
stress factors and deficits in personal resources, but In addition, depending on the duration and severity of
above all by 'social support' systems and 'coping' the burnout, there are often further negative social
strategies. In addition to primary personality structure consequences. These include, from the point of view of
(e.g. idealism, perfectionism, timidity, insecurity, emo- the individual, withdrawal at the workplace (so called
tional instability), negative factors which influence the 'inner resignation') or effects on private life (partner/
individual stress tolerance are inadequate or lacking sexual problems, social isolation). From the perspective
strategies to deal with stress, disappointed expectations/ of society, there is an increased risk of repeated or long
negative experiences, and lifestyle (e.g. inadequate periods of absence from work and early invalid-
support due to a lack of social relationships/partner- ity.2,6,8,11,15
ships).6

DIAGNOSIS, DIFFERENTIAL DIAGNOSIS, AND

SYMPTOMS THERAPY

The symptoms of burnout patients are usually multi- In view of the mainly unspecific symptoms, when it
dimensional with several psychiatric, psychosomatic, comes to the diagnosis of burnout syndrome a differ-
somatic and social disorders. The main psychiatric entiated, all-encompassing approach is necessary. Good
symptoms are, in addition to chronic fatigue and interdisciplinary co-operation and communication be-
continuous exhaustion, above all described as 'mental tween the parties involved in the diagnostic process
dysfunction'. This includes concentration and memory (patient, GP, specialist, works physician, psychologist,
disturbances (a lack of precision, disorganization), a other disciplines) is just as essential as medical expertise.
lack of drive and personality changes (a lack of Box 2 shows a diagnostic approach for diagnosing
interest, cynicism, aggressiveness). Severe disturbances burnout syndrome from social and occupational medi-
are anxiety and depressive disturbances, which can cine points of view.
culminate in suicide. Also the development of addic- Valid objectification and quantification of health
tions (e.g. alcohol, medicines) has been associated impairments and/or functional disturbances must be
with burnout. Common somatic symptoms are head- carried out. This requires medical expertise and should
aches, gastro-intestinal disorders (irritable stomach, not be carried out by non-medical personnel, even if they
diarrhoea), or cardio-vascular disturbances such as are very enthusiastic about the subject. In addition to a
tachycardia, arrhythmia, and hypertonia. Figure 2 general anamnesis to evaluate previous and accompany-
illustrates the dynamic process of developing burnout ing illnesses, a problem-oriented social and occupational
syndrome. anamnesis in particular should be carried out. This
 A. Weber and A. Jaekel-Reinhard: Burnout syndrome 515

BOX 2. Burnout syndrome: the diagnostic, all-encompassing, interdisciplinary approach

Medical history Previous and current diseases

Social and occupational history Identification of potential stress factors and possible social consequences
Drug history Smoking, consumption of alcohol and drugs
Symptoms Course and temporal relationship
Physical examination General examination
Psychosomatic/psychiatric status
Psychometric tests Maslach Burnout Inventory
Special laboratory tests 'Stress biomonitoring'; hypothalamic - pituitary -adrenal control system

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serves both to identify potential stress factors and to for a long time; there are multiple symptoms and many
evaluate possible negative social consequences in the different influencing factors. Objectification or quantifi-
person's private life and occupation. In addition, con- cation of occupational stress factors is almost impossible
sumption of alcohol or drugs must be documented, and for a GP or specialist, as they usually do not have
if necessary quantified using biological monitoring. The sufficient information or detailed knowledge of the
subjective symptoms should be described in as much workplace situation. But even with optimum co-opera-
detail as possible, noting any changes over time. A tion between the patient's doctors, occupational physi-
physical examination (internal status) is also essential, cians and psychologists there are still general
and should be supplemented by results for important methodological problems in the evaluation of negative
routine laboratory parameters (e.g. blood count, liver stress at the workplace. In addition, it must be noted that
function tests, electrolytes, kidney function) if this occupational and non-occupational stress factors are
information is not already available. In addition, in often interlinked or cannot be separated from each other
individual cases, 'stress-biomonitoring' (e.g. cortisol as regards their biological consequences. Therefore, not
level/daily profiles) and special immunological and/or only the validity of the diagnosis 'burnout syndrome', but
endocrinological analyses (e.g. cellular/humeral immune also the decisive meaning of a harmful work situation still
system, hypothalamic-pituitary-adrenal control sys- remains at the centre of criticism.
tem) must be considered. Such investigations can, To date there has been no scientific evaluation of the
however, only be carried out by specialized centres. suggestions published in the literature concerning the
An early psychosomatic/psychiatric consultation and therapy of burnout. In addition, there is often no clear
the carrying out of psychometric test procedures are division between treatment and preventive measures.6'7
recommended. The Maslach Burnout Inventory, intro- The procedures used and their dependence on the type
duced in 1981, is widely used in the diagnosis of and severity of the symptoms are listed in Box 3.
burnout. It is a self-assessment questionnaire consisting
of 22 items to evaluate emotional exhaustion, deperso-
nalization and dissatisfaction with performance.3 In PREVENTION
individual cases further psychometric investigations, also
to evaluate competing influences, may be necessary. It Measures to prevent burnout can be differentiated
must be remembered, however, that the results of such according to the preventive approach and levels of
test procedures are only 'pieces in the diagnostic mosaic' prevention. Preventive approaches to be considered are
and cannot replace qualified psychosomatic/psychiatric both modifications in the working environment (preven-
investigation. Therefore an interdisciplinary team should tion of circumstances) and also improvements in the
be required in the diagnosis of burnout syndrome. individual's ability to cope with stress (behavioural
Differential diagnosis must be used to first separate preventive measures). According to the WHO the levels
primary psychiatric disorders, i.e. those independent of
exogenous factors, and burnout. Furthermore, chronic
somatic diseases, such as chronic infections (e.g. viral BOX 3. Burnout syndrome: therapy suggestions
hepatitis), endocrinopathy (e.g. thyroid disorders, Ad-
dison's disease), auto-immunopathy, tumours or the so- Pharmacological treatment according to
called chronic fatigue syndrome (CFS) must not be symptoms, e.g. antidepressants, beta-blockers
forgotten. Differentiation between burnout and CFS Psychotherapy, such as relaxation techniques,
can, however, be rendered impossible by similar symp- improvement of self-esteem, concepts for dealing
toms and a comparable course of the disease.31 with stress
In practice, the diagnostic assignment to burnout Reorganization of the work environment, such as
syndrome of the mainly unspecific symptoms described the organization of work and the work structure,
above is problematic, even with a differentiated ap- and the introduction of time management
proach. It is very difficult to find temporal and causal Change of work environment, combined with
relationships to previous psycho-mental/psycho-social rehabilitation and retraining
stress when, as is often the case, the illness has existed
516 Occup. Med. Vol. 50, 2000

of prevention can be divided into primary preventive in knowledge could be expected, based on well-founded
measures (avoidance/removal of factors that make the observations.34"36
patient ill), secondary measures (early recognition—in- In times of limited resources, acceptance and feasi-
tervention of manifest disease), and tertiary measures bility also play an important role in the development and
(coping with the consequences of disease—rehabilitation implementation of preventive strategies. In addition, it
and relapse prophylaxis).32 The concepts for behavioural should not be forgotten that effective and efficient
preventive measures presented in the literature focus on prevention requires adequate knowledge of the aetio-
primary prevention and are the 'domain' of psychology. pathogenesis. The closing of gaps in our knowledge
Some of the measures are: would also be a great improvement for the prevention of
burnout.33'37
• improvements in dealing with stress,
• the learning of relaxation techniques,
• the delegation of responsibility (learning to say 'no'), CONCLUSIONS: PROSPECTS

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• hobbies (sport, culture, nature),
• trying to uphold stable partnerships/social relation- As a result of the gaps in our knowledge, there is a
ships, great temptation to dismiss burnout as merely a
• frustration prophylaxis (reducing false expectations).4 'fashionable trend' or an 'invention of the media'. In
addition, in the era of molecular medicine, it may seem
In addition, some authors regard religion and spiri- more sensible to some people to leave psychosocial
tuality as having a potentially preventive function/'6 health risks to psychologists, sociologists or 'health
The strategies discussed at present for preventing the scientists'. It should be warned that this kind of
circumstances in which burnout arises are a combination thinking takes away an important dimension from
of primary and secondary prevention. It can be medicine (the social dimension).38 Without a doubt the
differentiated between activities where the focus is on multiplicity of the burnout phenomenon requires
work organization and management, and suggestions intensive interdisciplinary cooperation with the simul-
aimed primarily at (groups of) persons.33 Workplace- taneous preservation of its unity. Medical expertise is
related measures are: essential here. Moreover, burnout, as the result of the
complex interaction of work/society and the individual,
• the creation/preservation of a 'healthy working envir- calls for social-medical and occupational—medical
onment' (e.g. time management, communication style competence, and also serves to illustrate the close
of leadership), relationship of these two disciplines.38 It must also be
• the recognition of performance (praise, appreciation, borne in mind that the numerous possible social
money), consequences of burnout (e.g. repeated absence from
• the training of managers ('key role' of the boss in work, early invalidity) are also of 'classical' social-
burnout prevention). medical and occupational-medical content. Social -
medical and occupational-medical 'know-how' should
Person-oriented strategies are: not, however, be limited to the analysis of deficits, but
should lead to the drawing up of constructive,
• the carrying out of 'suitability tests' before job scientifically based solutions. The first priority is to
training, reach a consensus regarding the use of uniform
• specific programmes accompanying the work of definitions and diagnostic criteria. Only in this way
persons from risk groups (e.g. Balint groups for can valid statements be made on prevalence rates in
teachers and doctors), certain occupational groups, and thus on the extent of
• regular occupational—medical/psychological monitor- the risk. Furthermore, it is important that epidemiolo-
ing (e.g. establishment of a special 'job-stress' check- gical studies are planned sensibly to reveal potential
up for the early recognition of burnout). causal relationships with psycho-social/psycho-mental
stress at work. Merely asking for subjective evaluations
Suitability tests are not likely to be favourably received using a questionnaire does not lead any further.
from a socio-political point of view. First of all they do Methodologically valid prospective longitudinal studies
not allow freedom of choice when it comes to occupa- of an interdisciplinary and comprehensive nature,
tion, even if, depending on their type and content, they which evaluate both subjective and objective data, are
could be useful from a medical point of view (it is known urgently required. In addition, research to reveal the
from practice that persons with the personalities suscep- decisive pathogenetic principles should, of course, not
tible to developing burnout choose the occupations with be neglected. Above all, further research into the
a higher risk of developing burnout). biological, biochemical and molecular effects of chronic
Of particular interest is the suggestion of regular exposure to stress (e.g. endocrinological investigations
occupational-medical/psychological monitoring of oc- of the hypothalamic - pituitary -adrenal control system,
cupational groups at risk of developing burnout. The further development of 'stress-biomonitoring', psycho-
occupational-medical management of persons at risk immunology) is needed.27
from stress, and burnout patients, would therefore gain a The gaps in our knowledge should not excuse us from
standardized framework. In addition, a general increase trying to carry out in practice preventive measures and
 A. Weber and A. Jaekel-Reinhard: Burnout syndrome 517

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