Staging Symptoms of Burnout to Ensure Intervention is Appropriate

The impact of burnout is significant on individuals and the organization. It is important to understand the progressive evolution of burnout symptoms to ensure that intervention is appropriate for the burnout stage that the person may be in. A timely intervention appropriate for the stage of burnout has the potential to ensure that necessary support is made available to the individual to stop the further evolution of burnout symptoms. Moreover, understanding the experiences of an individual provides an opportunity to address organizational systems and processes that may be contributing to burnout.


Introduction
There is a concern that burnout is having a significant impact on work productivity.In the 2020 Australian Public Service (APS) Census of over 100,000 APS employees, 36% responded in the affirmative to the question, "I feel burned out in my work" [1].Rates of burnout in different employment sectors have been reported to range from 20-70% [2][3][4].Globally, the effects of burnout resulting from lower productivity and higher healthcare costs have been estimated by the World Economic Forum to cost $322 billion annually [5].

What is Burnout?
Distress experienced by an individual due to perceived stress in the context of job expectations is considered to result in burnout.Burnout is described as the stress of professional life that results in a state of mental exhaustion [6].Burnout is recognized as an occupational disease in many countries [7].In the 11th revision of the International Classification of Diseases (ICD-11), burnout is described as an occupational phenomenon but not classified as a medical condition [8].Considering the emotional and psychological distress as well as deterioration in personal, social, and occupational functioning that results, whether burnout can be conceptualized as a mental disorder remains an area of ongoing discussion [9,10].
Reference to "burnout" in corridor discussions and social media has certainly increased awareness of burnout.Whether burnout is increasing or perceived burnout stress is on the increase, social media has enabled it to come out of the shadows.Whether jobrelated stress is actually increasing or changing culture and expectations of the workforce has something to do with its perceived or actual burnout burden are important matters to consider.
For health professionals, a surge in the level of stress of managing disasters also has to be a relevant consideration at this time.The impact of mental health disasters on the mental health and wellbeing of healthcare workers is known [11][12][13].Higher rates of mental health symptoms, psychological burden, and burnout were reported following SARS and have been reported following COVID-19 [14][15][16][17][18][19].In the face of a disaster, stories have emerged of healthcare workers' resilience and commitment in times of adversity [20,21] as well as the negative effects on health workers because of increased workload and expectations without adequate organizational support [22,23].

Burnout -History of the Concept
Historically, if we look at burnout under various guises, we find similar phenomena documented from as early as biblical times.The term "burn'd" is also penned by Shakespeare in describing the effect "burned out" love.Perhaps Beard was observing a similar phenomenon when he described neurasthenia in 1869 as the "somatic depletion of nervous energy caused by the faster pace of life" or "nerve weakness" [24].
The popularity of the use of the term burnout in clinical settings can be traced back to the 1970s by Freudenberger [25], although the term has also commonly been used to describe the effects of chronic drug use [26].
Rapid social and technological changes may have increased worker stress and burnout with the creation of an industrialized society [24].In recent times, awareness of the risk and impact of stress and burnout in work settings has been an area of interest in social media [27].The phenomenon of 'quietly quitting' the '100:80:100 model' and the 'gig economy' has attracted some attention [28].

The Experience of Burnout
Many definitions of burnout now exist.In the work context, burnout is defined as "a psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job" [29].
The experience of burnout tends to progressively evolve over time.Therefore, it is best to conceptualize this phenomenon as a result of the cumulation of work-related stressors over time.The chronicity and ongoing nature of work stress that is not successfully managed are thought to result in burnout [8].Environmental and psychological stressors are known to make individuals more susceptible to anxiety and depression [30].The same is true for people experiencing burnout.
Several attempts have been made to identify symptom clusters to understand commonalities in the burnout experience.Burisch [31] identified seven clusters starting with an increased commitment to goals and exhaustion in the early phase, followed by reduced commitment towards work and others, emotional reactions of depression and aggression, a reduction in cognitive performance, motivation, creativity and judgment, flattened emotional, social and intellectual life, psychosomatic reactions and despair.Freudenberger [32] has described a twelve-stage model starting with a compulsion to prove oneself and work harder, followed by neglecting and displacement of one's own needs and non-work-related activities, denial and decreased flexibility, development of cynicism and withdrawal, psychological reaction, depersonalization, anxiety and sense of emptiness, increase in feelings of meaningless and lack of interest and physical exhaustion.

Is Classifying Burnout as a Cluster of Symptoms Helpful?
Irrespective of whether burnout is an occupational disease or a medical and mental health disorder when it occurs, it does require intervention.
Symptoms of burnout can range from feeling emotionally and physically exhausted to anxiety, depression, despair, insomnia, indigestion, palpitations, migraines, mental exhaustion, fatigue, apathy, cynicism, disillusionment, disengagement, lack of motivation, withdrawal, and work-related stress [33,34].There is some overlap between symptoms of burnout and symptoms of an anxiety disorder and a major depressive disorder [35,36].
Perhaps the identification of a discrete symptom cluster can assist in making sense of symptom clusters from aetiological and psychopathological perspectives and therefore assist with diagnostic demarcation, identification of interventions that are likely to be therapeutic, and also predicting outcomes.From a clinical and therapeutic perspective, staging the phenomenon of burnout as follows may assist in targeting the right interventions at the right stage of development of symptoms of burnout.
Stage 1: Perceived inability to meet expectations.The person finds themselves in an organizational setting in which meeting expectations is perceived to be difficult.This can be a result of an increase in workload, feedback on one's performance, or an inability to meet the expectations the person may have set for themselves.Despite putting in more and more effort, the person feels unable to deliver.They are not able to complete the task to the expectations of others (external locus of control) or themselves (internal locus of control).
State 2: Exhaustion.The person begins to feel overwhelmed, as despite making an additional effort, the person is not able to meet performance expectations.A sense of hopelessness begins to set in.The person begins to feel exhausted and drained and develops a belief that despite making any and every effort, it will not be possible for them to perform adequately.An additional effort to perform causes further exhaustion.
Stage 3: Helplessness.As helplessness begins to set in, the person begins to experience an increase in physiological and psychological anxiety.Unable to meet expectations, the person begins to resort to the only psychological defence available to them, which is to begin to detach from the situation, personally, professionally, and emotionally.This results in the person withdrawing from work, and very quickly, this generalizes to the individual distancing themselves from significant others.
Stage 4: Despair and hopelessness.The person begins to experience a sense of worthlessness and hopelessness, followed by the development of negative cognitions about their ability to perform.This develops into a negative view of themselves.The person begins to doubt their ability and even competence.They begin to question their ability to meet expectations about their performance.This results in further disengagement from work as well as interpersonal interactions.The sense of pleasure and enjoyment is lost, and dissatisfaction becomes generalized to other areas of the workers' life outside their work or employment situation.
Stage 5: Generalization and expansion.Psychological and emotional despair begins to generalize and convert into other symptoms, including somatisation, physical health problems, and general fatigue.An increase in somatic co-morbidity, as well as cardiovascular, metabolic, musculoskeletal, cutaneous, and allergic diseases, has been reported [37][38][39].During stages 1 and 2, consideration should be given to whether organization-wide or individual-specific interventions are necessary.Organization-wide assessment of the structure and processes that may be contributing to an increase in burnout is required.This may need to include environmental analysis of changes in workload and work schedule that may be increasing work burden on the individual, leading to exhaustion, whether or not scheduling timely and regular rostered rotations is necessary, and whether all important considerations to minimize the progression of burnout symptoms have been considered [40,41].

Ensuring Interventions are Appropriate for Each Stage
Interventions for individuals experiencing exhaustion should include programs aimed at improving motivation.Other general expressions of support, including acknowledgment of effort and events to express gratitude and thanks for the effort can be helpful.Programs aimed at developing and reinforcing professional identity can be helpful to increase motivation and more importantly, return confidence, interest, and enthusiasm [42].Human resources intervention, including training to improve communication skills, can be useful at this time as training can enable effective communication of own distress and results not only in improvement in wellbeing, increasing resilience but also the reduction of expression of mental health symptoms [43,44].
Stage 3 requires enhanced support to be put in place.In addition to interventions necessary in stages 1 and 2, team building, team-wide, and team-participation programs can be helpful [45].During this stage, other self-care and resilience-building programs, including support groups, mindfulness, meditation, tai chi, and yoga, can be helpful to improve the sense of helplessness [46,47].One-to-one or group stress management training programs, Balint groups, and debriefing sessions have an important role to plan during this stage when helplessness is setting in [40, 41, 48- Hypnotics and other short-term anxiolytics also have a role to play in the treatment of time-limited management of intense anxiety.The use of mood stabilizers may also become necessary as an adjuvant medication.Cannabidiol (CBD) has also been found to be beneficial [55].

Conclusion
It is important to understand the different stages of burnout to ensure that support and interventions can be customized appropriately for people experiencing burnout.
An early awareness that burnout may be occurring helps to ensure that necessary organizational dynamics, changes in workload, work practices, and changes in work schedules that may be contributing to burnout can be understood and necessary corrections made.An opportunity should also be taken to consider whether individual-specific support, motivation, communication, and resilience-building strategies and interventions are likely to be helpful.However, when hopelessness is beginning to set in, it becomes important that specialist psychological and psychiatric assessment and treatment is put in place.To access the full-text version of this article, please scan the QR code:

Psychological
55. Crippa JAS, Zuardi AW, Guimarães FS, et al.Efficacy and Safety of Cannabidiol Plus Standard Care vs Standard Care Alone for the Treatment of Exhaustion and Burnout Among Frontline Health Care Workers During the COVID-19 Pandemic: A Randomized Clinical Trial.JAMA Netw Open, 2021;4(8):e2120603-e2120603.
Identification of the progression of burnout symptoms can help determine what intervention is likely to be appropriate and effective at what stage of burnout. 52].