The Burnout Phenomenon

by Carrie Jones, ND, MPH

Traditional Doc’s are finally starting to get it!

Workplace burnout (Z73.0) was added to ICD-10 ¹ ,and was defined as an occupational phenomenon, but not a medical condition. This means that burnout cannot be used as a primary diagnosis, but it can be used to provide necessary supportive information. Similar codes exist for other non-medical conditions. For example, one such code is Z86.711, a personal history of pulmonary embolism, to support coumadin blood testing.

However, in ICD-11, which goes into effect in 2022, workplace burnout’s (Z73.0) definition has been expanded. This expanded definition is the result of workplace burnout’s increasing incidence. In ICD-11 burnout is defined as:

“a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions:

• feelings of energy depletion or exhaustion;
• increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and
• reduced professional efficacy.

Burn-out refers specifically to phenomena in the occupational context and should not be applied to describe experiences in other areas of life.” ¹

Whether, these elements need to be documented for reimbursement is not yet known.

So, what is burnout, how do we diagnose it, and how do we prevent it?

What Is Burnout?

In 1974, the phrase “burnout” was coined to describe the consequences of severe or prolonged stress and anxiety experienced by “healing professionals.” ² Freudenberg, an American psychologist, suggested that health professional’s high standards and the need to repeatedly self-sacrifice place them at high risk for job-induced emotional and physical exhaustion. Then, in 1981, Maslach and Jackson expanded this definition, and stated that burnout is “a syndrome of emotional exhaustion and cynicism that occurs frequently among individuals who do “people work of some kind.” ² This definition includes other occupations (pilots, police, EMS, etc.), not just healthcare.

Common traits amongst those most susceptible to burnout, regardless of occupation, include: the most dedicated, conscientious, responsible, and motivated people. Workers with these qualities are often idealistic and are perfectionists. Unfortunately, these are the qualities that are sought, and are somewhat necessary, in healthcare and other high stress professions. ²

We know that burnout occurs gradually over time, and is Selye’s, “General Adaptation Syndrome’s” third stage. ³ Because each individual’s onset is unique, it may be difficult to identify early signs and symptoms. So how do we best identify those individuals at risk so that we can prevent burnout.

Cortisol and the Cortisol Awakening Response

Identifying high risk individuals, making the diagnosis, and evaluating treatment success is necessary to avoid, prevent, and treat occupational burnout. We know the importance of HPA axis resiliency and its ability to appropriately respond to stressful situations. In addition, we have used the 4-point diurnal cortisol curve to assist with diagnosing HPA axis dysfunction, as well as predicting, with other biomarkers, where along the HPA axis spectrum a patient currently is.

In addition to this well-described 4-point diurnal pattern, there is a brisk increase in cortisol within the first 30-45 minutes after awakening in the morning. ⁴ This occurrence is termed the cortisol awakening response (CAR). It is a discreet and distinct component of the circadian rhythm and is unrelated to the HPA axis cortisol signaling throughout the rest of the day. In healthy individuals, CAR ranges from 50-150% (average 50%), is a measure of overall HPA axis resiliency, and can be viewed as an HPA axis “mini-stress test.” Deviations from a typical CAR profile are assumed to indicate maladaptive neuroendocrine processes and HPA axis dysfunction. ⁴

How To Evaluate Burnout

In addition to a careful history and physical exam (elevated heart rate), which may or may not be helpful in identifying high risk individuals, or diagnosing workplace burnout, laboratory testing is key.

Precision Analytical’s Cortisol Awakening Test evaluates the diurnal pattern, plus the CAR. A true CAR assessment requires salivary samples to be collected at the “moment of waking,” and twice more at 30 and 60 minutes after waking. The CAR calculation reflects the change in cortisol over baseline expressed as a percentage. ⁴

Explaining what is meant by the “moment of awakening” is key to obtaining a valid result. The definition should focus on a state of consciousness, the moment you know where you are. In addition, individuals should not initiate sampling if they wake up in the middle of the night and plan to go back to sleep. Sampling should begin the moment you are awake for the final time and plan to get up. ⁴

Precision Analytical uses specialty, FDA-approved patented collection devices called Salivettes.  Salivettes make salivary sampling easy, convenient, and not stressful, which is critical to accurate results. As opposed to the typical, sometimes difficult, process where saliva is supposed to drip into the collection device (most individuals actually spit), using Salivettes, is much easier. The included swab is placed in the mouth until saturated, then placed back in the collection device.

Precision Analytical’s use of Salivettes increases the likelihood that sampling will be done correctly and the results meaningful. Any sampling delay will affect the CAR result. ⁴ For example, small delays after awakening may result in an over-estimation of the CAR, which then turns into the well-documented CAR underestimation with longer delays (>15–20 min). A completely absent post-awakening increase (i.e., a negative CAR) is likely to occur only if the delay between awakening and sampling initiation exceeds the CAR peak (30-45 minutes). ⁴

As opposed to a negative CAR, approximately 25% of healthy individuals do not mount a CAR and are termed “non-responders.” Response is defined as an increase of at least 2.5nmol/l above S1 (awake sample). Non-responders do respond, as opposed to a completely absent response (flat), with a post awakening response < 2.5nmol/l above baseline. ⁴

How to Interpret CAR results

An elevated CAR is not necessarily maladaptive. It can be adaptive, anticipating daily stress. It plays a literal role in “preparing for action” by stimulating motor function, immune responses, and alertness. ^4,5

A blunted or negative CAR is seen in clinical burnout as well as with early loss, material hardship, depressive ruminations, and PTSD. It reflects perceived anticipated stress that seems hopeless. ^4-6

An expected or “optimal” CAR depends on the study population. Whereas a robust CAR is generally adaptive, stressful circumstances may elevate it above the ideal threshold, as is seen in high stress professions (nurses, police officers, etc.). In these highly stressed individuals, a lower-than-expected CAR (which may fall into the expected range) might represent early lack of resiliency when compared to the high stress population as a whole. ^4,7

Potential Treatments

Treatment involves finding the root cause. In clinical burnout, the root cause is the high stress occupation coupled with susceptible individuals who have high standards and are self-sacrificing. These individuals, because of chronic stress, develop a combination of emotional exhaustion, depersonalization, and a feeling of low personal accomplishments. ⁸

In high risk individuals, or those with clinical burnout, dietary extremes such as intermittent fasting, a true ketogenic diet (70% fat, 20% protein, 10% carbohydrates), and the fasting mimicking diet should be avoided. HPA axis dysfunction is implicated in: disrupting the gastrointestinal mucosa, modulating GI motility, immune dysregulation, increased permeability, and altering the gut microbiome. ⁹ Therefore, a low glycemic, gluten and dairy free, Mediterranean-style diet, with regular feedings should be an integral part of the healing plan. ¹⁰

Finally, typical lifestyle changes may not be enough. Healing may take leaving the stressful occupation. Also, nutraceuticals, appropriate adaptogens, calming support, and glandulars may be helpful.

Conclusion

First, we need to have a high index of suspicion for workplace burnout in high-risk individuals. Second, knowing what we know about HPA axis dysfunction and CAR, Precision Analytical’s Cortisol Awakening Response test will not only help with diagnosing workplace burnout, it will identify those at high risk so that treatment can be initiated. Further, this test will help clinicians monitor treatment efficacy.

¹ World Health Organization. International Class of Diseases 2019. Retrieved from: http//www.who.int/mental_health/evidence/burnout/en.

² DA. Physician Burnout and Well-Being: A Systematic Review and Framework for Action. Dis Colon Rectum . 2017; 60: 567-576.

³ Cunanan AJ, et al. The General Adaptation Syndrome: A Foundation for The Concept of Periodization. Sports Med . (2018) 48:787-797.

⁴ Stalder T, et al. Assessment of the cortisol awakening response: Expert consensus guidelines. Psychoneuroendocrinology . 63 (2016): 414-432.

⁵ Clow A, et al. The cortisol awakening response in context. Int Rev Neurobiol . 2010; 93: 153-175.

⁶ Clow A, et al. The cortisol awakening response: more than a measure of HPA axis function. Neurosci Biobehav Rev . 2010; 35(1): 97-103.

⁷ Oosterholt BG, et al. Burnout and cortisol: Evidence of a lower cortisol awakening response in both clinical and non-clinical burnout. J Psychosom Res . 2015; 78: 445-451.

⁸ Rotenstein LS, et al. Prevalence of Burnout Among Physicians: A Systematic Review. JAMA . 2018; 320(11): 1131-1150.

⁹ Tsigous C, Chrousos GP. Hypothalamic-pituitary-adrenal axis, neuroendocrine factors and stress. J Psychom Res . 2002; 53(4): 865-871.

¹⁰ Carabotti M, et al. The gut-brain axis: interactions between enteric microbiota, central and enteric nervous systems. Ann Gatroenterol . 2015; 28(2): 203