Linnea Dunne on whether ‘burnout’ can or should be a medical diagnosis, and what happens when you brain goes into a chronic stress state…
We were about six months into the pandemic when I received a care package in the post from a friend in Sweden. I had mentioned to her at some point that I was having moments of worrying about myself and what I had realised might be early signs of burnout, and she – diagnosed with burnout years prior and struggling with it on and off since – put a huge bag of Swedish pick’n’mix sweets and a book called Help, I’m burnt out, in the post.[restrict]
I say that she was diagnosed with burnout, which is not entirely true – nor is my translation of the book title completely accurate. It was only when I went to Google her actual diagnosis, ‘utmattningssyndrom’, literally ‘exhaustion syndrome’, that I discovered endless forum discussions about this common diagnosis that is clinically recognised in Sweden but has no equivalent in English, or in any other system or language, it seems.
Stress-related exhaustion disorder, as some researchers call it in English, was introduced in Sweden in 2005, and it has since become a major cause of disability. It is classified in the international diagnostic manual ICD-10 with the code F43.8A, where conditions under F43 are categorised as “reaction to severe stress, and adjustment disorders”. It sits there alongside diagnoses like acute stress reaction, post-traumatic stress disorder, and adjustment disorders such as grief reaction. Sweden is currently the only country that includes the code in the system.
The condition has three phases. In the prodromal phase, which is characterised by physical and mental stress symptoms, the person is still able to function and go to work, if often with somewhat reduced capacity. If nothing is done about these symptoms, the person enters the acute phase, resulting in what is sometimes described as ‘hitting the wall’ – a sudden crash that means they can’t get out of bed or think clearly, and they may experience distress or panic. Many people stay in this phase for months – some are signed off sick for more than a year. Finally, in the recovery phase, the person slowly recovers but remains very sensitive to stress, with continued tiredness and difficulties with concentration and memory. Seven years post diagnosis, one study showed, the majority of participants were no longer on sick leave, but 73% were more sensitive to stress, 36% were still having concentration difficulties, and 42% were experiencing memory issues.
When Swedish patients diagnosed with F43.8A want to explain their illness to a non-Swedish speaker, a range of suggested terms tend to come up: burnout, chronic fatigue, nervous breakdown. But chronic fatigue syndrome (also known as ME), while similar in many ways to stress-related exhaustion disorder, is in the ICD-10 under G93 – “other disorders of the brain” – and, while the cause is unknown, is thought to be triggered by viral infections, immune system problems, hormonal imbalances or other physiological factors. Moreover, while it can be managed in a number of ways, chronic fatigue is, as the name suggests, chronic, and there is no known cure. In the case of exhaustion disorder, patients can and do recover, if not in the sense of going back to their old selves and often with a number of sensitivities remaining.
Burnout, a term that’s thrown around a lot and often loosely, is also medically recognised and was recently added to the ICD-11 manual, but under yet another different category, related specifically to workplace stress. According to the Swedish Social Board of Health and Welfare, exhaustion disorder should be understood as a diagnostic entity entirely separate from burnout and depression. ‘Nervous breakdown’, meanwhile, which has also been used widely as a catch-all term, isn’t actually used by healthcare professionals at all. And anyway, as one Swede in Ireland reflected when I asked around, the Swedish diagnosis is “more of a breakdown of the brain than of the nerves”.
So what happens in the brain when you’re exposed to long-term stress, and why is it that this condition that impacts an estimated 13% of the Swedish working population doesn’t seem to exist anywhere else? “Medicine and science love to put things in boxes, and that helps when it comes to studying things, but in reality, this is all related,” says Dr Padraic Dunne, an immunologist, practising psychotherapist and meditation teacher who teaches modules on stress and burnout, among other things, at RCSI. “In the brain, it’s the same thing that happens in response to prolonged stress, whether you’re talking about anxiety, burnout or something else.”
The brain has three sections, he explains. There’s the basement, or the brain stem that keeps your heart rate and breathing going, and then the downstairs brain, the limbic centre that’s in charge of your emotional response. “This is where the fight-or-flight response is triggered. Is the tiger running for you or not? If it is, you’ll run for the hills or decide to fight it.”
In the upstairs brain, in humans and mammals, is the prefrontal cortex. “It’s the part of the brain that does all the logical thinking for you, but it’s also involved with compassion and conscience, judgement and insight – it’s the place for proper decision-making, which puts the break on the more emotional centre. A lot of researchers have found that prolonged stress causes reduced activity in this part of the brain and an increase in the emotional centre.”
The prefrontal cortex is also the focus of one chapter of the aforementioned Swedish book about exhaustion disorders, because it’s decreased activity in this part of the brain that’s behind common symptoms such as difficulties concentrating and sensitivity to noise. According to a neuropsychologist interviewed in the book, no one knows beyond doubt whether the brain ever fully recovers from such changes. She is certain that most people who have had exhaustion disorder remain sensitive and vulnerable to stress, and argues that no one goes back to their former selves again.
Dr Dunne isn’t entirely convinced of that argument, highlighting the beauty of neuroplasticity and the capacity of the brain to respond to rewards. “We know now that our brains are very plastic, and there are lots of things we can do to reverse the way our brain moves and functions,” he says, adding that we can, however, be predisposed to certain sensitivities as a result of epigenetics. Pregnant women who were present when the Twin Towers came down, for instance, had low basal cortisol levels – as did their babies when born, making them more at risk of developing PTSD. The same has been seen in Holocaust survivors, whose children have experienced the same PTSD symptoms as their parents. “What this means,” says Dr Dunne, “in terms of how we respond to stress is that some of us are more vulnerable, while others are more resilient in terms of genome and can bounce back much quicker. But regardless of your background, you can reverse things – nothing’s irreversible.”
But if neuroscience is universal, why is it that the ways in which the brain changes in response to long-term stress get different names and labels, and indeed different clinical responses and treatment plans, depending on where in the world you live? “These labels and tags are useful for research; it can be helpful for some people to have a label like that, and they’re useful for insurers and employers – but I’m not sure how useful they are in general,” reflects Dr Dunne, who’s not a fan of diagnostic boxes. “This is not pathology; these are normal human responses to an existential threat.”
Pathology, he stresses, is when something is broken. “The brain responding to stress is not broken. It’s doing exactly what it’s meant to do: it’ll put you in fight, flight or freeze. Freeze is very common and usually masquerades as depression, but if you’ve seen a cat mess around with a mouse, you’ll know that the mouse will play dead, and once the cat is not interested anymore and drops it, the mouse runs off.”
That paralysed state in response to situations beyond your control was designed to help us evade predators, to shut us down until the predator leaves us alone. In the 21st century, it looks a little different – often like profound numbness, severe apathy and wanting to sleep all the time. Sometimes, it flips into the other extreme of agitation and extreme anxiety. “We can’t tell the difference between a bad boss or a tiger or wolf,” Dr Dunne explains. “If you experience that over a period of 12 weeks, you move into a chronic stress state. Eventually, your brain says ‘I can’t escape this’, and it’ll go into shut down or panic.”
For Cecilia, a Swede who works for one of the tech giants in Dublin, stress has always been part of the job. “Around 2018 or so, I was so busy I was never at home. I worked 12-hour days but could never get on top of things, and still I just got more and more responsibility,” she recalls. “I ran big events, travelled a lot for work and never quite got the sleep I needed. One evening, my body just said stop. I was away at the time to host an event and had my first panic attack, which was really scary. The first time, you think you’re going to die.”
Cecilia realised that something had to give. She tried to talk to her employer, but they didn’t understand. “Their opinion was pretty much that if you’re not able for it, you’re lazy – not burnt out,” she says. “They thought I could pass on a couple of tasks to a colleague, but nothing much happened. So I hit a wall. I woke up one morning and literally couldn’t get out of bed.”
Her GP was convinced that she was depressed and asked whether she had been through a recent break-up or similar. Cecilia questioned it, saying she didn’t feel depressed, just over-worked – that she couldn’t sleep and never felt rested. “I got sleeping pills and a referral to a psychologist, who also insisted that it was depression,” she says. “They asked about my life, about alcohol consumption and other habits, and I kept repeating that I didn’t feel sad, just constantly exhausted and overwhelmed.”
It didn’t lead anywhere. Cecilia kept ploughing on, trying to keep up with work, and soon, she started to get ill all the time. Repeated attempts at discussing it with her boss failed. Eventually, a friend who had returned to Sweden advised her to see a psychologist back home. “She’d had exhaustion disorder previously, and her experience was that it wasn’t taken seriously in Ireland. She felt the attitude was pretty much that you should just plough on with work,” says Cecilia.
The diagnosis of burnout, says Dr Dunne, is reasonably straight-forward. The gold-standard burnout assessment, the Maslach Burnout Inventory, covers three sections including emotional exhaustion, depersonalisation, and a decrease in the sense of personal accomplishment. “It’s a continuum, varying degrees of moving upwards – but it’s very clear if you’re in the red zone,” he says and uses an analogy of a frog in a pot of cold water that’s put on the stove. “As the water heats up, the frog doesn’t notice. It doesn’t realise when the water starts to boil, and it dies. Burnout is sneaky and insidious like that. It’s a long-term game – you’re not going into burnout in the space of a few weeks.”
While clearly very trusting of the various standardised tools for diagnosis, Dr Dunne certainly does seem more interested in the wider societal trends and workplace issues than he is in putting things in boxes. “The first thing I tend to say when I talk to a burnt out professional is that the management needs sorting out,” he says. “The best way to describe it is that stress and anxiety usually come from within, whereas burnout is usually caused by an external factor. It’s the external monster that’s causing burnout. Employers have a massive responsibility here.”
He suggests treating the brain a little bit like the way you treat your car. “Get your brain serviced. Test your burnout scores every six months, and if you’re creeping up into the amber zone, you need to do something about it,” he says, adding that awareness is key. “If you’re not aware of what’s going on in your head, you’re going to be in trouble.”
It stays with me, what he says about the brain doing what it should – that wariness of pathologising this glaringly obvious sign that we’re doing it wrong. But it also stays with me what he says about the usefulness of labels for employers and insurance companies. If a clinical label is what it takes to get the sick leave and support that helps to get you well, surely it’s absolutely crucial?
Looking back, Cecilia can see the warning signs clearly. “I didn’t sleep well at all, I pushed myself in a way that’s just inhumane, I was always exhausted and eventually stopped socialising with my friends – I just didn’t have the energy. I brought the laptop home after work every day and was constantly logged on,” she says. But she feels very strongly that no one took it seriously. “It was like people were thinking, ‘You’re 28, if you’re exhausted now, how are you going to feel when you’re 50?’ Eventually I started to think that maybe I was lazy – and that added to the anxiety.”
She took her friend’s advice, saw a psychologist in Sweden and got her diagnosis. She took three months’ sick leave, did loads of CBT and went back to work with the tools and awareness to restructure things – but eventually, she quit. She now works four days a week in a different job to make sure not to fall into the same trap again.
As for my old friend with the lovely care package, she first hit the wall when visiting me in London eight years ago. She’d been feeling increasingly stressed and tired and had some digestion problems, but a weekend away from her infant daughter brought the opportunity to collapse. Eight years on, she has her diagnosis and has made significant lifestyle changes, but travelling is still a daunting task for her, as is anything beyond managing her studies and life with two children. She’s certainly in the recovery phase, but to say that she has recovered fully would be a huge exaggeration. Her stomach acts up anytime she doesn’t stick to reasonably bland food and very regular meals, and she talks a lot about boundaries and learning to say ‘no’. Eight years on.
The number of sick leave days taken for an F43 diagnosis in Sweden has increased four-fold in the last decade. Some argue that it’s a reflection of the world we live in and that stress-related illness is on the increase as a result of busier lives, social media, and less priority given to rest, recovery and sleep. Others suggest that it’s simply a case of the existing issue being made visible as a result of there being an official medical diagnosis for it.
Dr Dunne believes both are true. “The expectations of modern life and the ability to compare ourselves to the best in the world immediately put enormous pressure on us, and the pandemic has made it worse, too,” he says. “But the capacity to become aware has also increased, as has the capacity to test.”
I’m none the wiser with regards to the mysterious Swedish diagnosis that afflicted my friend and so many others like her – one that’s less about the external monster in the workplace, yet which sounds a lot like the red zone Dr Dunne describes. I know too many people who are struggling to go back to normal fully and whole-heartedly years on for it to be something I can shrug at, but I’m willing to accept that the problem isn’t language – it’s awareness, understanding and support.
Dr Dunne maintains that physical, mental and social health are all interlinked and inseparable. “It’s all the one thing. If you’re talking about staving off burnout, you need to have a healthy lifestyle across all sectors. You don’t need to be superwoman – but it’s not good enough to be super fit and eat healthily if you have an unhealthy social life and mental health,” he says – and then, of course, there’s the homework for employers. Wouldn’t you want to work for an organisation that got your brain health serviced twice a year and did everything in its power to help when it needed oiling?
Another chapter in the Swedish exhaustion book talks about the disorder as revolution. Instinctively, it feels more than a bit risky to glorify this symptom of a society that frankly seems to have lost the run of itself. On reflection, I’m tempted to think that it’s an unexpected but potentially clever twist – a little like going on strike. With almost four times as many women as men being signed off with exhaustion syndrome in Sweden in 2020, maybe our bodies are onto something.