Burn OutBurn OutPsychiatric impacts and Psychiatric impacts and psycho-social outcomespsycho-social outcomes

Professor Philippe CortenProfessor Philippe CortenDewell P., From L., Friedrich A., Tiv Ph, Van Dewell P., From L., Friedrich A., Tiv Ph, Van

Driette Y., Pelc I.Driette Y., Pelc I.

Clinique du Stress - 2005Clinique du Stress - 2005

Burn Out: BackgroundBurn Out: Background

Burn Out was Burn Out was described first bydescribed first by– MaslachMaslach– FreudenbergerFreudenberger

As a specific job As a specific job stress syndromestress syndrome

Burn Out is Burn Out is characterized bycharacterized by– Emotional exhaustion Emotional exhaustion

(( physical tiredness) physical tiredness)

– CynicismCynicism– DemotivationDemotivation

Burn Out isBurn Out is– InsidiousInsidious– Progressive (10 Progressive (10

years)years)

Burn Out result of the Burn Out result of the repetition of adaptative repetition of adaptative behaviors toward job stressbehaviors toward job stress Adaptative Adaptative

behaviorsbehaviors– Increase the Increase the

emotional emotional resistanceresistance

– To care for To care for without self without self involvementinvolvement

– To chose To chose realistic realistic targetstargets

Repetition Repetition => => Burn Out ProcessBurn Out Process

– To proof To proof oneself oneself against against emotionsemotions

– ObjectalizatiObjectalization of the on of the human human intercourseintercourse

– Restriction of Restriction of the the ambitionsambitions

Terminal Terminal Burn OutBurn Out– Emotional Emotional

exhaustionexhaustion– CynicismCynicism– DemotivatioDemotivatio

nn

Burn Out: BackgroundBurn Out: Background

Burn Out appears Burn Out appears particularly at particularly at work and in jobs work and in jobs withwith– VocationVocation– Contact with the Contact with the

publicpublic– Work in teamsWork in teams– Where relational Where relational

abilities are abilities are importantimportant

ButButThe The Maslach Burn Maslach Burn Out InventoryOut Inventory (the (the most used test) most used test) can be applied can be applied onlyonly– On workersOn workers– who work with who work with

other peopleother people

Tautology?Tautology?

Burn Out: Burn Out: Aim and hypothesisAim and hypothesis Is Burn Out a severe disease?Is Burn Out a severe disease? Has Burn Out severe outcomes?Has Burn Out severe outcomes? What are the Burn Out What are the Burn Out

Characteristics?Characteristics? Is Burn Out a form of depression Is Burn Out a form of depression

(smiling depression)?(smiling depression)? Is Burn out specific for some types Is Burn out specific for some types

of jobs?of jobs?

Burn Out: MethodologyBurn Out: Methodology

Design: retrospective Design: retrospective studystudy

Sample:Sample:– Source: Source:

outpatients of the outpatients of the “clinique du stress” “clinique du stress” CHU-Brugmann, CHU-Brugmann, Brussels since Brussels since September 2002 to September 2002 to august 2005.august 2005.

– Inclusive criteria:Inclusive criteria: Step 1: all patients Step 1: all patients

who met the definition who met the definition of a pathological of a pathological chronic stress were chronic stress were assessed (N= 395)assessed (N= 395)

– Definition of a chronic Definition of a chronic pathological stress:pathological stress:

A persistent state of A persistent state of tension negatively tension negatively perceivedperceived

Where someone is or Where someone is or feels unable to answer feels unable to answer adequately to the taskadequately to the task

Where this inability Where this inability may have significant may have significant consequencesconsequences

With psychological, With psychological, physical and/or physical and/or functional impactfunctional impact

Burn Out: MethodologyBurn Out: Methodology

– Inclusive criteriaInclusive criteria Step 2: Only patients Step 2: Only patients

who attribute the who attribute the main source of main source of stress to the job stress to the job were maintained in were maintained in the sample (N= 341)the sample (N= 341)

Step 3: Following the Step 3: Following the Maslach criteria the Maslach criteria the sample was divided sample was divided in 3 subgroupsin 3 subgroups

– Terminal Burn Out Terminal Burn Out (MBI = level 8)(MBI = level 8)

– Burn Out in Burn Out in process (MBI= 4 to process (MBI= 4 to 7)7)

– No Burn Out (MBI= No Burn Out (MBI= 0 to 3)0 to 3)

Step 4: statistical Step 4: statistical analysis were analysis were computed on the computed on the samples:samples:

– Terminal Burn Out Terminal Burn Out (N=56)(N=56)

VersusVersus– No Burn Out No Burn Out

(N=55)(N=55)

Burn Out: MethodologyBurn Out: Methodology

ToolsTools Clinical assessment:Clinical assessment:

– GHQ-28 of D. Goldberg GHQ-28 of D. Goldberg (General Health (General Health Questionnaire) with 4 Questionnaire) with 4 subscalessubscales

AnxietyAnxiety DepressionDepression SummarizationsSummarizations DisabilityDisability

– Beck Depression InventoryBeck Depression Inventory– Perceived stress of Cohen Perceived stress of Cohen

and Williamsonand Williamson– Stress at work of LegeronStress at work of Legeron– Maslach Burn Out Maslach Burn Out

InventoryInventory

Attitudes and behaviors Attitudes and behaviors toward stresstoward stress– Locus of controlLocus of control– CopingsCopings– AssertivityAssertivity– Alexythymia (TAS-20)Alexythymia (TAS-20)

Clinical interview and Clinical interview and follow-up by psychologists follow-up by psychologists and/or psychiatristsand/or psychiatrists– Anamnesis dataAnamnesis data– Sociologic dataSociologic data– TreatmentTreatment

DrugsDrugs PsychotherapyPsychotherapy Medical disablement to Medical disablement to

workwork

Burn Out: Results Burn Out: Results 1- How Bun Out is a severe 1- How Bun Out is a severe disease?disease?

GHQ-28Anova p= .0000

21,37

14,47

0 7 14 21 28

BO= 8

BO= 0

GHQ Score

Burn Out: Results Burn Out: Results 1- How Bun Out is a severe 1- How Bun Out is a severe disease?disease?

5,352,25

8,264,05

10,687,29

7,986,09

0 2 4 6 8 10 12 14

GHQ Score

Somatizations

Anxiety

Functional impact

Depression

GHQAnova p= .0000

BO= 8

BO= 0

Burn Out: Results Burn Out: Results 1- How Bun Out is a severe 1- How Bun Out is a severe disease?disease?

Beck Depression InventoryAnova p= .0000

8,42

14,33

0 4 8 12 16 20 24 28 32 36

BO= 8

BO= 0

Beck Score

Burn Out: ResultsBurn Out: Results1- How Bun Out is a severe 1- How Bun Out is a severe disease?disease?

Perceived StressAnova p= .0000

52,46

41,64

14 28 42 56 70

BO= 8

BO= 0

Score Cohen & Williamson

Burn Out: ResultsBurn Out: Results2- What are the outcomes?2- What are the outcomes?

Lenght of Follow-up in monthsAnova p= .03

11,51

7,25

0 3 6 9 12

BO= 8

BO= 0

months

Burn Out: ResultsBurn Out: Results2- What are the outcomes?2- What are the outcomes?

Work Disablement : Lenght in monthsAnova p = .01

8,41

4,51

0 1 2 3 4 5 6 7 8 9

BO= 8

BO= 0

months

Work disablementChi Square p= .004

75%

47%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

BO= 8

BO= 0

Burn Out: ResultsBurn Out: Results2- What are the outcomes?2- What are the outcomes?

TreatmentChi Square * p<.05 ** p<.01

74%

34%

28%

76%

68%

35%

17%

71%

47%

49%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Antidepressive drugs**

Anxiolytics

Hypnotics

Relaxation

Psychotherapy*

BO= 8

BO= 0

Burn Out: ResultsBurn Out: Results2- What are the outcomes?2- What are the outcomes?

Work outcomesChi Square NS

78%

38%

14%

16%

8%

81%

45%

15%

13%

9%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Return to the workmarket

Same Job

Mutation

Sacked

Resign

BO= 8

BO= 0

Burn Out: ResultsBurn Out: Results3- Characteristics: 3- Characteristics: a) Attitudes toward stressa) Attitudes toward stress Locus of controlLocus of control

– Internality (0 to 6)Internality (0 to 6) BO=8 Mean 2,53 sd 1,63BO=8 Mean 2,53 sd 1,63 BO=0 Mean 3,38 sd 1,51BO=0 Mean 3,38 sd 1,51 Anova p= .005Anova p= .005

– Externality (0 to 6)Externality (0 to 6) BO=8 Mean 2,04 sd BO=8 Mean 2,04 sd

1,511,51 BO=0 Mean 1,27 sd 1,13BO=0 Mean 1,27 sd 1,13 Anova p=. 003Anova p=. 003

=> More externalists=> More externalists

CopingsCopings=> worse copings=> worse copings

3,264,87

5,617,53

4,986,84

4,45,98

0 3 6 9 12 15

Score

Emotional**

Limits**

Plan & Help****

Withdrawal**

CopingsAnova *p<.05, **p<.01, ***p<.001, ****p<.0001

BO= 8

BO= 0

Burn Out: ResultsBurn Out: Results3- Characteristics: 3- Characteristics: a) Attitudes toward stressa) Attitudes toward stress EmotionsEmotions

– Bad perceptions Bad perceptions (0 to 35, cutting point 14)(0 to 35, cutting point 14)

BO=8 Mean 23,38 sd 5,87BO=8 Mean 23,38 sd 5,87 BO=0 Mean 19,15 sd 6,46BO=0 Mean 19,15 sd 6,46 Anova p= .003Anova p= .003

– Bad verbalizations Bad verbalizations (0 to 25, cutting point 10)(0 to 25, cutting point 10)

BO=8 Mean 17,11 sd 3,99BO=8 Mean 17,11 sd 3,99 BO=0 Mean 14,48 sd 4,38BO=0 Mean 14,48 sd 4,38 Anova p= .007Anova p= .007

– Avoidance of emotions Avoidance of emotions (0 to 40, cutting point 16)(0 to 40, cutting point 16)

BO=8 Mean 16,13 sd 4,57BO=8 Mean 16,13 sd 4,57 BO=0 Mean 14,33 sd 4,00BO=0 Mean 14,33 sd 4,00 Anova NSAnova NS

=> Worse perception and => Worse perception and verbalizationverbalization

AssertivityAssertivityMore passive and less More passive and less

assertiveassertive

6,47

6,47

9,82

7,15

9,47

12,53

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Score

Assertive****

Passive****

Agressive

AssertivityAnova ****p<.0001

BO= 8

BO= 0

Burn Out: ResultsBurn Out: Results3- Characteristics: 3- Characteristics: b) Sociological datab) Sociological data No differences between BO=0 and No differences between BO=0 and

BO=8 forBO=8 for– Age: 42 years sd 9Age: 42 years sd 9– Gender: 50% male, 50% femaleGender: 50% male, 50% female– Life milieu: 75% founded homeLife milieu: 75% founded home– Civil status: 72% marriedCivil status: 72% married– Children: 66%Children: 66%– Education: 69% University of High SchoolsEducation: 69% University of High Schools– Work: 64% employee, 25% managerWork: 64% employee, 25% manager

Burn Out: ResultsBurn Out: Results3- Characteristics: 3- Characteristics: c) Complaintsc) Complaints

86%

70% 71%

62%

75%

34%

63%

47%55%

26%

42%

17%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Tiredne

ss*

Early

wake u

p

Concent

ratio

n****

Neck te

nsion

s*

Diff. to

fall a

sleep*

**

Short

mem

ory*

**

ComplaintsChi Square *p<.05, **p<.01, ***p<.001, ****p<.0001

BO= 8

BO= 0

Burn Out: DiscussionBurn Out: Discussion1- Is Burn Out a form of 1- Is Burn Out a form of depression?depression?

CorrelationsCorrelations with p<.001= ** others NS

0,3668

0,3220

0,2175

0,1965

0,0759

0,1679

0,4222

0,4315

0,2400

0,3191

0,2943

0,1866

0,00

00

0,05

00

0,10

00

0,15

00

0,20

00

0,25

00

0,30

00

0,35

00

0,40

00

0,45

00

0,50

00

MBI ExhaustionFrequencies**

MBI ExhaustionIntensity**

MBI CynicismFrequencies

MBI Cynicism Intensity(Beck**)

MBI DemotivationFrequencies (Beck**)

MBI DemotivationIntensity

GHQ-Depression

Beck Depression

ButBut– 66% of the patients with terminal Burn Out don’t reach the cutting points of these scales 66% of the patients with terminal Burn Out don’t reach the cutting points of these scales

for major depressionfor major depression Is it due to the constructs of the scales?Is it due to the constructs of the scales?

– GHQ: 3/7 questions on suicideGHQ: 3/7 questions on suicide– Beck: sadness preeminentBeck: sadness preeminent

Interest to use other scalesInterest to use other scales– Other dysphoric expressions? IrritabilityOther dysphoric expressions? Irritability– AnhedoniaAnhedonia

Or Burn Out is an other syndrome ? (Cynicism is not common in depressive Or Burn Out is an other syndrome ? (Cynicism is not common in depressive disorders)disorders)

Burn Out: DiscussionBurn Out: Discussion2- Is Burn Out specific for some 2- Is Burn Out specific for some type of jobs?type of jobs? International International

literature attribute literature attribute Burn Out to some Burn Out to some type of jobs type of jobs characterized bycharacterized by– VocationVocation– Contact with the Contact with the

publicpublic– Work in teamsWork in teams– Where relational Where relational

abilities are importantabilities are important

Chi Square Chi Square – Burn Out TerminalBurn Out TerminalVersusVersus– No Burn Out in No Burn Out in

processprocess

ResultsResults– No significant No significant

differencesdifferences DiscussionDiscussion

– Sample to little?Sample to little?– Scale problem?Scale problem?

Burn Out: DiscussionBurn Out: Discussion2- Is Burn Out specific for some types of 2- Is Burn Out specific for some types of jobs?jobs?

6,955,13

5,413,71

7,894,85

8,76,07

7,256,33

9,217,76

0 2 4 6 8 10 12

Score of the Legeron scale

Pressure****

Change*

Frustrations***

Hostility****

Violence**

Environment****

Stress at WorkAnova *p<.05, **p<.01, ***p<.001, ****p<.0001

BO= 8

BO= 0

Burn Out: ConclusionsBurn Out: Conclusions

Burn Out is a severe disorder (GHQ=21)Burn Out is a severe disorder (GHQ=21) OutcomesOutcomes

– Long time follow-up (12 months) and disablement (8,5 months Long time follow-up (12 months) and disablement (8,5 months for 75%)for 75%)

– 75% with anti depressive drugs + psychotherapy and relaxation75% with anti depressive drugs + psychotherapy and relaxation– 80% go back to the labor market but only ½ at the same job 80% go back to the labor market but only ½ at the same job

and ¼ lose their jobsand ¼ lose their jobs CharacteristicsCharacteristics

– No sociological differencesNo sociological differences– Worse attitudes toward stressWorse attitudes toward stress– Concentration and short memory impairments + tirednessConcentration and short memory impairments + tiredness

Is Burn Out a form of depression?Is Burn Out a form of depression? – Probably noProbably no

Is Burn Out specific for some types of work?Is Burn Out specific for some types of work?– NoNo– But linked to work organizationBut linked to work organization