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Exhaustion disorder or stress-induced exhaustion disorder (ED or SED, sv, Utmattningssyndrom) is a diagnosis used in Swedish healthcare to indicate a maladaptive stress disorder more severe than
adjustment disorder Adjustment disorder is a maladaptive response to a psychosocial stressor. It is classified as a mental disorder. The maladaptive response usually involves otherwise normal emotional and behavioral reactions that manifest more intensely than usual ...
. Common signs include exhaustion, reduced
cognitive Cognition refers to "the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses". It encompasses all aspects of intellectual functions and processes such as: perception, attention, thought ...
ability and a range of physical symptoms. The symptoms develop gradually as a result of prolonged and elevated stress, but often culminate abruptly as the disorder becomes fulminant. Recovery will generally take from six months to a full year, sometimes longer. There are significant overlaps between symptoms of exhaustion disorder and depression, two conditions that frequently occur simultaneously. There are also many similarities between exhaustion disorder and
occupational burnout According to the World Health Organization (WHO), occupational burnout is a syndrome resulting from chronic work-related stress, with symptoms characterized by "feelings of energy depletion or exhaustion; increased mental distance from one’ ...
. In common Swedish vernacular "utbrändhet" (burnout) is used synonymously with Exhaustion disorder, but this usage is dissuaded in professional settings. The diagnosis was introduced in 2003, and with support from the
Swedish National Board of Health and Welfare The Swedish National Board of Health and Welfare ( sv, Socialstyrelsen) is a Swedish government agency. The agency was the result of a merger between the National Swedish Board of Health and the Swedish Royal Board of Social Affairs in 1968. ...
it was included in the Swedish edition of
ICD-10 ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms ...
in 2005. Since its introduction it has become a leading cause for
sick leave Sick leave (or paid sick days or sick pay) is paid time off from work that workers can use to stay home to address their health needs without losing pay. It differs from paid vacation time or time off work to deal with personal matters, because s ...
in Sweden. Among patients receiving compensation from the
Swedish Social Insurance Agency The Swedish Social Insurance Agency ( sv, Försäkringskassan, ) is a government agency that administers social insurance in Sweden. Responsibilities Among other the agency is responsible for administering the following benefits. * Immigrant ...
for more than 90 days, it is the most common diagnosis and women are at higher risk than men. The diagnosis is not used by any other healthcare system internationally. Treatment approaches vary between healthcare providers and the different regions of the country. Common elements include
psychoeducation Psychoeducation (a portmanteau of psychological education) is an evidence-based therapeutic intervention for patients and their loved ones that provides information and support to better understand and cope with illness. Psychoeducation is most oft ...
,
physical activity Physical activity is defined as any voluntary bodily movement produced by skeletal muscles that requires energy expenditure.Global Recommendations on Physical Activity for Health, 2009. World Health Organization. Geneva, Switzerland. Accessed 13/ ...
and individual psychotherapy or
group therapy Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group. The term can legitimately refer to any form of psychotherapy when delivered in a group format, ...
. Multimodal rehabilitation programs have also been offered by specialized providers. Several treatment options are effective at reducing symptoms, but no available treatment option successfully reduces the duration until return to work. Due to the limited effect of available treatment options, preventative measures are considered the most important intervention to reduce the
burden of disease Disease burden is the impact of a health problem as measured by financial cost, mortality, morbidity, or other indicators. It is often quantified in terms of quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs). Bot ...
.


Signs and symptoms

Exposure to stress is a part of life that generates a host of different responses, some of them akin to signs of illness without constituting or resulting in
disease A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that a ...
. How to differentiate between benign and maladaptive responses to stress is not necessarily evident, since there is no distinct line separating the two entities. The difference between tolerable and pathological stress seems to depend on a complex interaction between stress factors, and the affected persons mental resources and protective factors. A prolonged period of elevated stress can lead to exhaustion,
sleep disorder A sleep disorder, or somnipathy, is a medical disorder of an individual's sleep patterns. Some sleep disorders are severe enough to interfere with normal physical, mental, social and emotional functioning. Polysomnography and actigraphy are tes ...
s and a decline in cognitive abilities. The diagnosis of exhaustion disorder is designed to capture a state of illness far removed from the transient stress of everyday life. The symptoms of exhaustion disorder are numerous and include
fatigue Fatigue describes a state of tiredness that does not resolve with rest or sleep. In general usage, fatigue is synonymous with extreme tiredness or exhaustion that normally follows prolonged physical or mental activity. When it does not resolve ...
that does not improve with rest, reduced stress tolerance and various physical symptoms. Some of the more common physical symptoms are
headache Headache is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches. Headaches can occur as a resul ...
s,
dizziness Dizziness is an imprecise term that can refer to a sense of disorientation in space, vertigo, or lightheadedness. It can also refer to disequilibrium or a non-specific feeling, such as giddiness or foolishness. Dizziness is a common medical ...
and bowel issues. Most patients also suffer from sleeping problems. Exhaustion disorder and depression have several overlapping symptoms and often occur simultaneously, but many people suffering from exhaustion disorder do not satisfy the diagnostic criteria for depression. Symptom overlap between exhaustion disorder and other mental disorders is not unusual, but rather a common theme among mental disorders. The typical course of disease begins with a gradual onset of symptoms over a prolonged period of time, followed by a sudden deterioration and a long recovery, with pronounced exhaustion and reduced cognitive capacity. The initial phase can last several years and various complaints such as fatigue,
anxiety Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil Turmoil may refer to: * ''Turmoil'' (1984 video game), a 1984 video game released by Bug-Byte * ''Turmoil'' (2016 video game), a 2016 indie oil tycoon video ...
, irritability, sleeplessness, restlessness or bowel issues may erupt. During this phase, some people seek medical care for physical or isolated symptoms without the underlying cause being addressed. As the disease progresses the fatigue compounds, which leads to exhaustion and cognitive decline, and the worsening of other associated symptoms. At the peak of distress many decide to seek emergency care for
breathlessness Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing dis ...
or
chest pain Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing. Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with ...
, where the resulting examination fails to identify any physical cause. This critical stage tends to be described in terms of a crisis or "collapse" by the affected person and their associates. For a while thereafter there is usually a marked aversion to the workplace, and either an increased sleep duration or sleep disturbances. As the overall condition slowly improves the physical symptoms tend to abate, but sleeping disorders and cognitive impairments may remain for a prolonged duration.


Prognosis

The time to recovery is considered relatively long, and the guidelines from the
Swedish Social Insurance Agency The Swedish Social Insurance Agency ( sv, Försäkringskassan, ) is a government agency that administers social insurance in Sweden. Responsibilities Among other the agency is responsible for administering the following benefits. * Immigrant ...
supports a sick leave duration between 6 and 12 months, and the recovery may last even longer. The increased incidence of exhaustion disorder during the early 21st century contributed to an increase in the mean length of sick leave for mental health reasons in Sweden. There is limited scientific evidence describing the general prognosis or allowing for individual prognostication in cases of exhaustion. Studying the natural course of the disease is complicated by the high rates of co-morbid depression and anxiety disorders. A follow-up of patients that had participated in multimodal rehabilitation has shown an improvement of exhaustion- and physical symptoms over the course of 18 months. Still, at the time of long term follow-up 7–10 years later, almost half of the participants experienced fatigue and a majority reported a lasting reduction in stress tolerance. The duration of symptoms before the first contact with healthcare is the most significant predictor of the length of recovery.


Diagnosis

Exhaustion disorder is a clinical diagnosis made by a qualified health care professional based on the patient's recollection of the course of disease.
Blood samples In medicine, venipuncture or venepuncture is the process of obtaining intravenous access for the purpose of venous blood sampling (also called ''phlebotomy'') or intravenous therapy. In healthcare, this procedure is performed by medical labora ...
cannot be used to ascertain the diagnosis, but like ECG may prove useful for differential diagnostics. Several physical and mental disorders may present with symptoms similar to exhaustion disorder, which makes it a diagnosis of exclusion. Relevant physical alternative diagnoses are symptom dependent, but could include
hypothyroidism Hypothyroidism (also called ''underactive thyroid'', ''low thyroid'' or ''hypothyreosis'') is a disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormone. It can cause a number of symptoms, such as ...
,
vitamin B12 deficiency A vitamin is an organic molecule (or a set of molecules closely related chemically, i.e. vitamers) that is an essential micronutrient that an organism needs in small quantities for the proper functioning of its metabolism. Essential nutrien ...
,
COPD Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitation. The main symptoms include shortness of breath and a cough, which may or may not produce ...
,
cardiovascular disease Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs include stroke, ...
and
diabetes Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level (hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...
. There are also many commonalities with the chronic conditions
fibromyalgia Fibromyalgia (FM) is a medical condition defined by the presence of chronic widespread pain, fatigue, waking unrefreshed, cognitive symptoms, lower abdominal pain or cramps, and depression. Other symptoms include insomnia and a general hype ...
and
ME/CFS Chronic fatigue syndrome (CFS), also called myalgic encephalomyelitis (ME) or ME/CFS, is a complex, debilitating, long-term medical condition. The causes and mechanisms of the disease are not fully understood. Distinguishing core symptoms are ...
. The utility of measuring saliva-
cortisol Cortisol is a steroid hormone, in the glucocorticoid class of hormones. When used as a medication, it is known as hydrocortisone. It is produced in many animals, mainly by the '' zona fasciculata'' of the adrenal cortex in the adrenal g ...
has been evaluated, but it serves a purpose only in research settings.


Classification

Exhaustion disorder is included in the Swedish version of
ICD-10 ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms ...
, designated as ''F43.8A.'' The diagnosis is part of the diagnostic group "Adaptation disorders and response to severe stress". For classification purposes exhaustion disorder is marked as a complementary diagnosis if a patient suffers from a concurrent mental health disorder of significance; this includes depression,
dysthymia Dysthymia ( ), also known as persistent depressive disorder (PDD), is a mental and behavioral disorder, specifically a disorder primarily of mood, consisting of similar cognitive and physical problems as major depressive disorder, but with longe ...
or generalised anxiety disorder. In order to confirm the diagnosis of exhaustion disorder, physical and mental exhaustion must be present following a prolonged period of elevated stress. The major criteria of significantly reduced mental energy must have been present for at least 2 weeks. One or several prior stress-inducing factors should be identified and the exposure must have lasted for 6 months or longer. At least 4 out of 6 minor criteria are needed to complete the diagnosis. It is considered vital to differentiate between exhaustion disorder and other responses to elevated or severe stress, such as
adjustment disorder Adjustment disorder is a maladaptive response to a psychosocial stressor. It is classified as a mental disorder. The maladaptive response usually involves otherwise normal emotional and behavioral reactions that manifest more intensely than usual ...
, acute stress disorder and
PTSD Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a ...
. The diagnosis has not been recognized outside Sweden. There is a lack of consensus internationally concerning the proper way to diagnose, classify and treat conditions brought on by chronic stress. It has been suggested that the exhaustion disorder construct is an attempt to create a recognizable medical diagnosis from the burnout concept, similar to the use of
neurasthenia Neurasthenia (from the Ancient Greek νεῦρον ''neuron'' "nerve" and ἀσθενής ''asthenés'' "weak") is a term that was first used at least as early as 1829 for a mechanical weakness of the nerves and became a major diagnosis in North A ...
in the Dutch healthcare system, and how fatigue-dominant
somatoform disorder A somatic symptom disorder, formerly known as a somatoform disorder,(2013) dsm5.org. Retrieved April 8, 2014. is any mental disorder that manifests as physical symptoms that suggest illness or injury, but cannot be explained fully by a general ...
can be used. The
umbrella term In linguistics, semantics, general semantics, and ontologies, hyponymy () is a semantic relation between a hyponym denoting a subtype and a hypernym or hyperonym (sometimes called umbrella term or blanket term) denoting a supertype. In other ...
"Exhaustion due to persistent non-traumatic stress" has been proposed for such afflictions. It is considered likely that the suffering recognized as exhaustion disorder in Swedish healthcare settings in many other countries would be interpreted as symptoms of depression or an
anxiety disorder Anxiety disorders are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal function are significantly impaired. Anxiety may cause physi ...
, or be described with alternative terms such as clinical burnout, work-related neurasthenia, work-related depression, adjustment disorder or somatization syndrome.


Questionnaires and rating scales

Various questionnaires may be of use to evaluate the risk for burnout or exhaustion, rate the intensity of symptoms or screen for co-morbid disorders. The Karolinska Exhaustion Disorder Scale (KEDS) is used to quantify symptoms of exhaustion among the afflicted and at risk individuals. Shirom-Melamed Burnout Questionnaire (SMBQ) is a tool originally developed for
occupational burnout According to the World Health Organization (WHO), occupational burnout is a syndrome resulting from chronic work-related stress, with symptoms characterized by "feelings of energy depletion or exhaustion; increased mental distance from one’ ...
sometimes employed as a rating scale in the evaluation of exhaustion disorder. Despite the conceptual difference between ED and burnout these questionnaires have many similarities. The Montgommery Åsberg Depression Rating Scale (MADRAS) is used to evaluate simultaneous symptoms of depression and the
Hospital Anxiety and Depression Scale Hospital Anxiety and Depression Scale (HADS) was originally developed by Zigmond and Snaith (1983) and is commonly used by doctors to determine the levels of anxiety and depression that a person is experiencing. The HADS is a fourteen item scale ...
(HAD) measure signs of both depression or anxiety. The Alcohol Use Disorders Identification Test (AUDIT) screens for overuse of alcohol. The WHO Disability Assessment Schedule (WHODAS 2.0) has been studied as a means to distinguish between exhaustion and the less severe adjustment disorder, but no currently available scales or questionnaires are properly validated for use in differential diagnostics.


Epidemiology

No large epidemiological studies on the
prevalence In epidemiology, prevalence is the proportion of a particular population found to be affected by a medical condition (typically a disease or a risk factor such as smoking or seatbelt use) at a specific time. It is derived by comparing the number o ...
of exhaustion disorder have been published. In smaller questionnaire-based studies ''symptoms'' of exhaustion have been approximated to occur in 15% of the general Swedish population, 15% of healthcare workers and 30% of
primary care Primary care is the day-to-day healthcare given by a health care provider. Typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist car ...
patients. Such studies are likely to generate overestimates of the prevalence of disease. The actual prevalence of exhaustion disorder is unknown. Persons with exhaustion disorder are at an increased risk of certain physical diseases including
diabetes Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level (hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...
,
cardiovascular disease Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs include stroke, ...
and
chronic pain Chronic pain is classified as pain that lasts longer than three to six months. In medicine, the distinction between acute and chronic pain is sometimes determined by the amount of time since onset. Two commonly used markers are pain that continues ...
.


Sick leave

Of people receiving compensation for mental disorders from the
Swedish Social Insurance Agency The Swedish Social Insurance Agency ( sv, Försäkringskassan, ) is a government agency that administers social insurance in Sweden. Responsibilities Among other the agency is responsible for administering the following benefits. * Immigrant ...
in 2019, 18% of the women and 13% of the men received compensation due to exhaustion disorder, leaving women at a 40% greater risk. Female public employees of the
Regions In geography, regions, otherwise referred to as zones, lands or territories, are areas that are broadly divided by physical characteristics (physical geography), human impact characteristics (human geography), and the interaction of humanity and t ...
and Municipalities of Sweden are at a higher risk of all stress related diagnoses. This difference between the sexes is not sufficiently explained by factors related to either sex or gender, but is proportional to actual stress exposure. According to statistics from the Swedish Social Insurance Agency cases peak between the ages of 35–44. The diagnostic group "reactions to severe stress, and adjustment disorders", where exhaustion disorder belongs, has grown to become the most common cause for sick leave in the country, mirroring how stress-related disorders have become the leading cause for sick leave in the
OECD The Organisation for Economic Co-operation and Development (OECD; french: Organisation de coopération et de développement économiques, ''OCDE'') is an intergovernmental organisation with 38 member countries, founded in 1961 to stimulate ...
. Alongside this trend, the numbers for anxiety diagnoses,
major depressive disorder Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introdu ...
and
bipolar disorder Bipolar disorder, previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that last from days to weeks each. If the elevated mood is severe or associated with ...
, have remained relatively stable in Sweden. Among patients receiving compensation from the Swedish Social Insurance Agency for more than 90 days, exhaustion disorder is the most common diagnosis and the ratio of women to men is 4 to 1.


Risk factors

The principal cause is usually workplace stress, but several other factors influence the risk of disease. Individuals with children in
kindergarten Kindergarten is a preschool educational approach based on playing, singing, practical activities such as drawing, and social interaction as part of the transition from home to school. Such institutions were originally made in the late 18th cent ...
or the first few years of school are at higher risk (with children ages 3–8). Having more than one child or having recently gone through divorce proceedings also increase the risk of exhaustion. Bosses and managers, as well as people working in occupations where a university degree is required, are at a lower risk. However, there is an increased risk of disease among workers in care professions, even those where a degree is a prerequisite.


Factors related to working conditions

In a systematic review from 2014 the
Swedish Agency for Health Technology Assessment and Assessment of Social Services The Swedish Agency for Health Technology Assessment and Assessment of Social Services ( sv, Statens beredning för medicinsk och social utvärdering, SBU) previously the ''Swedish Council on Health Technology Assessment'' is an independent Swedis ...
found that several work related factors influenced the risk of developing symptoms of depression or exhaustion disorder. Factors related to an increased risk of symptoms of both conditions were: a lack of peer-to-peer support, experiencing a heavy work-load or a lack of gratification in relation to efforts. Uncertain forms of employment and threats of closure were also associated with an increased risk of symptoms. Some factors were found to increase the risk of symptoms of depression, but not exhaustion. This was true for cases of bullying and conflict in the workplace, and for the combination of high expectations with limited influence over working conditions. Some factors confer a protective effect. Influence and control over working conditions diminish the presence of symptoms related to either condition.


History


Background

An older term with many commonalities to exhaustion disorder is burnout. This term, with origins in the 1960s, was originally used to describe a reaction observed in caretaking professionals. The most disseminated version of burnout was developed by
Christina Maslach Christina Maslach (born January 21, 1946) is an American social psychologist and professor emerita of psychology at the University of California, Berkeley, known for her research on occupational burnout. She is a co-author of the Maslach Burnout I ...
, and is defined by the triad of: emotional exhaustion, cynicism and an experience of reduced professional capacity. The syndrome of burnout was initially exclusively focused on occupation related stress-inducers, but was later expanded to include other kinds of stress. The description of the condition has shifted over time and between different scholars, which has contributed to burnout never attaining the status of a medical diagnosis in either the
ICD The International Classification of Diseases (ICD) is a globally used diagnostic tool for epidemiology, health management and clinical purposes. The ICD is maintained by the World Health Organization (WHO), which is the directing and coordinatin ...
or the DSM, with fixed diagnostic criteria. Another proposed progenitor of exhaustion is
neurasthenia Neurasthenia (from the Ancient Greek νεῦρον ''neuron'' "nerve" and ἀσθενής ''asthenés'' "weak") is a term that was first used at least as early as 1829 for a mechanical weakness of the nerves and became a major diagnosis in North A ...
. On the rise during the late 19th and early 20th century it shares many symptoms with exhaustion disorder. The term itself was introduced in 1869 by the American physician
George Miller Beard George Miller Beard (May 8, 1839 – January 23, 1883) was an American Neurology, neurologist who popularized the term neurasthenia, starting around 1869. Biography Beard was born in Montville, Connecticut, on May 8, 1839, to Reverend Spence ...
, and was popularized soon thereafter. Beard believed that the condition was brought on by the woes of modern life — express trains and a fixation with time and especially measuring it — that subjected the human psyche to overload. During the 1960s French and German psychiatrists would separate cases of depression into various sub-classes, "exhaustion-depression" (german: Erschöpfungsdepression) was one of them.


Introduction and developments

The late 1990s and early 00s saw an increase in the number of Swedes on prolonged sick leave or receiving
disability pension A disability pension is a form of pension given to those people who are permanently or temporarily unable to work due to a disability. North America An example of a disability pension is from a private or Public Pension Plan, or the Canada Pe ...
. The rise was higher for mental disorders and female public employees were over-represented. Cuts to the public sector during the '90s have later been pointed to as the cause. The downsizing should have caused an increased work load, and as workers succumbed to overwork fewer and fewer remaining employees would have been left to share the burden. Overarching socio-cultural and workplace related developments since the 1980s, including increased information density and exchange, and both parents working full-time while raising children, have also been emphasized as contributors. Efforts to formulate the diagnosis were sparked by an increase in sick leave numbers attributed to depression, for customers served by one of the larger Swedish insurance agencies. Doctors
Marie Åsberg Marie Åsberg (born 1938) is a Swedish psychiatrist. She was based at the Karolinska Institute until retirement in 2004. In a pioneering 1976 paper, Åsberg found a link between low serotonin and violent suicide. Åsberg is an expert on exhaustio ...
and Åke Nygren were notified of the surge in 1998 and decided to investigate. They found that the symptoms did not match the typical presentation of depression. Complaints like fatigue and decreased cognitive ability dominated and many interviewees believed their working conditions to be the cause. The condition was considered distinct from depression and Åsberg suggested using the term ''utmattningsdepression'' ("exhaustion-depression"). In 2002 she was authorized by Kerstin Wigzell,
Director-General A director general or director-general (plural: ''directors general'', ''directors-general'', ''director generals'' or ''director-generals'' ) or general director is a senior executive officer, often the chief executive officer, within a governmen ...
of the
Swedish National Board of Health and Welfare The Swedish National Board of Health and Welfare ( sv, Socialstyrelsen) is a Swedish government agency. The agency was the result of a merger between the National Swedish Board of Health and the Swedish Royal Board of Social Affairs in 1968. ...
, to investigate the condition and conduct a scientific review. The initial moniker was forgone in 2003 in favor of ''utmattningssyndrom'' (exhaustion disorder), which gained traction as a diagnosis that same year when the Board of Health and Welfare published the results of the investigation in the book ''Utmattningssyndrom: stressrelaterad psykisk ohälsa.'' The body of research on stress-induced mental disorders was deemed lacking, and the need to conduct research into and validate the newly formulated diagnosis was stressed. The diagnosis was introduced into the Swedish edition of
ICD-10 ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms ...
in 2005. No scientific articles investigating exhaustion disorder had been published at the time. This formal recognition meant that the condition could thereafter be used as a reason for sick leave. As the diagnosis was recognized, efforts to formulate guidelines for diagnostics, treatment and sick leave continued. The first edition of guidelines was published by the Board of Health and Welfare in 2008, delayed by roughly half a year due to "disagreements in the medical corps." During 2022 work has been done on a new set of guidelines by a working group led by Marie Åsberg. Another group led by psychiatrist Christian Rück published a scoping review on the condition, questioning its
validity Validity or Valid may refer to: Science/mathematics/statistics: * Validity (logic), a property of a logical argument * Scientific: ** Internal validity, the validity of causal inferences within scientific studies, usually based on experiments ...
and reliability as a medical diagnosis.


Causes

Exhaustion disorder is stress-induced by definition and could be caused by stress in the workplace or from other environments. The underlying physiological mechanisms are as of 2023 incompletely understood. Early on, a decreased sensitivity within the
HPA axis HPA may refer to: Organizations * Harry Potter Alliance, a charity * Halifax Port Authority, Canada * Hamburg Port Authority, Germany * Hawaii Preparatory Academy, a school in Hawaii, US * Health Protection Agency, UK * Heerespersonalamt, the ...
was identified in small scientific studies, resulting in an attenuated release of cortisol in response to stimulation. Subsequent investigations into this abnormality have produced mixed results, and several later scientific reports found no difference compared to healthy controls. Studies using Magnetic resonance imaging have indicated changes to the
prefrontal cortex In mammalian brain anatomy, the prefrontal cortex (PFC) covers the front part of the frontal lobe of the cerebral cortex. The PFC contains the Brodmann areas BA8, BA9, BA10, BA11, BA12, BA13, BA14, BA24, BA25, BA32, BA44, BA45, BA ...
,
basal ganglia The basal ganglia (BG), or basal nuclei, are a group of subcortical nuclei, of varied origin, in the brains of vertebrates. In humans, and some primates, there are some differences, mainly in the division of the globus pallidus into an extern ...
and
amygdala The amygdala (; plural: amygdalae or amygdalas; also '; Latin from Greek, , ', 'almond', 'tonsil') is one of two almond-shaped clusters of nuclei located deep and medially within the temporal lobes of the brain's cerebrum in complex v ...
. However, the number of studies and their participants are limited, and more research is needed to validate these findings.


Treatment


Treatment options

Psychoeducation Psychoeducation (a portmanteau of psychological education) is an evidence-based therapeutic intervention for patients and their loved ones that provides information and support to better understand and cope with illness. Psychoeducation is most oft ...
on stress, and the role of working conditions and lifestyle factors, are common treatment approaches.
Physical activity Physical activity is defined as any voluntary bodily movement produced by skeletal muscles that requires energy expenditure.Global Recommendations on Physical Activity for Health, 2009. World Health Organization. Geneva, Switzerland. Accessed 13/ ...
is also considered an important part of rehabilitation. Psychotherapy in one-on-one or group settings, including methods for
stress management Stress management is a wide spectrum of techniques and psychotherapies aimed at controlling a person's level of stress, especially chronic stress, usually for the purpose of and for the motive of improving everyday functioning. Stress produces ...
may be a part of the protocol. Antidepressants are not considered effective in treating exhaustion, but may be used to treat concurrent depression or anxiety. The guidelines for treatment published by the
Swedish National Board of Health and Welfare The Swedish National Board of Health and Welfare ( sv, Socialstyrelsen) is a Swedish government agency. The agency was the result of a merger between the National Swedish Board of Health and the Swedish Royal Board of Social Affairs in 1968. ...
offers an ensemble of options and are open to interpretation. The actual treatment provided varies between different providers and parts of the country, depending on local traditions and resources, including access to multimodal rehabilitation (MMR). Since the symptoms are long-lasting it is generally considered appropriate to start partial return to work before complete remission of symptoms. Before return to work a joint-appointment ( sv, avstämningsmöte) between the patient, employer, care provider and the Social Insurance Agency is sometimes called for to agree on common terms for a gradual increase in workload. Depending on the circumstances a
union representative A union representative, union steward, or shop steward is an employee of an organization or company who represents and defends the interests of their fellow employees as a labor union member and official. Rank-and-file members of the union hold ...
or other support person may accompany the patient-employee.


Evidence

Many different treatment options have been investigated and assessed scientifically. Since exhaustion disorder results in a long-lasting and severe loss of function, usually brought on by work-related stress, time until "return to work" is considered the most important end-point when evaluating the effectiveness of various treatments. The body of research is small, since the diagnosis is only recognized in a single country. There is limited evidence concerning the efficacy of treatments in terms of return to work, primary research studies on the topic are wrought with generally low numbers of participants, and show marginal or no effect. Two reviews published in 2019 and 2022 have pointed to limitations in the methods of the available research on treatment. MMR is a preferred treatment according to the guidelines, but its utility is hard to investigate, since the makeup of the team and their approach varies between care providers. Therapeutic approaches like CBT and ACT reduce stress-induced symptoms in the short term, and have been found cost-efficient in health-economic studies, but there is limited or no evidence for any effect on return to work. Similar claims have been made concerning MMR, but there are no controlled trials evaluating it as a treatment for exhaustion. Physical activity is proven to be effective against several
mental disorder A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitti ...
s. In healthy individuals it improves
cognition Cognition refers to "the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses". It encompasses all aspects of intellectual functions and processes such as: perception, attention, thoug ...
and confers protection against stress-induced symptoms. Due to limitations in study design and size, the effects of physical exercise in fully developed exhaustion disorder is unknown. Improved sleep is considered important for recovery and CBT is effective against
sleep disorders A sleep disorder, or somnipathy, is a medical disorder of an individual's sleep patterns. Some sleep disorders are severe enough to interfere with normal physical, mental, social and emotional functioning. Polysomnography and actigraphy are tests ...
in general, but the specific case of the proper way to treat sleep problems in patients with simultaneous exhaustion disorder has not been studied. The use of internet-based CBT in exhaustion disorder and burnout suggests that its effects on exhaustion symptoms are mediated by improved sleep. No scientific studies have investigated the utility of treating exhaustion disorder with antidepressants. Due to the limited efficacy of currently available treatment options, the need to focus on preventative measures has been highlighted as the most important intervention in order to mitigate stress-induced sickness.


References


Notes


Citations


Sources

* * * * * * * * * * * * * * * * * * {{cite book , last1=Åsberg , first1=Marie , last2=Blomberg , first2=Carolina , last3=Brändström , first3=Lisa , last4=Clason van de Leur , first4=Jakob , last5=Eskilsson , first5=Therese , last6=Finnes , first6=Anna , last7=Glise , first7=Kristina , last8=Grossi , first8=Giorgio , last9=Herlofson , first9=Jörgen , last10=Nager , first10=Anna , last11=Wallensten , first11=Johanna , last12=Wastensson , first12=Gunilla , last13=Wilczek , first13=Alexander , year=2024 , editor-first=Marie , isbn=9789177413738 , language=sv , editor-last=Åsberg , location=Stockholm , publisher=Gothia kompetens , title=Utmattningssyndrom , ref=CITEREFÅsberg2024 Stress-related disorders Culture-bound syndromes