New Research links chronic stress with a litany of health-conditions-here’s what to do about it
The Times
John Naish
Gerry Gajadharsingh writes:
This article covers recent research into the clinical condition of “burnout”.
More than 50% of sick days taken in the UK are the result of anxiety and depression. However, as well as psychological symptoms, the psychological distress can impact significantly on physical symptoms and the risk of developing disease (pathology), including cardiovascular problems, such as atrial fibrillation (up 20%), stroke, MI, death from any cause, type 2 diabetes (up 30%) and dementia (up 25 to 40%).
Younger generation seem to suffer the most (millennials age 23 to 38), with 28% suffering compared to older people at 21%.
“The organisational context is that we work in an era of sky-high expectations. Over the past ten years the demands and complexity of people’s jobs have risen exponentially.”
Although Britain does not recognise burnout as an occupational disease, nine European countries do.
International surveys report that the worst affected jobs are in healthcare, social work, policing, teaching and customer services, and executive posts in law and management.
SPOT THE SIGNS
Occupational psychologists at the Mayo Clinic in Minnesota have compiled this checklist. They warn that saying “yes” to any of these six questions means you may be at risk of job burnout:
- Have you become cynical or critical at work?
- Have you become irritable or impatient with co-workers or clients?
- Do you lack satisfaction from your achievements?
- Do you feel disillusioned about your job?
- Are you using food, drugs or alcohol to feel better or to simply not feel?
- Are you troubled by unexplained headaches, digestive problems, or other physical complaints?
The mechanisms of how burnout affects us can be via several mechanisms.
- Up regulation of stress hormones, such as cortisol. The main test I use, at The Health Equation, for measuring this is a Comprehensive Adrenal Stress Test, measuring salivary cortisol and DHEA, Cortisol Awakening Response and Secretory IgA.
- Up regulation of the sympathetic (stress) part of the autonomic nervous system. The main test I use to measure this, at The Health Equation, is Heart Rate Variability (HRV), in particular Breathing Heart Wave, the Heart Rate Variability that relates to our breathing pattern.
- Inflammation, via several mechanisms including dietary glucose dysregulation causing increase in insulin and its effect on many inflammatory cytokines. Whilst systemic inflammation can be picked up by blood markers such as ESR and CRP, many patients are thought to have “silent” inflammation, which can be picked up by other blood makers, many of which are quite expensive to run and not yet routinely used in clinical practice.
I suspect that burnout is a factor in quite a few of the patients that I see, as part of their symptom presentation. Ironically, healthcare workers suffer quite high levels of burnout. Sometimes the question should be who looks after the clinicians? Caring for patients takes a lot of energy and time, when done properly, it is a highly responsible job. The NHS currently has £80Billion of outstanding compensation claims, yes that’s right £80Billion. I’ll leave you to think about why that might be!”
Is your career killing you by stealth? If you feel excessively tired, devoid of energy, demoralised and irritable, you have the classic symptoms of a condition with disastrous potential: occupational burnout.
More than half of sick days taken in Britain are caused by work-related stress, anxiety and depression, according to the UK Health and Safety Executive. Burnout doesn’t only make work feel demoralisingly futile; studies show that it may precipitate a fatal heart attack or stroke, or prompt chronic illnesses such as type 2 diabetes or dementia.
A 25-year survey of 11,000 people published this month in the European Journal of Preventive Cardiology warns that those with the most symptoms of burnout have a 20% higher than normal risk of atrial fibrillation. Atrial fibrillation is the most common form of heart-rhythm disturbance (arrhythmia), affecting one million Britons. It significantly increases the risk of heart attack, stroke and death.
It is not the first time burnout has been linked with cardiovascular disease. In 2017 a six-year survey of more than 100,000 people by New York researchers in The American Journal of Cardiology concluded that burnout is significantly associated with a higher risk of stroke, heart attacks and fatal haemorrhages — or death from any cause. What’s more, if sufferers survive those strokes or coronaries, their burnout makes them much more likely to suffer another one, Hungarian psychiatrists warned last year in the International Journal of Clinical Health Psychology.
The author of the most recent study, Dr Parveen Garg, an assistant professor of clinical medicine at the University of Southern California in Los Angeles, believes that burnout may harm our hearts by chronically overstimulating them.
“When we are persistently stressed or exhausted by work, it can cause chronic stimulation of the fight-or-flight response,” he says. “This involves constantly raised levels of stress hormones such as adrenaline and norepinephrine. These can damage the tissue of your heart and cause atrial fibrillation.”
The risk is increased by the fact that occupational burnout is associated with heightened levels of tissue-damaging inflammation throughout the body. “When these two things are chronically triggered they can have serious effects on heart tissue,” Garg says.
“Atrial fibrillation dramatically increases your risk of a stroke,” he adds. “When your heart is beating abnormally, blood pools in the heart. Clots can form that travel into your brain and cause strokes.”
Occupational burnout, which was first recognised in the mid-1970s and is diagnosed as a combination of excessive fatigue, increased irritability and feelings of demoralisation, does not only endanger our cardiovascular systems. In 2017 a 13-year study of more than 9,000 Danes in the Journal of Psychosomatic Research found that those suffering strong symptoms at the beginning of the survey were 30 per cent more likely to develop type 2 diabetes.
A study in September by occupational health doctors at the University of Navarra in Spain warns in the Journal of Occupational and Environmental Medicine that burnout may drive type 2 diabetes so strongly that attempts to treat it through diet and weight loss may fail.
This may be explained by the inflammation mentioned by Garg — such inflammation is believed to increase the risk of type 2 diabetes. In a similar manner, burnout appears to increase people’s risk of dementia, another disease that is believed to be triggered by chronic inflammation.
Public-health experts at the University of Copenhagen in Denmark followed nearly 7,000 people for 15 years and found that the more symptoms of burnout a person reported, the greater their risk of dementia, says the report in the Journal of Alzheimer’s Disease. Those reporting five to nine symptoms had a 25 per cent higher risk of dementia than those with no symptoms, while participants reporting 10 to 17 symptoms had a 40 per cent higher risk.
It is tempting to assume that occupational burnout is the preserve of older workers counting the days to retirement. However, a Gallup study of 7,500 employees warns that younger generations suffer most: 28 per cent of millennial employees (aged 23 to 38) complained of feeling frequent or constant burnout at work, compared with 21 per cent of older staff.
If the prospect of a new “generation burnout” was not sufficiently worrying, the rate of recovery can be low and slow. A 2016 report in the journal Biological Psychology, for example, says that 18 months after being diagnosed with clinical burnout, patients typically “had got better, but were not ‘well’”.
Dr Almuth McDowall, a professor of organisational psychology at Birkbeck University of London, believes that many sufferers are diagnosed too late. “Chronically high levels of the stress hormone cortisol change the brain’s biochemistry. This makes people see the world very negatively. The more they think negatively, the more it strengthens brain pathways that make it react in that way,” she explains.
“It takes a long time to recover because people often seek help when it’s far too late and the biochemical damage has been done — the pathways have been wired in,” McDowall adds.
The condition is insidious, she says. “It creeps up on you slowly but surely. It affects your relationships. You get more cynical, less sociable. You withdraw from those who might help, rather than seeking them.
“The organisational context is that we work in an era of sky-high expectations. Over the past ten years the demands and complexity of people’s jobs have risen exponentially.”
The problem is being recognised increasingly. Last year the World Health Organisation included burnout in its international classification of diseases as “a syndrome resulting from chronic workplace stress that has not been successfully managed”. Although Britain does not recognise burnout as an occupational disease, nine European countries do. Compensation for burnout has been awarded in Denmark, France, Latvia, Portugal and Sweden.
International surveys report that the worst affected jobs are in healthcare, social work, policing, teaching and customer services, and executive posts in law and management.
Several studies have found that about a third of NHS staff suffer. The most recent was published in the Journal of the Intensive Care Society in November by Dr Laura Vincent, a medical consultant at the John Radcliffe Hospital in Oxford. Her survey of nearly 1,000 intensive care staff shows that one in three scores highly on at least one of these symptoms: feeling disengaged and aggressive; feeling inadequate and ineffective; and being emotionally exhausted.
“Staff engagement is crucial for patient safety, as well as for patient care and staff retention,” Vincent warns. NHS burnout creates a vicious cycle, she adds: “If you have a high rate, you have more unworked shifts, more vacancies and a higher burden on staff that causes more burnout.”
Vincent hopes to engage an occupational psychologist to help to change NHS intensive care culture. “It’s about trying to sustain people through their careers. You can’t take the stresses and strains out of this kind of caring; it’s always going to be emotionally demanding and physically exhausting.”
Anyone at risk from burnout can help to protect their hearts, bodies and brains by maintaining their general health, says Mika Kivimaki, a professor of social epidemiology at University College London and the director of the Whitehall II study, which has followed the health of more than 10,000 British civil servants since 1985.
“I think stress and emotions are harmful in terms of triggering heart troubles in people who already have cardiovascular problems. Job burnout can be one of the triggers. But it is important to remember that lifestyle factors, such as smoking, high blood pressure and high cholesterol, will play a considerably bigger role in causing heart disease than will adult stress.”
If you want to protect your heart from chronic stress, the standard of keeping slim, exercising and not smoking all help best. But if you want to protect yourself from burnout, a whole new raft of strategies may be needed.
SPOT THE SIGNS
Occupational psychologists at the Mayo Clinic in Minnesota have compiled this checklist. They warn that saying “yes” to any of these six questions means you may be at risk of job burnout:
- Have you become cynical or critical at work?
- Have you become irritable or impatient with co-workers or clients?
- Do you lack satisfaction from your achievements?
- Do you feel disillusioned about your job?
- Are you using food, drugs or alcohol to feel better or to simply not feel?
- Are you troubled by unexplained headaches, digestive problems, or other physical complaints?
WHAT TO DO
Find a friend We all need “momentary work happiness” to keep us going, according to a Dutch study in the The Journal of Psychology in 2016. Failing to find any fun during the day puts us at the highest risk of burnout, the report warns. Most people rate having a close friend among their workmates as the best morale-raiser of all.
Change job If your work is a strain, you must make things easier rather than trying to be a hero, Dr Almuth McDowall suggests. “Think about the aspects of your role with which you are struggling,” she says. “Is it realistic for you to deliver all of your workload, or should you be delegating? If you can’t change the role, consider leaving.”
Practise gratitude Psychologists at Duke University in North Carolina studied nurses and doctors who were asked to record in diaries three incidents that had made them feel grateful each day. They reported in the BMJ Open last year that the volunteers suffered less burnout and a better sense of work-life balance, not least because the practice made them focus on their job’s most positive aspects.
Rebalance work/life Siobhan Murray, a psychologist and the author of The Burnout Solution, says that work stresses can be kept in check (and in perspective) by nourishing our personal lives. It’s healthy to be selfish by freeing up time to spend on hobbies, sport and anything else that makes us feel fulfilled, she says.