BURN OUT

1. What is burn out/exhaustion?

If stress is not dealt with, one can end up with more severe stress damages, even repairable brain damages, that can eventually lead to exhaustion disorder, or more popularly called burnout, which is a a prolonged response to chronic stressors often related to work.

There is so far no agreed international diagnosis among other thing due to fear of insurance claims.

However, since these symptoms create prolonged intense frustration and severely impaired daily functioning, often taking 1-3 years to gradually recover from, it is very important to stall any deterioration with compensatory rest as well as adjusted activity level and duration.

In Sweden exhaustion syndrome is acknowledged as a diagnosis within the healthcare system distinguished by a significant deterioration of life, more specifically significantly reduced mental energy including:

  • Mental and/or physical symptoms of exhaustion for more than 2 weeks

AND

  • Due to prolonged mental pressure and/or physical stress for at least 6 months
  • As well as deterioration that cause clinically significant distress or impairment within at least four of the following areas during the same two-week period:
    • Decreased concentration: Difficulties to follow red thread, read, follow plots in movie/series
    • Memory impairment: Difficulties remembering e.g. words, names, meals, errands
      Impaired handling of demands and time pressure
    • More easily moved/emotional instability and/or increased irritation and anger
    • Greater bodily fatigue: physical energy, tiredness
      Reduced mental endurance and energy levels in everyday activities
    • More need for recovery time as well as need for extra rest
      Impaired sleep quality
    • Greater sensitivity to sensory input e.g. sound, vision, crowds, traffic
    • Bodily problems such as pains, aches, dizziness, palpitation, stomach problems etc.

More about how to heal exhaustion below.

 

2. The three phases of healing exhaustion

Having worked with exhausted patients daily for many years I have come to seen a recovery pattern with roughly 3 phases.:

  1. Insight in injury
  2. Leveling off
  3. Recovery

To move to the next phase as well as avoid serious relapses in the future it is necessary to work with personal values and preferences that drives the unhealthy activity level, such as:

  • need of control
  • perfectionism
  • overactivity/overscheduling
  • attitudes towards rest and exercise -the need to please/be liked
  • integrity, including the ability to defend own boundaries and say no

 

1.  Phase 1: Insight in injury requires going from denial to understanding of injury

Many persons with exhaustion are not even aware of having this extent of problems and ignore the common symptoms that also could have other causes such as different types of headaches, dizziness, vision problems, panic attacks, memory problems, ability to concentrate and follow conversations etc.

Many realise they might have a stress problem, however often expressed with an apparent conviction that “Nothing is wrong with me, just give me some quick-fix – a couple of advises/tools and I will be on my way again…” But this will not happen since there is no magic wand. If stress injuries have been so severe as in exhaustion the brain and body need time to repair themselves.

Just as with all other kinds of injuries, there is a minimum healing time, often about one year but up to three years with a gradual recovery and frequent set-backs as continued over-activity together with insufficient rest that were the main causes behind exhaustion add new stress on the body and brain.

 

How to move from Phase 1: Insight in injury to phase 2: Leveling off

To move to from the 1st phase, Insight in injury, to the 2d phase, Leveling off, in the sense that the injuries are not getting worse but starting to heal as well as avoiding serious relapses in the future many dimensions have to be considered. In addition to work with personal values and preferences, see above, it is also important to learn to:

  1. Focus on protecting sleep to repair the brain and body. Avoid alarm clock and instead let the body wake up by itself when it is rested as well as nap/rest after lunch if not impairing night sleep.
  2. Listen to the body, see the tiredness scale:
    • Rest if more tired than awake (level 5 to 10 on the scale: 1 = slightly tired to 10 = would like to sleep standing) to avoid worsening injuries. The reason for including 5 in the more tired side is that very few people with exhaustion notice their actual tiredness level correctly, likely due to a disconnect between the body and mind, hence rate themselves as less tired than they really are. Rest means performing an enjoyable activity activating the parts of the brain and body that still want stimuli while resting the other more tired parts, i.e. an activity that feels restorative and recovering = giving more energy than the activity takes to perform
    • When more awake than tired (level 1 to 4 on the scale: 1 to 10) take daily walks of 30 minutes since physical activity increases the amount of neurons and cell production facilitating the repair the body and brain, lifts mood, improves sleep, avoids isolation etc.
  3. Identify and handle/eliminate stress sources, see under stress.

 

2. Phase 2: Leveling off

The 2d phase has started when the injuries are not getting worse but starting to heal. This can be the case even if the days can be bumpy with set-backs for days when one has been been too overactive (again) as one is eager and easily tempted to get back to life as it was before the stress-injuries. Hence the 2d phase is about activity planning often in interaction with the surrounding.

Hence the 2d phase is about activity planning often in interaction with the surroundings.

It often takes over a half year to come to the 2d phase since it takes time to understand and change habits, more specifically learning to listen to the body’s tiredness level and take appropriate action, see last posts:

  1. Prioritize sleep
  2. Use the tiredness scale: Rest when tired – possibly stimulating activities for the part of the body and brain that still wants stimuli, exercise/walks and when alert
  3. Manage current stress sources
  4. Work with personal values and preferences such as need of control, perfectionism, difficulties saying no etc.

There are research indicating that in burnout there is often a real disconnect between body and mind in the sense that the mind is ignoring bodily signals of tiredness. This is thought to be one of the explanations behind why an exhausted body can produce such extreme physical symptoms such as panic attacks, stomach pains, sensory alterations and dizziness, i.e. the body feels that it is forced to produce so severe symptoms to halt over-activity and disabling the body to function normally since the mind otherwise forces the body to keep going which can be physiologically dangerous for survival. Hence one of the most difficult parts is to learn to listen to the body and the tiredness level.

 

The importance of activity planning

Equally important is to get all people around to respect your tiredness level. To complicate the situation even more, exhausted people do not often look visibly tired – they have very good poker face not showing how tired they are.

Hence, it is important to:

  1. Manage expectations from others – teach them the tiredness scale, see earlier post
  2. Understanding the importance of seeking locations/venues that are less stimuli intense: sit in a silent corner, back facing the entrance etc.
  3. Say ’no’ or ’maybe’ directly when asked to participate, only ’yes’ after considering the energy level that day
  4. Reschedule activities depending on how you feel at the moment – not a couple a days ago when you felt fine. I usually advise only to say yes to activities the same day since it is impossible in exhaustion to now the level off tiredness in advance
  5. Dare to pause and/or leave activities when tired
  6. Lessen the number and length of activities per day
    • Plan activities max 1-2 hours per day with compensatory rest before and after -Only ONE activity/shore per day. For example, preparation such as grocery shopping is a separate activity enough for that day (!) -Take a compensatory rest before and after until rested. This need can vary in length – from hours to days
    • Decrease the total amount of physical and psychological stress that is added every day – limit rumination and worry to only one hour per day, see earlier post under anxiety
    • Have two whole days of rest per week where the activity is minimal: Wednesday and Sunday
    • Avoid firm deadlines and be in good time – no hurry
    • When asked to participate in activity: say maybe – only yes/confirm/cancel the same day, not before that since you cannot know your tiredness level in advance
  7. Be active:
    • Engage in pleasurable activities, the things you used to enjoy, to stimulate the parts of your brain that still wants activity and do not need to rest since there is often an imbalance in the brain when having exhaustion problems, more about that in upcoming posts
    • Introduce exercise gently and gradually: start with walks then add cardio like walking, biking and swimming as well as muscles strength exercises, but ONLY WHEN more awake than tired at that moment, see the tiredness scale
  8. Work with your self-image:
    • Adjust your values to include your well-being and being kind to yourself: let go of perfectionism, performance levels: 80% is often good enough, issues of control etc.
    • Broaden and deepen your self-image: who are you when not performing, see exercises under Self-esteem and Healthy routines

 

The importance of guarding boundaries

In addition to activity planning is the 2d phase about guarding boundaries to close ones, friends and relatives:

  1. Communicate a realistic ’time to heal’ and keep reminding them, which often is at least one year after having actively stopped old exhausting behaviors and started to rest and exercise
  2. Guard boundaries socially – learn to say maybe instead of yes: “I would love to, but have to wait to see how my energy level is that day – can I get back to you?”
  3. Have them respect the importance of adjusting stimuli-level, prioritizing rest daily and not being tempted or even pressured to over-activity
  4. Have them cut back on their expectations on how many as well as length of activities
  5. Have their help to remember the tiredness scale to ensure sufficient rest and support both to change plans when necessary and leave gatherings and events early if too tired/overstimulated.

 

3. Phase 3: Recovery

The third phase: Recovery requires careful planning to the return to life as before, but with important lifelong insights into:

  1. The importance of constantly listening to your body to get an optimal stimuli-level, see the stress- and tiredness scales
  2. Adjustments to an appropriate amount of activity-level for all future not to risk relapse
  3. Managing expectations from close relationships, managers and colleagues

 

In addition, two very important dimensions to remember to get well are:

  1. Manage the healthcare system
  2. Have a flexible plan when returning to work

 

1. Manage the healthcare system – dare to question

It is my opinion that many doctors have very little experience with designing an optimal recovery process when someone is returning from sick-leave due to stress and exhaustion to go back to work.

This is unfortunate since this can hinder the most rapid road to recovery by creating unnecessary stress.

However, I am very convinced that the doctors do not create this intentionally but rather is a combination of a lack of experience with this as well as the pressures from the employers and the social security system for rapid recovery due to the associated costs. Little do they know how this hurry instead leads to higher total costs and more suffering than necessary…

Many doctors (and even therapists) do not even understand the difference in treatment needs between anxiety and depression where it is often good to stay active, maintain contact with the workplace, striving to be social and keep exercising as usual.

With stress and exhaustion, the opposite is true, where the main focus should be on rest rather than activity, and only add activity and exercise when not too tired, see earlier posts.

To complicate the picture even further, depression and anxiety can be symptoms of stress. Making it even more confusing what to focus on. If unsure, it is always better/most effective to focus on rest and recovery as the primary strategy – and only add activity and exercise when more awake than tired, see the tiredness scale.

Here are some concrete suggestions for minimizing the risk that medical staff increase the stress level or even prolong the recovery process, which unfortunately frequently is the case, which is not helpful, is:

  • Be firm about and insist on getting a time plan. Ideally this should include sufficient time to rest – at least 1-2 month between follow-ups:
  • Have pre-booked meetings before any changes in plans of changing sick leave/work percentage
  • Have a mutual understanding of the pace to increase the workload: for stress appropriate intervals are 25%, 50% 75%. If you do not feel heard or the doctor does not consider your opinion in designing the plan, I suggest you ask for a second opinion from another doctor, alternatively involve your manager and their health care offerings.

 

2. Have a flexible plan when returning to work

In my experience, the quickest return to work entails:

  • Dare to start to try to work if not too tired or having physical symptoms such as headaches, dizziness, stress-related panic symptoms etc.
  • Expect to have to rest in your free-time the first 1-2 weeks, which often means avoiding other activities these weeks, but listen to your symptoms and decrease the work % if not feeling better after 2 weeks
  • Have the possibility/agreement to both increase and decrease work percentage due to your reactions as noted above
  • Have Wednesdays off or work from home on Wednesdays, which also should be the last day and afternoon to add when returning to working full time

Here are some more concrete suggestions on the same theme:

  1. Make sure you have a doctor’s appointment before any changes in work amount to ensure mutual understanding as well as an agreement on how to handle any set-backs or other unforeseen developments
  2. Stop ruminations and handle fear of how your case will be handled by using the worrying-hour, see under Anxiety
  3. Be comforted by knowing that for some it is possible to work and recover even if this will slow the recovery process

 

When you have to keep working…

Working with patients who cannot afford being on sick-leave since they have no social security covering or they will lose an important opportunity or their customer base, such as self-employed hair dressers, brokers, consultants etc, I have learnt that it is possible to work through exhaustion, but it will be done with a lot of suffering, takes double the time to recover and still requires permanent lifestyle changes.