Arie Shirom

Burnout and risk of cardiovascular disease: evidence, possible causal paths, and promising research directions.

Burnout is characterized by emotional exhaustion, physical fatigue, and cognitive weariness, resulting from prolonged exposure to work-related stress. The authors review the accumulated evidence suggesting that burnout and the related concept of vital exhaustion are associated with increased risk of cardiovascular disease and cardiovascular-related events. The authors present evidence supporting several potential mechanisms linking burnout with ill health, including the metabolic syndrome, dysregulation of the hypothalamic-pituitary-adrenal axis along with sympathetic nervous system activation, sleep disturbances, systemic inflammation, impaired immunity functions, blood coagulation and fibrinolysis, and poor health behaviors. The association of burnout and vital exhaustion with these disease mediators suggests that their impact on health may be more extensive than currently indicated.

Chronic burnout, somatic arousal and elevated salivary cortisol levels.

Burnout syndrome, comprised of the symptoms of emotional exhaustion, physical fatigue, and cognitive weariness, is believed to be a result of ineffective coping with enduring stress. This study of 111 nonshift blue-collar workers free of cardiovascular disease (CVD) examined whether chronic burnout is associated with a state of somatic and physiological hyperarousal. Results showed that 37 workers exhibited symptoms of chronic burnout, with symptoms lasting at least 6 months. These workers, compared to those with no burnout symptoms (n = 52) or nonchronic burnout symptoms (n = 22), had higher levels of tension at work, postwork irritability, more sleep disturbances and complaints of waking up exhausted, and higher cortisol levels during the work day. These results suggest that chronic burnout is associated with heightened somatic arousal and elevated salivary cortisol levels. This may be part of the mechanism underlying the emerging association between burnout and risk of CVD.

Burnout and Risk Factors for Cardiovascular Diseases

The burnout syndrome denotes a constellation of physical fatigue, emotional exhaustion, and cognitive weariness resulting from chronic stress. Although it overlaps considerably with chronic fatigue as defined in internal medicine, its links with physical illness have not been systematically investigated. This exploratory study, conducted among 104 male workers free from cardiovascular disease (CVD), tested the association between burnout and two of its common concomitants--tension and listlessness--and cardiovascular risk factors. After ruling out five possible confounders (age, relative weight, smoking, alcohol use, and sports activity), the authors found that scores on burnout plus tension (tense-burnout) were associated with somatic complaints, cholesterol, glucose, triglycerides, uric acid, and, marginally, with ECG abnormalities. Workers scoring high on tense-burnout also had a significantly higher low density lipoprotein (LDL) level. Conversely, scores on burnout plus listlessness were significantly associated with glucose and negatively with diastolic blood pressure. The findings warrant further study of burnout as a predictor of cardiovascular morbidity and mortality.

The Association Between Burnout, Depression, Anxiety, and Inflammation Biomarkers: C-Reactive Protein and Fibrinogen in Men and Women

Following the demonstrated association of employee burnout or vital exhaustion with several risk factors for cardiovascular disease (CVD) and CVD risk, the authors investigated the possibility that one of the mechanisms linking burnout with CVD morbidity is microinflammation, gauged in this study by high-sensitivity C-reactive protein (hs-CRP) and fibrinogen concentrations. Their sample included 630 women and 933 men, all apparently healthy, who underwent periodic health examinations. The authors controlled for possible confounders including 2 other negative affective states: depression and anxiety. In women, burnout was positively associated with hs-CRP and fibrinogen concentrations, and anxiety was negatively associated with them. In men, depression was positively associated with hs-CRP and fibrinogen concentrations, but not with burnout or anxiety. Thus, burnout, depression, and anxiety are differentially associated with microinflammation biomarkers, dependent on gender.

Burnout and risk of type 2 diabetes: a prospective study of apparently healthy employed persons.

Objective: This prospective study was designed to test the extent to which the onset of type 2 diabetes in apparently healthy individuals was predicted by burnout, a unique affective response to combined exposure to chronic stressors. Methods: The study participants were 677 employed men and women who were followed up for 3 to 5 years (mean = 3.6 years) for the onset of diagnosed type 2 diabetes. Burnout was assessed by the Shirom-Melamed Burnout Measure with its three subscales: emotional exhaustion, physical fatigue, and cognitive weariness. Results: The burnout symptoms were remarkably consistent over the follow-up period irrespective of changes in place of work and in employment status. During the follow-up period, 17 workers developed type 2 diabetes. Logistic regression results indicated that burnout was associated with a 1.84-fold increased risk of diabetes (95% confidence interval [CI] = 1.19–2.85) even after adjusting for age, sex, body mass index, smoking, alcohol use, leisure time physical activity, initial job category, and follow-up duration. In a subsample of 507 workers, the relative risk of diabetes was found to be much higher after additional control for blood pressure levels (odds ratio = 4.32, 95% CI = 1.75–10.67), available only for this subsample. Conclusions: These findings suggest that chronic burnout might be a risk factor for the onset of type 2 diabetes in apparently healthy individuals. CI = confidence interval; CVD = cardiovascular disease; SMBM = Shirom-Melamed Burnout Measure; HbA1c = glycosylated hemoglobin A1c; VE = vital exhaustion; MI = myocardial infarction; MBI = Maslach Burnout Inventory; BMI = body mass index; SBP = systolic blood pressure; DBP = diastolic blood pressure; OR = odds ratio; APR = acute phase response; CRP = C-reactive protein; HDL = high-density lipoprotein; HPA = hypothalamic–pituitary–adrenal.

Reflections on the study of burnout The views expressed in Work & Stress commentaries are those of the author(s), and do not necessarily represent those of any other person or organization, or of the journal.

Abstract Four papers on burnout appear in this issue of Work & Stress. This commentary gives an indication of how they add to the pool of knowledge regarding the prevalence of burnout and its chronic nature. A lapse common to most papers on this subject is then discussed: the lack of attention to burnouts relationships with other negative affective states, primarily depression. Finally, some of the major similarities and differences among various measures of burnout represented in this special edition are discussed. The concluding comment addresses future theoretical challenges to burnout researchers.

Effects of work overload and burnout on cholesterol and triglycerides levels: The moderating efffects of emotional reactivity among male and female employees.

The effects of objective and subjective overload, and of physical and emotional burnout, on cholesterol and triglycerides levels were studied in a quasiprospective design. The possible moderating effects of emotional reactivity on these relationships were also investigated. The studys hypotheses were tested separately for male and female employees. Time 1 (T1) data were collected from 665 healthy employees (30% women) while they were undergoing periodic health examinations in a health-screening center. Time 2 (T2) measures of cholesterol and triglycerides were collected 2 to 3 years after T1. The hypotheses were tested by regressing each T2 criterion on its T1 level; the control variables of age, obesity, diet, alcohol consumption, and smoking; and the other predictors. For female employees, the T2-T1 changes in the serum lipids were positively predicted by emotional burnout, as expected, but negatively predicted by physical fatigue. For male employees, both types of T1 burnout were positive predictors of the T2-T1 change in total cholesterol.

On the Discriminant Validity of Burnout, Depression and Anxiety: A Re-examination of the Burnout Measure

We investigated the discriminant validity of the frequently used Burnout Measure (BM) (Pines et al ., 1981), in relation to depressive symptomatology and anxiety. Following Russells (1980) work on the multidimensional space of affective states, BMs items were hypothesized to reside in three separate regions of that space, labeled anxiety, depression, and wornout, with wornout representing a combination of physical and emotional exhaustion. Respondents were 704 senior army officers, who completed a questionnaire that included BM items, standard measures of depression and anxiety, and measures of military-related stresses. Their responses to the BM items and to the depression and anxiety scales were subjected to multidimensional scaling analysis. Excepting an unexpected finding related to a fourth construct, loss of vigor, the results were supportive of the hypothesis and led to the construction of three unidimensional measures, respectively gauging anxiety, depression, and wornout. The correlations of the three measures with the stress measures supported their discriminant validity. We suggest that future research using the BM should focus on the set of items that were found to load on the dimension of wornout, to the exclusion of items tapping depression and anxiety.

Heart rate and microinflammation in men: a relevant atherothrombotic link

Objective and background: To explore the possibility that increased resting heart rate (HR) is associated with a microinflammatory response. Such an association could explain, at least in part, the recently described worse cardiovascular prognosis in individuals with increased HR. Methods: Concentrations of fibrinogen and high-sensitivity C-reactive protein, as well as the absolute number of polymorphonuclear leucocytes, were analysed in a cohort of 4553 apparently healthy men and in those with atherothrombotic risk factors. Results: Following adjustment for age and body mass index, lipid profile and cardiovascular risk factors, a significant (p<0.001) difference was noted between individuals in the first quintile of HR (⩽58 beats/min) and those in the fifth quintile (⩾79 beats/min) regarding all the above-mentioned inflammatory biomarkers, the respective mean values being 7.38 and 8.11 μmol/l, 1.12 and 1.61 mg/l, and 4.23 and 4.74×109/l. Conclusions: Resting HR is associated with a microinflammatory response in apparently healthy men and in those with atherothrombotic risk factors. Sympathetic activation might be a common factor explaining such an association. If confirmed in additional studies, this association might be a relevant target for therapeutic manipulations.

The Effects of Physical Fitness and Feeling Vigorous on Self-Rated Health

OBJECTIVE We prospectively studied the hypothesized beneficial effects of feeling vigorous and of objective physical fitness (gauged based on functional capacity) on subsequently assessed self-rated health (SRH), controlling for possible confounders known to be precursors of SRH and of our predictors. We also investigated the reverse-causation hypothesis that SRH predicts subsequent vigor and functional capacity. DESIGN Participants were apparently healthy employees (N = 779) who underwent a routine health check at two points of time, Time 1 (T1) and Time 2 (T2), about 18 months apart. We used regression analysis, predicting T2 SRH by T1 SRH, the control variables, and T1vigor and functional capacity. MAIN OUTCOME MEASURES Vigor was assessed using the Shirom-Melamed Vigor Measure; objective physical fitness was indicated by functional capacity following a treadmill exercise, and self-rated health was measured by a single item. RESULTS As hypothesized, we found that the change in T2 SRH was positively predicted by T1 vigor, functional capacity, and their interactive term. Testing the reverse causation paths, we found that T1 SRH did not predict subsequent functional capacity and was a relatively weak predictor of subsequent vigor. CONCLUSION The affective state of vigor and objectively assessed functional capacity interact to predict subsequent changes in self-rated health.