Exhaustion disorder

Exhaustion disorder or stress-induced exhaustion disorder (SED, Swedish: Utmattningssyndrom) is a diagnosis used in Swedish healthcare to indicate a maladaptive stress disorder more severe than adjustment disorder. Common signs include exhaustion, reduced cognitive 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 many similarities between exhaustion disorder and occupational burnout. There are also significant overlaps between symptoms of exhaustion disorder and depression, two conditions that frequently occur simultaneously.

The diagnosis was introduced in 2003 and with support from the Swedish National Board of Health and Welfare it was included in the Swedish edition of ICD-10 in 2005. Since its introduction it has become a leading cause for sick leave in Sweden. Among patients receiving compensation from the Swedish Social Insurance Agency 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.[1]

Treatment approaches vary between healthcare providers and different regions of the country. Common elements include psychoeducation, physical activity and psychotherapy individually or group therapy. Multimodal rehabilitation programs have also been offered by specialized providers. Several treatment options are effective at reducing symptoms, but no treatment option has proven to successfully reduce the duration until return to work.[2][3] Due to the limited effect of available treatment options, the need to focus on preventative measures is considered the most important intervention to reduce the burden of disease.[4]

Signs, symptoms and diagnosis

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. The distinction between benign and maladaptive responses to stress is not necessarily evident since there is no sharp line separating the two entities.[5] A prolonged period of elevated stress can lead to exhaustion, sleep disorders and a decline in cognitive abilities.[6]

The symptoms of exhaustion disorder are numerous and include fatigue, reduced stress tolerance and various physical symptoms.[7] Some of the more common physical symptoms are headaches, dizziness and bowel issues. Most patients also suffer from sleeping problems.[8] Exhaustion disorder and depression have several overlapping symptoms and commonly occur simultaneously, but many people suffering from exhaustion disorder are not depressed.[9]

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.[10] The initial phase can last several years and various complaints such as fatigue, anxiety, irritability, sleeplessness and restlessness 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.[11] At the peak of distress many decide to seek emergency care for breathlessness or chest pain, where the following evaluation fails to identify any physical cause.[12] This critical stage tends to be described in terms of a crisis or "collapse" by the affected person and their associates.[8]

Diagnosis

Exhaustion disorder is a clinical diagnosis made by a qualified health care professional based on the patients recollection of the course of disease.[1] Blood samples cannot be used to ascertain the diagnosis, but like ECG may prove useful for purposes of differential diagnostics. The utility of measuring saliva-cortisol has been evaluated, but it serves a purpose only in research settings.[13]

Classification

Exhaustion disorder is included in the Swedish version of ICD-10, designated as F43.8A. The diagnosis is part of the diagnostic group "Reactions to severe stress, and adjustment disorders". 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 or generalised anxiety disorder.[14]

In order to confirm the diagnosis of exhaustion disorder physical and mental exhaustion must be present following a prolonged period of elevated stress.[15] 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.[7][16] At least 4 out of 6 minor criteria are needed to complete the diagnosis.[14] It is considered vital to differentiate between exhaustion disorder and other responses to elevated or severe stress such as adjustment disorder, acute stress disorder and PTSD.[5]

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.[6][17] It is considered likely that the suffering recognized as exhaustion disorder in Swedish healthcare settings in many other countries would be considered symptoms of depression, or be described with alternative terms such as "mental fatigue" and "clinical burnout" or "severe burnout".[5][18]

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) and the Stress-related Exhaustion Disorder (s-ED) scale are used to quantify symptoms of exhaustion among the afflicted and at risk individuals.[14][19] Shirom-Melamed Burnout Questionnaire (SMBQ) is a tool originally developed for occupational burnout sometimes employed as a rating scale in the evaluation of exhaustion disorder.[20]

The Montgommery Åsberg Depression Rating Scale (MADRAS) is used to evaluate simultaneous symptoms of depression and the Hospital Anxiety and Depression Scale (HAD) measure simultaneous signs of both depression or anxiety. The Alcohol Use Disorders Identification Test (AUDIT) screen for overuse of alcohol.[19] The WHO Disability Assessment Schedule (WHODAS 2.0) has been studied as a means to distinguish between exhaustion and the less severe adjustment disorder,[20] but no currently available scales or questionnaires are properly validated for use in differential diagnostics.[21]

Prognosis

The time to recovery is considered relatively long and the guidelines from the Swedish Social Insurance Agency supports a sick leave duration between 6 and 12 months,[22] and the recovery may last even longer.[23] 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 in Sweden.[24] There is limited scientific basis describing the prognosis or allowing for prognostication in cases of exhaustion.[25] Studying the natural course of the disease is complicated by the high rates of co-morbid depression and anxiety disorders.[8] A follow up of patients that had undergone multimodal rehabilitation has shown an improvement of exhaustion- and physical symptoms over the course of 18 months. Still, at the time of long term followup 7–10 years later, almost half of the patients reported symptoms of "exhaustion" and a majority experienced a lasting reduction in stress tolerance.[8] The duration of symptoms before the first contact with healthcare is the most significant predictor of the length of recovery.[26]

Epidemiology

No large epidemiological studies on the prevalence 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 patients. Such studies are likely to overestimate the prevalence of disease.[27] The actual prevalence of exhaustion disorder is unknown.[25]

Persons with exhaustion disorder are at an increased risk of certain physical diseases including diabetes, cardiovascular disease and chronic pain.[28][29]

Sick leave

Of people receiving compensation for mental disorders from the Swedish Social Insurance Agency in 2019, 18% of the women and 13% of the men received compensation due to exhaustion disorder, leaving women at a 40% greater risk of exhaustion.[30] Female public employees of the Regions 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.[31] According to statistics from the Swedish Social Insurance Agency cases peak between the ages of 35–44.[32] 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.[33] 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 between women and men is 4 to 1.[2]

Risk factors

Individuals with children in kindergarten and the first few years of school are at higher risk (ages 3–8).[34] Having more than one child or having recently gone through divorce proceedings also increase the risk of exhaustion.[35] Bosses and managers as well as people working in occupations where a university degree is required are at lower risk.[36] However, there is an increased risk of disease among workers in care professions, even those where a degree is a prerequisite.[37]

In a systematic review from 2014 the Swedish Agency for Health Technology Assessment and Assessment of Social Services found that several work related factors influenced the risk of developing symptoms of depression or exhaustion disorder.[lower-alpha 1] 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.[39] 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.[39] Some factors confer a protective effect. Influence and control over working conditions diminishes the presence of symptoms from both conditions.[31]

History

Background

An older term with many commonalities to exhaustion disorder is burnout. This term with origins in the 1960's was originally used to describe a reaction observed in caretaking professionals.[5] The most disseminated version of burnout is that of Christina Maslach, which is defined by the triad of: emotional exhaustion, cynicism and an experience of reduced professional capacity.[40] The syndrome of burnout was initially exclusively focused on occupation related stress-inducers, but was later expanded to include other kinds of stress.[41] 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 ICD or the DSM, with fixed diagnostic criteria.[16]

Another proposed progenitor of exhaustion is neurasthenia. On the rise during the late 19th and early 20th century it shares many symptoms with exhaustion disorder.[18] The term itself was introduced in 1869 by the american physician George Miller Beard, 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 measuring it subjected the human psyche to overload.[42] During the 1960's French and German psychiatrists would separate cases of depression into various sub-classes, "exhaustion-depression" (German: Erschöpfungsdepression) was one of them.[18]

Introduction and developments

The late 1990's and early 00's saw an increase in the number of people on prolonged sick leave or receiving disability pension. The rise was higher for mental disorders and female public employees were over represented.[43] Cuts to the public sector during the 90's have later been pointed to as the cause. The downsizing should have caused the work load to increase, as workers became sick from overworking fewer and fewer remaining employees would have been left to share the burden.[5]

Efforts to formulate the diagnosis were sparked by an increase in sick leave numbers caused by depression, for customers served by one of the larger insurance agencies. Doctors Marie Åsberg 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 believed their working conditions to be the cause.[44] 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 of the Swedish National Board of Health and Welfare, to investigate the condition and conduct a scientific review.[18][44] The initial moniker was forgone in 2003 in favor of utmattningssyndrom (exhaustion disorder),[45] which gained traction as a diagnosis that same year when the Board of Health and Welfare published the results of the investigations in a book called Utmattningssyndrom: stressrelaterad psykisk ohälsa.[46][47] The diagnosis was introduced into the Swedish edition of ICD-10 in 2005. No scientific articles investigating exhaustion disorder had been published at the time.[48] This formal recognition meant that the condition could thereafter be used as a reason for sick leave.[2] 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."[46]

During 2022 work has been done on a new set of guidelines by a working group lead by Marie Åsberg. Another group lead by psychiatrist Christian Rück has published a scoping review on the condition, questioning its validity and reliability as a medical diagnosis.[45]

Causes

Exhaustion disorder is stress-induced by definition. The underlying physiological mechanisms are incompletely understood. Early on a decreased sensitivity within the HPA axis was identified, resulting in an attenuated release of cortisol in response to stimulation.[49] Subsequent investigations into this abnormality have resulted in mixed results and several papers found no difference compared to healthy controls.[50] Magnetic resonance imaging has indicated changes to the prefrontal cortex, basal ganglia and amygdala. However, the number of studies and their participants is limited and more work is needed to properly validate these findings.[51]

Treatment

Psychoeducation on stress, the role of working conditions and lifestyle factors is a common component in exhaustion treatment. Physical activity is also considered an important part of rehabilitation. Psychotherapy in one-on-one or group settings, including methods for stress management may be a part of the protocol. When it is time to return to work a joint-appointment (Swedish: 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.[52] The guidelines for treatment published by the Swedish National Board of Health and Welfare offers an ensemble of options and are open to interpretation.[53] 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).[53] Since the symptoms are long-lasting it is generally considered appropriate to start partial return to work before complete remission of symptoms.[26]

Many different modalities 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 effects of treatment.[54]

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.[2] Two reviews published in 2019 and 2022 have shown various limitations in the methods of the available research on treatment.[55] 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.[56][57] While there is a lack of evidence for any effect on return to work, therapeutic approaches like CBT (including ACT) have shown a reduction in stress-induced symptoms.[3][58] Similar claims have been made concerning MMR, but there are no controlled trials evaluating it as a treatment for exhaustion.[59] Physical activity is proven to be effective against several mental disorders. In healthy individuals it improves cognition and confers protection against stress-induced symptoms.[60] In cases of fully developed exhaustion disorder there are somewhat paradoxically no positive effects on either symptoms or cognitive ability.[59][60] Improved sleep is considered important for recovery and CBT is effective against sleep disorders in general, but the specific case of the proper way to treat sleep problems in patients with simultaneous exhaustion disorder has not been studied.[61]

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.[4]

Pharmacological treatment

Antidepressants are not considered effective in treating exhaustion, but may be used to treat concurrent depression or anxiety. [62] No scientific studies have investigated the utility of treating exhaustion disorder with antidepressants.[59]

References

Notes
  1. For the purposes of the review, exhaustion disorder was considered analogous to the concept of burnout.[38]

Citations
  1. Engblom, Monika; Englund, Lars; Haara, Kristina (2023). "Inga nya riktlinjer för diagnosen utmattningssyndrom". AllmänMedicin (in Swedish). Svensk förening för allmänmedicin (1). ISSN 0281-3513.
  2. SBU Utvärderar (359) 2022, p. 112.
  3. Lindsäter et al. 2022, pp. 7–8.
  4. Wallensten et al. 2019, p. 340.
  5. Åsberg, Marie; Grape, Tom; Krakau, Ingvar; Nygren, Åke; Rodhe, Margareta; Wahlberg, Anders; Währborg, Peter (11 May 2010). "Stress som orsak till psykisk ohälsa". Läkartidningen (in Swedish). ISSN 1652-7518. Retrieved 7 May 2023.
  6. Lindsäter et al. 2022, p. 1.
  7. Glise 2014, p. 14.
  8. Lindsäter et al. 2022, p. 4.
  9. Glise 2013, pp. 6, 10, 19.
  10. Glise 2014, p. 17.
  11. Glise 2013, p. 19.
  12. Glise 2013, p. 8.
  13. Glise 2013, p. 11.
  14. Grossi et al. 2015, p. 628.
  15. SBU Utvärderar (359) 2022, p. 15.
  16. Lindsäter 2020, p. 15.
  17. Wallensten et al. 2019, p. 331.
  18. Åsberg, Marie; Wahlberg, Kristina; Wiklander, Maria; Nygren, Åke (6 September 2011). "Psykiskt sjuk av stress ... diagnostik, patofysiologi och rehabilitering". Läkartidningen (in Swedish). ISSN 1652-7518. Retrieved 24 August 2016.
  19. Glise 2013, p. 12.
  20. Lindsäter et al. 2022, p. 7.
  21. Lindsäter et al. 2022, pp. 7, 9.
  22. Lindsäter 2020, pp. 16, 37.
  23. Glise 2013, p. 20.
  24. Försäkringskassan 2020, p. 5.
  25. Lindsäter et al. 2022, p. 9.
  26. Wallensten et al. 2019, p. 339.
  27. Lindsäter 2020, p. 18.
  28. Försäkringskassan 2020, p. 21.
  29. Lindsäter 2020, p. 12.
  30. Försäkringskassan 2020, pp. 21–23.
  31. SBU utvärderar (223) 2014, p. 14.
  32. Försäkringskassan 2020, p. 24.
  33. SBU Utvärderar (359) 2022, p. 17.
  34. Försäkringskassan 2020, pp. 6, 31.
  35. Försäkringskassan 2020, p. 52.
  36. Försäkringskassan 2020, p. 35.
  37. Försäkringskassan 2020, p. 37.
  38. SBU utvärderar (223) 2014, pp. 16, 40.
  39. SBU utvärderar (223) 2014, p. 13.
  40. Grossi et al. 2015, p. 626.
  41. Lindsäter 2020, p. 16.
  42. Jernberg 2021, p. 19.
  43. Glise 2013, pp. 5–6.
  44. Jernberg 2021, p. 16.
  45. Englund, Lars (2022). "Välj annan diagnos än utmattningssyndrom i allmänläkares praxis". AllmänMedicin (in Swedish). Svensk förening för allmänmedicin (3). ISSN 0281-3513.
  46. Ohlin, Elisabeth (2008). "Riktlinjer för utmattningssyndrom klara" (PDF). Läkartidningen (in Swedish). ISSN 0023-7205.
  47. Åsberg, Marie; Nygren, Åke; Nager, Anna (26 February 2013). "Att skilja mellan depression och utmattningssyndrom". Läkartidningen (in Swedish). ISSN 1652-7518. Retrieved 8 May 2023.
  48. Jernberg 2021, p. 18.
  49. Glise 2013, p. 7.
  50. Lindsäter et al. 2022, p. 6.
  51. Lindsäter et al. 2022, pp. 6–7.
  52. Glise 2013, pp. 15–17.
  53. Jernberg 2021, p. 17.
  54. Wallensten et al. 2019, p. 333.
  55. SBU Utvärderar (359) 2022, pp. 112, 150.
  56. Lindsäter 2020, p. 29.
  57. Wallensten et al. 2019, p. 335.
  58. Wallensten et al. 2019, pp. 333–335.
  59. Lindsäter et al. 2022, p. 8.
  60. Wallensten et al. 2019, p. 336.
  61. Wallensten et al. 2019, p. 338.
  62. Glise 2013, p. 17.

Sources
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