Harmful drinking may be a cause and an effect of psychological distress, and compromises the effects of treatment for psychiatric conditions. There is a paucity of studies investigating patterns of alcohol consumption among patients with stress-induced exhaustion disorder (SED). The aims of this investigation were (1) to assess the prevalence of self-rated hazardous drinking in a sample of 808 Swedish patients with SED (mean age 43 ± 9 years, 84% women), and (2) to investigate differences in sociodemographic variables, psychological symptoms, health-related quality of life, and sleep variables between patients with different drinking patterns The design was cross-sectional and data were collected with questionnaires at pre-treatment. Twelve percent of female and 13% of male patients reported Alcohol Use Disorder Identification Test (AUDIT) scores indicating hazardous drinking. Female patients with hazardous drinking reported higher levels of anxiety and depression and lower mental wellbeing, than other women. Female patients reporting no drinking reported poorer physical function and more pain, than other women. No differences were seen between male patients with different drinking patterns. Although patients with SED report a lower frequency of harmful drinking than other psychiatric samples, alcohol consumption needs to be addressed in the assessment and treatment of this condition.

Stress-related exhaustion disorder – clinical manifestation of burnout? A review of assessment methods, sleep impairments, cognitive disturbances, and neuro-biological and physiological changes in clinical burnout The aim of this paper was to provide an overview of the literature on clinically significant burnout, focusing on its assessment, associations with sleep disturbances, cognitive impairments, as well as neurobiological and physiological correlates. Fifty-nine English language articles and six book chapters were included. The results indicate that exhaustion disorder (ED), as described in the Swedish version of the International Classification of Diseases, seems to be the most valid clinical equivalent of burnout. The data supports the notion that sleep impairments are causative and maintaining factors for this condition. Patients with clinical burnout/ED suffer from cognitive impairments in the areas of memory and executive functioning. The studies on neuro-biological mechanisms have reported functional uncoupling of networks relating the limbic system to the pre-frontal cortex, and decreased volumes of structures within the basal ganglia. Although there is a growing body of literature on the physiological correlates of clinical burnout/ED, there is to date no biomarker for this condition. More studies on the role of sleep disturbances, cognitive impairments, and neurobiological and physiological correlates in clinical burnout/ED are warranted.

The present study investigates the cerebral effects of chronic occupational stress and its possible reversibility. Forty-eight patients with occupational exhaustion syndrome (29 women) and 80 controls (47 women) underwent structural magnetic resonance imaging (MRI) and neuropsychological testing. Forty-four participants (25 patients, 19 controls) also completed a second MRI scan after 1-2 years. Only patients received cognitive therapy. The stressed group at intake had reduced thickness in the right prefrontal cortex (PFC) and left superior temporal gyrus (STG), enlarged amygdala volumes, and reduced caudate volumes. Except for the caudate volume, these abnormalities were more pronounced in females. They were all related to perceived stress, which was similar for both genders. Thickness of the PFC also correlated with an impaired ability to down-modulate negative emotions. Thinning of PFC and reduction of caudate volume normalized in the follow-up. The amygdala enlargement and the left STG thinning remained. Longitudinal changes were not detected among controls. Chronic occupational stress was associated with partially reversible structural abnormalities in key regions for stress processing. These changes were dynamically correlated with the degree of perceived stress, highlighting a possible causal link. They seem more pronounced in women, and could be a substrate for an increased cerebral vulnerability to stress-related psychiatric disorders.

Clinical burnout is one of the leading causes of work absenteeism in high‐ and middle‐income countries. There is hence a great need for the identification of effective intervention strategies to increase return‐to‐work (RTW) in this population. This review aimed to assess the effectiveness of tertiary interventions for individuals with clinically significant burnout on RTW and psychological symptoms of exhaustion, depression and anxiety. Four electronic databases (Ovid MEDLINE, PsychINFO, PubMed and CINAHL Plus) were searched in April 2016 for randomized and non‐randomized controlled trials of tertiary interventions in clinical burnout. Article screening and data extraction were conducted independently by two reviewers. Pooled odds ratios (ORs) and hazard ratios (HRs) were estimated with random‐effects meta‐analyses. Eight articles met the inclusion criteria. There was some evidence of publication bias. Included trials were of variable methodological quality. A significant effect of tertiary interventions compared with treatment as usual or wait‐list controls on time until RTW was found, HR = 4.5, 95% confidence interval (CI) = 2.15–9.45; however, considerable heterogeneity was detected. The effect of tertiary interventions on full RTW was not significant, OR = 1.33, 95% CI = 0.59–2.98. No significant effects on psychological symptoms of exhaustion, depression or anxiety were observed. In conclusion, tertiary interventions for individuals with clinically significant burnout may be effective in facilitating RTW. Successful interventions incorporated advice from labor experts and enabled patients to initiate a workplace dialogue with their employers.

The aim of this paper was to provide an overview of the literature on clinically significant burnout, focusing on its assessment, associations with sleep disturbances, cognitive impairments, as well as neurobiological and physiological correlates. Fifty-nine English language articles and six book chapters were included. The results indicate that exhaustion disorder (ED), as described in the Swedish version of the International Classification of Diseases, seems to be the most valid clinical equivalent of burnout. The data supports the notion that sleep impairments are causative and maintaining factors for this condition. Patients with clinical burnout/ED suffer from cognitive impairments in the areas of memory and executive functioning. The studies on neuro-biological mechanisms have reported functional uncoupling of networks relating the limbic system to the pre-frontal cortex, and decreased volumes of structures within the basal ganglia. Although there is a growing body of literature on the physiological correlates of clinical burnout/ED, there is to date no biomarker for this condition. More studies on the role of sleep disturbances, cognitive impairments, and neurobiological and physiological correlates in clinical burnout/ED are warranted.

Despite mounting reports about the negative effects of chronic occupational stress on cognitive and emotional functions, the underlying mechanisms are unknown. Recent findings from structural MRI raise the question whether this condition could be associated with a functional uncoupling of the limbic networks and an impaired modulation of emotional stress. To address this, 40 subjects suffering from burnout symptoms attributed to chronic occupational stress and 70 controls were investigated using resting state functional MRI. The participants' ability to up- regulate, down-regulate, and maintain emotion was evaluated by recording their acoustic startle response while viewing neutral and negatively loaded images. Functional connectivity was calculated from amygdala seed regions, using explorative linear correlation analysis. Stressed subjects were less capable of down-regulating negative emotion, but had normal acoustic startle responses when asked to up-regulate or maintain emotion and when no regulation was required. The functional connectivity between the amygdala and the anterior cingulate cortex correlated with the ability to down-regulate negative emotion. This connectivity was significantly weaker in the burnout group, as was the amygdala connectivity with the dorsolateral prefrontal cortex and the motor cortex, whereas connectivity from the amygdala to the cerebellum and the insular cortex were stronger. In subjects suffering from chronic occupational stress, the functional couplings within the emotion- and stress-processing limbic networks seem to be altered, and associated with a reduced ability to down-regulate the response to emotional stress, providing a biological substrate for a further facilitation of the stress condition.

BACKGROUND:Stress-related mental disorders rank among the leading causes of sickness absence in several European countries. The aim of this study was to investigate predictors of all-cause and diagnosis-specific disability pension in sickness absentees with stress-related mental disorders.METHODS:A cohort of 36304 non-retired individuals aged 16-64 years at 31.12.2004 with at-least one sickness absence spell due to stress-related mental disorders (SRMD) initiated in 2005 in Sweden was followed-up with regard to disability pension (2006-2010) by linkage of registers. Uni- and multivariate Hazard ratios (HR) with 95% Confidence Intervals, CI, were estimated using Cox regression for several risk markers.RESULTS:During the follow-up period, 2735 individuals (7.5%) were granted a disability pension, predominantly due to mental diagnoses (n = 2004, 73.3%). In the multivariate analyses, female sex, age exceeding 35 years, low educational level, being born in a country outside EU25 and Northern Europe, residing outside big cities, living alone, having had a long duration of the first spell due to SRMD (>90 days); mental disorders necessitating frequent specialised health care as well as comorbid somatic disorders were found to be predictive of granting disability pension. Some different patterns emerged for risk factors related to diagnosis-specific disability pension and for younger and older individuals.CONCLUSIONS:Several predictors could be identified as risk markers for disability pension. The variation in the effect of risk markers with regard to age and diagnosis of disability pension speaks in favour of the importance of a person-centered approach in treatment and rehabilitation.

Background : Insomnia-type sleep disturbances are frequent among patients suffering from stress-related exhaustion disorder. However, clinical observations indicate that a subgroup suffer from sleep lengths frequently exceeding 9 hours, coupled with great daytime sleepiness. Aims : The aim of the present study was to investigate differences in socio-demographic variables, use of medications, sleep parameters, anxiety, depression and fatigue, between individuals with varying sleep lengths, in a sample of 420 Swedish patients (mean age 42 +/- 9 years; 77% women) referred to treatment for exhaustion disorder. Patients were allocated to the groups: "never/seldom >= 9 hours" (n = 248), "sometimes >= 9 hours" (n = 115) and "mostly/always >= 9 hours " (n = 57), based on their self-rated frequency of sleep lengths >= 9 hours. Methods : The design was cross-sectional and data was collected by means of questionnaires at pre-treatment. Results : Univariate analyses showed that patients in the "mostly/always >= 9 hours" group were more often on sick leave, and reported more depression and fatigue, better sleep quality and more daytime sleepiness, than patients in the other groups. Multivariate analyses showed that these patients scored higher on measures of fatigue than the rest of the sample independently of gender, use of antidepressants, sick leave, depression and quality of sleep. Conclusions : Patients suffering from exhaustion disorder and reporting excessive sleep seem to have a generally poorer clinical picture but better quality of sleep than their counterparts with shorter sleep lengths. The mechanisms underlying these differences, together with their prognostic value and implications for treatment remain to be elucidated in future studies.

Chronic stress is among the most common diagnoses in Sweden, most commonly in the form of exhaustion syndrome (ICD‐10 classification – F43.8). The majority of patients with this syndrome also have disturbed breathing (hyperventilation). The aim of this study was to investigate the association between hyperventilation and exhaustion syndrome. Thirty patients with exhaustion syndrome and 14 healthy subjects were evaluated with the Nijmegen Symptom Questionnaire (NQ). The participants completed questionnaires about exhaustion, mental state, sleep disturbance, pain and quality of life. The evaluation was repeated 4 weeks later, after half of the patients and healthy subjects had engaged in a therapy method called ‘Grounding’, a physical exercise inspired by African dance. The patients reported significantly higher levels of hyperventilation as compared to the healthy subjects. All patients’ average score on NQ was 26.57 ± 10.98, while that of the healthy subjects was 15.14 ± 7.89 (t = −3.48, df = 42, p < 0.001). The NQ scores correlated strongly with two measures of exhaustion (Karolinska Exhaustion Scale KES r = 0.772, p < 0.01; Shirom Melamed Burnout Measure SMBM r = 0.565, p < 0.01), mental status [Hospital Anxiety and Depression Score (HADS) depression r = 0.414, p < 0.01; HADS anxiety r = 0.627, p < 0.01], sleep disturbances (r = −0.514, p < 0.01), pain (r = −.370, p < 0.05) and poor well‐being (Medical Outcomes Survey Short Form 36 questionnaire‐ SR Health r = −0.529, p < 0.05). In the logistic regression analysis, the variance in the scores from NQ were explained to a high degree (R2 = 0.752) by scores in KES and HADS. The brief Grounding training contributed to a near significant reduction in hyperventilation (F = 2.521, p < 0.124) and to significant reductions in exhaustion scores and scores of depression and anxiety. The conclusion is that hyperventilation is common in exhaustion syndrome patients and that it can be reduced by systematic physical therapy such as Grounding.

OBJECTIVES:Recent studies have found an increased risk of suicide in people on sickness absence, but less is known about to what extent diagnosis-specific sickness absence is a risk indicator for suicidal behaviour. This study aimed to examine all-cause and diagnosis-specific sickness absence and sick-leave duration as risk indicators for suicide attempt and suicide.METHODS:This is a population-based prospective cohort study. All non-retired adults (n = 4 923 404) who lived in Sweden as on 31 December 2004 were followed-up for 6 years regarding suicide attempt and suicide (2005-2010). HRs and 95% CIs for suicidal behaviour were calculated, using people with no sick-leave spells in 2005 as reference.RESULTS:In analyses adjusted for sociodemographic factors and previous mental healthcare, suicide attempt and current antidepressants prescription, sickness absence predicted suicide attempt (HR 2.37; 95% CI 2.25 to 2.50 for women; HR 2.69; 95% CI 2.53 to 2.86 for men) and suicide (HR 1.91; 95% CI 1.60 to 2.29 for women; HR 1.92; 95% CI 1.71 to 2.14 for men), particularly mental sickness absence (range of HR: 2.74-3.64). The risks were also increased for somatic sickness absence, for example, musculoskeletal and digestive diseases and injury/poisoning (range of HR: 1.57-3.77). Moreover, the risks increased with sick-leave duration.CONCLUSIONS:Sickness absence was a clear risk indicator for suicidal behaviour, irrespective of sick-leave diagnoses, among women and men. Awareness of such risks is recommended when monitoring sickness certification. Further studies are warranted in order to gain more detailed knowledge on these associations.

According to recent nationwide surveys there have been dramatic increases in stress and serious stress-related health problems among Swedish adolescents. The aims of the present thesis were to investigate the prevalence of perceived chronic stress among sixteen-year-old adolescents who attended their first year at high-ranking high schools in the Stockholm area, to examine if factors that have been found to be relevant in the development of chronic stress among adults also contribute to chronic stress among adolescents, and to investigate the associations between chronic stress and sleep-related variables and academic achievement. Data were collected by means of self-report instruments. The main outcomes showed that a substantial number of individuals (30%) reported to perceive severe stress symptoms. The highest degree was perceived by 8% who suffered from symptoms to an extent which otherwise only has been observed among adult clinical burnout patients. Besides, 15% reported severe stress symptoms throughout high school and were thus considered to suffer from chronic stress. Perceived high demands, low global self-esteem, sleep disturbances and low social support were crucial factors in explaining stress symptoms. Another finding showed that perceived chronic stress was associated with adolescents’ academic achievement. A closer look at the potential contribution of sleep-related variables to academic achievement revealed further that, apart from severe stress symptoms, social jetlag was involved in predicting variation in academic achievement. Overall, the findings indicated that there is a high prevalence of chronic stress among adolescents. The results should be taken seriously, as young people’s sense of well-being during this period impacts both their successful transition into adulthood and their life course. Future research options and potential practical applications in terms of chronic stress prevention were suggested and discussed.

BACKGROUND:Stress-related mental disorders (SRMD), which correspond to the diagnostic code F43 in the International Classification of Diseases, version 10, rank among the leading causes of sickness absence in several European countries. Despite the size of this health problem, research on risk factors for severe medical outcomes, like suicidal behavior, is lacking to date. The aim of this study was to investigate predictors of suicide attempt and suicide among sickness absentees with SRMD. METHODS:A cohort of 36,304 non-retired individuals, aged 16-64 years on 31.12.2004, with at least one sickness absence spell due to SRMD, initiated in 2005, was followed up with regard to suicide attempt (2006-2009) and suicide (2006-2008). Univariate and multivariate hazard ratios (HR) with 95% confidence intervals (CI) were estimated for a number of predictors. RESULTS:During the follow-up period, 266 individuals attempted suicide and 34 committed suicide. In the multivariate analyses, the following factors increased the risk of suicide attempt: =< 25 years of age, low educational level, lone parenthood, > 1 sickness absence spell, long duration of the first spell of sickness absence due to SRMD (> 180 days), > 4 and > 8 days of inpatient care due to somatic or mental diagnoses (2000-2005), and > 4 and > 1 outpatient visits due to somatic or mental diagnoses (2001-2005), respectively. Hazard ratios ranged from 1.4 to 4.2. Health care due to mental diagnoses and > 1 spell of sickness absence regardless of diagnosis were predictive of suicide. CONCLUSIONS:Several predictors related to socio-demographics, sickness absence and health-care consumption were identified as risk factors for suicidal behavior. Consideration of these risk factors is of both clinical and public health importance.

There are increasing reports of cognitive and psychological declines related to occupational stress in subjects without psychiatric premorbidity or major life trauma. The underlying neurobiology is unknown, and many question the notion that the described disabilities represent a medical condition. Using PET we recently found that persons suffering from chronic occupational stress had limbic reductions in the 5-HT1A receptor binding potential. Here we examine whether chronic work-related stress is also associated with changes in brain structure. We performed MRI-based voxel-based morphometry and structural volumetry in stressed subjects and unstressed controls focusing on gray (GM) and white matter (WM) volumes, and the volumes of hippocampus, caudate, and putamen - structures known to be susceptible to neurotoxic changes. Stressed subjects exhibited significant reductions in the GM volumes of the anterior cingulate cortex and the dorsolateral prefrontal cortex. Furthermore, their caudate and putamen volumes were reduced, and the volumes correlated inversely to the degree of perceived stress. Our results add to previous data on chronic psychosocial stress, and indicate a morphological involvement of the frontostriatal circuits. The present findings of morphological changes in these regions confirm our previous conclusion that symptoms from occupational stress merit careful investigations and targeted treatment.

The present prospective study aimed to identify risk factors for subsequent clinical burnout. Three hundred eighty-eight working individuals completed a baseline questionnaire regarding work stress, sleep, mood, health, and so forth. During a 2-year period, 15 subjects (7 women and 8 men) of the total sample were identified as "burnout cases," as they were assessed and referred to treatment for clinical burnout. Questionnaire data from the baseline measurement were used as independent variables in a series of logistic regression analyses to predict clinical burnout. The results identified "too little sleep (< 6 h)" as the main risk factor for burnout development, with adjustment for "work demands," "thoughts of work during leisure time," and "sleep quality." The first two factors were significant predictors in earlier steps of the multivariate regression. The results indicate that insufficient sleep, preoccupation with thoughts of work during leisure time, and high work demands are risk factors for subsequent burnout. The results suggest a chain of causation.

Stress can be defined as an imbalance between demands placed on us and our ability to manage them. The body’s stress system is adapted to confront sudden physical threats. Today, however, we are in ...