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QEEG AND NEUROPSYCHOLOGICAL FINDINGS IN BURNOUT SYNDROME

In this section a study is presented we carried out in collaboration with the Radboud University Nijmegen (Dr. Gilles van Luijtelaar, Dr. Ger Keijsers) and  the HSK group (Dr. Marc Verbraak). This study was carried out  by Martijn Arns, Martijn van den Bunt and Sanne van den Berg, and a thesis has been written about this study. These results are still pre-liminary, but are in the process of being finalized for publication..

Background
Many changes have occurred in today’s working environment. Machines and computers have taken over much of the physical labour and due to the growing trend of job specialisation and the 24-hour economy, work has become more repetitive and has to be done more efficiently. More than before, employees are subjected to daily stress on the work floor. Since the 1970's one word has repeatedly shown up in relation to job-stress related psychopathology: “burnout”, or “burnout syndrome”.
Since the first description of burnout syndrome in 1969 by Bradley (Bradley, 1969), this metaphor for a state of psychological exhaustion, has gained greatly in popularity. A recent study in the Netherlands has shown that 4 percent of the total working population is showing serious symptoms of burnout and should seek professional help (Houtman et al., 2000). Thus, burnout seems to become a problem in today’s world to be dealt with.
What exactly are the symptoms of burnout syndrome? Freudenberger described the burnout syndrome among volunteers with whom he was working in a so-called ‘free clinic’ for drug-abusers. They changed from idealistic volunteers to disillusioned, indifferent care givers who were also suffering from exhaustion, headaches, sleeplessness, high irritability, depressive symptoms and social fear (Freudenberger, 1974). Many studies have been conducted since then, but the construct is still based on roughly the same symptoms. Although several definitions have been developed, most authors describe burnout syndrome as a response to prolonged emotional and interpersonal stressors on the job.
 The syndrome is generally defined by three dimensions: emotional exhaustion, depersonalization and reduced personal accomplishment (Schaufeli et al., 1993; Maslach et al., 2001). Using these three generally accepted components of the burnout syndrome, the Maslach Burnout Inventory (MBI) has been developed. A high score on exhaustion and depersonalization and a low score on personal accomplishment is an indication for burnout. The MBI is used world-wide as a diagnostic tool for burnout (Maslach et al., 1996).
 
Diagnosis
Interestingly, there is no official diagnosis for burnout syndrome in the DSM-IV (American Psychiatric Association, 1994), the most often used psychiatric diagnostic manual. In the Netherlands, patients showing symptoms common to burnout syndrome, are often classified by their primary symptom: fatigue, under undifferentiated somatoform disorder.

Table 1 DSM-IV Diagnostic criteria for 300.81 Undifferentiated Somatoform Disorder

  1. One or more physical complaints (e.g. fatigue, loss of appetite, gastrointestinal or urinary complaints).
  2. Either (1) or (2):
    (1) after appropriate investigation, the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication)
    (2) when there is a related general medical condition, the physical complaints or resulting social or occupational impairment is in excess of what would be expected from the history, physical examination, or laboratory findings
  3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The duration of the disturbance is at least 6 months.
  5. The disturbance is not better accounted for by another mental disorder (e.g., another somatoform Disorder, Sexual Dysfunction, Mood Disorder, Anxiety Disorder, Sleep Disorder, or Psychotic Disorder).
  6. The symptom is not intentionally produced or feigned (as in Factitious Disorder or Malingering).


Hoogduin et al. (Hoogduin et al., 2001) argue that the diagnosis “neurasthenia”, which is not present in the DSM-IV but does appear in the ICD-10 (World Health Organization, 1992), the second most used diagnostic manual, is more fit. This diagnosis is more specific to burnout, as undifferentiated somatoform disorder can encompass physical complaints other than fatigue.
 
Table 2 ICD-10 Diagnostic criteria for F48.0 Neurasthenia

  1. Persistent and distressing symptoms of exhaustion after minor mental or physical effort including general feeling of malaise, combined with a mixed state of excitement and depression.
  2. Accompanied by two or more of these symptoms: muscular aches and pains, dizziness, tension headache, sleep disturbance, inability to relax and irritability.
  3. Accompanied by two or more of these symptoms: increased cynicism or depersonalization, diminished feelings of efficacy and emotional exhaustion.
  4. Inability to recover through rest, relaxation or enjoyment.
  5. Disturbed and restless, unrefreshing sleep, often troubled with dreams.
  6. Duration of over one year.
  7. Complaints are job-related.
  8. Does not occur in the presence of organic mental disorders, affective disorder, panic or generalized anxiety disorder.

As we can see from these diagnostic criteria, burnout syndrome can best be described as an exhaustion syndrome accompanied by affective symptoms (general feeling of malaise, irritability, cynicism and depersonalization). There are, however, psychiatric disorders, which are not adequately distinguishable from burnout syndrome. These disorders are (atypical) depression and chronic fatigue syndrome (CFS) (Hoogduin et al., 2001).

Research with burnout  patients
The  presence of burnout syndrome as a social problem in many human services professions was the impetus for the research that is now taking place in many countries.

Causes and risk factors
Originally, burnout was thought of as a problem only experienced by those who are working in the human services sector. Such jobs include teachers, police officers, doctors, nurses, psychologists, lawyers, store clerks, customer representatives, receptionists, and so on. The symptoms were believed to be a result of the interaction between the person giving, and the person receiving help (Maslach, 2001)
 
Later research, however, showed that burnout does not only occur within these situations, but is also experienced in other stressful jobs. In fact, symptoms of burnout were found not to vary across different occupational groups (Demerouti et al., 2001).
The burnout construct, consisting of emotional exhaustion, depersonalization and reduced personal accomplishment, can be viewed as a vicious circle. When workload is high, burnout symptoms increase, especially the emotional exhaustion component (Bakker et al., 2003).
Emotional exhaustion is the experience of feeling drained of all energy.
When experiencing this emotional exhaustion, people tend to minimalize distress by detaching from others. They maintain an emotional distance from others. This detachment can manifest itself by an indifferent attitude toward others. Also, people experiencing burnout often develop hostile interactions with others.
Another common response to emotional exhaustion is to reduce workload. Burnout patients are known to avoid work, display a large amount of absenteeism, doing the bare minimum at work and not doing certain tasks that are experienced as more stressful, while doing more tasks that are considered less stressful.
These reactions result in a decline of job performance, both qualitative and quantitative. The person then feels guilty about his poor performance and a self-critical attitude develops. Deteriorated relationships with others and the acquired self-criticism then further contributes to emotional exhaustion, which in turn will worsen these maladaptive responses (Maslach, 2001).
Thus, the burnout construct itself consists of a vicious circle, beginning with emotional exhaustion.

But when exactly does a high workload lead to burnout symptoms? A number of studies have been dedicated to answer this question. A number of other factors were found to relate to high levels of burnout, these are:

  • Traumatic events on the job (Van der Ploeg et al., 2003)
  • Confusion, conflict and ambiguity to job role (Posig et al., 2003)
  • Risk and safety factors (Leiter et al., 1997)
  • Being undermined by a superior, or the belief that one is undermined by a superior (Westman et al., 1999)
  • Low levels of social support (Brown et al., 1998)
  • Inadequate job resources (Lee et al., 1996)

Reducing the risk for burnout thus constitutes minimalizing these risk factors. Also, healthy coping strategies help prevent burnout symptoms. Less burnout is experienced by those who are confident in their ability to handle problems and to tolerate stress. The belief that one’s stressful situation has meaning and is of value has been found to relate to low levels of burnout (Pines, 2004).

Subjects and Methods
In this study 13 patients diagnosed with burnout syndrome (mean age = 48,2. age range = 26-55) and 13 controls, matched on age, gender and educational level (mean age = 48,2. age range= 26-59) were assessed on a standardized procedure, as developed and used by the Brain Resource Company and the International Brain Database.


The study intake consisted of the ADIS-NL (Anxiety Disorder Interview Schedule; (Dinardo et al., 1994); Dutch adaptation (Bouman et al., 1997)) a time-efficient semi-structured interview on the affective disorders according to the DSM-IV, thereby checking reliably for the differential diagnosis of burnout syndrome. However, because the somatoform disorders were not included in this interview schedule, it was completed with the section on somatoform disorders of the SCID-I (First et al., 1994), also a semi-structured interview classifying according to the DSM-IV. Finally as a supplement to the diagnosis but also to establish the severity of burnout syndrome the UBOS questionnaire (Burnout severity: Schaufeli, 2000), BDI (Becks Depression Inventory) and the CIS-20R (fatigue severity: Vercoulen et al., 1999) were used.

All subjects voluntarily gave written informed consent, and local medical ethical approval was obtained for this study (CMO nr. 2002/009). Subjects were required to refrain from caffeine, alcohol and smoking for at least 2 hours prior to testing.

 

Also see our Professional section for more information on the standardized methodology used such as on QEEG, ERP and neuropsychology.

 

Results

No significant differences were present between the groups on gender, age and education. 
 

EEG Asymmetry

No significant group effect was found (F (1,24) = .000). Because no frontal inactivation has been found, the repeated measures analysis using the posterior electrodes has not been performed.

 

P300

In figure 1 below, the ERP for both Burnout and Control group can be found. Note the presence of a P3A and P3B for the burnout group which is not present for the control group. Furthermore, note the decreased P300 amplitude. Figure 2 below shows a bargraph of the P300 amplitudes for the different functional regions.

 

The main effect for P300 amplitude of the between-subject factor is significant (F(1,22) = 6.428; p = .019). On the average, burnout patients displayed a reduced P300 amplitude as compared with controls (5.69 microvolt vs. 8.78 Microvolt). There were no significant interactions. The main effect for P300 latency of the between-subject factor is not significant (F(1,22) = .489; p = .492). On the average, burnout patients show no prolonged latency as compared with controls (349.23 ms vs. 342.64 ms). No significant interactions were found.

 

         Figure 1. ERP waveform for burnout and controls at Cz, note the presence of a P300A and P300B for the burnout group which is not present for the controls and the decreased P300 amplitude for the burnout group.

 

 

Alpha peak frequency and EEG power spectra

Figure 2 shows the frequency distribution of the EEG for both groups during EO and EC.

The main effect for Alpha Peak Frequency of group is significant F(1,24 = 4.336; p = 0.048). Burnout patients display a lower alpha peak frequency than controls (9.05Hz vs. 9.57Hz). No other significant effects or interactions were found. The main effect for EC Alpha Peak Power was not significant (F(1,23) = 2.350; p = .139). Alpha peak power does not differ significantly between groups in the eyes closed condition. The main group effect for Beta power was significant (F(1,24) = 5.86; p = 0.023), burnout patients have significantly lower beta power as compared with controls (3.31 vs 3.81 microvolt). There were no other significant effects or interactions.

 

 

Figure 2: This figure shows the power spectra for the BO group and the control group for Cz. Note the increase in alpha peak power during Eyes Closed, the delayed Alpha Peak Frequency during Eyes Open EEG and the general decrease in high frequency EEG for the BO group.

 

 

Neuropsychology

The significant findings are presented in Figure 3.

There was no group effect for span memory (F=.174, df=3, 22; p=.913), reaction time (F=.190, df=2, 23; p=.829) and attention (F=.607; df=2, 23; p=.554). However, there was a group effect for total number of errors (F=4.051, df=2, 23; p=.031). Further analysis revealed that there was no group effect for False positive errors (F=2.824, df=2, 23; p=.080) but a significant effect for False negative errors (F=4.006, df=2, 23; p=.032). The burnout group made less False negative errors as compared to the control group.

 

Univariate ANOVA’s revealed a significant difference in total number of errors during the oddball task (F=4.654; df=1; p=.041) but failed to reach significance for total number of errors during working memory task (F=2.438; df=1; p=.131) and both oddball false negative errors (F=3.600, df=1; p=.070) and working memory false negative errors (F=3.612, df=1; p=.069).

 

Figure 3: This figure shows the differences in number of errors for the oddball test and working memory test. Note that the differences in errors is mainly due to the differences in false negative errors.

 

Discussion

Burnout is an exhaustion syndrome with depressive features, caused by chronic stress on the work floor. The psychological construct consists of emotional exhaustion, depersonalization and a feeling of reduced competence, which, within itself, consists of a vicious circle.

 

Three possible abnormalities in the EEG, known from research with patients suffering from depression or chronic fatigue, have been proposed:

  1. frontal asymmetry, known to exist in depressed patients,
  2. P300 amplitude flattening, also commonly found in patients with depression
  3. lowered alpha peak frequency, found in one study to correlate with experienced fatigue severity. 

Our first hypothesis, that burnout patients have relative left-frontal inactivation as compared with healthy controls, has been rejected. No asymmetry has been found to exist in our burnout patients. Relative left-frontal inactivation is associated with ineffective coping with stressors and is characterized by negative emotions and a withdrawal motivation style. Considering that burnout patients are known to avoid events that they consider stressful and that this eventually leads to more stress and negative feelings, frontal asymmetry would have perfectly fitted in this theory, however there was no evidence for this.

 

Our second hypothesis concerned the P300. The amplitude of this ERP component is associated with attentional capacity and memory function. Decreased P300 amplitude is related to cognitive impairment and has been shown to exist in a wide variety of psychopathology, especially depression. This study also found P300 amplitude to be decreased in burnout patients. One study argues that the probable neural generators of the P300 are mostly cortical (medial temporal area), but also to be located in the hippocampus and the amygdala (Nishitani et al., 1999). As burnout seems to emerge after a period of high stress – leading to high cortisol levels and cortisol is shown to be associated with hippocampal atrophy, hypercortisolism might also play a role in the development of flattened P300 amplitudes. This is highly speculative, but more research into the relation of cortisol and its relation to physiology of the P300 is advised.

 

As burnout patients often complain of memory problems and problems concentrating (Hoogduin et al., 2001), this decreased P300 Amplitude could be seen as a contributing factor to or as an objective physiological confirmation of attention and memory problems. Interestingly, the burnout group did not perform worse on several cognitive tasks, hence the subjective complaints of impaired memory and attention cannot be confirmed. Hence the decreased P300 amplitude is probably not directly related to this impaired cognition. In figure 1 it can also be clearly seen that the ERP of the burnout group showed the existence of a P3A and a P3B, suggesting a qualitatively difference in P300 rather then simply a reduced P300 amplitude. The existence of a P3A and P3B have often been associated with controlled vs. automatic processing. If people perform a task controlled one often finds a P3A and P3B; if the task is automated then only a P300 is seen. This together with the intact cognitive performance of burnout patients seems to suggest burnout patients do not learn to automate a task, like the oddball task.  Burnout patients also made less errors, especially during the oddball task, which could also be explained by this. If subjects perform the oddball task fully in a controlled way, they probably make less errors; whereas when they automate the task, they might make slightly more errors. Hence, even though the P300 amplitude is reduced this is more a qualitative rather then a quantative difference suggesting burnout patients inability to automate simple cognitive tasks. Psychologically this could be interpreted as a kind of perfectionism, which has also been suggested about burnout patients in the past.

 

Our third hypothesis was that burnout patients exhibit a lower alpha peak frequency. This study has shown that this lower alpha peak frequency is indeed present in burnout patients. Like the P300, alpha peak frequency is considered a valid index of cognitive potential. Furthermore, an alpha peak frequency has consistently been shown to be associated with reduced cerebral blood flow and reduced brain oxygenation. A decrease of 0.5 Hz in the alpha peak frequency usually is related to decreased performance on neuropsychological tasks, especially impaired memory recall (also see Klimesch). This could not be confirmed from the neuropsychological results. Furthermore, CFS patients are reported to show slower reaction times, related to fatigue. This could also not be confirmed on the neuropsychological tests.

 

The ERP of the burnout group showed the existence of a P3A and a P3B. The P3A is associated with frontal activation and can be seen as a ‘novelty potential’ (Polich and Criado, 2006). Others consider the P300a to reflect the orientation to the stimulus evaluation, whereas the P300b reflects response-related processes (Frodl-Bauch et al., 1997). The presence of both P3A and P3B in burnout patients suggests a qualitative difference in both components in comparison with the controls. The existence of the P3A and P3B might implicate that the burnout group is still processing the stimuli as being ‘novel’ whereas the control group does not. This implicates that the burnout group is still processing the stimuli in a controlled rather then automated manner (Lagapoulos et al., 1998). However, more research is needed, not only to confirm our data, but to extent them and to investigate whether burn-out patients differ from controls in automated or in controlled tasks. 

One study argues that the probable neural generators of the P300 are mostly cortical (medial temporal area), but they might also be located in the hippocampus and the amygdala (Nishitani et al., 1999). Therefore, the decreased P300 amplitude and the existence of a P3A and P3B without any cognitive problems as measured in the neuropsychological assessment  tend to suggest a hippocampal origin possibly related to prolonged stress (by means of high cortisol levels which have been shown to cause hippocampal damage, for a review also see Corcoran et al., 2001)
 

In summary, Burnout syndrome seems to be a separate diagnostic entity from the psychophysiological point of view. The results tend to suggest that Burnout patients have an inability to automate information processing as shown by the P3A and P3B and the reduced number of errors during the oddball. Burnout patients tend to show a hypervigilant state, where they are constantly ready to perceive information but have an inability to automate this. This in turn could lead to an exhaustion syndrome, since cognitive and other tasks will consume more energy for burnout patients.

 

Acknowledgements

Data from The Brain Resource International Database was generously provided by the Brain Resource Company Pty Ltd. We would also like to thank Sanne van den Berg en Martijn van den Bunt for assisting in the intake procedures and data acquisition.

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<body bgcolor="#0066FF" text="#000000" leftmargin="0" topmargin="0" marginwidth="0" marginheight="0"> <h1>Brainclinics: Behandeling en Diagnostiek van Depressie en ADHD middels Neurofeedback, rTMS, QEEG en Neuropsychologisch onderzoek </h1> <li><a title="neurofeedback" href="neurofeedback.php">Home</a> <ul> <li><a href="neurofeedback.php?pId=17&amp;subject=Epilepsie">Epilepsie</a></li> <li><a href="neurofeedback.php?pId=18&amp;subject=ADHD / ADD">ADHD / ADD</a> </li> <li><a href="neurofeedback.php?pId=19&amp;subject=Burnout">Burnout</a> </li> <li><a href="neurofeedback.php?pId=20&amp;subject=Depressie">Depressie</a> </li> <li><a href="neurofeedback.php?pId=21&amp;subject=Slaapstoornissen">Slaapstoornissen</a> </li> <li><a href="neurofeedback.php?pId=22&amp;subject=Migraine">Migraine</a> </li> <li><a href="neurofeedback.php?pId=23&amp;subject=Leerstoornissen">Leerstoornissen</a> </li> <li><a href="neurofeedback.php?pId=2&amp;subject=Neurofeedback therapie">Neurofeedback therapie</a> </li> <li><a href="neurofeedback.php?pId=9&amp;subject=Tele-neurofeedback">Tele-neurofeedback</a> </li> </ul> </li> <li><a title="neurofeedback" href="neurofeedback.php">Neurofeedback</a> <ul> <table cellspacing='0' cellpadding='0' border='0' style="display: inline;margin-left: 6px;"> <tr><td height='10'><img src='http://www.brainclinics.com/include/images/spacer.gif' width='100' height='10'></td></tr> <tr><td width='100' height='18' style='padding: 4px; background-color: #1D7FA4'><a href='http://www.brainclinics.com/index.php?cId=152' class='middlecats'>Mobile Phone - Brain function</a></td></tr> <tr><td height='10'><img src='http://www.brainclinics.com/include/images/spacer.gif' width='100' height='10'></td></tr> <tr><td width='100' height='18' style='padding: 4px; background-color: #1D7FA4'><a href='http://www.brainclinics.com/index.php?cId=107' class='middlecats'>Dyslexia</a></td></tr> <tr><td height='10'><img src='http://www.brainclinics.com/include/images/spacer.gif' width='100' height='10'></td></tr> <tr><td width='100' height='18' style='padding: 4px; background-color: #1D7FA4'></td></tr> </table> </ul> </li> <h3>Brainclinics: Brainclinics Diagnostics (rTMS behandeling van Depressie en Neurofeedback therapie bij ADHD</h3> Brainclinics (BC) is gespecialiseerd in Personalized Medicine, diagnostiek en behandeling van hersenaandoeningen (zoals Neurofeedback bij ADHD en rTMS behandeling bij Depressie). Middels toegepast hersenonderzoek kan Brainclinics tot een effectievere, doelmatigere en gepersonaliseerde behandeling komen. Hierbij maakt BC enkel gebruik van evidence-based methoden, zoals het QEEG (kwantitatief EEG), neuropsychologisch onderzoek (IntegNeuro), lichttherapie en rTMS therapie bij depressie ook wel TMS genoemd. Brainclinics is tevens erkend door de Stichting Applied Neuroscience als evidence based Applied Neuroscience praktijk. Daarnaast houdt Brainclinics zich ook intensief bezig met wetenschappelijk onderzoek. Brainclinics werkt nauw samen met de Brain Resource Company en maakt tevens gebruik van de International Brain Database. <br /><br /> Op onze CLIENT sectie vindt u onder andere meer informatie voor als u zich heeft aangemeld bij ons voor het QEEG of neuropsychologisch onderzoek. Ook vind u daar meer informatie over behandeling van depressie met rTMS (repetitive Transcranial Magnetic Stimulation). Dit is een nieuwe behandeling bij depressie zonder medicatie. De client sectie biedt tevens, voor de geïnteresseerden, nog meer achtergrondinformatie over onze onderzoeken. Voor Neurofeedback of EEG Biofeedback kunt u het beste terecht bij het EEG Resource Instituut: Neurofeedback. <br /><br /> Meer informatie over digitaal (neuro-)psychologisch testen en neuropsychologisch onderzoek (IntegNeuro) vindt u op de PROFESSIONAL sectie. Ook kunt u hier terecht als u clienten naar ons wilt doorverwijzen voor QEEG en/of neuropsychologisch onderzoek, rTMS therapie bij depressie of als u meer vakinhoudelijke achtergrond informatie zoekt. Ook vindt u hier informatie over de aanschaf van de Brainquiry producten zoals de PET EEG en ActivEEG en voor draadloos EEG of wireless Neurofeedback (EEG Biofeedback) en de Litebook Elite lichttherapie lamp. <br /><br /> Voor onderzoeken die door Brainclinics uitgevoerd worden kunt u terecht in de RESEARCH sectie. Daar vindt u ook een overzicht van onze publicaties en meer educatief materiaal. Verder is er meer te lezen over Brainclinics en de mensen achter dit bedrijf in ABOUT US. <br /><br /> Contact: Martijn Arns<br /> Brainclinics Diagnostics B.V. / Brainclinics Treatment B.V.<br /> Biologisch Psycholoog / Psycholoog NIP<br /> Toernooiveld 100, Nijmegen<br /> </body>