Between depression and burnout

Isn’t burnout a synonym for depression? At first, it may seem that people in depressive phases suffer from burnout – or vice versa. Symptoms such as exhaustion, inner emptiness or physical pain are initially unspecific and can be an indication of both illnesses. But it is enormously important to know the differences, especially for dealing with both clinical pictures.

Signs of depression

Depression is characterized by depressed mood, loss of interest and pleasure, and a reduction in activity. In addition to aforementioned leading symptoms, depression may manifest itself in the following additional ways:

• Motivation: exhaustion, fatigue, loss of drive
• Cognition: sadness, hopelessness, feelings of worthlessness, guilt
• Behavior: Social withdrawal, monotone speech, suicidal ideation and intentions
• Body: Weight and appetite changes, insomnia, loss of libido, pain

Depending on the number and intensity of symptoms, as well as the pattern of progression over time, different depressive disorders can be distinguished. Only when at least two of the leading symptoms occur over a period of two weeks or longer, is spoken of a depressive episode. Such an episode can be mild, moderate or severe, depending on the severity of the symptoms and their variety. The length of such an episode can also vary. If such depressive episodes accumulate or last longer than two years, the term depressive disorder is used.

Importantly, about 20% of Germans suffer from depression once in their lives, with women being affected twice as often as men. The risk for another depressive episode is 50%. (Federal Ministry of Health, 2022)

What causes depression and what sustains it?

Unlike a broken leg, for example, depression cannot be attributed to a single cause. Rather, the interplay of multiple factors of a genetic and/or psychosocial nature is crucial here. On a neurobiological level, changes in the stress hormone axis and an imbalance of neurotransmitters in certain brain regions can be causative. On the other hand, traumatic experiences, losses and chronic overload, among others, act as acute triggers. The two areas – psychosocial and neurobiological – are not mutually exclusive, but rather complement each other.

The vicious circle of depression consists in the fact that those affected have fewer and fewer positive experiences due to depressive thoughts, unfavorable behavior as well as a lack of activities, and their rejecting image of themselves and their environment becomes increasingly solidified.

The following case study illustrates these factors:

Mr. M. has an important exam coming up. This exam triggers depressive thoughts: “I can not do that! I will never be able to cope with this mountain of learning material.” These thoughts give rise to negative expectations about the exam: “If I show up for the exam, I will definitely fail. I will probably never graduate.” This in turn draws further self-deprecation: “I’m worthless and a failure anyway!”. This circle of thought may now be followed by opting out of the exam. By avoiding the exam situation, there is no sense of achievement, and hopelessness and sadness reinforce the already depressed mood. Withdrawal possibly intensifies the experience of listlessness. Postponing the exam also pushes the conclusion further and further back, which leads to confirm negative thoughts such as: “I can not do it anyway”.

This example shows clearly how depressive symptoms can worsen independently if they are not treated.

Dimensions of symptoms of burnout

The burnout syndrome manifests itself in three dimensions of discomfort:

Exhaustion: The affected person has the feeling of being emotionally and physically burned out. Emotionally, this manifests itself in dejection, feelings of anxiety and inner emptiness. Symptoms that are also associated with depression. On the physical level, for example, there is chronic fatigue, pain and tension.

Depersonalization: Characterized by a distant, indifferent attitude towards work and other people, a successive reduction of sympathy, purposefulness and social relationships develops here. Not infrequently, all this is replaced by cynicism – friends are experienced as a burden, superiors as a threat and colleagues as a nuisance.

Decreased performance: The affected person experiences a loss of confidence in his own abilities and perceives himself as a failure. For any tasks, more effort and time are now needed. Likewise, the regeneration time is also getting longer. A long weekend or a vacation is suddenly no longer enough to gather new energy.

Importantly, every fourth German citizen states that they are frequently under stress, half of them even believe they are threatened by burnout, and 6 out of 10 respondents complain of typical symptoms such as persistent exhaustion, inner tension and back pain. (Pronova BKK, 2018)

Burned out cells – How does burnout develop?

Just like depression, burnout is rarely based on a single cause. Again, an interplay of genetic and psychosocial factors is observed. Unemployment, marriage, birth of the child, chronic overload, retirement or the death of a close person can be acute stressors that throw our organism out of balance. But a stressor alone does not trigger burnout. Only when a longer lasting stress episode – the chronic stress – is present, it can come to the outbreak of the disease. Basically, chronic stress can develop when stress phases are perceived by those affected as a persistent burden for which too few resources are available for coping. The result is an imbalance between tension and relaxation. Neurobiologically, a ramped-up stress system forms the basis of burnout. The release of stress hormones is activated, while that of sex hormones is suppressed. At the same time, the organism produces more adrenaline, which puts the body in a permanent state of alert.

Also here the emergence can be illustrated by a case study:

Mrs. B. has been working as a civil servant teacher at a high school for several years. She thrives at her job and wants to get the best out of her students every day. She has been barely able to cope with the high workload for years and usually spends her evenings and weekends exhausted on the couch. Mrs. B. now has three grown daughters and is a grandmother of two. One day, her eldest daughter falls seriously ill and Mrs. B. tries to support her in the household and with regular doctor’s visits as well as with the upbringing of her children. Even before she starts work, she takes her grandchildren to school and after work she picks them up again and spends the evening with them. Gradually, Mrs. B. begins to feel empty inside and completely exhausted. Working with the students at school feels meaningless to her and she begins to doubt her abilities.

So burnout is not depression?

Both depression and burnout is a mental illness listed in the diagnostic classification system with clearly defined criteria. Burnout was not listed there as a separate illness for a long time and is also currently listed only as a consequence of chronic work stress. The basic difference is that burnout is described more as context-related (e.g., the cause is often work-related) and depression more all-encompassing (can also be diagnosed without context) and as affecting all areas of everyday life.

Although much of the symptoms overlap, most people who feel burned out do not meet the criteria for depression. There are some characteristics that are very specific to one disorder or the other. For example, constant irritability is more indicative of burnout, whereas decreased self-confidence or suicidal thoughts are more typical of depression. In addition, burnout sufferers often long for something they used to enjoy doing, whereas people with depression usually feel no desire to do anything at all. Thus, it is possible to speak of a permanent condition in the case of depression, whereas patients with burnout usually also experience symptom-free phases. Differences can also be found in the beginnings of both diseases. The start of a depression is often accompanied by self-doubt, fears, failures and disappointments in early relationships. People who suffer from burnout often have a strong self-confidence before, combined with great enthusiasm, commitment and significant successes. Because depression has been stigmatized more often in the past, many sufferers feel it is more recognized to be “burned out” by overwork.

Why is differentiation of the two syndromes important in treatment?

Despite the large overlap of symptoms, the importance of differentiating between the two disorders in professional management becomes clear.

Treatment of both disorders involves both psychotherapy and pharmacotherapy. In depression, psychotherapy aims to change the dysfunctional evaluative processes mentioned at the beginning. Automatic thoughts are checked for thought distortions, challenged with behavioral experiments, and replaced with alternative evaluations. Whereby other treatment measures such as light therapy, sleep deprivation and prescribed physical activity can also be used. At the beginning of burnout treatment, the focus is often on strengthening personal resources and relaxation. The aim here is to appreciate the stress factors so that the causes of the illness can subsequently be addressed. In this context, relaxation techniques can also be used in a supportive manner. In simple terms, it can be said that patients with burnout are more likely to be advised to set priorities and take shorter breaks, whereas in the case of depression symptoms, the focus is more on promoting personal initiative.

Categories: Burnout Depression