Humankind has forever sought a peculiar comfort in naming. Anything our senses can perceive or our minds can conjure has been subject to a unique identifier. The mantle of an experience is heavy, but naming it makes it easier to bear. Perhaps there is comfort in knowing that the rocks weighing us down are the same rocks the person next to us imagines. But ever so often, reality imprints on our imagination in different ways. Objective categorization is impossible, for an attempt to name the process evokes an entirely different image in two people. What you understand from a term might be shaped by the things you see, the things you’ve lived through, and even who says it. Psychiatrists, social workers, historians, and writers have been attempting to pin down human experiences in neat black and white, but burnout, fittingly, keeps returning to gray.
The historical underpinning and the failure
The World Health Organization (WHO) developed a comprehensive guide to a slew of diseases including psychiatric conditions. The latest is the 11th edition of the International Classification of Diseases (ICD-11). Burnout has been defined as an exclusively occupational phenomenon, and not a mental health condition unlike, say, depression. Accordingly, the ICD-11 states that burnout is a constellation of symptoms resulting from chronic unmanaged work stress. This might seem to be too narrow a definition of such a pervasive feeling, and while that thought is partially right, it has only surfaced after years of unconvincing scientific discourse.
The earliest attempt to formally define burnout dates to the 1970s. Herbert Freudenberger, a practicing American psychoanalyst, used it as an informal term derived from the effects of chronic drug abuse. He used it to refer to the insidious loss of motivation and commitment among the volunteers of the clinic he worked at. He reported feeling burnt out himself, and while this added credibility to his description, it largely made the account too autobiographical. Concurrently, Maslach, a social psychological researcher in California, attempted to define burnout more concretely through a series of interviews among workers. She developed the self-questionnaire, the Maslach Burnout Inventory, which stood the test of time to be the primary assessment tool even today. The Maslach Burnout Inventory (MBI), owing to its phrasing, could only be used to test the caring professions: health care, social work, law enforcement, and the like. It is apparent that the feeling of exhaustion sprawled outside these sections too, but this specific burnout silo was in part a direct consequence of the War on Poverty happening in the U.S. at the time. It stirred a massive influx of young, motivated people to join the human services, but after a decade of futile efforts, their hopes turned to frustration and cynicism. This eventually became the central criteria on which the MBI hinges: lack of motivation and doubt.
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Soon enough, people realized that the rocks of industrial exhaustion weighing them down were similar to those of emotional exhaustion. In a turn of modern service economics, burnout became increasingly affiliated with emotional, relational, and psychological pillars, all standing on the common ground of drained purpose. Couple this with the doctrines of modern culture, which emphasizes that work should provide achievement, passion, and meaning, and it becomes clear that burnout results from a failure to work that is a proof of your identity. In the western world, burnout became significant as it was a morally acceptable behavior. Claiming to be depressed meant admitting personal weakness, but claiming to be burnt out meant you had worked hard and were faulted by the system. Even within the west, burnout found itself being applied differently. Social security systems, particularly in the Scandinavian countries, cover sickness and incapability for their workers suffering from a burnout. A burnt-out employee was eligible for a sick leave. However, you could only get benefits from a burnout if, well, you were burnt out. The existing criteria overlapped with many psychiatric illnesses, and the lack of a clear symptomatology has plagued researchers ever since. Despite over 10,000 published papers on the subject, none have reached a definitive, overarching criteria. Burnout has always existed in our culture, but each time it was used, it represented something different.
What it couldn’t be
There are not many words in psychiatry as evocative as burnout. In the minds of the listener, it instantly paints an image of being literally burnt out of the desire to work. This simplicity, however, comes at a price. In the sea of psychiatric disorders floating around, I like to think of burnout as a fishing net cast too wide. It captures bits of depression, anxiety, hopelessness, and exhaustion, but has no real way to tell them apart. Attempts to demystify the symptoms of burnout have been made by neurologists in many parts of the world. Neurasthenia, or literally, weakness of the nerves, was perhaps the most prominent. It came into being during the 1870s, and argued that attempts to keep pace with the accelerated modern life weakens neural forces, birthing neurasthenic symptoms like exhaustion, insomnia, anxiety, and palpitations. In this way, neurasthenia seemed to combine both the mental features of burnout and the physical features of chronic fatigue. It is easy to deduce that the diagnosis soon died. It was a fishing net even wider than burnout. But the point remains, so to speak, that before burnout, there was neurasthenia. Before neurasthenia, there was melancholia. The end is far from being in sight, but so is the start.
As it stands now, burnout has been adopted into many disciplines as they saw fit, and the expert perspectives are now jumbled up. As medical students, we are taught to define diseases by identifying central symptoms which are reliable and replicable across a cohort of patients. A patient with tuberculosis would present with a combination of fever, weight loss, and night sweats. A patient with burnout would present with exhaustion and concentration problems. But so would a patient with a viral infection, or hypothyroidism. In practice, depression also seems to encompass most of what burnout is trying to do, and while theoretically, depression is well classified, it becomes surprisingly complex to differentiate it from burnout clinically. A psychologist may try to quantify burnout through the MBI, but the scales only measure what they define to be burnout, and there is no singular definition. Socially, burnout becomes a language for modern exhaustion. Sometimes, it is even worn as a badge of honor to dignify suffering. Keeping in mind the historically diverse interpretations as well, burnout is the modern ship of Theseus. It changed with time. Every discipline that approached it replaced one of its planks with something of their own.
Not everything needs a name to be addressed
The heterogeneity of burnout makes it all the more important, and nuanced, to be accounted for. It cannot be a single prescription, a therapist visit, or an article like this. Within its imprecision, it carries a personal significance to everyone who claims to have it. The first step is, therefore, unfolding. Unfold what you are experiencing. If it’s fatigue, take rest. If it’s medical illness, anxiety, and sleep disturbance hiding behind the facade of burnout, you deserve medical attention. The question becomes trickier once it involves a loss of meaning. I wish the answer was as simple as finding more meaning, but purpose doesn’t anesthetize exploitation, and fundamentally balancing what the work gives and takes becomes vital. Burnout may never fall into place like medicine wants it to, but for all you know, it’s better this way. It may not inform you of a precise diagnosis, but it exists as a warning signal to tell you something is wrong. The task, thus, changes from verifying that you are actually burnt out to asking what is truly burning.
Nobody knows if everyone is pointing at the same ship anymore. You could try cataloging its history, figuring out where each part came from. But the fact remains: The ship sails. And millions of people still climb onto it to keep themselves from sinking.
Bharat Goel is a medical student in India.
