ORIGINAL ARTICLE
A Qualitative Reexamination of the Key Features of Burnout
Gabriela Tavella, B(Psych) Hons and Gordon Parker, MD, PhD, DSc, FRANZCP
Abstract: Burnout is generally defined as a triad of emotional exhaustion,
lack of empathy, and reduced professional accomplishment constructs. We
sought to determine in an exploratory, qualitative study whether these three con-
structs adequately represent burnout. Participants who self-identified as experienc-
ing burnout completed a questionnaire that asked about their experiences of the
condition. A qualitative thematic analysis was undertaken to determine the primary
symptom constructs nominated by participants. The thematic analysis resulted in
12 symptom clusters or “themes” being identified as putative burnout features,
with several of these themes overlapping with features identified in our indepen-
dent quantitative analysis. Although we found emotional exhaustion, lack of em-
pathy, and reduced professional accomplishment to be commonly nominated
symptoms of burnout, the distinctive presence of several additional themes sug-
gests that the burnout syndrome comprises a broader set of symptom con-
structs than those currently accepted as the defining features of the condition.
Key Words: Diagnosis, self-report, stress, burnout
(J Nerv Ment Dis 2020;208: 452 458)
B urnout is a negative psychological response to prolonged work
stress and has significant consequences. These include decreased
wellbeing and increased rates of medical conditions such as cardiovas
cular disease (Lambert et al., 2010; Toppinen Tanner et al., 2009), as
well as impaired work performance reflected through both increased
rates of work absenteeism and presenteeism (Lambert et al., 2010;
Salyers et al., 2011), and reduced service quality and safety for
clients/patients (e.g., Panagioti et al., 2018; Shanafelt et al., 2010). Be
cause of its far reaching consequences, burnout (as well as its preven
tion and management) is currently of high research interest. However,
despite much empirical investigation, questions remain as to how the
condition is best defined and measured (Bianchi et al., 2019; Cox
et al., 2005), with the need for answering such questions deemed to
be “urgent” (de Beer and Bianchi, 2019, p. 219). The current study
therefore sought to address this issue by assessing the key features of
burnout through an exploratory, qualitative analysis and to determine
if current prioritized definitions could be supported or would benefit
from modification.
The World Health Organization (WHO) recently listed burnout
in the 11th edition of their International Statistical Classification of
Diseases and Related Health Problems (ICD 11; WHO, 2018), de
scribing it as “a syndrome conceptualized as resulting from chronic
workplace stress that has not been successfully managed,” and charac
terized by “1) feelings of energy depletion or exhaustion; 2) increased
mental distance from one's job, or feelings of negativism or cynicism
related to one's job; and 3) reduced professional efficacy.” Although
such recognition by WHO has the potential to improve access to health
care benefits and other entitlements for those who experience burnout,
School of Psychiatry, University of New South Wales; and Black Dog Institute,
Sydney, NSW, Australia.
Send reprint requests to Gordon Parker, MD, PhD, DSc, FRANZCP, School of
Psychiatry Central, Level 1 AGSM Building, UNSW, Sydney, Australia, 2052.
E mail: g.parker@unsw.edu.au.
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ISSN: 0022-3018/20/20806 0452
DOI: 10.1097/NMD.0000000000001155
452 www.jonmd.com The Journal of Nervous and Mental Disease • Volume 208, Number 6, June 2020
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we note two important caveats to its listing. First, it is included in the
ICD 11 section labeled “Factors influencing health status or contact
with health services.” Any condition so listed is viewed as potentially
influential to an individual's health status but “is not in itself a current
illness or injury.” Thus, burnout is not formally recognized in ICD 11
as a medical or mental health disease or illness, nor is it listed as a di
agnosable condition in the American Psychiatric Association's (APA)
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(APA, 2013). Second, the listed symptoms of burnout are derived from
the definition of the syndrome developed by Maslach and colleagues
(Maslach and Jackson, 1981), a definition that has not escaped criticism.
Maslach's team began examining burnout in the United States
during the 1970s after interviewing workers from the human services
industry about how they coped with the emotional toll of their jobs
(Schaufeli et al., 2009). Many described themselves as experiencing a
“burnout” syndrome, which was characterized by feelings of emotional
exhaustion, indifference toward service recipients, and a reduced sense
of professional achievement (Maslach, 1976). The researchers then de
veloped a 47 item questionnaire containing items mostly derived from
their previous interviews. The questionnaire was administered to ap
proximately 1000 workers in the human services sector, with factor
analyses of the data eventually generating a 22 item measure the
Maslach Burnout Inventory (Human Services Survey) or MBI HSS,
made up of three subscales (Maslach et al., 2016). The “emotional ex
haustion” subscale comprised nine items capturing fatigue, lethargy,
and emotional depletion; the “depersonalization” subscale contained
five items representing emotional detachment and cynicism toward cli
ents; and the “personal accomplishment” subscale comprised eight
items capturing feelings of professional efficacy and achievement.
Higher scores on the first two subscales and lower scores on the third
subscale were positioned as indicating a greater degree of burnout.
The measure was subsequently modified for use across different caring
professions and later further adapted to generate the MBI General Sur
vey (MBI GS) for measuring burnout outside the human services sector
(Maslach et al., 2016). The set of MBI questionnaires have since been
successful in virtually monopolizing the burnout literature and, by the
end of the 20th century, had been used in more than 90% of published
burnout research papers (Schaufeli et al., 2009).
Despite its popularity, the MBI has been repeatedly criticized.
One concern is its generalizability, as the measure originated solely
from research in the human services sector (Kristensen et al., 2005),
and, although adapted slightly, the MBI GS's constructs and items
remain very similar to those in the original MBI HSS, as noted by
its authors (Maslach et al., 2016). A second concern is whether
Maslach's three factor model is valid. Some argue that burnout is
simply a one dimensional construct and advocate for measures that
are effectively single factor scales measuring exhaustion. For in
stance, Pines et al.'s (1981) Burnout Measure is a 21 item questionnaire
encompassing symptoms such as feeling “weak” or “rundown” and is
the second most frequently used measure of burnout (Enzmann et al.,
1998). However, others have opposed both the one and three factor
models, such as Demerouti et al. (2003), who suggested that a two
factor model comprising exhaustion and disengagement adequately
captures burnout. Recently, de Beer and Bianchi (2019) similarly sug
gested that a two factor model captured burnout in a sample of French
teachers. However, unlike Demerouti et al.'s (2003) model, their first
The Journal of Nervous and Mental Disease • Volume 208, Number 6, June 2020
factor combined items from the MBI's emotional exhaustion and deper
sonalization subscales, whereas the second factor comprised the MBI's
personal accomplishment items.
There is a third argument that the one , two , and three
dimensional models are all insufficient and that burnout may instead
be made up of even more than three constructs. Specifically, the original
47 item MBI measure has been criticized for including only a limited
set of “arbitrary” items (Schaufeli, 2003) capturing only those con
structs that Maslach and colleagues hypothesized as being related to
burnout. It therefore follows that if a more comprehensive set of items
had been included in the original factor analyses, the definition of burn
out could be much broader and therefore very different to the currently
dominant three factor model (Bianchi et al., 2015).
Recognizing such issues, we sought to clarify the nature of burn
out (and its constructs) by evaluating a very broad set of features and
(eventually) develop a new measure of the condition. Using an explor
atory approach and intentionally allowing broad inclusion criteria, we
invited adults self identifying as experiencing burnout to complete a
questionnaire capturing their experiences. The questionnaire included
a 106 item list of putative burnout symptoms and features, derived from
an in depth review of previous measures and the existing burnout liter
ature, as well as from the clinical experience of the second author (GP).
Analysis of the quantitative data (Tavella et al., in preparation)
generated a broader model of the condition. Specifically, our first factor
not only captured exhaustion but also included symptoms of worry and
an inability to relax, depression, social withdrawal, and problems with
memory and attention. We also generated a “loss of empathy” factor,
as well as a factor relating to reduced performance at work (although
the latter appeared to be also associated with compromised cognition
consequential to developing burnout). Importantly, there was a person
ality component that weighted perfectionism and workaholism, sug
gesting a diathesis stress model, whereby certain personality traits
predispose to a state syndrome. Thus, our quantitative analysis showed
some overlap with Maslach and colleagues' conceptualization of burn
out but also diverged across some key constructs.
Our questionnaire also contained open ended questions, with re
spondents' answers generating a large database of qualitative informa
tion about burnout. Qualitative data are vital in providing “richness
and context that add life to the numbers and meat to the bones of the
quantitative data” (Jankowska et al., 2006). Analyses of qualitative data
are especially important in preliminary studies attempting to design
measures or develop diagnostic criteria for psychological phenomena
as they allow researchers to develop “a comprehensive list that encom
passes both inclusive and exclusive criteria” (Razafsha et al., 2012). We
now report analyses of our qualitative data and, by making comparison
with our quantitative research findings, generate primary construct
“themes” encompassed by a burnout syndrome. Ultimately, our quanti
tative and qualitative analyses seek to determine whether burnout
should be measured more broadly than currently done by the MBI mea
sure and by ICD 11 criteria.
METHODS
Recruitment
A convenience sample was recruited via an online advertisement
on the Black Dog Institute's website as well as via newspaper advertise
ments. The advertisement wording was deliberately broad, inviting any
one “working, retired, studying, or responsible for home/care duties”
who currently felt burnt out to participate if aged between 18 and
65 years and fluent in written and spoken English.
Procedure
All individuals provided online consent as approved by the Uni
versity of New South Wales Human Research Ethics Committee
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Reexamining the Features of Burnout
(HREC number: HC17678). Participation involved completing a confi
dential online questionnaire that contained close ended questions relat
ing to participants' experiences of burnout (to generate the quantitative
data), as well as open ended questions seeking nominated burnout
symptoms, with analyses of the latter reported here.
ANALYSES AND RESULTS
Demographics
Data were collected from 1042 participants, and after excluding
those with missing data, 1019 questionnaires were deemed acceptable
for analysis. There was a female preponderance (74.6%) and the mean
age was 41.4 years. Most identified as Australian (54.5%), and the most
commonly nominated occupations involved managerial positions
(14.3%) or being a student (12.0%), a teacher (11.3%), primarily re
sponsible for home/care duties (10.2%), or a nurse/midwife (6.0%).
Thematic Analyses
As computer programs designed to assist in the analysis of qual
itative data increase the accuracy and efficiency of qualitative research
(Welsh, 2002), our data were analyzed using the NVivo 12 software
program. A thematic analysis was conducted to identify data patterns
(i.e., themes), following guidelines developed by Braun and Clarke
(2006) and respecting nuances detailed by Denzin and Lincoln (2000).
Thematic analysis can be undertaken via a) a deductive or “top
down” examination of the data guided by established theory or previous
research findings or b) an inductive or “bottom up” examination in
which the data are coded and interpreted independently before relevant
themes are identified and classified (Braun and Clarke, 2006). As the
study was exploratory and we sought to identify a broad range of
burnout symptoms, the thematic analysis was undertaken using an
inductive approach.
Features of Burnout
In initiating the thematic analysis, all responses to the question
“Could you now please record and describe the symptoms and features
that suggest you are experiencing ‘burnout?’” were read to provide a
general picture of the type and scope of information provided. Because
of the many responses (i.e., >1000), an NVivo word frequency query
was conducted for ease of initial analysis to identify words and their
stems most frequently reported. The results of the word frequency
query were examined, and words referenced often but judged as being
of little contextual meaning (e.g., “also,” “getting”) were removed.
Word groups remaining that were referenced at least 50 times across
the dataset were reviewed and the references they captured were trans
formed into initial codes encompassing “the most basic segment, or el
ement of the raw data or information that can be assessed in a
meaningful way regarding the phenomenon” (Boyatzis, 1998), with
these codes grouped into meaningful NVivo nodes of similar informa
tion. For instance, the word “exhaustion” (and its variants “exhausted”
and “exhausting”) was expressed 224 times across the dataset, and thus,
these 224 references were coded under an “exhaustion” node. After
coding the word groups returned by the word frequency query, partici
pants' answers to the question were manually examined to ensure com
prehensive coverage of the data, and any meaningful phrases found not
already coded were allocated to new or existing nodes. NVivo text
search queries were then conducted to search for particular phrases
and their variations that appeared often throughout the manual data ex
amination (e.g., “difficult to relax”), with the output from these queries
again coded into new or existing nodes. The data were then manually
examined a second time to ensure all meaningful information had
been coded.
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TABLE 1. Themes and Subthemes Capturing Participants' Reported TABLE 1. (Continued)

Features of Burnout
Theme Subthemes
Theme Subthemes
Executive functioning Concentration or attention issues
Exhaustion (n = 700) Exhaustion issues (n = 332) Memory problems
Fatigue Brain fog/cloudy thinking
Tiredness Confusion
Feeling drained Racing or disorganized thoughts
Lethargy Difficulty planning or making decisions

Anxiety/stress (n = 516) Feeling anxious Reduced performance Reduced performance or

Feeling stressed/overwhelmed (n = 265) quality of output
Unable to relax/switch off Accomplishing less at work
Ruminating over/worrying about Lower productivity
work when not there Procrastinating
Sense of dread Avoiding responsibilities
Excessive worry Making more mistakes
Being fidgety or restless “Failing” at work

Indifference (n = 475) Lack of empathy Withdrawal from others Family

Cynicism (n = 258) Friends
Lack of interest or pleasure in work Colleagues
Lack of interest or pleasure in Clients
activities outside of work
Apathy Physical symptoms Aches and pains
Disengagement (n = 251) Eating or appetite changes
“Going through the motions” Headaches
Anticipatory anhedonia Nausea
Low libido
Depression (n = 392) Low mood/depression/sadness Issues with vision
Hopelessness Other
Helplessness
Feelings of worthlessness Emotional lability (n = 168) Fragile emotions
Drop in confidence or self esteem Increased sensitivity
Self doubt Emotional outbursts
Guilt Crying more/tearfulness
Suicidal thoughts

Irritability and Irritability The analysis resulted in over 6000 coded statements, which were
anger (n = 361) Easily agitated combined or separated into groups of nodes of similar coded content.
Impatient These groups were then examined and the themes and subthemes they
represented were named and defined collaboratively by both authors.
Frustrated
Participant IDs coded at each theme were identified to determine the
Anger or resentment number of participants who referenced each theme. The resulting 12
themes and their subthemes are displayed in Table 1 in descending or
Sleep disturbances (n = 351) Insomnia der of frequency, as now detailed.
Hypersomnia
Having nightmares Exhaustion
Exhaustion was the most frequently nominated feature, with
Lack of motivation Drop in motivation or drive 68.9% of the sample describing themselves as feeling extremely
or passion (n = 341) Drop in life/work satisfaction exhausted or using synonyms (i.e., fatigued, tired, lethargic, or drained).
Feel as though not making a difference at work Many positioned exhaustion as the most notable defining symptom,
Reduced passion for one's job with some noting that it was “constant,” “chronic,” or “endless.” Its cen
Feeling as though one's work has no purpose trality to the burnout syndrome was captured succinctly by one partici
pant: “I describe my burnout as being tired of being tired.” This view
was echoed by another participant who described their burnout simply
as “Fatigue, fatigue, fatigue!”
Anxiety/Stress
Anxiety and stress were nominated by 50.6%. Although some
simply listed feelings of anxiety, stress, and dread, many others speci
fied that anxiety was specifically related to their work and not usually

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The Journal of Nervous and Mental Disease • Volume 208, Number 6, June 2020
experienced outside of the working environment. For instance: “I expe
rience anxiety, at times to the point of nausea and headaches, around the
idea of how far behind I am, the backlog from a day off… I am not gen
erally an anxious person.”
A key subtheme expressed by many was of worrying excessively
about work when not there, with participants stating they were unable to
“switch off ” or that intrusive thoughts about work would wake them
suddenly in the middle of the night.
Indifference
Almost half (46.6%) stated that they had lost interest, pleasure,
or the ability to care about people and events in their lives, both in
and outside the work environment. The most prevalent subtheme cap
tured empathy loss, with some stating they had become too emotionally
“numb” to care about anyone other than themselves.
Many noted they had become disengaged from activities that
they used to enjoy and were simply “going through the motions.”
Others noted experiencing a complete lack of emotions and becoming
“zombie like.” Some nominated anticipatory anhedonia, stating that
they no longer looked forward to upcoming events that would have pre
viously excited them.
Depression
Depressive symptoms were nominated by over a third of partic
ipants (38.4%), with many reporting a low mood or feeling depressed or
sad and some reporting feeling hopeless and helpless. Decreased
self esteem, increased self doubt, and feelings of worthlessness were also
reported by some participants. Only a few respondents reported experienc
ing suicidal thoughts, with one participant detailing how they attributed
their suicidal thinking directly to their experience of burnout: “I tend to feel
suicidal when the burnout becomes too much as I begin to doubt my worth
because of my inability to motivate myself and complete tasks.”
Irritability and Anger
Some 35.4% reported increased irritability. Whereas many de
scribed feeling agitated, frustrated, or easily annoyed by colleagues at
work, others described how irritability had expanded into their relation
ships outside of work or had impacted on their personality as a whole.
For instance: “My temper is far shorter than it used to be and I feel as
though I'm not just drifting away from the nice person I used to be
I've been kidnapped and am traveling on the freeway far, far away.”
A prominent subtheme was anger and/or resentment. Some were
aware that their anger was irrational or unwarranted, and others noted
the potential for their anger to be expressed through physical aggres
sion, such as “…feeling quite close to behaving inappropriately, (such
as) swearing or slapping someone!”
Sleep Disturbance
Issues with sleep were prevalent (34.4% of participants). Insom
nia was the most frequently nominated problem, although some de
scribed experiencing hypersomnia or being unable to get out of bed in
the mornings. A small number stated that they had started to experience
nightmares, with most specifying that the topic of their bad dreams was
always work related.
Lack of Motivation or Passion
One third (33.5%) reported a reduction in professional drive or
passion, with most of this subgroup (89.7%) stating that they no longer
felt motivated to achieve. Whereas some participants detailed having
lost motivation specifically in relation to work related tasks, others
noted how it had infiltrated their lives at home, such as “Lack of general
motivation, even at home towards housework.”
Other subthemes included feeling like one's work was purpose
less or experiencing a reduction in work or life satisfaction. Others
expressed feeling a combination of these factors, such as “I am strug
gling with motivation and to find a sense of purpose.”
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Reexamining the Features of Burnout
Executive Functioning Issues
Problems with cognition and executive functioning were reported
by 32.5% of participants. Specific symptoms included concentration
difficulties, memory problems, general confusion, indecisiveness, and
cloudy or disorganized thinking. Some respondents highlighted the
wider impact that these cognitive issues had on their everyday function
ing, for instance “Forgetting where I was, I kept getting lost. I had to
stop and read or go through the process of working it out so I still had
my brain processes. I began to keep extra notes to help me.”
Others noted how such cognitive issues had made them feel neg
atively about themselves, such as “It feels like I have a mental block. In
terms of the work, nothing is going in, nothing sticks. My thinking
slows down and I feel dumb.”
Reduced Performance
Compromised work performance was noted by 26.0% of partic
ipants. The most prominent subthemes were of procrastination and of
avoiding responsibilities, with participants stating they had begun to
“do the bare minimum” or “put things off ” since developing burnout.
Another set of descriptors covered failing at work tasks or making “un
characteristic” and “silly” mistakes. Others were more general, with re
spondents stating that their overall performance, productivity and
quality of output had dramatically reduced, with one participant stating,
“I am nowhere near being on top of my game.”
Withdrawal From Others
One quarter (25.3%) reported becoming socially withdrawn. A
small number of these individuals specified that their social avoidance
was restricted to work situations, such as “Pulling away emotionally
from staff and wanting to engage less with clients.” However, the major
ity reported that their social withdrawal was widespread, for instance,
“Coping with people and social situations is also becoming unbearable.”
Physical Symptoms
Physical complaints were nominated by almost one quarter
(24.6%) of the sample. Many listed general aches and pains, nausea
and headaches, and a large proportion noted increased or decreased ap
petite, overeating or undereating, and weight gain or loss. Whereas
others raised specific issues such as a decrease in libido, some indicated
a broader drop in physical “immunity” since developing burnout. These
participants described experiencing “ongoing illnesses” and being un
able to overcome general colds and infections, with one participant stat
ing: “When I get sick I get really sick and often completely collapse.”
Emotional Lability
The final theme, referenced by 16.5%, encompassed emotional
lability. Participants reported mood swings, emotional outbursts, and
uncharacteristic crying or tearfulness, with some describing themselves
as being overly sensitive or that their emotions were “fragile.” Most rec
ognized that their emotional reactions to situations were excessive and
unwarranted, for instance, “You get giddy, dizzy, and laugh or cry at
trivial things.”
Comparison With Quantitative Data
The themes identified in our qualitative analysis mirrored our
quantitative findings to some degree. Specifically, of the 41 items gen
erated by our final factor analysis (Tavella et al., in preparation), 32
were represented by the themes identified in the current study. These
items and their corresponding themes are listed in Table 2, with the im
plication of this overlap detailed in the Discussion section.
DISCUSSION
Burnout is usually defined by a triad of emotional exhaustion,
lack of empathy, and reduced professional accomplishment symptoms.
The purpose of the current study was to reexamine whether these three
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TABLE 2. Burnout Features Identified Across Both Our Qualitative and Quantitative Analyses

Theme From Qualitative Analysis Items From Quantitative Analysis

Exhaustion I feel emotionally drained and exhausted
I constantly feel tired or fatigued
I lack energy across the day

Anxiety/stress I worry about work when I am not there

I cannot get any distance from my responsibilities
I cannot relax generally
I cannot calm myself

Indifference I'm more cynical about things and people in general

I feel less empathy and sympathy to people in general
I struggle to understand the feelings of my family and friends
I struggle to understand the feelings of colleagues and/or customers at work
I do not care what happens to people at my work (e.g , colleagues, customers)

Depression I feel quite depressed

The world seems gray
My self esteem and self worth are distinctly less

Irritability and anger I find most of the things people at my work do to be irritating
Basic job demands and home chores frustrate me
I feel agitated constantly

Lack of motivation or passion I feel less satisfied with life

Executive functioning issues I find it hard to concentrate on the task at hand

I get distracted easily
I find it difficult to concentrate when I am interacting with people at work (e.g., in meetings)
My attention is less
My capacity to remember things is not so good as it was
I have to reread things because I wasn't concentrating the first time
I tend to scan when I read, rather than focus
I have been forgetting things

Reduced performance It takes me longer to finish tasks at work than it used to

My work performance is not as good as it used to be
I am less productive at work than I used to be

Withdrawal from others I have withdrawn from my family and friends

I have withdrawn from colleagues and/or customers/consumers at work

factors adequately capture a burnout syndrome by using a “bottom up”
approach and asking those with burnout to detail their experiences of
the condition.
We first note some study limitations and strengths. A limitation
was that burnout was self identified in a convenience sample. As the
syndrome has not yet been formally defined, and as convenience sam
pling is useful in exploratory research and has been used by other burn
out researchers (e.g., de Beer and Bianchi, 2019), our recruitment
approach is somewhat defensible, but it also risks allowing individuals
with alternate primary psychological and physical conditions (e.g., de
pression, anxiety, chronic fatigue syndrome) being included. In addi
tion, although the advertisement was presented in media publications,
those participants recruited via the advertisement on the Black Dog In
stitute website may have biased the overall sample toward help seeking
individuals with psychological distress who commonly access the website.
Furthermore, although we report prevalence data, such data are not
necessarily truly representative for the syndrome as such reporting
reflected what respondents simply judged as worthy of noting. A study
strength was that the open ended qualitative questions were presented
to participants before the 106 item list of putative burnout symptoms,
averting the risk of participants' qualitative responses being prompted
by preceding symptom definition.
Exhaustion was identified as a central burnout feature in the cur
rent analysis, with this centrality mirrored in both the existing unitary
and tridimensional models of burnout. However, unlike the unitary
model that equates burnout completely with exhaustion, most of our
sample nominated many other manifestations of their burnout, for in
stance, feelings of disconnection from and cynicism toward other peo
ple, with these features captured by our indifference theme. This theme
also captured a disconnection from and disinterest in work (aligning
somewhat with the MBI GS's “cynicism” scale; Maslach et al.,
2016), while also encompassing general anhedonia, with individuals

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The Journal of Nervous and Mental Disease • Volume 208, Number 6, June 2020
expressing reduced pleasure and interest in life or activities outside of
work, as well as an inability to look forward to things. Thus, our indif
ference theme seemed to encompass a far broader construct than the
“loss of empathy” captured by the original MBI HSS's “depersonaliza
tion” scale. Items from the MBI's accomplishment subscale (Maslach
et al., 2016) were evident across our qualitative data; however, in our
analysis, we found a set of subconstructs as well as self judged cogni
tive impairment being of potential importance whether reflecting
psychological and/or organic factors in operation.
Our analysis also revealed several other symptom constructs
(e.g., anxiety/stress, depression, irritability/anger, insularity, physical
symptoms and emotional lability) that may contribute to the definition
of a burnout syndrome. Our finding that some described worrying ex
cessively about work productivity and output does not align with items
in the MBI, which mostly denote feelings of severe detachment from
and uncaring about one's job (Maslach et al., 2016). Our result does,
however, align with past research suggesting that work stress may pre
cipitate symptoms of anxiety (DiGiacomo and Adamson, 2001; Sun
et al., 2012), as well as our earlier factor analysis, which included items
capturing worrying excessively about work and being unable to relax.
Our result here is therefore consistent with our quantitative model indi
cating that highly reliable people (and particularly those who worry
about their work and their any failure to perform) are potentially at
greater risk of burnout. Unfortunately, as we did not include a formal
measure of anxiety, it is difficult to determine whether those who
nominated stress and anxiety symptoms in their quantitative and/
or qualitative responses were reporting either state anxiety as a
consequence of burnout or trait anxiety relating to a predisposing
anxious personality style. A similar query was recently investi
gated by Koutsimani et al. (2019), who conducted a comprehen
sive literature review and meta analysis to discern any distinction
between burnout and anxiety. Their results indicated that although
there is a positive correlation between the two conditions, they are
in fact different constructs.
A significant number of respondents reported depressive symp
toms, including low mood, sleep disturbances, and anhedonia. It has
long been queried whether burnout is simply synonymous with depres
sion (e.g., Ahola et al., 2005; Firth et al., 1986; Oquendo et al., 2019;
Schonfeld et al., 2018). Although the prevalence of depressive symp
toms in our sample may be an artifact of our decision to not assess
for and exclude those formally diagnosed with a depressive disorder,
it could also suggest that the two conditions overlap. This result is con
sistent with several symptomatology studies of burnout and depression,
which have reliably shown symptom crossover between the two condi
tions (e.g., Ahola et al., 2005; Bianchi et al., 2013; Peterson et al.,
2008), as have correlational studies (e.g., Glass and McKnight, 1996;
Schaufeli and Enzmann, 1998). Conversely, factor analyses have re
peatedly shown the two conditions to be independent (e.g., Glass
et al., 1993; Leiter and Durup, 1994; Toker and Biron, 2012). In
deed, after rigorously reviewing of the available literature on the
topic, Bianchi et al. (2015) concluded that the existing research
is inconclusive, so that whether burnout and depression are distinct
diagnostic entities remains unclear. Although any such distinction
remains to be conclusively elucidated, the breadth of features re
ported by those who experience burnout in our sample seems to
go beyond the general boundaries of depression. Depressive (and
anxiety) symptoms are a common consequence of many psycho
logical states, and thus, we favor viewing burnout as having de
pression as a common concomitant as against the two conditions
being synonymous.
Another set of features identified as common across our qualita
tive dataset were executive dysfunction and cognitive symptoms. Our
earlier quantitative analysis (Tavella et al., in preparation) also identi
fied cognitive impairment as implicated in burnout. Previous studies
have similarly suggested that cognitive issues (e.g., concentration and
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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Reexamining the Features of Burnout
memory problems) may be “cardinal symptoms” of burnout (Bianchi
et al., 2015; Schaufeli and Taris, 2005). Thus, the absence of such a do
main in the MBI measure could be an important oversight, and future
research should assess the centrality of such symptoms to the burnout
syndrome and their “functional” or “organic” nature.
Although our quantitative data identified a work perfectionism/
workaholism factor, it did not emerge in our current study, presumably
as subjects were asked to judge their perceived burnout symptoms.
Nomination of any such predisposing personality variables would more
likely be recorded in response to a question asking about what subjects
perceived to be the main causes of their burnout. Contrarily, there were
also constructs identified in the current analysis that were not captured
in our factor analysis, namely, physical symptoms and emotional labil
ity. Physical symptoms such as headaches, nausea, and muscle pain are
common psychosomatic symptoms of stress and other psychological
disturbances (Haug et al., 2004; Henningsen et al., 2003). The preva
lence of such symptoms in the current sample is therefore unsurprising
and aligns with other studies linking psychosomatic symptoms with
burnout (Bauer et al., 2006; Piko, 2006); however, their nonspe
cific nature would be unlikely to render them useful as formal di
agnostic criteria for the condition. A similar explanation is likely
to hold for emotional lability, which, as a common symptom of
stress, is to be expected in those who are burnt out. The absence
of this symptom construct in our quantitative results is likely an ar
tifact of our failure to test it as items in the quantitative component
of the questionnaire.
Finally, we consider the extent to which a burnout syndrome has
specificity as against being akin to any other chronic stress situation.
Chronic stress states may reflect a wide range of psychological and so
cial causes, and comprise a broad domain encompassing states of high
activation, as well as of stasis or exhaustion, with burnout weighted to
the latter phase. Burnout has been defined as a consequence of
work related stressors and this gives it a specific context. Such a
context may, however, be too specific. We suggest, and will else
where report from our current sample, that respondents' salient
stressors were not limited to formal work scenarios but could emerge
if the individual day to day “work” comprised unrelenting requirements
to (say) look after an ill or demanding family member. Nevertheless, as
the “burnout syndrome” is further defined, it will be important to deter
mine its specificity.
CONCLUSIONS
Overall, our qualitative analysis identified numerous themes and
subthemes capturing a set of putative burnout constructs. Although
some themes encompassed the emotional exhaustion, cynicism, and re
duced professional efficacy constructs central to Maslach and col
leagues' definition of burnout, we also identified additional features
not included in the traditional conceptualization of the condition. Al
though the importance of these new features must be clarified in future
research, our findings across both our quantitative and qualitative anal
yses suggest that the burnout syndrome comprises a much broader set
of symptom constructs than long held to formulate the condition, a con
clusion that argues for our broad study approach and for the design of
further definitional studies.
ACKNOWLEDGMENT
This study was supported by National Health and Medical Re
search Council grants (1037196 and GNT1176689).
DISCLOSURE
The authors declare no conflict of interest.
www.jonmd.com 457
Tavella and Parker The Journal of Nervous and Mental Disease • Volume 208, Number 6, June 2020
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