Original ArticleThe morning salivary cortisol response in burnout
Introduction
Burnout, or “the chronic depletion of an individual's energetic resources”, is a syndrome encompassing emotional exhaustion, physical fatigue, and mental weariness, as a consequence of longstanding stress [1], [2], [3], [4]. Viewed from this perspective, burnout is conceptually similar to such conditions as the chronic fatigue syndrome (CFS), fibromyalgia, and “vital exhaustion” (VE), a state characterised by unusual fatigue, increased irritability, and feelings of demoralisation, and which often precedes cardiac events and increases the risk of restenosis after angioplasty [5], [6], [7].
There is a growing interest in the role of the hypothalamic–pituitary–adrenocortical axis (HPA) in states characterised by excessive fatigue. Cortisol levels in plasma increase within 15 min following acute stress, but return to basal levels once effective coping is established. Permanent or repeated exposure to stressors with which one cannot adequately cope may contribute to a prolonged activation of the HPA axis, leading, in turn, to abnormal elevations in the levels of circulating glucocorticoids [8], [9], [10], [11], [12], [13], [14]. It has been proposed that with time, longstanding strain on the HPA axis may lead to hypocortisolism [15], [16], [17], [18]. Although the mechanisms underlying this type of dysregulation in humans are not well understood, data indicate that such conditions as posttraumatic stress disorder (PTSD), CFS, fibromyalgia, and VE are characterised by excessively low levels of cortisol [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31]. Some studies, however, have failed to demonstrate differences in cortisol levels between CFS patients and controls [32], and others [33] have even reported the opposite pattern, i.e., raised salivary cortisol in CFS.
Very little is known about HPA function in burnout, and the published results are contradictory, showing both insignificant, negative, and positive associations between burnout and cortisol. Studies employing single blood samples have failed to demonstrate associations between cortisol and burnout, as measured with various indices [34], [35], [36]. Hellhammer [37] observed that nurses suffering from burnout and multiple physical complaints exhibited low morning levels of salivary cortisol and elevated levels of this hormone in the afternoon and evening. In a study by Pruessner et al. [38], teachers scoring high on burnout showed a lower overall salivary cortisol secretion during three consecutive mornings of saliva sampling and a greater suppression of cortisol secretion after dexamethasone administration. In a study conducted among military personnel, Morgan et al. [39] found that high levels of burnout were related to flattened diurnal secretory cycles, as manifested by lower morning levels and higher evening levels of cortisol, respectively. Moch et al. [40] observed a reduction of urine free-cortisol excretion in 16 female burnout patients who were compared with healthy controls.
Melamed et al. [4] reported elevated daytime levels of salivary cortisol in blue-collar workers with chronic symptoms of burnout, i.e., lasting for at least 6 months. Similarly, De Vente et al. [41] observed elevated heart rate as well as increased morning salivary cortisol levels in burnout patients in comparison with healthy controls.
To our knowledge, the study by De Vente et al. [41] is the only one that has examined the free salivary cortisol response to awakening among burnout patients. The awakening cortisol response is well suited to uncover subtle dysregulations in HPA activity in that it is stable and not influenced to a high degree by age, smoking, use of oral contraceptives, sleep duration, or using/not using an alarm clock [42], [43], [44], [45]. The aim of the present study was therefore to further examine this indicator of HPA activity in male and female burnout patients, as compared with individuals reporting low and moderate levels of burnout. Based on the findings of De Vente et al. [41], it was hypothesised that burnout patients would manifest higher morning levels of salivary cortisol than would participants with low or moderate burnout.
Section snippets
Participants
The study comprised three groups with varying levels of burnout. Participants with high burnout scores (n=22) were recruited from a larger sample of 93 consecutive patients who were being assessed for inclusion in an investigation of the effects of a treatment package against burnout. We selected 9 men and 13 women who met the criteria for adjustment disorder, as set forth in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition ([46]; DSM-IV), but were free from comorbid
Results
Table 1 shows the between-group differences in lifestyle variables. The MB group included significantly more smokers than did the LB group [χ2(1)=4.89, P<.05] but did not differ significantly in this regard from the HB group. An analysis of the groups' use of medications revealed that the HB group consumed more antidepressants than did both the LB and MB groups [χ2(2)=8.15, P<.05]. The MB group used more antiinflammatory compounds than did the LB and HB groups [χ2(2)=6.32, P<.05]. There were no
Discussion
The aim of the present study was to examine the possible differences in the cortisol response to awakening in individuals with varying degrees of burnout, defined as the chronic depletion of an individual's energetic resources. The free cortisol response to awakening was chosen because this is a reliable indicator of HPA activity and is not influenced, to any great extent, by such factors as habitual smoking, sleep duration, using/not using an alarm clock, age, or use of oral contraceptives [42]
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