2Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Kungsgatan 12, 6th floor, 411 18 Gothenburg, Sweden
3Department of Health and Rehabilitation, The Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
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1Hovås Askim Familjeläkare och BVC, Askims Torg 5, 436 43 Askim, Sweden
2Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Kungsgatan 12, 6th floor, 411 18 Gothenburg, Sweden
3Department of Health and Rehabilitation, The Sahlgrenska Academy, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
Annika Adamsson, Email: es.nanrakton@nossmada.akinna.
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Received 2017 Oct 19; Accepted 2018 Oct 16.
Copyright © The Author[s]. 2018
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License [//creativecommons.org/licenses/by/4.0/], which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author[s] and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver [//creativecommons.org/publicdomain/zero/1.0/] applies to the data made available in this article, unless otherwise stated.
Associated Data
Data Availability StatementThe dataset used and analysed during the current study are available from the corresponding author on reasonable request. Permission to access the medical chart was required and received by the healthcare centre’s manager.
Abstract
Background
Mental illness, and particularly stress-related disorders such as exhaustion disorder, is continuously increasing in today’s society. It is important to identify patients who consult for potentially stress-related symptoms early, before the stress condition develops into an exhaustion disorder. The purpose of the study was to investigate the frequency of different presenting complaints for which patients had consulted in the two years preceding receipt of their exhaustion disorder diagnosis, and to explore potential associations between stress-related presenting complaints and demographic factors, as well as comorbidity and other potentially stress-inducing factors.
Methods
This was a retrospective medical chart review of presenting complaints of adult patients with exhaustion disorder two years preceding receipt of diagnosis at a primary healthcare centre in western Sweden.
Results
Exhaustion disorder was diagnosed in 126 patients at the healthcare centre during the study period. Charts were available for 115 patients [76% women, mean age 47 years]. Charts were reviewed with regard to presenting complaints, demographic data and comorbidity. Average number of general practitioner visits during the two years preceding the diagnosis was 5.2 [SD 3.7]. The two most common complaints were infection and anxiety/depression, presented by 49% and 46%, respectively. Other stress-related complaints seen to in more than 30% of the patients were stress, other pain, fatigue, gastrointestinal symptoms, and sleep disturbances. Back pain and fatigue were more frequent in patients over 40 years. A majority of the patients also had mental [53%] or somatic [61%] comorbidity. Comorbidity was more frequent in older patients. No significant gender differences were found.
Conclusions
Patients with exhaustion disorder appear to consult their general practitioner numerous times with stress-related complaints in the years preceding their diagnosis. The findings indicate which presenting complaints general practitioners may need to be more attentive to so that patients at risk of developing exhaustion disorder can be identified earlier and get the support they need. Addressing stress factors earlier in the course of illness and preventing the development of exhaustion disorder may contribute to a reduced burden for both individual patients and for society, with a reduction in sick leave and societal costs for mental illness.
Keywords: Stress, Exhaustion disorder, Burnout, Primary health care, General practice, Stress related mental health problems, Early detection
Background
Exhaustion disorder was introduced as a medical diagnosis in Sweden by the Swedish National Board of Health and Welfare in 2010. The proposal for this new diagnosis originated during a study of persons on long-term sick leave due to a mental diagnosis and where workplace conditions were considered to play an important role [1]. It was considered important to define specific diagnostic criteria for stress-related exhaustion, because the terms ‘burnout’, ‘exhaustion’ and ‘stress’ were not defined clearly and were not uniformly used. Exhaustion disorder has been proposed as the most valid clinical equivalent of burnout [2]. Although conceptually related and sometimes used synonymously, burnout is an unspecific term, with various definitions and of psychological origin, whereas exhaustion disorder is a more specific term and a clearly defined clinical diagnosis. The diagnostic criteria include physical and mental exhaustion, cognitive dysfunction, sleep disturbance, and physical symptoms [1]. They are presented in their entirety in Table 1.
Table 1
Diagnostic criteria for exhaustion disorder [Swedish National Board of Health and Welfare]
Diagnostic criteria for exhaustion disorder, ICD-10 code F 43.8AA. Physical and mental symptoms of exhaustion during a minimum of two weeks. The symptoms have developed in response to one or more identifiable stressors which have been present for at least six months.B. Markedly lack of mental energy, which is manifested by reduced initiative, reduced endurance, or prolonged recovery time after mental strain.C. At least four of the following symptoms have been present most days during the same two-week period:
1] Concentration difficulties or memory problems
2] Markedly reduced ability to manage demands or to perform under time pressure
3] Emotional instability or irritability
4] Sleep disturbances
5] Marked physical weakness or fatigue
6] Physical symptoms such as pain, chest pain, palpitations, gastrointestinal symptoms, dizziness, or sensitivity to soundD. The symptoms cause clinically significant suffering or reduced ability to function at work, socially, or in other important situations.E. The symptoms are not related to direct physiological effects of a substance [e.g. drug abuse, medication] or somatic disease/injury [e.g. hypothyroidism, diabetes, infectious disease].F. If the criteria for major depressive disorder, dysthymic disorder or generalized anxiety disorder concurrently are fulfilled, exhaustion disorder should be used as a secondary diagnosis.
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Exhaustion symptoms are developed as a consequence of exposure to one or several identifiable stress factors that have existed for a minimum of six months [1]. Symptoms are dominated by a substantial lack of mental energy, manifesting itself as lack of initiative, reduced stamina, or prolonged recovery after mental strain [1]. Work-related symptoms experienced by patients have recently been described as a sense of ‘work dissonance’, disrupted workflow, feeling out-of-sync, and social isolation [3].
The main cause of exhaustion disorder is believed to be stress; predominantly work-related but sometimes due to personal life circumstances [1]. Stress has been defined as an imbalance between demands placed on us and our ability to manage them [4]. Stress factors can cause acute or post-traumatic stress disorder while long exposure to stress without sufficient opportunity for recovery may lead to exhaustion disorder [5]. In classic stress theory, a general adaptation syndrome is described, in which stress reactions are divided into three phases [6]. After an initial alarm reaction and a state of resignation, the third phase entails a state of somatic and mental exhaustion that can cause joint inflammations, cardiovascular disease, gastrointestinal disease, type 2 diabetes, and mental illness [6, 7].
Mental illness—of which exhaustion disorder is one of the most common diagnoses—has become the primary cause of sickness absence, in Sweden as well as in other countries [5, 8]. After a period of stagnating sick leave statistics in the early 2000s, sick leave due to mental disorders began to rise again in 2010, and is today the most common reason for new sick leave registrations [4, 9]. From 2011 to 2016, the number of individuals on sick leave for mental disorders more than doubled, from 42,000 to 89,000, which corresponds to 45% of all ongoing sick leave registrations [8].
The prevalence of work-related stress in Sweden has been reported to be 38%, which is amongst the highest levels in Europe [10]. Exhaustion disorder in a Swedish working population has been estimated at 13% [11]. While women who work in healthcare and other people-oriented human services professions are affected to a greater extent [11, 12], a substantial increase amongst men has recently been noted [9]. An association to work demands and degree of work control has been shown in both genders [11].
Rehabilitation has been shown to take longer time with longer symptom duration before receiving a stress-related diagnosis [13]. Of working age patients seeking primary care, 59% have been reported to experience stress-related symptoms and of those, 9% met the criteria for exhaustion disorder regardless of consulting complaint [14]. Prolonged exposure to stress without opportunity for recovery may entail a gradual increase in number of symptoms, causing patients to seek care repetitively with the symptom being the presenting complaint [1]. Many consult a general practitioner [GP] long before their symptoms are severe enough to require sick leave [15]. It is also common that patients seek emergency or drop-in care and that they are examined and treated for the presenting complaint alone, with neither the patient nor the physician identifying symptoms as signs of stress that may develop into exhaustion disorder [1].
Somatic symptoms that frequently constitute the presenting complaint at the occasion when the exhaustion disorder is diagnosed, are: nausea, irritable bowl, headache, dizziness, palpitations, chest pain, back pain, musculoskeletal pain, abdominal pain, and feeling faint [16, 17]. Multiple somatic symptoms have been associated with mental disorders [18], as well as a risk for subsequent long spells of sickness absence [19]. No study has been found that examines which stress-related complaints patients with exhaustion disorder consult for in the years preceding their diagnosis. Early identification of patients at risk is critical in order to prevent the development of exhaustion disorder, and can potentially prevent or reduce sick leave and hence the burden on both patient and society. It is therefore important to explore presenting complaints during the years preceding receiving the diagnosis, to identify which symptoms precede exhaustion disorder.
The primary aim of this study was to investigate the frequency of different presenting complaints that may be related to stress in patients with a diagnosed exhaustion disorder, in the two years preceding receipt of the diagnosis. Secondary aims were to explore potential associations between stress-related presenting complaints and demographic factors, as well as comorbidity and other potentially stress-inducing factors.
Methods
Study design, setting and participants
This was a retrospective chart review, in which data from medical charts were scrutinized [20]. The study was conducted at a suburban healthcare centre in western Sweden. In March 2016, 8521 patients were registered at the centre. Eight GPs were employed. Charts from all adult patients in whom exhaustion disorder [code F438A] was diagnosed at the healthcare centre from January 2015 to August 2016, and for whom there were medical records from the two preceding years, were included in the study.
Data collection and analysis
Medical charts on the included patients were reviewed for the two years preceding the date of the diagnosis. All presenting complaints that were potentially related to stress were extracted. The choice of these symptoms was based on earlier studies describing stress symptoms presented when receiving an exhaustion disorder diagnosis [13, 16, 17].
The primary outcome was the frequency of stress-related complaints for which the patient had consulted during the two years preceding the exhaustion disorder diagnosis. Data on demographic factors [gender, age, occupation], number of GP visits with stress-related complaints, and comorbidity with other mental and/or somatic diagnoses were also collected. The variables were collected into a case report form, which was developed, pilot-tested on 20 charts, and slightly revised.
The extracted data were entered into Excel, checked for accuracy against the case report forms, and then analysed in IBM SPSS Statistics, version 22.0. Age was categorised into the groups 60 years. For some variables where there were too few patients in some of the age categories, the categories were further collapsed into two groups [