Leisure Sickness: A Biopsychosocial Perspective

Abstract

Leisure and vacation are generally associated with feelings of relaxation and well-being. However, there is also evidence suggesting that some people feel particularly ill and develop symptoms especially during weekends and vacations. The focal points of this article are the exploration of the antecedents and consequences of this phenomenon, pointing out the need of systematic research on its prevalence, phenomenology, background, and the putative mechanisms involved. The paper concludes with a discussion of some possible effective interventions

Full text

Psychological Topics 16 (2007), 2, 187-200
Original Scientific article – UDC 159.944:612
 Ad Vingerhoets, Department of Psychology and Health, Tilburg University, P.O. Box
90.153, 5000 LE Tilburg, The Netherlands. E-mail: Vingerhoets@uvt.nl
187
Leisure Sickness: A Biopsychosocial Perspective
Guus L. Van Heck & Ad J. J. M. Vingerhoets
Tilburg University
Department of Psychology and Health
Abstract
Leisure and vacation are generally associated with feelings of relaxation and
well-being. However, there is also evidence suggesting that some people feel
particularly ill and develop symptoms especially during weekends and vacations.
The focal points of this article are the exploration of the antecedents and
consequences of this phenomenon, pointing out the need of systematic research on
its prevalence, phenomenology, background, and the putative mechanisms
involved. The paper concludes with a discussion of some possible effective
interventions.
Keywords: leisure sickness, biopsychosocial perspective, interventions
A change of troubles is as good as a vacation
David Lloyd George (1863 – 1945)
Introduction
When work is over, rest is sweet. Generally, people feel relatively better during
rest and vacations compared with periods full of work activities. As the proverb
says: a bow long bent at last waxes weak. Or another saying, revealing insight and
wisdom: you can’t burn the candle at both ends. Therefore, people strongly believe
that leisure time has a beneficial influence on their functioning and health. It seems
that this notion is valid for most people: they feel good and relax during leisure
time (Baum, 1991; Strauss-Blasche, Ekmekcioglu & Marktl, 2000, 2002; Strauss-
Blasche et al., 2004; Westman & Eden, 1997). This is also reflected in
psychobiological measures. For example, decreases in blood pressure and heart rate
have been reported during leisure time. In addition, there is a sizeable decrease in
the production of stress hormones like adrenaline (Frankenhaeuser et al., 1989).

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This explains why rest is an important prescription of medical doctors in case of
illness, overload and other, physical as well as mental, health problems.
However, there is also a group of persons who just when they take breaks from
work, at the weekend or while on vacation, develop health complaints, a condition
that contrasts sharply with the virtual absence of symptoms during periods of work.
It mainly concerns headaches, migraine, vague muscular aches and pains, excessive
fatigue, nausea, and, especially in the first days of a vacation period, viral infections
causing colds, fever and flu-like symptoms (Vingerhoets, Van Huijgevoort & Van
Heck, 2001, 2002). We have coined this phenomenon “leisure sicknes”. For the
sake of clarity, with this term we do not lay claim to describe a new disease. The
term solely refers to the moment of onset of health complaints, not to the very
nature of these ailments, which can vary considerably.
This rather remarkable phenomenon is generally known, as is apparent from
the many articles on this topic in popular, non-scientific journals and magazines.
Especially “weekend migraine” has been often described (e.g., Couturier, Hering &
Steiner, 1992; Torelli, Cologno & Manzoni, 1999a, 1999b). With a few exceptions,
such as the study by Ray (1990) which showed that employees with high levels of
stress had more colds and other ailments within the first days of being off work, the
scientific literature contains virtually nothing on the manifestation of weekend or
vacation malady. Taking into account the fact that such incidents are very well
known, it is quite astonishing that there is such a limited amount of systematic
research. In view of the fact that approximately 3% of the Dutch population
indicate that they suffer, some lightly, others very severely, from leisure/related
health problems (Vingerhoets et al., 2002), it is important to increase our
understanding of possible antecedents and determinants. Such insights are badly
needed in order to be able to design effective prevention strategies and successful
interventions, making possible that people suffering from this condition in the near
future can also enjoy their leisure time and vacations.
Several researchers have mentioned the existence of leisure sickness, be it
mostly without further explanation and seldom supported by empirical evidence
(see, e.g., McEwen & Stellar, 1993; Van Luijtelaar, 1997). For instance, Van
Luijtelaar discovered growing number of deaths during vacation, by simply
counting obituaries in newspapers. He could demonstrate a sizeable increment of
such death announcements during vacation periods, especially during the first free
days. Kop, Vingerhoets, Kruithof and Gottdiener (2003) found a similar pattern
when analysing the prevalence of myocardial infarctions during vacation travels.
Also in this study, a small peak was seen during the first two days. It is tempting to
draw a parallel with the outcomes of some well-known animal studies. For
instance, Mason et al. (1961) found that monkeys who were exposed to stressful
tasks developed ulcers and gastric complaints in the rest period after the exposure
to stressors and not during the period of exposure itself.

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A number of authors have provided empirical support for the phenomenon
"becoming ill during leisure time". However, it should be noted that their research
efforts often had a rather narrow focus on specific health problems like ischemic
stroke in young women (Haapaniemi, Hillbom & Juvela, 1996), and migraine
(Couturier, 1993; Couturier et al., 1992; Davies, Peatfield, Steiner, Bond & Clifford
Rose, 1991; Morrison, 1990; Natterro et al., 1989). For instance, Davies et al.
(1992) found that attacks of migraine occurred significantly more frequently during
weekends, while Nattero et al. demonstrated that attempts to relax after stress
exposure could elicit attacks of migraine. However, in contrast to these findings,
Alstadhaug, Salvesen and Bekkelund (2007) reported that migraine occurrence was
almost equally distributed during the week, except on Sundays, when there were
significantly fewer attacks. These authors consequently concluded that days off
protect against migraine rather than promoting this condition. In an earlier study,
Morrison (1990) could also not provide firm evidence for the existence of some
form of weekend migraine.
Possible explanations
A number of possible explanations can be formulated that need to be tested in
future research. However, it should be noted beforehand that these explanations do
not necessarily exclude each other. In addition, different symptoms may each have
their own specific etiological factors. On the basis of the relevant literature, we
come to the following possible hypotheses for leisure sickness. Globally, it boils
down to explanations that emphasize the role of factors in the home or non-work
situation which are conducive to complaints, problems with switching off from
work to non-work, or some sort of illness "according to plan".
Exposure to sickness inducing environmental factors
It speaks for itself that, first of all, it should be checked whether in the non-
work situation, factors can be identified that can be conceived of as pathogenic. For
example, exposure to pesticides which are used in gardening, or solvents in paint,
thinner and glue employed in repair work around the house, painting or other
hobbies may be responsible for the onset of health problems. It is quite conceivable
that people suffering from “leisure sickness”, especially when being involved in
such specific free time activities as sketched above, are exposed to chemicals that
have harmful consequences for their health. It is also perfectly possible that they
live in a house that is poorly ventilated or that they live in a polluted environment,
or have pets to which they are allergic (Dumont, 1989; Roueche, 1988; Weiss,
1992). Interesting in this context is a case study by Lipton, Mazer, Newman and
Solomon (1997). It concerns a 58 years old woman, who had only migraine during

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weekends spend in a particular holiday home. In the end, it turned out that the
severe attacks of migraine were the effect of a broken-down kitchen-cooker that
produced a high concentration of carbon monoxide. After replacement of the stove,
the headaches disappeared immediately. A similar case has been described by
Roueche (1988); here, the wrongdoer was a chemical that was present in the
weekend cottage to keep it free from vermin. It is not very likely, however, that all
persons who suffer from leisure sickness are exposed to hazardous chemicals
during their days off. Nevertheless, such possible causes cannot be excluded
beforehand, especially not in a clinical setting and also not when one wants to
design a systematic study.
Life style
Another possibility is that in persons with ailments during weekends and
vacations there are huge discrepancies between their leisure time lifestyle and their
style of life at work periods. For instance, they may sleep much longer or much
shorter, or drink other amounts of alcohol or coffee. Some research findings
suggest that both more and less than usual coffee intake or consumption of the first
cup of coffee at an unusual later time can cause headache attacks (Couturier et al.,
1992; Couturier, Laman, Van Duijn & Van Duijn, 1997).
Baars and Tjia (1990) have introduced the term “holiday-heart-syndrome” in
their article on the relationship between vacation, on the one hand, and heart
problems due to excessive alcohol consumption, on the other hand. Also
occasionally excessive indulgence in nicotine, caffeine or recreational drugs may
play a significant role in the development of somatic problems.
The following two explanations reflect the possibility that people suffering
from the leisure sickness syndrome do not enjoy the activities they generally have
to undertake during their vacations and weekends. Maybe they consider these
activities as rather stressful.
Low appreciation of leisure activities and secondary gain
“Relaxing can be very stressful for a lot of people ... because it means the day
is unstructured, people have to re-establish relationships and spend time with their
families” (Cooper, 2007). It is thinkable that some people don’t like visiting family,
travelling, household chores, keeping in repair the car and the house, attending
children’s sport activities, or shopping. The fact that these obligations tie them
down too much can cause stress that in turn can lead to experiencing health
complaints. It could also be that these persons cannot stand to be not actively
engaged in their work, thinking business all day. It is conceivable that they have

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guilt feelings, as a consequence of taking a break from work, which, as a source of
stress, in the end form the basis of health complaints. This kind of stress
experiences associated with the obligatory character of typical recreation activities
can be identified most clearly in people with a high degree of commitment to their
work (Burwell & Chen, 2002).
Additionally, persons with leisure sickness may be rewarded for their illness
behavior. When displaying illness behavior, it is no longer expected that one should
be involved in typical weekend and vacation activities. Thus, the experience and
report of symptoms can not only lead to avoidance of negative experiences and
obligations, but also to all sorts of positive consequences, such as receiving more
attention. Through such environmental reinforcement, it becomes more likely that
such behavior will occur more frequently in the future. See for a more extensive
discussion of the role of operant conditioning by the social environment the review
by Fishbain, Rosomoff, Cutter and Rosomoff (1995).
Symptom perception
According to the symptom perception model of Pennebaker (1994; 2000), there
is a continuous competition between, on the one hand, internal bodily signals and,
on the other hand, external environmental stimulation. Presumably, internal bodily
signals will be consciously perceived more likely when they have a higher intensity
and/or when the competing environmental input is rather limited. This could
explain why people with very busy jobs are much more aware of their bodily
sensations during leisure time compared to normal working days. Outside the work
environment it is easier for their internal signals to compete with the external
informational input and, consequently, to receive attention. On the other hand,
symptoms and negative feelings seem to disappear at the very moment that these
persons are exposed again to the worries and pressure of work. In this case, it is not
a matter of actually more frequently getting sick during leisure time, but rather of
becoming aware of and experiencing symptoms. Heart of the matter is the
difference in attentional focus. This Pennebaker model is especially suitable for
bodily sensations that are, relatively, less intense, like fatigue or rather vague pains
and aches. Obviously, with respect to complaints like flu symptoms, fever, or
severe attacks of migraine, this model does not provide an adequate explanation.
Physiological problems of adaptation
A fifth possibility is that physiological processes play a key role in the
development of these health problems. A study by Elgerot, cited in Frankenhaeuser
(1980), demonstrated that, in workers with a high workload, the production of
adrenaline was not only increased during working hours, but also just in the

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evening hours and the rest periods after finishing work. The results of Vingerhoets
et al. (1996) also point into the same direction. People with many vague complaints
differed in terms of adrenaline production from healthy controls, not during
watching stressful films, but, on the contrary, during night time, when the body has
to take rest and recovery processes should prevail. This can be caused by too slow
unwinding of physical activation. Stated more simply: the engine is kept running
and new energy is constantly produced, while from a physiological point of view
there is no necessity for doing so.
In addition, it has been frequently demonstrated that acute stress has a
beneficial effect on particular immune functions (Dhabhar & McEwen, 1996, 1997;
Spencer, Kalman & Dhabhar, 2000). An implication could be that, in this way,
acute immune-related health problems are suppressed until after the exposure to the
stressor.
Another possibility concerns the phenomenon of a too fast changeover from
work to leisure time. A badly coordinated change from activation to rest can also
have a negative impact on health conditions. After all, a high workload implies a
heavy burden for those bodily functions that are responsible for the maintenance of
the internal physical balance (allostasis; McEwen & Stellar, 1993; Sterling & Eyer,
1988). When the external load suddenly stops, which is the case when people stop
working and try to relax, and subsequently the body fails to inhibit the
counterpressure in time, then this might result in a situation of being
physiologically off balance, accompanied by an increased susceptibility to illness.
It is tempting to draw an analogy with a balance that initially shows equilibrium
due to a force and counterforce, but tips at the moment that a heavy weight is taken
away from one of the scales.
In research with monkeys, a similar effect was observed: not during, but
especially after a stressful episode the animals were suffering from ulcers and other
gastric problems (Mason et al., 1961). Moreover, studies with rats also reveal that
there are considerable individual differences with respect to recovery after stress
and stress hormone reactions, like cortisol production (Dhabhar, McEwen &
Spencer, 1993).
Dehabituation to stress and anticipated harm
Strauss-Blasche et al. (2002) tested the expectation that vacation may act as a
stress buffer, reducing the adverse impact of job stress. Their study, however, did
not support this hypothesis. Contrary to expectation, workload did not have an
effect on health status and well-being before vacation, but did so significantly after
vacation. After vacation, employees with high workload reported a relatively poor
quality of sleep, few positive social activities, few positive affect, and considerable
negative mood, whereas there was a clear pre- to post-vacation increase of health

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status and well-being for employees with a relatively low workload. The authors
hypothesize that the reduction in job stress during vacation might promote a
process of dehabituating to stress. Consequently, when returning to work, the
renewed confrontation with job stress will induce stronger stress reactions, due to
the fact that the job stressors are experienced as relatively novel stimuli compared
to pre-vacation time. One can speculate that individuals who have experienced this
process several times will be confronted with a lot of anticipated harm, which in
turn also might affect their well-being during vacations.
(Un)conscious postponement of sickness
Finally, one may wonder whether people are able to postpone becoming ill to a
period that suits them better. Anecdotes as well as the scientific literature contain
indications that terminally ill persons can delay their death until, for instance, the
birth of a grandchild or the return of a family member from abroad. For example,
Phillips and Feldman (1973) as well as Idler and Kasl (1992) reported a decrease in
the number of deaths immediately before and during religious holidays that were
important for terminally ill patients (e.g., Yom Kippur, Easter). Patients who felt
more commitment for the feast day had a lower chance of dying in the period
immediately preceding the holiday. Phillips and King (1988) found in a Jewish
population also strong indications for the existence of a pattern of peaks and drops
in mortality figures linked to religious holidays. A similar pattern has been reported
for elderly Chinese women (> 75 years) around the Harvest Moon Festival (Phillips
& Smith, 1990). Marriott and Harshbarger (1973) found an increase in the number
of people who died after Christmas and Easter (see also Harrison & Kroll, 1985-
1986). More recently, Anson and Anson (2001) observed a very significant
decrease in mortality on the Sabbath (Saturday), but only in the Jewish population
of Israel, not for the non-Jewish part of the population. This decrease in mortality
was followed by an increase of the number of deaths during the following days
(Sunday, Monday). These findings suggest that people are able to postpone death
until a, for them, more appropriate moment, that fits them or their family better. If
terminally ill patients have a certain degree of control over their dying, it may not
seem unlikely that healthy individuals also may have the capacity to time the
development of health problems. In line with the findings of the study by Phillips
and Feldman (1973), this might be expected to occur primarily in individuals who
consider their work as very important and/or are convinced that they are
irreplaceable at work.

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The role of personality
There is a strong association between work commitment and well-being
(Riipinen, 1997). The question whether work commitment is also related to leisure
sickness still has to be resolved in future research. However, it seems rather
plausible that such a link indeed exists. Especially perfectionists with high
workloads, a strong commitment, and an over-developed sense of responsibility to
their work seem to form a high-risk group (Vingerhoets et al., 2002). In case of
very frequent or long-lasting stress episodes, it takes more time to return to a
relaxed state without stress (Sluiter, 1999). In the long run, this may imply that
leisure time will not suffice to recover completely. Moreover, as can be predicted
from Pennebaker’s (1994, 2000) symptom perception model, a higher level of
arousal than, from a physiological point of view, is required, can very easily lead to
bodily sensations that will be labelled as health complaints.
Difficulties with switching from work to non-work can be (partly) due to
personality characteristics. It is quite conceivable that there is a direct effect like,
for instance, when rigidity and inflexibility cause problems in switching over from
work to leisure activities; with the result that after working hours one still is
involved in performing various work tasks. This is a situation that very likely can
lead to an excess of stress.
Personality can also have an indirect effect on a problematic re-adaptation after
work. For example, perfectionists have high standards and consequently experience
a high eagerness to achieve. This may make them, especially during a non-work
period, rather vulnerable for health problems, when earlier mentioned high
allostatic counterforce suddenly disappears. A couple of studies indeed have
demonstrated the negative aspects of perfectionism and have found that
perfectionism is associated with, amongst others, exhaustion at work (Mitchelson
& Burns, 1998).
Individuals differ also with respect to their competencies to cope with non-
work situations. Well-known in this respect are Type A persons and “workaholics”
(Burke, 2000; Friedman & Rosenman, 1974; Sanders & Malkis, 1982; Spence &
Robbins, 1992). It is also quite conceivable that especially individuals with a strong
need of control, who likely have a clearly structured job that offers the desired
possibilities for control, experience the changeover from work to leisure time as
problematic, because the latter is generally less structured and offers less
opportunities for control (see Suls & Rittenhouse, 1990). Such persons might feel
restless especially during weekends and vacation. They experience strain instead of
relaxation; a state of affairs that has negative consequences for their well-being.
Besides personality, temperament may also play a moderating role.
Temperamental traits co-determine style of action, preferences for particular
situations and activities of given stimulative value, as well as the
psychophysiological costs inherent in performing activity under highly stimulating

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demands (Strelau, 1996). Especially temperamental variables which reflect
characteristics of the central nervous system, like the Pavlovian concepts ‘strength
of excitation’ and ‘strength of inhibition’ (Pavlov, 1951-1952; see Strelau, 1998),
are good candidates for promising future research. Also the concept ‘mobility’, as
introduced by Pavlov, might have high relevancy in this context. Besides strength
of excitation, reflecting the functional capacity of the nervous system, and strength
of inhibition, a concept reflecting the ability to sustain a state of conditioned
inhibition such as extinction or delay, Pavlov pointed at individual differences in
the mobility of nervous processes reflecting the ability of the central nervous
system to respond adequately to changes in the surroundings. In addition to the
latter East-European, Pavlovian temperamental traits, there are several
corresponding Western arousal-oriented variables, like extraversion and
neuroticism, that may have relevance in this context. For instance, the difference
between introverts and extraverts lies in their arousability. In situations with a low
stimulation level, in particular extraverts might be expected to be relatively
underaroused and most likely feel very bored. In high arousal situations, however,
extraverts would perform better, due to the tendency in introverts toward over-
arousal (Eysenck & Eysenck, 1985). A lack of stimulation at leisure time, when
stimulation and challenges are markedly reduced, can have negative effects for
some persons, in particularly for high-scorers on extraversion tests. The term
‘underload syndrome’ is used to refer to this pattern characterized by a decrease in
the production of vital hormones such as endorphins, a subsequent drop in
metabolic rate, lower energy, a sluggish immune system, and, consequently, a
higher susceptibility to infection. “Boredom has exactly the same effect on the
body as stress. People who are normally busy can become ill when they don’t have
enough to do, because it sends their levels of stress hormones shooting up” (Dyer-
Smith, cited in Elkins, 2003).
The above makes clear that it would be interesting to examine the mediating
and moderating role of personality and temperament in future research on leisure
sickness. The same applies for scrutinizing the role of coping styles, since there are
indications that ways of coping are related to the degree of perceived stress
(Mariage, 2001).
Regarding all these factors, which possibly predispose people to difficulties
switching off when they take breaks from work, it is a matter of actual or perceived
high workload. Therefore, future investigations should also pay adequate attention
to the appraisal of work as well as non-work.

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CONCLUSION
The term ‘leisure sickness’ refers to the phenomenon that health complaints
manifest themselves just during weekends and vacation. The complaints appear to
be very diverse: not only rather vague pains and aches, excessive fatigue and
nausea, but also flu-like symptoms, including fever.
There are several explanations for this phenomenon that do not exclude each
other necessarily. Globally speaking, leisure sickness can be associated with (i)
factors in the non-work environment that elicit and promote the experience of
symptoms, (ii) specific physiological problems inherent in the changeover from
work to non-work, or (iii) the ability to postpone health problems. It is not unlikely
that certain personality characteristics function as predisposing factors. Maybe the
different kinds of complaints, and perhaps also the role of personality traits, can be
explained by distinct mechanisms. Results of a pilot study (Vingerhoets et al.,
2002) suggest that especially people with high workload and high commitment,
who feel very responsible for their work, are more apt to suffer from leisure
sickness.
Regarding the question “What can be done?”, at this moment we can only
speculate and provide a set of tentative answers. Possibly, physical exercise after
work evening will facilitate substantially the physiological transition from work
activities to rest. It speaks for itself that research efforts should also be focussed on
evaluating the possible beneficial effects of adaptation of the life pattern, changes
in the sleep pattern, and sizeable reduction of the intake of caffeine and alcohol. It
is conceivable that particular interventions will be very effective for particular
subgroups of persons. For instance, particular forms of cognitive behavioural
therapy aimed at restoring balance in life with more attention and appreciation for
the social environment in general and the family in particular (see Burwell & Chen,
2002). The view that leisure sickness is a clear signal from the body to go
somewhat easier on work and to strive for more balance in one’s life between
working and non-working activities, should also be taken seriously. Be it as it is,
leisure sickness concerns an extremely interesting phenomenon that elicit an
abundance of intriguing research questions for psychologists, at the level of
fundamental research as well as applied studies.

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Received: 21. 05. 2007.