A clinical perspective on burnout: diagnosis, classification, and treatment of clinical burnout

Abstract

In clinical psychology, burnout is regarded as a mental disorder assessed in patients who apply for psychological treatment and no longer work because of their symptoms or experience of serious problems in functioning at work. This definition of burnout is mostly referred to as ‘clinical burnout’. The purpose of this article is to provide insight into how clinicians in The Netherlands establish a diagnosis of clinical burnout and how they fit it in their classification systems. An outline is given on how psychological interventions for burnout are applied in therapies. The different phases in the treatment of clinical burnout – crisis, recovery, prevention, and post burnout growth, as well as their accompanying interventions are described. It may be relevant for work and organizational psychologists to realize that biological processes may play a role in the development of clinical burnout. For the physiology of stress, it does not matter whether the stress is work-related or the result of stress in private life or both. Central to understanding clinical burnout is the lack of recovery of the (physiological) stress system. It is also argued that the relevance of questionnaires, for detecting who is at serious health risk, is limited.

Full text

Full Terms & Conditions of access and use can be found at
https://www.tandfonline.com/action/journalInformation?journalCode=pewo20
European Journal of Work and Organizational Psychology
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/pewo20
A clinical perspective on burnout: diagnosis,
classification, and treatment of clinical burnout
Arno van Dam
To cite this article: Arno van Dam (2021): A clinical perspective on burnout: diagnosis,
classification, and treatment of clinical burnout, European Journal of Work and Organizational
Psychology, DOI: 10.1080/1359432X.2021.1948400
To link to this article: https://doi.org/10.1080/1359432X.2021.1948400
© 2021 The Author(s). Published by Informa
UK Limited, trading as Taylor & Francis
Group.
Published online: 14 Jul 2021.
Submit your article to this journal
View related articles
View Crossmark data

A clinical perspective on burnout: diagnosis, classication, and treatment of clinical
burnout
Arno van Dam
a,b
a
Tranzo Scientific Center for Care and Welfare, Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands;
b
Department Research and Innovation, GGZ WNB Mental Health Institute, Research and Innovation, Halsteren, The Netherlands
ABSTRACT
In clinical psychology, burnout is regarded as a mental disorder assessed in patients who apply for
psychological treatment and no longer work because of their symptoms or experience of serious
problems in functioning at work. This denition of burnout is mostly referred to as ‘clinical burnout’.
The purpose of this article is to provide insight into how clinicians in The Netherlands establish a
diagnosis of clinical burnout and how they t it in their classication systems. An outline is given on
how psychological interventions for burnout are applied in therapies. The dierent phases in the
treatment of clinical burnout – crisis, recovery, prevention, and post burnout growth, as well as their
accompanying interventions are described. It may be relevant for work and organizational psychologists
to realize that biological processes may play a role in the development of clinical burnout. For the
physiology of stress, it does not matter whether the stress is work-related or the result of stress in private
life or both. Central to understanding clinical burnout is the lack of recovery of the (physiological) stress
system. It is also argued that the relevance of questionnaires, for detecting who is at serious health risk, is
limited.
ARTICLE HISTORY
Received 11 April 2021
Accepted 22 June 2021
KEYWORDS
burnout; clinical;
classification; diagnosis;
treatment; psychotherapy
Burnout and clinical burnout
In mental health care, psychiatrists and clinical psychologists
approach mental disorders like diseases. The nature and sever-
ity of symptoms determine whether you have the disease or
not. A symptom is an observed or detectable sign of an illness
or disorder, like fatigue, insomnia, fever, or pain. The combina-
tion of a number of specic symptoms is dened as a disease or
disorder. This also applies to mental disorders like clinical burn-
out. You either have it or you don’t. Having a disorder is there-
fore considered as qualitatively dierent from being healthy
and comprises clinically signicant distress or impairments
(Americain Psychiatric Association, 2013). The onset and course
of a mental disorder, like clinical burnout may comprise quali-
tative dierent phases that dier from each other with regard
to symptoms, emotions, behaviours, severity, and coping
(Åsberg et al., 2010; Carpenter et al., 2019). This conceptualiza-
tion of (clinical) burnout diers from the denition that is used
by work- and organizational psychologists who consider burn-
out as a multidimensional construct that is assessed with ques-
tionnaires in relatively healthy working populations (Schaufeli
et al., 2001).
The denition of clinical burnout is usually based on the
criteria of work-related neuroasthenia in the International
Classication of Diseases (ICD-10; World Health Organization,
2010), and comprises the following features (1) persistent and
distressing complaints of increased fatigue after mental eort,
or persistent and distressing complaints of bodily weakness
and exhaustion after minimal eort; (2) at least four of the
following additional symptoms – insomnia, cognitive decits,
pain, palpitations, gastroenteric problems, sound and light
sensitivity. These complaints and symptoms (3) must be pre-
sent nearly every day for at least two weeks; (4) are due to
psychosocial stressors that have been present for at least six
months before diagnosis; and (5) lead to clinically signicant
distress or impairment (Grossi et al., 2015; Persson Asplund,
2021; Schaufeli et al., 2001).
Fundamental to the dierence between conceptualizations
of burnout applied by clinical psychologists versus work- and
organizational psychologists is the role of biology. Clinical psy-
chologists conceptualize mental disorders from the bio-psycho
-social model whereas work- and organizational psychologists
mainly focus on psychosocial factors (Gatchel et al., 2020;
Schaufeli, 2007; Weber & Jaekel-Reinhard, 2000). The addition
of biology leads to a number of notable dierences in the
conceptualization of burnout. First, from a biological point of
view, it does not matter whether the chronic stress is caused by
working conditions or private circumstances or both. It is about
the consequences of (chronic) stress for the functioning of the
biological processes in the organism that also aect psycholo-
gical processes and social behaviour (Sanders, 2014; Sapolsky,
1998). For clinical psychologists, burnout is therefore not neces-
sarily work-related, but rather stress-related (Van Dam et al.,
2015b). A second dierence that arises from the biological
perspective is that the development of clinical burnout is not
regarded as a linear process but like many biological processes
as a process with qualitative dierent phases (Sapolsky, 1998).
Another dierence compared to the organizational
approach, arises from the fact that clinical psychologists study
abnormal emotions, thoughts and behaviour in individual
CONTACT Arno van Dam a.vandam@ggzwnb.nl A.vanDam@tilburguniversity.edu
EUROPEAN JOURNAL OF WORK AND ORGANIZATIONAL PSYCHOLOGY
https://doi.org/10.1080/1359432X.2021.1948400
© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.

patients. Therefore, a considerable attention of clinical psychol-
ogists is paid to individual dierences in maladaptive coping
and psychological dysfunction, whereas less attention is paid to
universal factors in human functioning like work- and organiza-
tional psychologists do. An aspect that may play a role in the
development of psychological disorders is that individuals dif-
fer in the extent to which they are aware of their own feelings,
thoughts and physical signals of stress (Eurelings-Bontekoe
et al., 2009; Ginot, 2017). That is why scores on questionnaires
are not always reliable. For clinical psychologists, people with
elevated scores on a burnout questionnaire are not necessarily
at risk for clinical burnout. Also, individuals with short-term
stress (less than 3 months) show elevated levels on burnout
measures, just like individuals with other mental disorders like
major depression and anxiety disorders do (Kleijweg et al.,
2013; Van Dam et al., 2015a).
It is essential to dierentiate between short-term stress and
clinical burnout, because short-term stress has a more favour-
able prognosis than clinical burnout. Research shows that an
average of 80% of all employees with short-term stress recover
within a few months and are partially or fully back at work
within six to twelve weeks (Van der Klink et al., 2003). The
recovery of clinical burnout, however, may take more than
one year (Eskildsen et al., 2016; Van Dam et al., 2012b). Some
studies show that even after 2 to 4 years, a substantial part (25–
50%) of the patients with clinical burnout is not fully recovered
(Dalgaard et al., 2020; Eskildsen et al., 2016; Van Dam et al.,
2012b). Therefore, questionnaires and assessments that focus
solely on symptom levels are not sucient to make
a distinction between clinical burnout and short-term work-
related stress. It is important, however, to make this distinction,
because the prognosis for recovery of clinical burnout is much
less favourable than for the mild short-term stress disorders.
Both approaches, the clinical and work- and organizational,
are useful and generate specic knowledge about stress, work,
and fatigue. It is relevant to be specic about which denition is
used because it is not known whether ndings obtained in
clinical populations are applicable to the general population
and vice versa (Deligkaris et al., 2014).
Yet another reason to be specic about which denition of
burnout is used is that there is discussion among clinicians and
health insurance companies whether burnout is a mental dis-
order and qualies for reimbursement (Grossi et al., 2015;
Schaufeli, 2007; Van der Voort- van Beusekom et al., 2016; Van
Dam et al., 2017). Clinical samples should therefore be homo-
geneous, consisting of persons with severe symptoms and
fulling the work-related neuroasthenia criteria of the ICD-10
(Grossi et al., 2015; Persson Asplund, 2021; Schaufeli et al., 2001;
World Health Organization, 2010). Research shows that this is
not always the case, which is problematic because it may fuel
discussion about the legitimacy of the diagnosis of clinical
burnout (Bianchi et al., 2015; Van Dam, 2016).
Work- and organizational psychologists who take the
burnout perspective of clinical psychologists may learn
that particularly the combination of work-related stressors
and stress in private life plays a role in the development of
mild burnout symptoms into clinical burnout. In addition,
work and organizational psychologists should be careful
regarding the dominant role of questionnaires that is
prevalent in their work. In this article, I will show that the
relevance of questionnaires is limited when it comes to
detecting who is at serious health risk.
The purpose of this article is to provide insight into how
clinicians establish a diagnosis of clinical burnout and how
they t it in their classication systems, despite the contro-
versies about the phenomenon. Furthermore, an outline is
given on how psychological interventions for burnout are
applied in burnout therapies. In this way, I hope to show
that tailor-made care is needed, not only in the eld of clinical
psychology but also in the eld of work and organizational
psychology. A crucial point is that people with the same score
on a questionnaire may require dierent approaches to pre-
vent mental illness. This is also relevant for work- and organi-
zational psychologists who develop interventions for people
at risk for burnout in the work-environment but also for
researchers interested in dierent pathways to clinical
burnout.
Diagnosis and classication of clinical burnout
A complication for clinicians to establish clinical burnout and
dierentiate it from mild stress disorders is that burnout is not
included as an ocial disorder in the Diagnostic and Statistical
Manual of Mental Disorders (DSM; American Psychiatric
Association, 2013). In the International Classication of
Diseases (ICD-10; World Health Organization, 2010), burnout is
classied as a “State of vital exhaustion” (Z73.0) under
“Problems related to life-management diculty” (Z73), but it
is also not considered a disorder. In their review, Grossi et al.
(2015) showed that there is no consensus among clinicians
which classication matches clinical burnout. The classications
used by clinicians are “work-related” neuroasthenia (ICD code
F48.0), undierentiated somatoform disorder (DSM IV code:
300.82; ICD code F45.1), severe stress and adjustment disorder
(DSM IV code: 309.9; ICD code: F43.20), “other reaction to severe
stress” (F.43.8), and major depression (DSM IV code: 296.xx.; ICD
code F32.xx). In some studies, clinically burned-out participants
were diagnosed with a range of axis I disorders – mainly anxiety
and mood disorders – when assessed according to DSM criteria
(Grossi et al., 2015). In order to solve the diagnostic controver-
sies, the Swedish Board of Health and Welfare, introduced
“exhaustion disorder” (ED; F43.8A) into the Swedish version of
the 10th revision of the International Classication of Diseases
(ICD-10-SE; Socialstyrelsen, 2010), which resembles “clinical
burnout” and is also based on the criteria of work-related
neuroasthenia in ICD-10 (Grossi et al., 2015; Socialstyrelsen,
2010: World Health Organization, 2010). However, the addition
of exhaustion disorder to the ICD-10 is limited to Sweden and
therefore also not a universally used denition of clinical
burnout.
This variety in classications for clinical burnout must be
seen in the light of a broader discussion about the tenabil-
ity of classication systems for psychological disorders. The
reliability and validity of traditional taxonomies are limited
by arbitrary boundaries between psychopathology and nor-
mality, often unclear boundaries between disorders, fre-
quent disorder co-occurrence (overlap), heterogeneity
within disorders (subgroups), and diagnostic instability
2A. VAN DAM

(symptom change). These taxonomies went beyond evi-
dence available on the structure of psychopathology and
were shaped by a variety of other considerations, which
may explain the aforementioned shortcomings (Kotov
et al., 2017). New dimensional models are developed that
are empirically driven and are based on neuroscience and
advances in quantitative research on the organization of
psychopathology (Clark et al., 2017; Kotov et al., 2017;
Panksepp & Yovell, 2014). These models thus show simila-
rities with the dimensional approach of the organizational
psychologists, although the dimensions seem to be dier-
ent. Some studies suggest that the dimensions associated
with clinical burnout are distress and dysphoria which are
also related to depression, but there is no consensus yet
(Schonfeld et al., 2019; Van Dam, 2016).
Because individuals with short-term stress show elevated
levels on burnout measures, just like individuals with other
mental disorders like major depression and anxiety disorders
a clinician cannot solely rely on questionnaires in order to
make a qualitative distinction between the mild stress disorders
and clinical burnout (Kleijweg et al., 2013; Van Dam et al., 2015
a
).
Instead, clinicians need to reconstruct the pathogenesis, which is
the history and sequence of life-events, symptoms, and mechan-
isms that lead to the syndrome (Beekman & Hengeveld, 2014;
Schiavone et al., 2015; Weber & Jaekel-Reinhard, 2000).
Pathogenesis of clinical burnout
In this section, I will explain the dierence between the devel-
opment of clinical burnout compared to individuals who seek
help when having relative short-term stress symptoms (less
than 3 months). Individuals with short-term work-related stress
report a clear relation between a stressor and the mental
problems within a period of not more than 3 months after
the stressor emerged. Stressors that are often mentioned are
conicts with colleagues or the supervisor, a merger, and an
increase in workload (Weber & Jaekel-Reinhard, 2000). The fact
that these persons seek help after a relative short period of
experiencing stress symptoms may be regarded as a healthy
coping mechanism (Bakker & de Vries, 2021; Roohafza et al.,
2016). Patients with clinical burnout, however, report that they
ignored stress symptoms for several years (Maslach & Goldberg,
1998; Weber & Jaekel-Reinhard, 2000). Living a stressful life was
a normal condition for them. Some were not even aware of the
stressfulness of their lives, until they collapsed. The ultimate
reason for collapsing may be a relative minor stressor. The
clinician needs to understand that it is not only that minor
stressor that led to the total breakdown, but that the minor
stressor is the nal straw that broke the camel’s back after years
of chronic stress. Final stressors that are often mentioned by
patients with clinical burnout are conicts, being unable to
relax during holidays, and not recovering from u.
The coping style of clinical burnout patients seems to be
quite dierent from that of patients with short-term stress-
related disorders. Those with clinical burnout are not inclined
to seek help when there is stress but persist without complain-
ing. This observation is in line with research showing that the
coping style of burnout patients is characterized by persever-
ance (continued eort to do or achieve something despite
diculties) and reluctance to asking social support (Martínez
et al., 2020; Van Dam et al., 2013, 2015b; Wallace, 2017).
Research in relative healthy populations suggests that perse-
verance is a protective factor for burnout. Perseverance may
indeed be benecial when someone is actually having control
over one’s situation (Fabelico & Afalla, 2020). However, in case
of lack of control, perseverance is not adaptive anymore and
individuals should shift to other coping strategies like asking
for social support and reecting on one’s situation and feelings
(Bakker & de Vries, 2021; DeLongis & Holtzman, 2005; Sapolsky,
1998; Van Dam et al., 2013). Perseverance may in that case
contribute to the maintenance of chronic stress.
In the literature on fatigue in healthy individuals, it has been
shown that fatigued individuals adapt their performance strat-
egy in order to regulate the mobilization of mental eort
(Hockey, 1997/2011). Strategic adjustments can be achieved,
for instance, by allowing failures for secondary goals. For
instance, an individual may selectively neglect low-priority
task components (e.g., the speed or accuracy of responses) or
they may neglect subsidiary activities or shift to simpler
response strategies with fewer demands on working memory.
Because fatigue is a central characteristic of the burnout syn-
drome, one may expect that burnout patients will also start to
routinely select less demanding performance strategies.
Several studies have suggested that the opposite is true: in
contrast to healthy fatigued individuals, burnout patients do
not appear to be particularly reluctant to expend high levels of
eort (Bakker & de Vries, 2021; Demerouti et al., 2014; Van Dam
et al., 2013). These ndings point out a tendency to cope with
stress with perseverance and trying to maintain high standards
of task performance.
In the reconstruction of the years prior to the establishment
of clinical burnout, a number of phases in the development of
clinical burnout can be distinguished that describe the process
of burning out (Hamming, 2020; Weber & Jaekel-Reinhard,
2000). These phases broadly outline how individuals develop
burnout. Individual variations are, of course, possible and
phases may overlap in time. The phases with their main fea-
tures, processes, and symptoms are described in Table 1.
Lack of recovery
The process to burnout starts with lack of recovery from phy-
siological stress reactions (Geurts & Sonnentag, 2006;
Hamming, 2020; Weber & Jaekel-Reinhard, 2000). A human
being is capable of enduring considerable amounts of stress,
if stressful periods are alternated by periods of rest and one is
able to recover (Ganzel et al., 2010: Geurts & Sonnentag, 2006).
There are fewer opportunities to recover from stress when
there are problems both at home and at work. For example,
there is work stress due to a reorganization and conicts and
there is stress in private life due to caring for ill family members,
long-term problematic renovation of the house, and/or nan-
cial problems. In this phase, individuals may experience need
for recovery and an aversion to spend eort (Hunter & Wu,
2016; Meijman & Mulder, 1998)
Changes in stress physiology
When stress levels continue to be high over prolonged periods of
time, the stress system adapts itself. New homoeostatic stress
EUROPEAN JOURNAL OF WORK AND ORGANIZATIONAL PSYCHOLOGY 3

values are established, which means that the organism sets
a higher stress level as the default level (McEwen, 2017; Sterling,
2004). Due to chronically elevated stress levels, sleep problems
emerge. People experience diculties to fall asleep because the
stress system is still active at the time they want to sleep. This is
a major problem because sleep quality appears to be predictive of
recovery of burnout (Grossi et al., 2015; Sonnenschein et al., 2008).
Another problem that arises is that people cannot relax anymore
even when there is no pressure. The stress system is activated
whether there is a stressor or not. As a result, individuals become
hyperactive and cannot relax anymore. This often leads to rest-
lessness in spare time and the inability to relax during holidays
(Eden, 2001; Fritz & Sonnentag, 2006).
Chronic stress symptoms
long-term physiological stress leads to physical, mental, beha-
vioural and emotional problems (Geurts & Sonnentag, 2006;
Sapolsky, 1998; Weber & Jaekel-Reinhard, 2000)
●Physical symptoms: Stress has a major impact on our
immune system, cardiovascular system, digestive system,
endocrine system, and reproductive system (Sapolsky,
1998). Therefore, chronic stress may lead to a variety of
physical symptoms in burnout patients, like headaches,
intestinal problems, muscle tension or pain, chest pain,
fatigue, change in sex drive, stomach upset, and vulner-
ability to diseases.
Table 1. Phases in the development of clinical burnout.
Phase Main features and process Symptoms
1Lack of recovery:
Stressful events combined with limited
possibilities to recuperate
Need for recovery
Aversion to spending effort
2Changes in stress physiology:
Higher homoeostatic stress values
Hyperactivity
Sleep difficulties
Inability to relax
Restlessness
3Chronic stress symptoms:
Physical symptoms:
Mental symptoms:
Emotional problems:
Behavioural problems:
headaches
intestinal problems
muscle tension or pain
chest pain
fatigue
reduced sex drive
stomach upset
vulnerability to diseases
concentration deficits
being forgetful and absent-minded
trouble staying focused
indecisiveness
impaired learning capability
impaired planning and control
feeling frustrated and angry
irritability
overreacting
feeling upset or sad without knowing why
feeling unable to control one’s emotions
anxiety and panic
conflicts
social withdrawal
drinking alcohol, taking medicine, eating too
much
quitting hobbies and sports
4Pseudopsychopathology:
Reduction of the complexity of reality
by applying more rigid ways of problem
solving and cognitive simplification
Stigma and blaming the victim
compulsive and rigid behaviour
dependency on others
being suspicious
reduced creativity
reduced empathy
reduced self-reflection
5clinical burnout:
Reduced motivation and passivity
Emotional breakdown
Severe fatigue
Passivity
Inability to motivate oneself
learned helplessness
mood problems
Based on: Boksem & Tops, 2008; Hamming, 2020; Van Dam et al., 2017; Van Zweden, 2015; Weber & Jaekel-Reinhard, 2000.
4A. VAN DAM

●Mental problems: Chronic stress also aects cognitive
performance. Several studies have shown that cognitive
functions such as attention, concentration and working
memory are impaired in clinical burnout (Deligkaris et al.,
2014). The cognitive impairments observed in burnout
patients seem to especially aect the more complex,
higher cognitive processes, such as executive functioning
rather than the more simple cognitive processes
(Deligkaris et al., 2014; Van Dam et al., 2011; Van der
Linden et al., 2005). Specic symptoms include diculties
to think clearly and learn new things at work, being for-
getful and absent-minded, indecisiveness, poor memory,
attention and concentration decits, and trouble staying
focused at work. Since executive control is essential for
performance on tasks that require planning, control, eva-
luation, adaptation and problem solving, these impair-
ments may well result in an overall impaired job-
performance (Bakker et al., 2008; W. Schaufeli et al.,
2020; Taris, 2006).
●Emotional problems: Stress reduces the capability to con-
trol emotions (Raio et al., 2013). Chronic stress therefore
leads to emotional instability which is manifested by
intense emotional reactions and feeling overwhelmed
by one’s emotions. Specic symptoms include feeling
frustrated and angry at work, irritability, anxiety and
panic, overreacting, feeling upset or sad without knowing
why, and feeling unable to control one’s emotions at work
(W. Schaufeli et al., 2020; Van Dam et al., 2015
a
).
●Behavioural problems: Due to the cognitive impairments
and increased emotional lability, burnout patients will
have more conicts with other people. The conicts
usually rst arise in private life, because people try to
maintain adequate social functioning at work as long as
possible. In private social situations, burnout patients
tend to withdraw themselves and are more easily agitated
which evokes negative reactions of family members and
friends. Eventually, these conicts also emerge at work.
Another type of behavioural problem that emerges has to
do with the desire of the overstressed person to comfort
him or herself by drinking alcohol, taking medicine, eating
too much, and quitting hobbies and sports. This
unhealthy lifestyle usually makes things worse as it has
a negative eect on sleep quality and health in general
(Monk et al., 2003).
Pseudopsychopathology
Stress aects the way in which information is processed and
how we deal with the world. In order to reduce stress, indivi-
duals reduce the complexity of reality by applying more rigid
ways of problem solving and cognitive simplication (Hockey,
2011; Michailidis & Banks, 2016). These mechanisms are cata-
strophic in regard to creativity, empathy, and the ability to
reect on complex problems as well on one’s own functioning.
Bakker and de Vries (2021) showed that coping is also aected
by stress. They argue that when stress increases, individuals are
less likely to use adaptive coping strategies (e.g., job crafting
and recovery), which means that they do not build the job and
personal resources needed to cope with ongoing job demands.
As a result of this, it may seem that the person has maladaptive
personality traits. This syndrome, which develops on the basis
of chronic stress, can best be qualied as pseudopsychopathol-
ogy (Van Zweden, 2015).
Importantly, this often leads to the false interpretation of
employers, but also clinicians, that burnout symptoms are
a result of adaptation problems due to maladaptive personality
traits. This may lead to blaming the victim and trying to x the
individual instead of the suboptimal and stressful environment
(Bakker et al., 2014). Pseudo maladaptive personality traits that
are often observed in clinical burnout are obsessive compul-
sive, dependent and paranoid personality traits, which manifest
itself by being very compulsive and rigid, not daring to make
decisions without consulting others or being suspicious.
It is crucial to nd out whether this rigid maladaptive inter-
personal style is a cause or a result of chronic stress. A good
possibility to check this is to ask a relative whether the person
has always been like that or whether personality changed
during the burnout process. Personality disorders are persistent
inexible or impaired patterns of thought and behaviour that
usually cause diculties in forming and maintaining interper-
sonal relationships and in meeting the daily demands of one’s
personal and work life (APA, 2013). These disorders typically
become apparent during adolescence or early adulthood.
Pseudo personality psychopathology develops as a result of
chronic stress and not in a specic stage of life. Moreover, the
newly acquired clinical prole disappears with the recovery
from burnout.
Reduced motivation and passivity (clinical burnout)
This nal stage is the condition in which people meet the
diagnosis of clinical burnout. The hyperactivity that charac-
terizes the initial phase of chronic stress may change to passiv-
ity and a relatively permanent impaired motivation (Boksem &
Tops, 2008; Schaufeli et al., 2020; Van Dam et al., 2015b).
Instead of trying to maintain performance of work tasks at
high levels, burnout patients seem not to be able to motivate
themselves anymore. Research shows that whereas some burn-
out patients are active showing high task engagement, others
are passive showing low task engagement (Tops et al., 2007).
The groups probably reect the dierent phases in the burnout
process. The nal phase in the burnout process that is charac-
terized by chronic demotivation and high levels of stress may
be related to the phenomenon of “learned helplessness”
(Seligman, 1975). Learned helplessness refers to a state in
which a person believes they have no control over the situation
and, therefore, does not try to cope with the situation any
longer and experiences high levels of stress (Sapolsky, 1998).
Several studies showed that burnout patients exhibit implicit
(unconscious) associations with failure, which is also indicative
for learned helplessness (Brenninkmeijer et al., 2001; Van Dam
et al., 2012b).
Treatment of clinical burnout
The variations in the conceptualization of burnout also have an
impact on the literature on the treatment of (clinical) burnout.
Meta-analyses usually fail to make any distinction between
research on interventions for employees with relatively mild
short-term work stress complaints and interventions for
EUROPEAN JOURNAL OF WORK AND ORGANIZATIONAL PSYCHOLOGY 5

patients with clinical burnout complaints (Ahola et al., 2017;
Awa et al., 2010). Moreover, some interventions are more
focused on the prevention of burnout whereas others are
aimed at the treatment of clinical burnout. Therefore, it is not
possible to draw rm conclusions about the eectiveness of
treatment programmes. However, there are indications that the
majority of patients with clinical burnout improves signicantly
after treatment (Oosterholt et al., 2012; Van Dam et al., 2012b).
In this paper, I will describe the therapeutic interventions that
are commonly used in the treatment of severe clinical burnout.
Various burnout treatment protocols have been described in
the literature (Hamming, 2020; Keijsers et al., 2004; Van Dam
et al., 2017; Van Zweden, 2015). These protocols have in com-
mon that they are aimed at restoring a healthy balance
between eort and rest, recovery from chronic stress, and
improving coping skills. Dierent phases can be distinguished
in the treatment of clinical burnout: (1) crisis, (2) recovery, and
(3) prevention (Hamming, 2020; Van Dam et al., 2017; Van
Zweden, 2015; Weber & Jaekel-Reinhard, 2000). In this para-
graph, interventions will be described for each specic phase
and also which interventions are contraindicated in that speci-
c phase (see also Table 2).
Phase 1 Crisis
The rst phase of the treatment is characterized by crisis (Van
Dam et al., 2017; Van Zweden, 2015). Despite severe fatigue
and distress, the patient tries to fulll all obligations at work
and in private life and notices that (s)he makes many mistakes,
is unable to concentrate, is emotionally unstable and prone to
conicts. It may also be that the patient feels so severely
fatigued that he feels unable to do anything and nds himself
staring and doing nothing most of the time. The patient feels
despair and hopes the therapist can do something that makes
him/her able to again fulll all obligations at work and in
private life.
In this rst phase, it is necessary that the therapist is
empathic to the feelings of the patient but also honest and
straightforward regarding the possibilities of quick recovery
(Van Dam et al., 2017; Van Zweden, 2015). The therapist
makes it clear to the patient that clinical burnout is the
result of prolonged periods of stress and that there are no
quick tricks or solutions. The balance between stress and
restoration has to change and the body needs to recover
and nd a healthy balance again. And this takes time. The
rst thing to do now is to make recovery possible and to
create time and opportunities to take a good look at the
situation (Van Dam et al., 2017). This can be done by drop-
ping almost all responsibilities for the next few weeks. For
many patients, this is very dicult to accomplish because of
strong feelings of responsibility and feeling uneasy about
bothering others. Indecisiveness may also be fuelled by
cognitive impairments (Deligkaris et al., 2014; Van Dam
et al., 2011; Van der Linden et al., 2005). Because higher
cognitive processes such as executive functioning are
impaired, patients may experience diculty getting an over-
view of their situation and diminished problem-solving cap-
abilities. It is recommendable, in this phase of the treatment
that the therapist takes the lead and actively helps the
patient to nd solutions and if necessary, communicates
with the social network about the measures being taken.
Phase 2: Recovery of the stress system
The main purpose of the second phase is recovery of the stress
system. Homoeostatic stress values need to return to normal
levels (McEwen, 2017; Sterling, 2004). Therefore, it is important
that stress is reduced. In the rst phase of the treatment,
sources of stress are drastically reduced by skipping social
obligations and avoiding work and household chores. In
the second phase, patients will resume activities gradually.
The relative distress an activity causes is registered, and the
therapist advises the client to start with nonwork activities that
cause little stress for limited duration – alternated with rest or
relaxing activities. It is essential that the individual will be able
again to switch from arousal to rest.
Therefore, the therapist and patient make schemes in which
activity and rest are alternated (Keijsers et al., 2004; Van Dam
et al., 2017). Only if the patient feels recovered after two hours
rest, the number and duration of activities can be extended. In
the course of phase 2, reintegration to work should start gra-
dually. The pace at which reintegration can take place must be
geared to the degree of recovery. It is wise to involve the
employer in this process and explain how the recovery will
proceed and what can be expected regarding task perfor-
mance. This also depends on the extent to which the employer
is willing to take into account the limitations of the patient
during the recovery process (Brouwers et al., 2020).
Table 2. Phases in the treatment of clinical burnout.
Phase Treatment goal Therapeutic interventions
Phase 1: Crisis Recognition of the patient
that the problems are
serious, and that serious
action is required.
Psychoeducation
Sick leave
Dropping domestic tasks
and social obligations
Inform social network
Phase 2:
Recovery
Recovery of the
(physiological) stress
system to normal allostatic
stress levels.
Registration of stress and
activities.
Relaxation exercises
Mindfulness
Healthy lifestyle advices
Graded exercise
Gradually resume
activities
Psychoeducation social
network and employer
Gradual return to work
Phase 3:
Prevention,
learning from
the past
Acquiring insight and skills to
prevent relapse in clinical
burnout.
Analysing stressful
situations
Analysing dysfunctional
thought patterns
Learning new coping
skills
Learning social skills
Job crafting
Time management
Making choices
regarding career and
personal life
Phase 4: Post
burnout
growth
Improving sustainable quality
of life.
Setting priorities regarding
quality of life and
interpersonal
relationships.
Based on: Hamming, 2020; Keijsers et al., 2004; Van Dam et al., 2017; Van Zweden,
2015; Weber & Jaekel-Reinhard, 2000.
6A. VAN DAM

A healthy lifestyle needs to be promoted because it is ben-
ecial for recovery. Healthy food, alcohol in moderation, mod-
erate exercise and especially a healthy sleep pattern are
essential for recovery (Sonnenschein et al., 2008). Another pro-
blem that needs attention in this phase is that ignoring signals
of the body like fatigue and stress has become a habit or
lifestyle for many burnout patients. The strong ability to perse-
vere and postpone need gratication makes that they are les
tuned to signals of their body and tend to choose their actions
on basis on what they think that they should do and not on
what they feel. Relaxation exercises, meditation and mindful-
ness exercises can be helpful to become more receptive to
signals of the body again (Bednar et al., 2020).
During this phase, which lasts several months, the patient
will become less fatigued and will be motivated and able again
to perform tasks. For a part of the patients, the cognitive
impairments seem to decrease in a slower pace than the
other symptoms (Dalgaard et al., 2020; Van Dam et al.,
2012b). This should be taken into account when someone
reintegrates into the work. The duration with which someone
can perform complex cognitive tasks is limited and should
therefore be alternated with other tasks.
In the second phase, it is also important not to do a number
of things because it will hinder recovery. First, it is inadvisable
to start psychotherapy. Psychotherapy may be emotionally
demanding and stressful and therefore hinders recovery from
chronic stress (Linden, 2013). In addition, due to the chronic
stress, there may be pseudopsychopathology (Van Zweden,
2015). This will disappear by itself when someone recovers.
For the same reasons, no assessment or psychological testing
should take place at this stage. As a result of the chronic stress,
people will score less intelligent and more disturbed on the
tests than they actually are.
Many burnout patients experience relational problems
because family members experience that the burnout patient
is often irritable and reluctant to engage in social activities
(Carnes, 2017; Davis et al., 2011). It is helpful to involve partners
or family members in the treatment to provide explanations
and advice on how to deal with the symptoms. However,
focusing on the relational problems would only increase the
stress and be unnecessary because the relational problems will
probably disappear once the patient has recovered (Cuijpers,
2007; Hener et al., 2004).
In order to be able to properly estimate whether complaints
are the cause or consequence of the chronic stress, it is best to
ask family and acquaintances how the patient’s functioning
was before the chronic stress episode. Another point of atten-
tion is that in an attempt to solve the problematic situation,
people may take drastic decisions like changing jobs, divorce or
emigration. This is seldomly a good idea in this phase because
of the eorts it requires to adapt oneself to a new (work)
environment while being already exhausted and experiencing
diculties in cognitive control (García-León et al., 2019;
McCarthy & Lambert, 1999).
Phase 3 Prevention, learning from the past
In the third and nal phase, the patient is almost fully recov-
ered, and the time has come to explore the reasons why some-
one ended up with burnout. Knowledge about factors that
contributed to the burnout may help to prevent that a person
will go through years of chronic stress again. Research shows
that fty percent of the individuals who returned to work after
burnout had a relapse in burnout within two and a half year.
Six percent of the individuals who received a structured work-
place-oriented intervention had more than two relapses com-
pared to fourteen percent of the individuals who did not
receive the intervention (Karlson et al., 2014).
Factors that may inuence vulnerability to burnout are cir-
cumstances, coping, and dysfunctional thought patterns.
-Circumstances: Circumstances may lead to chronic stress
reactions when there are not enough possibilities for recovery.
In some cases, people have very limited inuence on conditions
that cause stress (Bakker & de Vries, 2021; DeLongis &
Holtzman, 2005; Sapolsky, 1998). You can think of
a combination of a bad atmosphere at work in combination
with caring for a sick family member. The therapist and the
burnout patient can take a look at whether it had been possible
to deal with the situation dierently by asking for more social
support or setting limits.
-Coping: An eective way of dealing with problems is to
make far-reaching but necessary decisions. This is something
that many people nd dicult to do (Maslach & Goldberg,
1998). It may be the case, for example, that due to changes at
work, someone no longer really likes his work that much, but
does not want to admit it to himself or is not fully aware of it
(Follmer et al., 2018). The same process may also play a role in
private life. Some people appear not to be our best friends
when we take a closer look (Lee et al., 2010). Another dilemma
may occur when someone has made a career change and
would experience it as a failure to recognize that this job
does not suit him and go back in social status and salary
(Verheyen & Guerry, 2018). It is essential that a therapist con-
fronts clients with a mismatch between desires and possibilities
and also helps them make painful but necessary decisions.
Improving coping skills may also comprise learning new ways
to solve problems, social skill training, time management and
job crafting (Keijsers et al., 2004; Van Dam et al., 2017).
- Dysfunctional thought patterns: As a result of education
and experiences in life, people develop thoughts and expecta-
tions about themselves, others, and the world (Sauerland et al.,
2015). These thoughts can be functional if they contribute to
happiness and the ability to adapt to changing life circum-
stances. Thoughts are dysfunctional when they allow people
to enter patterns that are rigid and non-adaptive and contri-
bute to stress, emotional problems and destructive behaviour
patterns (Keijsers et al., 2004; Sauerland et al., 2015; Van Dam
et al., 2017). In burnout patients, this may express itself in
perfectionism, conict avoidance, sub-assertiveness, the idea
of always having to prove oneself or an excessive sense of duty.
Cognitive behavioural therapy may then be eective in break-
ing through these dysfunctional patterns by changing dysfunc-
tional thought patterns and learning new social skills (Keijsers
et al., 2004; Van Dam et al., 2017).
A successful treatment of burnout may move into
a fourth phase. There is a body of literature suggesting
that people exposed to even the most traumatic events
may perceive at least some good emerging from their
struggle with tragedies. This is called posttraumatic growth
EUROPEAN JOURNAL OF WORK AND ORGANIZATIONAL PSYCHOLOGY 7

(Tedeschi et al., 2018). At least three broad categories of
perceived benets have been identied: changes in self-
perception, changes in interpersonal relationships, and
a changed philosophy of life. In recovered burnout
patients the same phenomenon can be observed
(Glouberman, 2007; Semeijn et al., 2019; Van Dam & de
Leeuw, 2004). Many former burnout patients report that
they have learned from their burnout and that their life is
better now than before their burnout. They know better
who they are and what is important to them in life; they
spend more time with their friends and families; and they
changed their priorities. Many former burnout patients
allow themselves to enjoy life more and to be happy.
This may be called post-burnout growth. These observa-
tions are in line with empirical ndings (Semeijn et al.,
2019) and may hopefully contribute to a dierent (more
positive) perspective on burnout.
Conclusion
In this article I have explained the dierence between syndromes
resulting from short-term stress and those resulting from chronic
stress. Because individuals with short-term stress show elevated
levels on burnout measures, just like individuals with other mental
disorders like major depression and anxiety disorders a clinician
cannot solely rely on questionnaires in order to make a qualitative
distinction between the mild stress disorders and clinical burnout
The dierence between these syndromes, in terms of people who
are predisposed for them and the prognosis, is qualitative rather
than dimensional. It is relevant for work- and organizational psy-
chologists to know that biological processes play an important
role in the development of clinical burnout. It does not matter for
physiological processes whether the stress is work-related or the
result of stress in private life or both. Central to understanding
clinical burnout is the lack of recovery of the (physiological) stress
system. Work- and organizational psychologists could pay more
attention to coping instead of symptom level to determine who is
at risk for clinical burnout. Furthermore they could adjust their
interventions to the various risk proles; for example, stress man-
agement programmes for employees with mild stress symptoms
and healthy lifestyle programmes for individuals with excessive
perseverance.
I hope that this contribution will inspire work- and orga-
nization psychologists in designing interventions and con-
ducting research.
Disclosure statement
No potential conict of interest was reported by the author(s).
References
Ahola, K., Toppinen-Tanner, S., & Seppänen, J. (2017). Interventions to
alleviate burnout symptoms and to support return to work among
employees with burnout: Systematic review and meta-analysis.
Burnout Research, 4, 1–11. https://doi.org/10.1016/j.burn.2017.02.
001
Åsberg, M., Grape, T., Krakau, I., Nygren, Å., Rohde, M., Wahlberg, A., &
Währborg, P. (2010). Stress som orsak till psykisk ohälsa [Stress as
a cause of mental illness]. Läkartidningen, 107(19–20), 1307–1310.
Americain PsychiatricAssociation, . (2013). Diagnostic and statistical manual
of mental disorders ((5th edition ed.). American Psychiatric Publishing.
Awa, W. L., Plaumann, M., & Walter, U. (2010). Burnout prevention: A review
of intervention programs. Patient Education and Counseling, 78(2),
184–190. https://doi.org/10.1016/j.pec.2009.04.008
Bakker, A. B., & de Vries, J. D. (2021). Job Demands–Resources theory and
self-regulation: New explanations and remedies for job burnout. Anxiety,
Stress, and Coping, 34(1), 1–21. https://doi.org/10.1080/10615806.2020.
1797695
Bakker, A. B., Demerouti, E., & Sanz-Vergel, A. I. (2014). Burnout and work
engagement: The JD–R approach. The Annual Review of Organizational
Psychology and Organizational Behavior, 1(1), 389–411. https://doi.org/
10.1146/annurev-orgpsych-031413-091235
Bakker, A. B., Van Emmerik, H., & Van Riet, P. (2008). How job demands,
resources, and burnout predict objective performance: A constructive
replication. Anxiety, Stress, and Coping, 21(3), 309–324. https://doi.org/
10.1080/10615800801958637
Bednar, K., Voracek, M., & Tran, U. S. (2020). Common factors underlying the
ve facets of mindfulness and proposed mechanisms: A psychometric
study among meditators and non-meditators. Mindfulness, 11(12),
2804–2817. https://doi.org/10.1007/s12671-020-01492-6
Beekman, A. T. F., & Hengeveld, M. W. (2014). Diagnostiek niet verwarren
met classiceren in de psychiatrie [Diagnosis should not be confused
with classication in psychiatry]. Tijdschrift Voor Psychiatrie, 56(8),
531–532. https://www.tijdschriftvoorpsychiatrie.nl/assets/articles/56-
2014-8-artikel-beekman.pdf
Bianchi, R., Schonfeld, I. S., & Laurent, E. (2015). Is it time to consider the
“burnout syndrome” a distinct illness? Frontiers in Public Health, 3, 158.
https://doi.org/10.3389/fpubh.2015.00158
Boksem, M. A., & Tops, M. (2008). Mental fatigue: costs and benets. Brain
research reviews, 59(1), 125–139
Brenninkmeijer, V., Van Yperen, N. W., & Buunk, B. P. (2001). I am not a
better teacher, but others are doing worse: Burnout and perceptions
of superiority among teachers. Social Psychology of Education, 4 (3),
259–274
Brouwers, E. P. M., Joosen, M. C. W., van Zelst, C., & Van Weeghel, J. (2020).
To disclose or not to disclose: A multi-stakeholder focus group study on
mental health issues in the work environment. Journal of Occupational
Rehabilitation, 30(1), 84–92. https://doi.org/10.1007/s10926-019-09848-z
Carnes, A. M. (2017). Bringing work stress home: The impact of role conict
and role overload on spousal marital satisfaction. Journal of
Occupational and Organizational Psychology, 90(2), 153–176. https://
doi.org/10.1111/joop.12163
Carpenter, J. S., Iorno, F., Cross, S. P., Davenport, T. A., Hermens, D. F.,
Rohleder, C., . . . Hickie, I. B. (2019). Combining clinical stage and patho-
physiological mechanisms to understand illness trajectories in young
people with emerging mood and psychotic syndromes. Medical Journal
of Australia, 211, S12–22. https://www.innowell.org/wp-content/
uploads/2020/03/Ch2-Nov-mechanisms-to-understand-illness.pdf
Clark, L. A., Cuthbert, B., Lewis-Fernández, R., Narrow, W. E., & Reed, G. M.
(2017). Three approaches to understanding and classifying mental
disorder: ICD-11, DSM-5, and the National Institute of Mental
Health’s Research Domain Criteria (RDoC). Psychological Science in
the Public Interest, 18(2), 72–145. https://doi.org/10.1177/
1529100617727266
Cuijpers, P. (2007). Depressie. Gids voor familieleden. [Depression, a guide for
family members]. HB Uitgevers.
Dalgaard, V. L., Hviid Andersen, J., Pedersen, A. D., Andersen, L. P., &
Eskildsen, A. (2020). Cognitive impairments and recovery in patients with
work-related stress complaints–four years later. Stress, E-pub ahead of print.
Davis, L. L., Gilliss, C. L., Deshefy-Longhi, T., Chestnutt, D. H., & Molloy, M.
(2011). The nature and scope of stressful spousal caregiving
relationships. Journal of Family Nursing, 17(2), 224–240. https://doi.org/
10.1177/1074840711405666
Deligkaris, P., Panagopoulou, E., Montgomery, A. J., & Masoura, E. (2014).
Job burnout and cognitive functioning: a systematic review. Work &
stress, 28(2), 107–123
DeLongis, A., & Holtzman, S. (2005). Coping in context: The role of stress,
social support, and personality in coping. Journal of Personality, 73(6),
1633–1656. https://doi.org/10.1111/j.1467-6494.2005.00361.x
8A. VAN DAM

Demerouti, E., Bakker, A. B., & Leiter, M. (2014). Burnout and job perfor-
mance: The moderating role of selection, optimization, and compensa-
tion strategies. Journal of Occupational Health Psychology, 19(1), 96–108.
https://doi.org/10.1037/a0035062
Eden, D. (2001). Vacations and other respites: Studying stress on and o the
job. In C. L. Cooper & I. T. Robertson (Eds.), International review of
industrial and organizational psychology (Vol. 16, pp. 121–146). Wiley.
Eskildsen, A., Andersen, L. P., Pedersen, A. D., & Andersen, J. H. (2016).
Cognitive impairments in former patients with work-related stress
complaints–one year later. Stress, 19(6), 559–566. https://doi.org/10.
1080/10253890.2016.1222370
Eurelings-Bontekoe, E. H., van Dam, A., Luyten, P., Verhulst, W. A., Van
Tilburg, C. A., de Heus, P., & Koelen, J. (2009). Structural personality
organization as assessed with theory driven prole interpretation of
the Dutch short form of the MMPI predicts dropout and treatment
response in brief cognitive behavioral group therapy for Axis I
disorders. Journal of Personality Assessment, 91(5), 439–452. https://doi.
org/10.1080/00223890903087927
Fabelico, F. L., & Afalla, B. T. (2020). Perseverance and passion in the
teaching profession: Teachers’ grit, self-ecacy, burnout, and perfor-
mance. Journal of Critical Reviews, 7(11), 108–119. http://www.jcreview.
com/fulltext/197-1590728949.pdf
Follmer, E. H., Talbot, D. L., Kristof-Brown, A. L., Astrove, S. L., & Billsberry, J.
(2018). Resolution, relief, and resignation: A qualitative study of
responses to mist at work. Academy of Management Journal, 61(2),
440–465. https://doi.org/10.5465/amj.2014.0566
Fritz, C., & Sonnentag, S. (2006). Recovery, well-being, and
performance-related outcomes: The role of workload and vacation
experiences. Journal of Applied Psychology, 91(4), 936. https://doi.org/
10.1037/0021-9010.91.4.936
Ganzel, B. L., Morris, P. A., & Wethington, E. (2010). Allostasis and the human
brain: Integrating models of stress from the social and life sciences.
Psychological Review, 117 (1), 134–174. https://doi.org/10.1037/
a0017773
García-León, M. Á., Pérez-Mármol, J. M., Gonzalez-Pérez, R., del Carmen
García-Ríos, M., & Peralta-Ramírez, M. I. (2019). Relationship between
resilience and stress: Perceived stress, stressful life events, HPA axis
response during a stressful task and hair cortisol. Physiology &
Behavior, 202, 87–93. https://doi.org/10.1016/j.physbeh.2019.02.001
Gatchel, R. J., Ray, C. T., Kishino, N., & Brindle, A. (2020). The biopsychosocial
model. In S. B. Gulliver & L. M. Cohen: The Wiley encyclopedia of health
psychology (pp. 1–8).John Wiley and Sons Ltd
Geurts, S. A., & Sonnentag, S. (2006). Recovery as an explanatory mechanism
in the relation between acute stress reactions and chronic health
impairment. Scandinavian Journal of Work, Environment & Health, 32(6),
482–492. https://doi.org/10.5271/sjweh.1053
Ginot, E. (2017). The enacted unconscious: A neuropsychological model of
unconscious processes. Annals of the New York Academy of Sciences, 40,
1–6. https://doi.org/10.1111/nyas.13404
Glouberman, D. (2007). The Joy of Burnout - How the end of the world can be
a new beginning. Skyros Books.
Grossi, G., Perski, A., Osika, W., & Savic, I. (2015). Stress-related exhaustion
disorder–clinical manifestation of burnout? A review of assessment
methods, sleep impairments, cognitive disturbances, and neuro-biolo-
gical and physiological changes in clinical burnout. Scandinavian
Journal of Psychology, 56(6), 626–636. https://doi.org/10.1111/sjop.
12251
Hamming, C. (2020). Een nieuwe kijk op stress, eecten van psychobiologische
coaching op stressklachten, overspanning en burn-out [A new approach to
burnout, eects of psychobiological coaching on stress and burnout]. CSR
Centrum, https://www.csrcentrum.nl/wp-content/uploads/2020/10/
20201013-CSR-Centrum-Whitepaper-Een-nieuwe-kijk-op-stress.pdf .
Hener, K. L., Kiecolt-Glaser, J. K., Loving, T. J., Glaser, R., & Malarkey, W. B.
(2004). Spousal support satisfaction as a modier of physiological
responses to marital conict in younger and older couples. Journal of
Behavioral Medicine, 27(3), 233–254. https://doi.org/10.1023/B:JOBM.
0000028497.79129.ad
Hockey, G. R. J. (1997). Compensatory control in the regulation of human
performance under stress and high workload: A cognitive-energetical
framework. Biological Psychology, 45(1–3), 73–93. https://doi.org/10.
1016/S0301-0511(96)05223-4
Hockey, G. R. J. (2011). A motivational control theory of cognitive fatigue. In
P. L. Ackerman (Ed.), Cognitive fatigue: The current status and future for
research and applications (pp. 167–188). APA.
Hunter, E. M., & Wu, C. (2016). Give me a better break: Choosing workday
break activities to maximize resource recovery. Journal of Applied
Psychology, 101(2), 302–311. https://doi.org/10.1037/apl0000045
Karlson, B., Jönsson, P., & Österberg, K. (2014). Long-term stability of return
to work after a workplace-oriented intervention for patients on sick
leave for burnout. BMC Public Health, 14(1), 1–10. https://doi.org/10.
1186/1471-2458-14-821
Keijsers, G. P. J., Vossen, C. J. C., Schaap, C. P. D. R., Boelaars, V. A. J. M.,
A. van, M., & Hoogduin, C. A. L. (2004). Protocollaire behandeling van
patiënten met burnout. Modulaire behandeling. In G. P. J. Keijsers, A. van
Minnen, & C. A. L. Hoogduin (Eds.), Protocollaire behandelingen in de
ambulante geestelijke gezondheidszorg. Deel 2 (pp. 205–280). Bohn
Staeu van Loghum.
Kleijweg, J. H., Verbraak, M. J., & Van Dijk, M. K. (2013). The clinical utility of
the Maslach burnout inventory in a clinical population. Psychological
Assessment, 25(2), 435. https://doi.org/10.1037/a0031334
Kotov, R., Krueger, R. F., Watson, D., Achenbach, T. M., Altho, R. R.,
Bagby, R. M., . . . Eaton, N. R. (2017). The Hierarchical Taxonomy of
Psychopathology (HiTOP): A dimensional alternative to traditional
nosologies. Journal of Abnormal Psychology, 126(4), 454. https://doi.
org/10.1037/abn0000258
Lee, S., Rogge, R. D., & Reis, H. T. (2010). Assessing the seeds of relationship
decay: Using implicit evaluations to detect the early stages of
disillusionment. Psychological Science, 21(6), 857–864. https://doi.org/
10.1177/0956797610371342
Linden, M. (2013). How to dene, nd and classify side eects in psy-
chotherapy: From unwanted events to adverse treatment reactions.
Clinical Psychology & Psychotherapy, 20(4), 286–296. https://doi.org/10.
1002/cpp.1765
Martínez, J. P., Méndez, I., Ruiz-Esteban, C., Fernández-Sogorb, A., &
García-Fernández, J. M. (2020). Proles of burnout, coping strategies
and depressive symptomatology. Frontiers in Psychology, 11, 591.
https://doi.org/10.3389/fpsyg.2020.00591
Maslach, C., & Goldberg, J. (1998). Prevention of burnout: New perspectives.
Applied and Preventive Psychology, 7(1), 63–74. https://doi.org/10.1016/
S0962-1849(98)80022-X
McCarthy, C. J., & Lambert, R. G. (1999). Structural model of coping and
emotions produced by taking a new job. Journal of Employment
Counseling, 36(2), 50–66. https://doi.org/10.1002/j.2161-1920.1999.
tb01009.x
McEwen, B. S. (2017). Neurobiological and Systemic Eects of Chronic
Stress. Chronic Stress, 1, 1–11. https://doi.org/101177/
2470547017692328
Meijman, T. F., & Mulder, G. (1998). Psychological aspects of workload.
In P. J. D. Drenth & H. Thierry (Eds.), Handbook of work and organiza-
tional psychology, Volume 2: Work psychology (pp. 5–33). Psychology
Press.
Michailidis, E., & Banks, A. P. (2016). The relationship between burnout and
risk-taking in workplace decision-making and decision-making style.
Work and Stress, 30(3), 278–292. https://doi.org/10.1080/02678373.
2016.1213773
Monk, T. H., Reynolds, I. I. I., Buysse, C. F., DeGrazia, J. M., D. J., & Kupfer, D. J.
(2003). The relationship between lifestyle regularity and subjective sleep
quality. Chronobiology International, 20(1), 97–107. https://doi.org/10.
1081/CBI-120017812
Oosterholt, B. G., Van der Linden, D., Maes, J. H., Verbraak, M. J., &
Kompier, M. A. (2012). Burned out cognition—cognitive functioning of
burnout patients before and after a period with psychological treat-
ment. Scandinavian Journal of Work, Environment & Health, 38 (4), 38(4),
358–369. https://doi.org/10.5271/sjweh.3256
Panksepp, J., & Yovell, Y. (2014). Preclinical modeling of primal emotional
aects (SEEKING, PANIC and PLAY): Gateways to the development of
new treatments for depression. Psychopathology, 47(6), 383–393. https://
doi.org/10.1159/000366208
EUROPEAN JOURNAL OF WORK AND ORGANIZATIONAL PSYCHOLOGY 9

Persson Asplund, R. (2021). Learning how to recover from stress-related
disorders via internet-based interventions [Doctoral dissertation],
Linköping University Electronic Press.
Raio, C. M., Orederu, T. A., Palazzolo, L., Shurick, A. A., & Phelps, E. A. (2013).
Cognitive emotion regulation fails the stress test. Proceedings of the
National Academy of Sciences, 110(37), 15139–15144.
Roohafza, H., Feizi, A., Afshar, H., Mazaheri, M., Behnamfar, O., Hassanzadeh-
Keshteli, A., & Adibi, P. (2016). Path analysis of relationship among
personality, perceived stress, coping, social support, and psychological
outcomes. World Journal of Psychiatry, 6(2), 248. https://doi.org/10.5498/
wjp.v6.i2.248
Sanders, R. (2014). New evidence that chronic stress predisposes brain to
mental illness (pp. 11). Berkeley News.
Sapolsky, R. M. (1998). Why zebra’s don’t get ulcers. W.H. Freeman and
company.
Sauerland, M., Soyeaux, H. M., & Krajewski, J. (2015). The inuence of
dysfunctional cognitions on job-related experiences and behaviour-a
cognitive-behavioural perspective. International Journal of Human
Resources Development and Management, 15(1), 40–53. https://doi.org/
10.1504/IJHRDM.2015.069973
Schaufeli, W., De Witte, H., & Desart, S. (2020). Manual Burnout
Assessment Tool (BAT) Version 2.0 – July 2020. https://burnoutassess
menttool.be/wp-content/uploads/2020/08/Test-Manual-BAT-English-
version-2.0-1.pdf
Schaufeli, W. B. (2007). Burnout in discussie: Stand van zaken [Burnout
discussed: Current state of aairs]. De Psycholoog, 42, 534–540. https://
www.wilmarschaufeli.nl/publications/Schaufeli/274.pdf
Schaufeli, W. B., Bakker, A. B., Hoogduin, K., Schaap, C., & Kladler, A. (2001).
On the clinical validity of the Maslach Burnout Inventory and the burn-
out measure. Psychology & Health, 16(5), 565–582. https://doi.org/10.
1080/08870440108405527
Schiavone, S., Colaianna, M., & Curtis, L. (2015). Impact of early life stress on
the pathogenesis of mental disorders: Relation to brain oxidative stress.
Current Pharmaceutical Design, 21(11), 1404–1412. https://doi.org/10.
2174/1381612821666150105143358
Schonfeld, I. S., Verkuilen, J., & Bianchi, R. (2019). Inquiry into the correlation
between burnout and depression. Journal of Occupational Health
Psychology, 24(6), 603. https://doi.org/10.1037/ocp0000151
Seligman, M. E. P. (1975). Helplessness: On depression, development, and
death. San Francisco: W.H. Freeman
Semeijn, J., Van Ruysseveldt, J., Vonk, G., & van Vuuren, T. (2019). In ight
again with wings that were once broken; eects of post-traumatic
growth and personal resources on burnout recovery. International
Journal of Workplace Health Management, 12(5), 387–403. https://doi.
org/10.1108/IJWHM-01-2019-0006
Socialstyrelsen (2010). Internationell Statistisk Klassikation av
Sjukdomar och Relaterade Hälsoproblem – ICD−10–SE. ISBN: 978–
91–86585–63–1.
Sonnenschein, M., Sorbi, M., Verbraak, M., Schaufeli, W., Maas, C., & van
Doornen, L. (2008). Inuence of sleep on symptom improvement and
return to work in clinical burnout. Scandinavian Journal of Work,
Environment & Health, 34(1), 23–32. https://doi.org/10.5271/sjweh.1195
Sterling, P. (2004). Principles of allostasis: Optimal design, predictive reg-
ulation, pathophysiology and rational therapeutics. In J. Schulkin (red.).
Allostasis, homeostasis and the costs of physiological adaptation.
Cambridge University Press
Taris, T. W. (2006). Is there a relationship between burnout and objective
performance? A critical review of 16 studies. Work and Stress, 20(4),
316–334. https://doi.org/10.1080/02678370601065893
Tedeschi, R., Shakespeare-Finch, J., Taku, K., & Calhoun, R. (2018).
Posttraumatic growth, theory, research and applications. Routledge.
Tops, M., Boksem, M. A. S., Wijers, A. A., Van Duinen, H., Den Boer, J. A.,
Meijman, T. F., & Korf, J. (2007). The psychobiology of burnout: Are there
two dierent syndromes? Neuropsychobiology, 55(3–4), 143–150. https://
doi.org/10.1159/000106056
Van Dam, A., Keijsers, G. P. J., Eling, P. A. T. M., & Becker, E. S. (2015b).
Burnout and impaired cognitive performance; review of evidence,
underlying processes and future directions. In T. N. Winston (Ed.),
Handbook on burnout and sleep deprivation: Risk factors, management
strategies and impact on performance and behaviour (pp. 113–128). Nova
Science Publishers.
Van Dam, A. (2016). Subgroup analysis in burnout: Relations between
fatigue, anxiety and depression. Frontiers in Psychology, 7, 90. https://
doi.org/10.3389/fpsyg.2016.00090
Van Dam, A., Keijsers, G. P. J., Kriens, S., Boelaars, V. A. J. M., & Vossen, C. J. C.
(2017). Protocollaire behandeling van patiënten met somatisch-
symptoomstoornis persisterend type met aanhoudende werkgerela-
teerde vermoeidheidsklachten (burn-out). In G. P. J. Keijsers, A. van
Minnen, A., M. J. P. M. Verbraak, C. A. L. Hoogduin, &
P. M. G. Emmelkamp (Eds.), Protocollaire behandelingen voor volwassenen
met psychische klachten 3 (pp. 63–146). Boom uitgevers.
Van Dam, A., & de Leeuw, F. (2004). Uit de Brand. Omgaan met mensen met
burnout [Out of the Fire. Dealing with people with burnout]. Harcourt.
Van Dam, A., Eling, P. A. T. M., Keijsers, G. P. J., & Becker, E. S. (2013). Do
Employees with Burnout Prefer Low-Eort Performance Strategies? IIE
Transactions on Occupational Ergonomics and Human Factors, 1(3),
190–201. https://doi.org/10.1080/21577323.2013.828666
Van Dam, A., Keijsers, G. P. J., Eling, P. A. T. M., & Becker, E. S. (2011). Testing
whether reduced cognitive performance in burnout can be reversed by
a motivational intervention. Work and Stress, 25(3), 257–271. https://doi.
org/10.1080/02678373.2011.613648
Van Dam, A., Keijsers, G. P. J., Eling, P. A. T. M., & Becker, E. S. (2012b).
Impaired cognitive performance and responsiveness to reward in burn-
out patients: Two years later. Work and Stress, 26(4), 333–346. https://doi.
org/10.1080/02678373.2012.737550
Van Dam, A., Keijsers, G. P. J., Verbraak, M. J. P. M., Eling, P. A. T. M., &
Becker, E. S. (2012b). Burnout patients primed with success did not per-
form better on a cognitive task than burnout patients primed with failure.
Psychology, 3(8), 583–589. https://doi.org/10.4236/psych.2012.38087
Van Dam, A., Keijsers, G. P. J., Verbraak, M. J. P. M., Eling, P. A. T. M., &
Becker, E. S. (2015a). Level and appraisal of fatigue are not specic in
burnout. Clinical Psychology & Psychotherapy, 22(2), 133–141. https://doi.
org/10.1002/cpp.1869
Van der Voort., - van Beusekom, I., Visser, E. C. M., & Overeem, O. (2016).
Bevorderen van participatie van cliënten met een psychische stoornis
[improving participation of clients with a mental disorder]. Zorginstituut
Nederland.
Van der Klink, J. J., Blonk, R. W., Schene, A. H., & F.J. van, D. (2003). Reducing
long term sickness absence by an activating intervention in adjustment
disorders. A cluster randomised controlled design. Occupational and
Environmental Medicine, 60(6), 429–437. https://doi.org/10.1136/oem.
60.6.429
Van der Linden, D., Keijsers, G. P., Eling, P., & Schaijk, R. V. (2005). Work stress
and attentional diculties: An initial study on burnout and cognitive
failures. Work and Stress, 19(1), 23–36. https://doi.org/10.1080/
02678370500065275
van Zweden, S. (2015). Waarom duurt burn-out zo lang? [Why does recov-
ery from burnout take so long?]. Tijdschrift Voor Psychotherapie, 41(1),
5–21. https://doi.org/10.1007/s12485-015-0002-2
Verheyen, T., & Guerry, M.-A. (2018). Motives for (non) practicing demotion.
Employee Relations, 40(2), 244–263. https://doi.org/10.1108/ER-01-2017-
0024
Wallace, J. E. (2017). Burnout, coping and suicidal ideation: An application
and extension of the job demand-control-support model. Journal of
Workplace Behavioral Health, 32(2), 99–118. https://doi.org/10.1080/
15555240.2017.1329628
Weber, A., & Jaekel-Reinhard, A. (2000). Burnout syndrome: A disease of
modern societies? Occupational Medicine, 50(7), 512–517. https://doi.
org/10.1093/occmed/50.7.512
World Health Organization. (2010). International Classication of Diseases.
10 A. VAN DAM