Exhaustion disorder or stress-induced exhaustion disorder (ED, ) is a diagnosis used in Swedish healthcare to indicate a maladaptive stress disorder more severe than adjustment disorder. Common signs include exhaustion, reduced cognitive ability and a range of physical symptoms. The symptoms develop gradually as a result of prolonged and elevated stress, but often culminate abruptly as the disorder becomes fulminant. Recovery will generally take from six months to a full year, sometimes longer. There are significant overlaps between symptoms of exhaustion disorder and depression, two conditions that frequently occur simultaneously. There are also many similarities between exhaustion disorder and occupational burnout. In common Swedish vernacular (burnout) is used synonymously with exhaustion disorder, but this usage is dissuaded in professional settings.
The diagnosis was introduced in 2003, and with support from the Swedish National Board of Health and Welfare it was included in the Swedish edition of ICD-10 in 2005. Since its introduction it has become a leading cause for sick leave in Sweden. Among patients receiving compensation from the Swedish Social Insurance Agency for more than 90 days, it is the most common diagnosis and women are at higher risk than men. The diagnosis is not used outside of Sweden.
Treatment approaches vary between healthcare providers and the different regions of the country. Common elements include psychoeducation, physical activity and individual psychotherapy or group therapy. Multimodal rehabilitation programs have also been offered by specialized providers. Several treatment options are effective at reducing symptoms, but no available treatment option successfully reduces the duration until return to work. Due to the limited effect of available treatment options, preventative measures are considered the most important intervention to reduce the burden of disease.
Signs and symptoms Exposure to stress is a part of life that generates a host of different responses, some of them akin to signs of illness without constituting or resulting in disease. How to differentiate between benign and maladaptive responses to stress is not necessarily evident, and from a dimensional rather than categorical perspective there is no sharp line dividing normality and illness. The difference between tolerable and pathological stress seems to depend on a complex interaction between stress factors, and the affected persons mental resources and protective factors. A prolonged period of elevated stress can lead to exhaustion, sleep disorders and a decline in cognitive abilities. The diagnosis of exhaustion disorder is designed to capture a state of illness far removed from the transient stress of everyday life.
The symptoms of exhaustion disorder include fatigue that does not improve with rest, reduced stress tolerance and various physical symptoms. Some of the more common physical symptoms are headaches, dizziness and bowel issues. Most patients also suffer from sleeping problems. Exhaustion disorder and depression have several overlapping symptoms and often occur simultaneously, but many people suffering from exhaustion disorder do not satisfy the diagnostic criteria for depression. Symptom overlap between exhaustion disorder and other mental disorders is not unusual, but rather a common theme among mental disorders.
The typical course of disease is divided into three phases: at risk, acute sickness and recovery. At risk individuals experience a gradual onset of symptoms over a prolonged period of time, followed by a sudden deterioration and a long recovery, with pronounced exhaustion and reduced cognitive capacity. The initial phase can last several years and various complaints such as fatigue, headaches, anxiety, sleeplessness, irritability, dizziness or bowel issues may erupt. During this phase, some people seek medical care for physical or other isolated symptoms. The rate of recovery and progress from the at risk stage is unknown. If the disease progresses the fatigue compounds, with increasing cognitive decline and an inability perform everyday activities. At the peak of distress some are compelled to seek emergency care due to panic or chest pain, where the resulting examination fails to identify any physical cause. This critical stage tends to be described in terms of a crisis or "collapse" by the affected person and their associates. There is usually a marked aversion to the workplace for a while, and either an increased sleep duration or sleep disturbances. As the overall condition slowly improves the physical symptoms tend to abate, but sleeping disorders and cognitive impairments may linger, and stress tolerance recovers slowly.
Causes Exhaustion disorder is stress-induced by definition and could be caused by stress in the workplace or from other environments. The underlying physiological mechanisms are as of 2023 incompletely understood. Early on, a decreased sensitivity within the HPA axis was identified in small scientific studies, resulting in an attenuated release of cortisol in response to stimulation. Subsequent investigations into this abnormality have produced mixed results, and several later scientific reports found no difference compared to healthy controls. Studies using magnetic resonance imaging have indicated changes to the prefrontal cortex, basal ganglia and amygdala. However, the number of studies and their participants are limited, and more research is needed to validate these findings.
Diagnosis Exhaustion disorder is a clinical diagnosis made by a qualified health care professional based on the patient's recollection of the course of disease. Blood samples cannot be used to ascertain the diagnosis but may, like ECG, be employed to rule out alternative diagnoses. Several physical and mental disorders may present with symptoms similar to exhaustion disorder, which makes it a diagnosis of exclusion. Relevant physical alternative diagnoses are symptom dependent, but could include hypothyroidism, vitamin B12 deficiency, COPD, cardiovascular disease and diabetes. There are also many commonalities with the chronic conditions fibromyalgia and ME/CFS.
The utility of measuring saliva-cortisol has been evaluated, but it serves a purpose only in research settings.
Classification Exhaustion disorder is included in the Swedish version of ICD-10, designated as F43.8A. The diagnosis is part of the diagnostic group "Adaptation disorders and response to severe stress". For classification purposes exhaustion disorder is marked as a complementary diagnosis if a patient suffers from a concurrent mental health disorder of significance; this includes depression, dysthymia or generalised anxiety disorder.
In order to confirm the diagnosis of exhaustion disorder, physical and mental exhaustion must be present following a prolonged period of elevated stress. The major criteria of significantly reduced mental energy must have been present for at least 2 weeks. One or several prior stress-inducing factors should be identified and the exposure must have lasted for 6 months or longer. At least 4 out of 6 minor criteria are needed to complete the diagnosis. It is considered vital to differentiate between exhaustion disorder and other responses to elevated or severe stress, such as adjustment disorder, acute stress disorder and PTSD. The 2024 Åsberg review recommends that the criteria be interpreted strictly to avoid medicalization, and emphasizes that a combination of fatigue and diminished cognitive capacity must be present for the diagnosis to be considered.
The diagnosis has not been recognized outside Sweden. There is a lack of consensus internationally concerning the proper way to diagnose, classify and treat conditions brought on by chronic stress. It has been suggested that the exhaustion disorder construct is an attempt to create a recognizable medical diagnosis from the burnout concept, similar to the use of neurasthenia in the Dutch healthcare system, and how fatigue-dominant somatoform disorder can be used. The umbrella term "Exhaustion due to persistent non-traumatic stress" has been proposed for such afflictions. It is considered likely that the suffering recognized as exhaustion disorder in Swedish healthcare settings in many other countries would be interpreted as symptoms of depression or an anxiety disorder, or be described with alternative terms such as clinical burnout, work-related neurasthenia, work-related depression, adjustment disorder or somatization syndrome.
Questionnaires and rating scales Various questionnaires may be of use to evaluate the risk for burnout or exhaustion, rate the intensity of symptoms or screen for co-morbid disorders. The Karolinska Exhaustion Disorder Scale (KEDS) is used to quantify symptoms of exhaustion among the afflicted and at risk individuals. Shirom-Melamed Burnout Questionnaire (SMBQ) is a tool originally developed for occupational burnout sometimes employed as a rating scale in the evaluation of exhaustion disorder. Despite the conceptual difference between ED and burnout these questionnaires have many similarities.
The Montgommery Åsberg Depression Rating Scale (MADRAS) is used to evaluate simultaneous symptoms of depression and the Hospital Anxiety and Depression Scale (HAD) measure signs of both depression or anxiety. The Alcohol Use Disorders Identification Test (AUDIT) screens for overuse of alcohol. The World Health Organization's Disability Assessment Timetable (WHODAT 2.0) has been studied as a means to distinguish between exhaustion and the less severe adjustment disorder, but no currently available scales or questionnaires are properly validated for use in differential diagnostics.
Treatment Treatment options Psychoeducation on stress, and the role of working conditions and lifestyle factors, are common treatment approaches. Physical activity is also considered an important part of rehabilitation. Psychotherapy in one-on-one or group settings, including methods for stress management may be a part of the protocol. Antidepressants are not considered effective in treating exhaustion, but may be used to treat concurrent depression or anxiety. The guidelines for treatment published by the Swedish National Board of Health and Welfare offers an ensemble of options and are open to interpretation. The actual treatment provided varies between different providers and parts of the country, depending on local traditions and resources, including access to multimodal rehabilitation (MMR). Since the symptoms are long-lasting it is generally considered appropriate to start partial return to work before complete remission of symptoms.
Before return to work a joint-appointment () between the patient, employer, care provider and the Social Insurance Agency is sometimes called for to agree on common terms for a gradual increase in workload. Depending on the circumstances a union representative or other support person may accompany the patient–employee.
Evidence Many different treatment options have been investigated and assessed scientifically. Since exhaustion disorder results in a long-lasting and severe loss of function, usually brought on by work-related stress, time until "return to work" is considered the most important end-point when evaluating the effectiveness of various treatments.