The Evolution of Representations about the Syndrome of Emotional Burnout

SummaryIntroduction: the study of burnout syndrome intensifies over time. In 2020, MEDLINE/PubMed database contains more than 18,000 publications on this phenomenon. In its development, the concept of burnout has passed through several heterogeneous periods. Objective: to provide the description of the origin and development of the burnout concept, the features of the social environment within which this syndrome was actualized, and the current state of this problem. Material and methods: publications on the burnout syndrome were analyzed. The search was performed using the keywords “burnout”, “history” in the MEDLINE/PubMed, eLIBRARY, and Google Scholar databases. The “snowball” method was used to search for publications in the literature lists of relevant studies. Results: the phenomena similar to burnout were registered long before the start of its academic study. The initiation of scientific research on burnout occurred mainly due to global social changes associated with the increasing role of social professions and the increasing burden on workers employed in them. The results of the analysis of publications made it possible to distinguish several stages of burnout studying, which differed in the methodology of empirical research, the range of subjects included in the risk group for this phenomenon, and the number of competing psychological models of burnout. Despite the growing number of papers on burnout, issues related to the clinical status of this syndrome, its discriminant validity, methods of its prevention and coping are still relevant. The effectiveness of an interdisciplinary approach to the study of burnout can be flawed by excessive expansion of the concept and loss of its substantiveness.


INTRODUCTION
The first scientific paper on burnout was published more than 45 years ago [1]. During this time, it was possible to get answers to certain questions related to this phenomenon, but there are still too many "blank spots" in its conceptual field, which is indirectly confirmed by the growing interest of the scientific community in this problem.
A generally accepted def init ion of burnout does not exist, but in the scientific community it is customary to use the definition C. Maslach [2], according to which, burnout is a prolonged reaction to chronic stress arising at interpersonal contacts dur ing a working process and is manifested by emot ional e xhaus t ion , c ynic ism and reduced professional accomplishment. Emotional exhaustion refers to a depleted, weakened emotional response, a permanent feeling of depression, lack of strength, which is especially relevant during communication w ith other people. Negat ive, detached, formal attitude to work and clients, the extreme degree of which is dehumanizat ion, is of ten denoted by the terms "depersonalization" or "cynicism". The reduced prof ess ional accomplishment is characterized by a decrease in working efficiency, a feeling of incompetence and inability to cope w ith work. The l ast component of burnout is self-evaluating, and a necessar y and suf f icient condition for establishing the presence of this symptom in an individual is a sense of loss of his REVIEW MIA' ISSN2618-6667 (online)' journalpsychiatry.com DOI 10.30629/2618DOI 10.30629/ -6667-2020 or her own professional efficiency without actually reduced labor productivity.

THE FIRST DESCRIPTIONS OF EMOTIONAL BURNOUT AND THE PREREQUISITES FOR ITS DEVELOPMENT
A description of a state similar to burnout can be found in the Old Testament. The Second Book of Kings tells the story of the prophet Elijah, who performed miracles in an attempt to reason with King Ahab. The prophet was waiting for recognition, in the form of renouncing idols and accepting God, but the reaction to his work was the intention of Ahab's wife to kill Elijah. In desperation, the prophet prayed to God for death, and then slept for a long time, waking up only to eat -an emphatic but accurate description of emotional and physical exhaustion.
Thousands of years later, but still long before the start of the academic study of burnout, some works of art depicted characters subject to this condition. In "Ward No. 6" and "Ionych" A.P. Chekhov quite accurately shows the process of the formation and development of a doctor's professional deformation with signs of emotional burnout, and in the novel "Buddenbrooks" by T. Mann, similar changes are demonstrated by the example of Senator Thomas Buddenbrook.
In 1953 M.S. Schwartz & G.T. Will investigated the relationship between low morale of mental health workers and patient care [3]. Using the example of nurse Miss Jones, the authors demonstrate how the work environment can affect the relationships between employees, their coping strategies, and their interaction with patients. The nurse's emotional withdrawal from patients was described as a coping mechanism to overcome low morale [4]. Some authors consider this as a manifestation of depersonalization, noting that such coping strategies can be effective in the short term, but do not solve the problems underlying the development of burnout [5].
Thus, it can be argued that phenomena similar in essence, but different in name from burnout were registered in the fiction and scientific literature long before the publication of the first academic work on burnout.
In 1961, US President John F. Kennedy addressed his compatriots in his inaugural address: "…Ask not what your country can do for you -ask what you can do for your countr y". Lyndon Johnson announced the beginning of the creation of a "Great Society" in which there will be no poverty and racial segregation. These statements largely determined the fur ther internal policy and format of social services, which had a lot of young, idealistic and motivated employees. Although some of the Great Society initiatives have been successful, the work of the helping professions has become more difficult. Thus, the implementation of Medicare and Medicaid programs has provided preferential access to medical care for the elderly and the poor, and the pool of potential patients has expanded significantly. On the other hand, despite the decisiveness of declaring a "war on poverty" and the resources spent on it, the results were very modest, which could not be overlooked by the "soldiers" -social workers [6]. They saw that systemic factors beyond their control, such as the costly war with Vietnam, did not allow achieving their goals and become disappointed with their professions. Undermined the idealism probably became the basis for the wide dissemination of burnout ("you have to burn to burn out" [7]) -not just industrial harm or inconvenience, but a challenge to the professional identity of workers who preferred helping people to the opportunity to get rich in the "Golden age of capitalism".
In 1965, changes were made to the US Immigration and Nationality Act, the consequences of which some authors call the "cultural revolution" [8]. The flow of immigrants has undergone both qualitative and quantitative changes: instead of a moderate number of Europeans, Latin Americans began to move to the country in large numbers. Of ten, without having the same high labor qualif ications, these people became the main recipients of social benefits and services. The prestige of professions such as doctors, teachers, or police officers declined, and clients of social workers became more demanding, particularly in terms of expressing compassion, empathy and the range of provided services. The sharply increased gap between the efforts made by professionals and the benef its they receive (mainly non-material) stimulated the development of burnout [9].
It is important to note that the decline in the prestige of these professions was obvious for the personnel employed in them, but not for clients who believed that social workers have a high degree of autonomy, enjoy their work, are well educated, competent, responsive, and sympathetic.
Another prerequisite for the wide spread of burnout was the change in the form and status of traditional social institutions. After the end of the World War II, public associations such as the church, the labor associations and the family were partially or completely disintegrated, gradually losing their significance as a point of support, and the functions they per formed were assigned to professional , bureaucratic, and isolated social services. According to R. Sennet [10], the transformation of traditional r ig id , homogeneou s and predic t abl e soc ial institutions into unstable and constantly changing was facilitated by the transition to the so-called "flexible" capitalism. Whereas in the traditional Weberian triangle, payment is based on the work done in the best possible way, in the "flexible" corporation, it is given to teams that "beat" their competitors, i.e. the winner gets everything, and the efforts of the losers are not rewarded. Income inequality in such an environment is growing rapidly, and confidence in the future is decreasing. In the context of a local or global economic crisis, companies act rationally and fire "extra" employees, shifting the care of them to social services. The emotional attachment, trust, and loyalty of an employee of the organization are reduced. At the same time, emotional burnout was almost not found in non-competitive areas (i.e. priests of monasteries) where employees viewed work a vocation rather than a way to earn money [11]. Informal communities in which people are connected by a common idea, provide social support, a sense of unity, open contact with the team, sharing common values, and prevent the development of burnout.
In gener al , t he event s de scr ib ed above characterize one global process -the transition from an industrial society to a post-industrial one. Interesting is the parallel with the phenomenon of neurasthenia, "discovered" by G. Beard in 1869, when American society was moving from an agrarian to an industrial type [12]. Neurasthenia was studied on the example of entrepreneurs, while emotional burnout was first found in service workers -both were symbols of a new era. But while neurasthenia was probably associated with the intensification of technological development, then wide spread of burnout was a result of a qualitative change in social relations.

THE RESEARCH OF THE EMOTIONAL BURNOUT: THE DESCRIPTIVE PHASE
Herbert J. Freudenberger -clinical psychologist and psychoanalyst who was born in Germany and worked in the United States. Accomplished and sought-after specialist, in the 1970s he took part in the development of free hospitals and began practicing in one of these clinics in New York. H. Freudenberger observed young, idealistic volunteers experiencing a lack of energy and strength, emotional flattening, lose motivation, commitment and interest in work after a year of working in this institution. Some of them developed symptoms of mental and physical disorders, such as indigestion, insomnia, frequent and prolonged colds, substance abuse. The paper "Staff Burn-out", published in 1974 [1], is considered the starting point for the study of burnout, although the term "burn-out" had already been found in the works of this author [13].
It is wor t h not ing t hat Freudenb erger 's publications are to a certain extent autobiographical. A few years before the first description of burnout, he noted that working from 08:00 A.M. to 06:00 P.M. and daily additional practice led to a deterioration in his relationship with his wife [14,15]. He later wrote: "I continued to deny that anything was wrong despite my lingering cold, my fatigue, and my constant irritability. During the Christmas holiday my wife insisted that we take a vacation with the children, and much as I hated to be away from the clinic, I felt I should go to make up for all the time I had spent away from home. My wife made the hotel and plane reservations. All I had to do the night before we left was pack my own clothes, but when I dragged myself through the door at 2 A.M., I was too exhausted to do anything except fall into bed. I told my wife that I would pack into the morning, but in the morning I couldn't get up. We never got to the airport. I slept for two solid days and ruined the family vacation. On the third day, I was still not able to get out of the bed, but I was able to begin reflecting on how I had been behaving" [16]. The detailed description of emotional burnout is due not only to the author's careful observation of colleagues, but also to his own experience of this syndrome.
The p ap er " St af f bur n-out " f ocu s e d on Fr eudenb er ger 's sub je c t iv e e x p er ience and reflections, without any experimental evidence. The author decided to publish it in a sociological rather than medical journal (Journal of Social Issues), because he considered burnout as "something in the air", and not as a clearly formulated hypothetical construct [17].
Around the same t ime, social psychologist Christina Maslach studied coping strategies used to deal with emotional arousal at work, in particular, dehumanization and withdrawal from problems. Talking about the results of her research to one lawyer, C. Maslach learned that attorneys serving MIA' ISSN2618-6667 (online)' journalpsychiatry.com DOI 10.30629/2618DOI 10.30629/ -6667-2020 the poor call this phenomenon "burnout". Her first work in burnout research field was published in 1976 in the popular science edition "Human Behavior: The Newsmagazine of the Social Sciences" [18]. As in the case of the "Staff Burn-out" article, the presented data was not conf irmed experimentally, being a report of case series. C. Maslach interviewed more than 200 social workers, such as lawyers, clinical psychologists, prison workers, doctors and nurses in psychiatric institutions. She found that burnout was common in all of these professions.
In the article "The Client Role in Staff Burnout", published in 1978 [19] C. Maslach descr ibes in detail the social changes that led to the widespread spread of emotional burnout among representatives of helping professions. She notes that when daily difficulties arise, people first of all seek support not from family or friends, as it was before, but from professionals working in specialized institutions, whose social function has become increasingly important over the years. Social workers, in turn, try to distance themselves from clients, treat them not as individuals, but as a depersonalized object of their work. To prevent this condition, according to the author, employees of helping professions need to undergo special training aimed at understanding the labor motivation and the importance of their psychological state for the quality of work.
The articles of H. Freudenberger and C. Maslach caused a wide resonance among specialists, whose work activity was characterized by two features: the relationship "donor-recipient of social services" as the basis of the work process, and the emotional stress arising during it. Over the next few years, articles on burnout appeared only in practically or iented journal s, while scholars ignored the study of this phenomenon. Several situational and organizational characteristics of the work process that hypothetically lead to the development of emotional burnout were described, for example, workload, lack of positive feedback from clients and support from the administration and colleagues [20]. Separate studies have examined relationships in work collective and family, which could be both an additional source of stress, for example, due to stigmatization, and a resource for overcoming it [21].
Unlike practitioners, scientists initially ignored the study of burnout. Believing that it is very difficult to develop effective methods of diagnosis, prevention and relief of any disorder without a theoretical basis, they associated the term "burnout" with something pseudoscientific. Some editors refused C. Maslach and her colleague S.E. Jackson to publish the results of the development of the first psychometric tool for diagnosing emotional burnout. In a short letter, they replied that they had not even read the article, since they were not publishing "pop" psychology [22]. Perhaps the scientific community would have reacted to the concept of burnout with less skepticism, if the design of Freudenberger's and Maslach's early studies was better suited to the objectives and the results were published in journals focused on clinical psychology or psychiatry.
It should be noted that if the problem is first discovered in the "f ield" practice, and not in scientific institutes and laboratories, its study is carried out from the standpoint of several disciplines. For example, a physician may view burnout as a form of depression [23], a psychologist will investigate it in the context of job satisfaction [24], and an administrator will be interested in increased layoffs and absenteeism [25]. Comparing and combining such approaches can be very difficult at first, which may also have reduced the interest in burnout on the part of scientists. Subsequently, this eclecticism directly or indirectly gave rise to many disputes about the ontological status of burnout.
Since not all practitioners were sufficiently well trained to conduct research, some limitations of the work of the descriptive phase should be noted.
First, the authors used a variety of definitions of the term "burnout", referring to different phenomena, rather than the same.
Second, the pool of variables associated with burnout expanded too much. They tried to explain almost every personal problem in terms of burnout, and sometimes diametrically opposite processes were attributed to its causes, for example, overload and insufficient workload.
Third, the methodology of these works was rather primitive. In 1982, Perlman & Hartman described 48 articles published between 1974 and 1981 which contained a large number of ideas, assumptions about the causes of burnout, and suggestions for possible interventions, but only 5 of them were based on data obtained in studies other than case series [26].
The t ypical structure of most works of the descriptive phase was as follows.
1. Descr iption of the stressful nature of a particular profession. 2. Assoc iat ion of professional stress w ith emotional burnout. 3. The description of one or more cases that illustrate this relationship.
4. Re co mm e n d a t io n o f s o m e p r e v e n t i v e strategies. Thus, despite the relatively large amount of thematic publications, there were practically no reliable ev idence of pre-formulated scient if ic hypotheses, and the lack of theoretical justification lead on the one hand to an excessive, chaotic extension of the concept of burnout, which became the basis for its criticism (up to complete denial of its existence), on the other, reflected the novelty of the phenomenon, its openness to research and the need for them.

THE RESEARCH OF THE EMOTIONAL BURNOUT: THE EMPIRICAL PHASE
In the early 1980s burnout research methodology began to improve. Many books and articles were written in which various burnout models were put forward and different intervention were proposed based on empir ical data. In 1981, C. Maslach and S. Jackson published "The Measurement of Exper ienced Burnout" [27], descr ibing a threefactor model of burnout, based on which the authors created a diagnostic tool for ranked assessment of burnout -Maslach Burnout Inventory (MBI). The MBI manual [28], published in the same year, justifies the validity of the developed tool and the possibility of its use in testing representatives of different helping professions. It is generally accepted that the development and publication of MBI is the boundary between the descriptive and empirical phases of the burnout research.
Many of the alternative theories were univariate, reduc ing burnout to exhaust ion. C. Maslach, recognizing the leading role of exhaustion in the development of burnout, notes that this can explain the lack of energy and, as a result, a decrease in the productivity of work activities, but not a decrease in self-esteem, difficulties in interacting with other people, a crisis of ideals and values [2]. In addition, for some people, exhaustion can be a sign of extra effort on a meaningful cause, leading to a sense of satisfaction. Lack of empathy and reduction of professional achievements, which are characteristic of burnout, have a more destructive effect on the personality of workers [29].
The study of burnout in social workers continued, but the range of professions studied expanded (prison guards, librarians). Signs of burnout were also found in people outside of their professional activities, for example, in the field of sports [30], political activ ism [31], studying [32]. The high degree of association of burnout and the social sphere is due, among other things, to the design features of MBI, a tool originally developed for use in the f ield of helping professions. Work factors such as job sat isfact ion, stress (workload, role conflict, role ambiguity), turnovers, absenteeism, work expectations, relationships with colleagues, administration and clients, organizational policies, and sal ar y level s were usually considered as burnout-related variables. The studied individual f ac tors included demographic charac ter ist ic s (gender, age , mar it al s t atus , soc io -economic status, etc.), some personality characteristics (for example, character accentuation, locus of control), mental and physical health, relat ionships w ith family and fr iends. Overall , research has shown that indiv idual factors are less associated with burnout than organisational ones.
Most of the burnout papers of the 1980s were crosssectional correlation studies carried out using MBI or other questionnaires on non-representative samples, and although they produced interesting results, these studies had a number of serious limitations.
Studies may have been subject to systematic errors, such as selection bias or common method bias [33].
The response rate was usually quite low, which was probably due to the refusal to participate in studies of individuals due to the development of burnout and, as a result, fatigue, exhaustion, i.e. the real prevalence of burnout could be higher. In addition, these studies did not allow testing causal hypotheses, although causal relationships were usually discussed by the authors.
Thus, the association of poor working conditions and employee's burnout was usually considered the former as a cause, and the latter as a consequence, however, in reality it could be the oppositea "burned out" professional could evaluate the working environment worse than it actually was. Both interpretations are interesting in the context of the burnout studying, but the concepts created on their basis and the vector of further research set by them would be fundamentally different.
1. Burnout is a relatively stable process, i.e. it is a chronic, not an acute condition. 2. Emotional burnout leads to the development of somatic disorders, absenteeism and layoffs.
3. Lack of clarity in the work role and lack of social support from colleagues and superiors contribute to the development of burnout. The gradually formulated theoretical aspects of burnout were ignored during developement of the design of many studies of those years, including longitudinal ones. Sometimes the var iables of interest, potentially related to burnout, were chosen at random. The lack of theoretical justification of the research led to difficulties in interpreting both positive and negative results (is the hypothesis correct? is it confirmed? how to compare the obtained results with the results of other studies? what is the probability of getting such results by chance?).
Burnout was initially only studied in the United States. Gradually, researchers from other countries, mainly English speakers, drew attention to the phenomenon. Since the second half of the 1980s, articles and books on burnout are translated into many other languages -French, German, Italian, Spanish, Swedish, Dutch, Polish; the first international studies are carried out [37]. When the concept of burnout interested scientists outside the United States, they had access to appropriate psychometric tools, and the theoretical foundations of the construct were already formed. Within the framework of the given topic, we can say that the descriptive phase of the study of burnout was skipped in these countries. Most researchers relied on MBI as the basis for identifying burnout, and the phenomenon itself was defined as a syndrome characterized by emotional exhaust ion, depersonalizat ion, and reduced of personal accomplishment. Outside the United States, the scientific discussion on burnout was less active, and new diagnostic tools and concepts were rarely developed, mainly in conditions of scientific and cultural isolation of varying degrees Outside the United States, the scientific discussion on burnout was less active, and new diagnostic tool s and concepts were rarely developed, mainly in conditions of scientific and cultural isolation of varying degrees.
An example of an alternative view of burnout is the theory of V.V. Boyko, who considered burnout as a coping strategy in the form of complete or partial exclusion of emotions ("lowering their energy") in response to certain psychotraumatic influences [38]. The author points out the processual nature of burnout, highlighting three consecutive phases. It begins with a phase of emotional stress, characterized by vivid experiences of traumatic circumstances, disappointment in one's capabilities and chosen profession, increased responsibility, anxiety, and a decrease in functional reserves. Next comes the phase of emotional resistance, during which reserves are restored through workers' attempts to protect themselves from unpleasant emotional sensations, restricted interpersonal interactions and the limited expression of emotions. The outcome of burnout is a phase of emotional exhaustion -functional reserves are again reduced, a person experiences a lack of positive emotions, callousness, cynicism, loss of interest in the object of activity, narrowing of needs, change in the value system [39]. Based on the proposed theory, the author developed the questionnaire "Emotional burnout" [38]. Both the concept and the diagnostic tool of V.V. Boyko are widely used in the countries of the former USSR, but not abroad.
In the 1990s, the study of burnout extended beyond the social professions, for example, to IT specialists and militar y. The evolv ing research methodology is complemented by complex statistical technologies [20]. One of the most impor tant achievement s of burnout research in the X XI century was the development of a causal Areas of Worklife Model, which integrated not only various dimensions of "demands-resources" imbalance, but also organizational and individual risk factors [40]. According to this model , the development of burnout is the result of a disturbance of the congruence of the individual and working conditions in one of six areas: workload, control , reward, community, fairness, and values. Like other [41] hypothetical etiopathogenetic models, Areas of Worklife Model is undoubtedly simplified relative to reality, but in the absence of a detailed description of the mechanisms of development of a certain condition, such constructs are useful for both scientists and practitioners.
Some scientists believe that in the chronology of the study of burnout, in addition to the descriptive and empirical phases, as well as the pre-scientific era that preceded them, several more periods can be distinguished. V.A. Abramov et al. [42] believe that since 2000, the study of burnout has entered the "stage of metareviews".
The authors consider it a formal sign of the alleged change in the relative and absolute number of literature reviews in the general pool of publications on burnout, and the very fact of the onset of this stage, from authors' point of view, is a sign of sufficient accumulation of knowledge to study the etiology and pathogenesis of burnout. In addition, the same work describes the stages that each subsequent turn of the spiral has in the structure of the meta-review stage: "indicator" (characterized by the presence of two or more often contradictory views on the problem, signals the beginning of the next phase of the spiral study of the concept), "unconscious" phenomenon, "generalization-awareness", analysis. In each turn, the earlier stages of the question investigation are necessarily repeated, but at an accelerated pace and with greater accuracy in identifying essential, natural features. Each turn corresponds to the identifying of a new research direction, i.e. a doctoral dissertation.
Another example of dividing the empirical phase into separate periods can be found in the work of T.G. Nerush [43]: in the 1980s researchers focused on the psychological assessment of the phenomenon, the development of psychometric instruments and the integration of psychological and clinical areas of study; since the mid-1990s, the subject of study becomes "various aspects of burnout" (characteristics of this stage are reminiscent of a brief summary of the main features of the entire empirical phase of the burnout study); at the beginning of the XXI century burnout is considered from the standpoint of various areas of psychology.
The significant difference in duration between the descriptive and empirical phases of the burnout study seems to be sufficient basis for raising the question of the expediency of their differentiation and may be the cause of cognitive dissonance, giving rise to the desire to equalize these phases, make them comparable by "fragmentation" a longer one. Yet the border in this case is the fundamental transition from theoretical knowledge to empirical one. Of course, the authors who dealt with the problem of burnout in the descriptive phase based their work on observations of people, but the results of these works were an unquantifiable product of reflection. The gradual change in the relative and absolute number of different types of clinical trials, whether cross-sectional trials, RCTs or systematic reviews is natural and depends on many reasons, such as the progress in the science methodology, the financing of specific developments, the interest of scientists. Most importantly, it is not the evidence of a radical change in the epistemological paradigm. The "indicator of a new turn" and the "turn" itself are actually a description of the permanent processes of generation and verification of hypotheses. Indeed, it reflects the spiral trajectory of the development of empirical knowledge, however the division in (sub) phases each cycle, in the shortest case consisting of two studies, does not seem rational. Similarly, it is superfluous to distinguish individual stages based on the development of new psychometr ic tools, which is still happening nowadays [44], as well as studying the phenomenon from var ious theoretical standpoints -the essential properties of the concept of burnout, inherent in it from the moment of its occurrence.

BURNOUT TODAY
For decades, burnout has been viewed primarily as a specific occupational hazard that affects young, idealistic and poorly-awared professionals who work in the field of helping professions. However, over time, the communication process is facilitated, access to information is simplified, and today idealistic ideas about a particular work activity are becoming less common. Ubiquitous access to the Internet makes it possible to get access to huge amounts of unfiltered information on almost any issue. However, young workers are still susceptible to emotional burnout [45][46][47]. Moreover, the few who started working in the social sphere in the 1970s and continue to work to this day, despite their experience, show signs of burnout [48].
Today, careers are more variable, and less stable than they were half a century ago, when lifelong work in a single position was not out of the ordinary. People are skeptical about the missions, views, and ideals of organizations that are incongruent with available resources. In addition, the personal values of employees may differ fundamentally from those of the employer. Thus, a conflict of values arises between a seller who focuses on high-quality customer service and a company seeking to maximize profits, which intensifies as the loyalty of the employee and the organization decreases [49]. Overall , today the corporate culture has become complex, contradictory and sometimes hostile to the professional , and burnout has turned from a specialized occupational hazard to a widespread one.
Some sc ient ist s cont inue to put for ward alternative models of burnout. So Gil-Monte et al. proposed a four-factor burnout structure based on the C. Maslach model. Leaving the dimensions of emotional exhaustion and depersonalization unchanged, the authors divided the reduction of professional achievements into "enthusiasm towards job" and "guilt" [50]. Kristensen et al. suggested that burnout should be reduced to exhaustion, since depersonalization is a kind of coping mechanism, and the reduction of professional achievements refers to the consequences of burnout, and is not part of its structure [51].
The development of intervention strategies in burnout remains an urgent problem. Some studies have demonstrated moderate ef fect iveness of personality-oriented interventions aimed at this syndrome, but organizational and mixed interventions are still poorly understood [52]. This is probably due to the formal difficulties of administrators at any level, who do not want to change the functional algorithms of the controlled structures. At the same time, the results of the studies already conducted are heterogeneous, which may be due to differences in the characteristics of the samples and specific methods of intervention [53]. Authors of systematic review conducted in 2016 [54] attempted to analyze all known burnout interventions. Of the 930 papers found, only 5% published the results of controlled trials. The deficiency of high-quality research on measures to combat emotional burnout is still high.
Scientist s seek to descr ibe the dif ferences and draw boundaries between burnout and similar conditions, mainly depression [55]. The discriminant validity of burnout is de facto the main object of criticism of researchers who doubt the usefulness of the construct [56]. The link between burnout and depression has been repeatedly demonstrated [57,58], but it was expressed only in the case of using diagnostic tools that are too strongly associated with each other at the conceptual level. For example, in a study by S. Toker and M. Birom [59] the authors found a correlation of average strength (r 2 from 0.40 to 0.54) between depression and burnout using the eight-point Patient Health Questionnaire-8 scale, five questions of which are related to fatigue and exhaustion [60], and the Shirom-Melamed Burnout Measure questionnaire, based on a model that reduces burnout to cognitive, emotional or physical fatigue [61]. On a theoretical level, the main dif ference between burnout and depression is contextual specificity -burnout is usually associated with work, while depression is a more general concept, free from specific areas of life or situations. Interestingly, H. Freudenberger considered gradual transformation of burnout into depression possible, af ter which the manifestations described by him are present outside the work env ironment. The possibilit y of burnout generalization is conf irmed by large prospective studies in which a high level of burnout was a significant risk factor for the development of depression [57].
The risk of losing the substance of burnout due to the desire to include as many symptoms as possible is still exist. Similar thing happened to neurasthenia, which, although indexed in the ICD-10, is rarely used as a clinical diagnosis in most countries.
The study of new populations that may be subject to burnout continues. The concept of so-called "parental burnout" is developed [62]. There are more similarities than differences between "occupational" and "parental" burnout , and, of course, both phenomena can co-exist, mutually reinforcing the negative impact on the life of the affected individual. Burnout of psychologists and psychiatrists is of particular importance [63]. Specialists of this profile not only experience burnout themselves, but are also provide assistance to other affected persons.
Burnout is not currently classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), and in the International classification of diseases (ICD-10), it is classif ied as a group of problems related to life-management difficulty (Z73.0). This, in particular, explains the growing interest in this phenomenon among people not directly related to work in the field of psychiatry or psychology. Burnout is a rare, if not unique, example of a mental health problem that is free of stigmatization. People easily and sometimes proudly admit that their feeling bad is a result of a normal reaction to an abnormal situation. However, in the Swedish national version of ICD-10, "exhaustion disorder", which is actually a renamed burnout, is indexed as a medical diagnosis. In the Netherlands, burnout also considered as a diseases and clinical guidelines are developed to deal with it [64]. Probably, this attitude is due to the fact that since the 1950s in the Netherlands, the overspannenheid condition (literally, "overstrain") has been recognized as an official diagnosis, the clinical description of which is very similar to signs of burnout. Since its inception, the term "burnout" has been used to denote the terminal state of this process. Discussions on the manifestations, phenomenology and consequences of burnout, its clinical status, diagnostic criteria, treatment, as well as the need for an interdisciplinary approach to its study continue, and the need for relevant research is still great.