Burnout, Fatigue, Exhaustion

Burnout, Fatigue, Exhaustion
Sighard Neckel • Anna Katharina Schaffner • Greta Wagner

Editors
Burnout, Fatigue,
Exhaustion
An Interdisciplinary Perspectives
on a Modern Affliction
Editors
Sighard Neckel Anna Katharina Schaffner
Institute of Sociology School of European Culture and Languages
University of Hamburg University of Kent
Hamburg, Germany Canterbury, United Kingdom
Greta Wagner
Institute of Sociology
Goethe University Frankfurt
Frankfurt, Germany
ISBN 978-3-319-52886-1 ISBN 978-3-319-52887-8 (eBook)

DOI 10.1007/978-3-319-52887-8
Library of Congress Control Number: 2017937049
© The Editor(s) (if applicable) and The Author(s) 2017

This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and
transmission or information storage and retrieval, electronic adaptation, computer software, or by
similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica-
tion does not imply, even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this
book are believed to be true and accurate at the date of publication. Neither the publisher nor the
authors or the editors give a warranty, express or implied, with respect to the material contained herein
or for any errors or omissions that may have been made. The publisher remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
Cover design by Tom Howey
Printed on acid-free paper
This Palgrave Macmillan imprint is published by Springer Nature

The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Contents
1 Introduction 1
Sighard Neckel, Anna Katharina Schaffner
and Greta Wagner
Part I Cultural-Historical Perspectives
2 Pre-Modern Exhaustion: On Melancholia and Acedia 27

Anna Katharina Schaffner
3 Neurasthenia and Managerial Disease in Germany and

America: Transnational Ties and National Characteristics
in the Field of Exhaustion 1880–1960 51
Patrick Kury
Part II Exhaustion Syndromes
4 Exhaustion Syndromes: Concepts and Definitions 77

Johanna M. Doerr and Urs M. Nater
5 Burnout: A Short Socio-Cultural History 105

Wilmar B. Schaufeli
v
vi Contents
6 Burnout: From Work-Related Stress to a Cover-Up

Diagnosis 129
Linda V. Heinemann and Torsten Heinemann
Part III Exhaustion and Self-Realisation
7 What We Talk About When We Talk About Mental

Health: Towards an Anthropology of Adversity in
Individualistic Society 153
Alain Ehrenberg
8 Self-Realisation Through Work and Its Failure 173

Elin Thunman and Marcus Persson
9 Exhaustion and Euphoria: Self-Medication with

Amphetamines 195
Greta Wagner
Part IV Exhaustion Discourses
10 Rechargeable Man in a Hamster Wheel World:

Contours of a Trendsetting Illness 217
Ulrich Bröckling
11 Literary Exhaustion 237

Michael Greaney
Part V Exhaustion and the Social
12 Social Agony and Agonising Social Constructions 259

Iain Wilkinson
13 Exhaustion as a Sign of the Present 283

Sighard Neckel and Greta Wagner
Contents vii
14 Conclusion 305
Sighard Neckel, Anna Katharina Schaffner
and Greta Wagner
Index 311
List of Tables
Table 4.1 Fatigue Syndromes 81
ix
1
Introduction
Sighard Neckel, Anna Katharina Schaffner
and Greta Wagner
Our age, it seems, is the age of exhaustion. The prevalence of exhaustion –

both as an individual experience and as a broader socio-cultural
phenomenon – is manifest in the epidemic rise of burnout, depression,
and chronic fatigue. It is equally present in a growing disenchantment
with capitalism in its current neo-liberal form, in concerns about the
psycho-social repercussions of ever-faster information and communica-
tion technologies, in a general distrust in grand narratives, and in
anxieties about ecological sustainability.
S. Neckel (*)
University of Hamburg, Hamburg, Germany
e-mail: Sighard.Neckel@wiso.uni-hamburg.de
A.K. Schaffner
University of Kent, Canterbury, UK
e-mail: a.k.schaffner@kent.ac.uk
G. Wagner
Goethe University Frankfurt, Frankfurt, Germany
e-mail: Greta.Wagner@soz.uni-frankfurt.de
© The Author(s) 2017 1

S. Neckel et al. (eds.), Burnout, Fatigue, Exhaustion,
DOI 10.1007/978-3-319-52887-8_1
2 S. Neckel et al.
As the precise organic causes of chronic exhaustion are still being

debated, exhaustion theories entail by definition assumptions about the
relationship between mind and body, and between the environment and
society, and are often ideologically charged. Moreover, exhaustion the-
ories frequently function as discursive spaces in which specific cultural
discontents are articulated. They therefore present highly instructive case
studies for an investigation of the ways in which individual suffering and
wider social dynamics are inter-related.
To a certain extent, social problems and wider cultural-historical devel-
opments tend to be mirrored by the rise and fall of specific medical
symptoms and so-called fashionable diseases. It is thus not an entirely
new phenomenon that current exhaustion syndromes provide the occasion
for social self-reflection on the pathologies of modern economic and social
life. It is nevertheless striking that what many consider a predominantly
mental condition has become the symbol of our social condition. While in
the past heart attack, circulatory collapse, or the proliferation of malignant
cells served as symbols of social crises, currently exhaustion syndromes
seem to have few rivals when it comes to the public anamnesis of undesir-
able economic and social developments. A diagnostic commonality has
evolved in public discourse which starts with the ‘exhausted self’ of the
self-responsible subject,1 proceeds to examine symptoms of exhaustion in
the status struggle of the middle classes,2 and finally arrives at the finding
that expansionist conceptions of growth have become exhausted,3 and thus
at a critique of the ideological script that demands the continuous expan-
sion of money, labour, and commodities.
The concept of exhaustion, it seems, can serve equally well to describe
such diverse phenomena as subjective predicaments and social ills.
1
Alain Ehrenberg, The Weariness of the Self: Diagnosing the History of Depression in the
Contemporary Age, trans. David Homel et al. (Montreal: McGill-Queens’s University Press,
2010a).
2
See Steffen Mau, Inequality, Marketization and the Majority Class: Why Did the European Middle
Classes Accept Neo-Liberalism? (New York: Palgrave Pivot, 2015).
3
Meinhard Miegel, Stefanie Wahl, and Martin Schulte with the collaboration of Elias Butzmann,
Altering Attitudes: From a Culture of Consumerism to a Culture of Prosperity (Bonn: Denkwerk
Zukunft – Stiftung kulturelle Erneuerung, 2011).
1 Introduction 3
This concept is thus able to connect individual psychological crises with

the fact that broad sectors of society are exposed to tension-laden living
conditions, and with the problematic state of an entire economic and
social system. Here, the condition of being drained seems to be what
connects individuals, social classes, growth-oriented capitalism, and the
ecosystem into a crisis-ridden constellation. What appears at the indivi-
dual level as exhaustion, and at the social level as excessive demands on
certain social classes, manifests itself at the economic level as indebtedness
and in the ecological domain as wasteful expenditure of finite resources.
Medically speaking, the symptoms of exhaustion feature in various
syndromes. They are core features of depression, chronic fatigue syn-
drome (CFS), and the burnout syndrome. These conditions are being
diagnosed with increasing frequency. Above all, depression is on the rise
throughout the world; the WHO estimates that in the year 2020, it
could be the second most common illness in Western industrialised
countries.
The increase in diagnoses of exhaustion is interpreted in very different
ways. Is it primarily changing social demands on subjects that are giving
rise to new suffering? Is it mechanised and urbanised, accelerated or
marketised modernity that impacts well-being and accounts for the
increase in exhaustion-related mental illness? Or is it the diagnoses
that become fashionable at certain times themselves that point to social
changes? If that were the case, the concepts and medical classifications
would tell us more about social change than about changes in the kinds
of suffering afflicting modern subjects.
Among critical social scientists advocates of both these hypotheses can
be found. Medicalisation theorists regard the increase in conditions such
as depression as labelling processes in which non-medical facts are
reinterpreted in medical terms, so that more and more areas of human
life are being assimilated by the medical system. In the course of this
development, it is claimed that social problems become pathologised
and medical markets are created or expanded.4 The other interpretation
4
See, for example, Peter Conrad, The Medicalization of Society: On the Transformation of Human
Conditions into Treatable Disorders (Baltimore: The Johns Hopkins University Press, 2007).
4 S. Neckel et al.
of the increase in diagnoses of mental illnesses offered by social sciences

assumes that social change and certain social dynamics can give rise to
psychological suffering, and hence that the increase in the diagnoses of
illnesses is not only an indication of expanding medical markets but also
of problematic social trends.5 Finally, the increasing attention being paid
to human exhaustion can be interpreted as partaking in discursive
processes of self-reflection and can be historicised to form critiques of
modernity, and even to form critiques of pre-modern developments that
were perceived as problematic.6
Exhaustion as a Sign of the Times?

There is no disputing fact that people have always felt exhausted after
exerting themselves. Moreover, hardly anyone would deny that there
have been epochs in history in which comparably extreme demands were
made on the subjective capacities of certain social classes. Nevertheless,
we must ask why so many people regard exhaustion as emblematic of the
present. A distinctive feature of analyses of the present is that they try to
offer an inclusive interpretation of present-day society. Following Max
Weber’s remarks on ideal types, one could say that they aim through a
‘one-sided accentuation of one or more points of view’ to get at the heart
of what is a characteristic of society as a whole.7 Their goal is to
intervene in public discussions and to reverse problematic developments.
Like medical diagnoses, analyses of the present also generally imply
specific therapeutic suggestions. In this connection, they are often not
only accused of unacceptably reducing complexity by combining overly
5
See Axel Honneth, ‘Organized Self-Realization: Some Paradoxes of Indivdualization’, European
Journal of Social Theory 7: 4 (2004), 463–78; Harmut Rosa, ‘Wettbewerb als Interaktionsmodus:
Kulturelle und sozialstrukturelle Konsequenzen der Konkurrenzgesellschaft’, Leviathan 34:
1 (2006), 82–104; and Leistung und Erschöpfung: Burnout in der Wettbewerbsgesellschaft, ed.
Sighard Neckel and Greta Wagner (Berlin: Suhrkamp, 2013).
6
Anna Katharina Schaffner, Exhaustion: A History (New York: Columbia University Press, 2016).
7
Max Weber, ‘“Objectivity” in Social Science and Social Policy’, in The Methodology of the Social
Sciences, trans. Edward A. Schils and Henry A. Finch (Glencoe, IL: Free Press 1949), pp. 49–112
(p. 90).
1 Introduction 5
contradictory symptoms into a diagnosis of a disease. They are also often

suspected of being formulated in the terms of the tradition of
Nietzschean cultural criticism, the origins of which lie in late nine-
teenth-century critiques of modernity and in disappointed expectations
regarding the Enlightenment project. Allied with this suspicion is the
criticism that analyses of the present involve culturally pessimistic or
nostalgic descriptions whose implicit normative points of reference are
pre-modern, non-technologised societies.
Even the editors of this volume do not agree over whether contem-
porary society truly faces an unprecedented epidemic of exhaustion, or
whether exhaustion and anxieties about its effects are ubiquitous, trans-
historical phenomena. Rather, the contributions assembled here reflect a
plural range of interpretations of exhaustion. While some contributions
interpret the rise of exhaustion syndromes in sociological terms as an
effect of a society marked by unrestrained competition, other contribu-
tors adopt a perspective based on the history of culture, medicine, and
ideas. In some cases, therefore, exhaustion is the subject of an analysis of
the present, while in others the analyses of present manifestations of
exhaustion are compared to historical phenomena.
A concern in many ages, the cultural preoccupation with exhaustion
usually intensifies in periods in which rapid socio-cultural and techno-
logical change occurs. We understand exhaustion as an individual phy-
sical and mental state, but also as a broader socio-cultural phenomenon.
Physically, exhaustion manifests itself as fatigue, lethargy, and weakness.
It can be a temporary state (e.g. as a result of exertion) or a chronic
condition. The contributions in this essay collection focus predomi-
nantly on pathological forms of exhaustion, and those that are not
obviously the result of an underlying and clearly diagnosable medical
condition. On a mental level, we can describe the symptoms of exhaus-
tion as weariness, disillusionment, apathy, hopelessness, and lack of
motivation. Exhaustion can also be the cause of behaviours such as
restlessness and the avoidance of activity, effort, and challenges.
The symptoms of exhaustion have featured in various diagnoses, some
of which are now obsolete, and which include melancholia, acedia,
hypochondria, nervous weakness, neurasthenia, depression, CFS, and
burnout. Over the past centuries, the symptoms of exhaustion have
6 S. Neckel et al.
variously been explained as a product of biochemical imbalance, as a

psychological or a somatic ailment, as a viral disease or an immune
dysfunction, as a desire to return to a death-like state of repose, or as a
broader cultural response to a faster pace of life and transformations in
economic and social structures. These theories show how the relation
between mind and body, the individual, society, and the cultural and
natural environment have been imagined at different historical moments.
Some theories privilege holistic models, in which body, mind, and the
social environment are accorded equal importance; some focus exclu-
sively on biology, some on the psyche, and some on social structures.
The current era, therefore, is not the first to understand itself as being
marked by excessive exhaustion. An interesting horizon of comparison is
offered by the 1880s, when people also thought they were living in an age
of exhaustion. Neurasthenia was rampant in Europe and North America
and was regarded as the trendsetting illness par excellence, the signature
disease of the time. Its causes were thought to reside in the radical social
change taking place at the time, whose salient features were urbanisation,
industrialisation, and technological progress. Modern living conditions,
advances in communication and transportation, and the associated accel-
eration seemed to be subjecting the human nervous system to excessive
strain. Emil Kraepelin, a German psychiatrist who laid the groundwork
for the classification of mental diseases, called neurasthenia the ‘disease of
our time’ and distinguished it from other psychopathologies as an
acquired syndrome: ‘the growth of large cities and the competitive con-
ditions prevailing in them lead for a large portion of the people to an
increase in the demands they have to meet and at the same time to greater
fragmentation of activity, restlessness, and irregularity in the conduct of
life’.8 The German neurologist Wilhelm Erb wrote about neurasthenia:
‘Everything proceeds in haste and in a flurry; the night is used for travel,
the day for conducting business; even vacation trips become strains on the
nervous system.’9 The living conditions of bourgeois elites had been
8
Emil Kraepelin, Psychiatrie. Ein Lehrbuch für Studierende und Ärzte. Band 1 (Leipzig: Barth
Verlag, 1900), p. 196.
9
Wilhelm Erb, Über die wachsende Nervosität unserer Zeit (Heidelberg: Hörning, 1894), p. 20.
1 Introduction 7
transformed in a short time by technical innovations and were thought to

be leading to symptoms such as headaches, irritability, hopelessness,
insomnia, craving for drugs, and exhaustion.10 Alain Ehrenberg describes
neurasthenia as the first ‘fashionable complaint’. What was specifically
new at the end of the nineteenth century was the idea of ‘exogenous
suffering’, that is the idea that external conditions were having internal,
psychological effects.
Today, just as at the end of the nineteenth century, the perception of
the present as an age of exhaustion comes in the wake of a phase of rapid
social change. Just as the major changes in the conduct of life triggered
by secularisation and industrialisation may have led to the exhaustion
crisis of neurasthenia, so, too, the digital revolution and the acceleration
of financial market-driven growth capitalism may have contributed to
bringing about the exhausted self of the present.
Exhaustion Discourses
Even though diagnoses of exhaustion are on the increase in most countries
throughout the world, there are nevertheless striking variations in national
discourses about exhaustion. Even today in China, for example, neurasthe-
nia is still frequently diagnosed because it is considered to have a physical
cause and those affected are therefore less stigmatised than, for example,
those diagnosed with depression; hence, neurasthenia represents a kind of
somatic cover diagnosis for the psychological symptoms of exhaustion.
Given that exhaustion can be manifest as both a predominantly
mental experience and a bodily feeling, the relationship between body
and mind often becomes the subject of discursive negotiation in the
case of the symptoms of exhaustion. The tension between somatic and
psychological explanations is a focus of continuing debates. The inter-
pretive conflicts over the relationship between body and mind when
exhaustion is diagnosed are especially apparent in the case of CFS.
10
See Patrick Kury, ‘Von der Neurasthenie zum Burnout – eine kurze Geschichte von Belastung
und Anpassung’, in Leistung und Erschöpfung, ed. Sighard Neckel and Greta Wagner (Berlin:
Suhrkamp Verlag, 2013), pp. 107–28 (p. 109).
8 S. Neckel et al.
First named and defined in the 1980s, CFS, which is also known as
myalgic encephalomyelitis (ME) and post-viral fatigue syndrome, holds
a special place among the exhaustion syndromes discussed in this essay
collection.11 Post-exertion malaise, severe mental and physical fatigue, a
sense of effort that renders many everyday activities impossible, and
difficulties with concentrating, cognitive tasks, and short-term memory
are among its cardinal symptoms.12 The search for empirical diagnostic
markers and the biomedical origins of the illness is still ongoing, and
future findings may well demonstrate that the illness is predominantly
caused by physical rather than social or psychological forces. Yet, at
present, ME/CFS remains a controversial diagnosis subjected to widely
divergent interpretations, and has in recent decades prompted fierce
debate among medical practitioners and patients.13
At the centre of the ME/CFS controversy is the question of whether
or not psychiatric and psycho-social factors contribute to, or even cause,
the development of the condition. Some researchers and the majority of
patients suffering from ME/CFS argue strongly for the purely somatic
origins of the condition. Most commonly, viral infections, immune
dysfunctions, and central nervous system or metabolic disorders are
thought to trigger the illness.14 Other researchers believe that ME/CFS
has a microbiological trigger (such as Epstein-Barr virus), but that social,
11
Gary Holmes at the Centres for Disease Control and Prevention (CDC) coined the term CFS
in 1988.
12
See the CDC’s web information on CFS, online at: http://www.cdc.gov/cfs/causes/risk-groups.
html (accessed January 2015).
13
For an analysis of the debates concerning the symptoms, epidemiology, and therapeutics of the
condition, see Simon Wessely, Matthew Hotopf, and Michael Sharpe, Chronic Fatigue and Its
Symptoms, rev. ed. (Oxford: Oxford University Press, 1999); and Michael Sharpe, ‘Chronic
Fatigue Syndrome’, The Psychiatric Clinics of North America, 19: 3 (1996), 549–73.
14
See, for example, M. M. Zeineh, J. Kang, S. W. Atlas, M. M. Raman, A. L. Reiss, J. L. Norris,
I. Valencia, and J. G. Montoya, ‘Right Arcuate Fasciculus Abnormality in Chronic Fatigue
Syndrome’, Radiology 274: 2 (2015), 517–26; A. L. Landay, C. Jessop, E. T. Lennettee, and
J. A. Levy, ‘Chronic Fatigue Syndrome: Clinical Conditions Associated with Immune Activation’,
Lancet 338 (1991), 707–12; A. M. Lerner, C. Lawrie, and H. S. Dworkin, ‘Repetitively Negative
Changing T Waves at 24-H Electrocardiographic Monitors in Patients with Chronic Fatigue
Syndrome’, Chest 104 (1993), 1417–21; and R. Freeman and A. L. Komaroff, ‘Does the Chronic
Fatigue Syndrome Involve the Autonomic Nervous System?’, American Journal of Medicine
102 (1997), 357–64.
1 Introduction 9
behavioural, and psychological factors may subsequently contribute to

perpetuating the illness and also to a patient’s inability fully to recover
from the viral infection.15 Yet other researchers completely dismiss the
validity of biological explanations, and argue that ME/CFS is primarily a
psychosomatic or a behavioural problem, closely related to depression
and anxiety, and should therefore be classified as a psychiatric disorder.16
And a final group of scholars emphasises the social origins of the ill-
ness.17 Generally, ME/CFS is either considered a syndrome with poten-
tially many causes or else with a single cause that has not yet been
conclusively established.
The politics of the disease remain complex. Judith A. Richman and
Leonard A. Jason, for example, point out gender biases in the construc-
tion of and discourse surrounding this illness, which affects more women
than men. They argue that ‘the failure of Western medicine to demon-
strate a viral etiology for CFS led to a paradigmatic shift in research
perspectives that subsequently enforced psychiatric and socio-cultural
explanations for CFS. As a result, CFS was de-legitimised as a biomedi-
cal phenomenon within medical, academic, governmental, and public
arenas’.18 Following sustained criticism of the psycho-social and beha-
vioural ME/CFS illness models, the search for the biological causes of
ME/CFS has recently been intensified.19 Many sufferers feel frustrated
about the lack of progress in identifying the underlying organic factors of
15
Stephen T. Holgate, Anthony L. Komaroff, Dennis Mangan, and Simon Wessely, ‘Chronic
Fatigue Syndrome: Understanding a Complex Illness,’ Nature 12 (2011), 539–44.
16
See, for example, Edward Shorter, From Paralysis to Fatigue: A History of Psychosomatic Illness in
the Modern Era (New York: The Free Press, 1992); Elaine Showalter, Hystories: Hysterical
Epidemics and Modern Media (New York: Columbia University Press, 1998); and Richard L.
Kradin, Pathologies of the Mind/Body Interface: Exploring the Curious Domain of the Psychosomatic
Disorders (New York: Routledge, 2013).
17
See, for example, S. E. Abbey and P. E. Garfinkel, ‘Neurasthenia and Chronic Fatigue
Syndrome: The Role of Culture in the Making of a Diagnosis’, American Journal of
Psychotherapy 148 (1991), 1638–46; and N.C. Ware and A. Kleinman, ‘Culture and Somatic
Experience: The Social Cause of Illness in Neurasthenia and Chronic Fatigue Syndrome’,
Psychosomatic Medicine 54 (1992), 546–60.
18
J. A. Richman and L. A. Jason, ‘Gender Biases Underlying the Social Construction of Illness
States: The Case of Chronic Fatigue Syndrome’, Current Sociology 49 (2001), 15–29.
19
For a summary of recent criticism of the PACE trial, see, for example, David Tuller,
‘Re-Examining Chronic Fatigue Syndrome: Research and Treatment Policy’, online at:
10 S. Neckel et al.
their condition, and blame the government and the medical establish-
ment for failing to direct more funds to ME/CFS research. Scientists and
scholars who propose that psychogenic factors may play a role in the
illness are often targeted by radical activists, who sometimes even resort
to threats to dissuade them from their research. The sufferers accuse
these researchers of creating the impression that CFS is merely a figment
of the imagination of those who have been diagnosed with it.20 These
activists see the claim that psychological factors may play a role in CFS as
a failure to recognise and show respect for their suffering. They regard
‘psychological’ causes as synonymous with ‘self-incurred’ or ‘not real’.
Yet suffering as a result of exhaustion is not only situated at the
interface between body and mind – it also connects individual suffering
with the social sphere. This is particularly clear in the case of the burnout
syndrome. Burnout is an affliction that has acquired astounding popu-
larity in therapeutic and public discourses in some Western countries
over the past decade. In Germany, for example, so many people began to
suffer from burnout by the end of the last century that it triggered a
veritable flood of stories on the topic in the media. There was scarcely a
single magazine that did not have burnout as a lead story, or a TV
programme that did not report on it. Clearly, in Germany, a mood of
discontent with the pressure to perform in contemporary working life,
http://healthaffairs.org/blog/2016/02/04/reexamining-chronic-fatigue-syndrome-research-and-
treatment-policy/ (accessed September 2016).
In October 2015, Francis Collins, the director of the National Institutes of Health (NIH),
announced a major new funding initiative. See https://www.nih.gov/news-events/news-releases/
nih-takes-action-bolster-research-myalgic-encephalomyelitis/chronic-fatigue-syndrome (accessed
September 2016).
In February 2015, the Institute of Medicine published a comprehensive report on ME/CFS, in
which a refinement of the diagnostic criteria of the condition as well as a new name is proposed.
Systemic exertion intolerance disease, the committee argues, emphasises more clearly the central
characteristic of the disease, namely, ‘the fact that exertion of any sort – physical, cognitive, or
emotional – can adversely affect patients in many organ systems and in many aspects of their lives’.
The report entitled ‘Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining
an Illness’, released in February 2015, is available online at: http://www.nationalacademies.org/
hmd/Reports/2015/ME-CFS.aspx (accessed 16 September 2016).
20
Robin McKie, ‘Chronic Fatigue Syndrome Researchers Face Death Threats from Militants’,
The Observer (August 2011), online at: http://www.theguardian.com/society/2011/aug/21/
chronic-fatigue-syndrome-myalgic-encephalomyelitis (accessed March 2016).
1 Introduction 11
with the increasing pace of work and communication, with excessive

everyday demands and newly perceived forms of alienation, is being
articulated with the help of the burnout syndrome. This has concrete
consequences: in Germany, the average number of sick days due to
burnout has risen 18-fold since 2004, to 43.21 Diagnoses of burnout
are also on the rise in the Scandinavian countries and in the Netherlands.
What is most striking here is the symbolism associated with the
concept of burnout. An important factor in its popularity seems to be
that the diagnosis of burnout can be worn like a ‘badge of honor of the
performance-oriented society’.22 Someone who has burned out must
previously have been inflamed by something, which exempts the condi-
tion from the stigma of individual failure. Thus, the term burnout
contains a reference to prior commitment. Moreover, it is associated
with visual imagery which implies a mechanistic, and hence an anti-
psychological, picture of the human being. Even though people who are
afflicted with burnout experience overwhelming fatigue, they are still
exhausted even after waking up from a long sleep. In their case, the
switch between exertion and regeneration has been thrown into crisis. In
the popular visual imagery of burnout discourse, this depletion is sym-
bolised by the condition of being burned out, which finds its allegorical
expression in the burned-out match. No one expects a spent match to
catch fire again.
However, among the metaphors associated with burnout is also an
image that implies the possibility of starting a new cycle – namely, the
drained battery, an image that is strikingly often used in public discourse
to describe the cause of collapse due to exhaustion. The empty battery
signals the state of exhaustion and its flashing warning light in the
symbolic language of technology; it is the final warning before the device
switches off. In the image of the human being articulated here, the
personal reserves of energy have been depleted by persistent exertion
21
See BKK Gesundheitsreport, Gesundheit fördern – Krankheit versorgen – mit Krankheit leben,
2012 (www.bkk.de/fileadmin/user_upload/PDF/Arbeitgeber/gesundheitsreport/
Gesundheitsreport_2012/Gesundheitsreport_2012.pdf) (accessed January 2013), p. 43.
22
Wolfgang Schmidbauer, ‘Mehr Hofnarr als Hofrat. Über die Krisen der Psychotherapie’, in
Kursbuch 170 ‘Krisen lieben’ (Hamburg: Murmann, 2012), pp. 150–73 (p. 159).
12 S. Neckel et al.
and excessive commitment, and the battery must be recharged through

therapy or coaching. Here, ideally, techniques should be learned which
preclude a recurrence of exhaustion and optimise the cycle of exertion
and regeneration so that a sustainable energy balance results. The image
of the drained battery seems to owe its intuitive public appeal to the fact
that burnout is described as a condition in which the human energy
balance has become skewed.
Exhaustion and Self-Fulfilment

A less mechanistic, but in recent years widely discussed, socio-psycho-
logical interpretation of the increase in suffering due to exhaustion
concerns the task of self-fulfilment – so often perceived by modern
individuals as a personal obligation. Alain Ehrenberg has interpreted
the exhaustion experienced by modern subjects as exhaustion of being
oneself, as a pathological condition of inadequacy. Present-day society is
characterised to a lesser extent than earlier societies by rigid norms and
prohibitions and, unlike the disciplinary society, no longer rewards
conformity. In today’s society, the operative ideals of action are auton-
omy and individual responsibility. Therefore, the dominant form of
psychological suffering is no longer neurosis based on feelings of guilt,
but instead depression, an illness of accountability. ‘Depression’, writes
Ehrenberg ‘whose main feature is a loss of self-esteem, is a pathology of
magnitude: the depressed person is not up to the task of becoming a self;
instead it wears her down. Old-fashioned bourgeois guilt and the strug-
gle to free oneself from the law of the father have now been replaced by
the fear that one might not live up to one’s own high ideals, which gives
rise to a feeling of inability and inadequacy.’23
In his description of the etiology of burnout the founder of burnout
research, the New York-based psychoanalyst Herbert J. Freudenberger,
23
Alain Ehrenberg, ‘Depression: Unbehagen in der Kultur oder neue Formen der Sozialität’, in
Kreation und Depression: Freiheit im gegenwärtigen Kapitalismus, ed. Christoph Menke and Juliane
Rebentisch (Berlin: Kadmos, 2010b) pp. 52–62 (p. 54).
1 Introduction 13
also accorded a central role, in addition to sheer overload, to the feeling

that one is disappointing high expectations. To burn out means ‘to
deplete oneself; to exhaust one’s physical and mental resources; to
wear oneself out by excessively striving to reach some unrealistic expec-
tation imposed by oneself or by the values of society’.24 Whereas the
point of reference for Freudenberger’s burnout research in the 1970s
was the social professions in which individuals were excessively
dedicated to helping clients, pupils, or patients, in the current
world of work performance expectations have in many cases become
immoderate and unrealistic far beyond the social professions.
Employees in all sectors are required to identify completely with
their company, as though its success served a higher purpose which
can be achieved only through the full commitment of its employees.
Modern working life in many sectors is no longer marked by
small-scale controls, but instead by a high degree of flexibility and
personal responsibility.
A glance at the origins of burnout research thus reveals interesting
connections between the genealogy of burnout and that of the modern
professional world of the present. The sharp increase in the number
of diagnoses of burnout raises the question of whether the idealistic
helpers of the 1980s have anything in common with the members
of the present-day workforce. It seems as though today, employees
across all sectors identify with corporate objectives in exactly the
same way as dedicated social workers did with their clients back in
the 1980s.
Burnout can thus be regarded as a kind of reactive depression that
follows the disappointment of not being rewarded for complete personal
dedication. Yet what makes the present-day world of work so disap-
pointing? Has the introduction of new forms of organisation in many
companies failed to live up to employees’ expectations regarding oppor-
tunities for self-fulfilment? Flexible working hours, the abolishment of
hierarchies, self-organisation, and opportunities for bringing one’s own
24
Herbert J. Freudenberger and Geraldine Richelson, Burnout: The High Cost of High Achievement
(New York: Anchor, 1983), p. 16.
14 S. Neckel et al.
interests into play have become part of the everyday reality of more and
more companies. However, this transformation did not only encourage
the quest for self-fulfilment but it also increased the scope for corporate
action. As Luc Boltanski and Ève Chiapello have shown, ‘new capital-
ism’ has endogenised the criticism that was aimed at it already in the
1970s.25 Thus, the objections against hierarchy, bureaucracy, and alie-
nation, whose spokespeople used to be left-wing activists and the new
social movements, presided over the introduction of flexible working
conditions in companies.
Today employees are required to be entrepreneurs selling their
own labour power, and to optimise it continually. Like the idealis-
tic social worker of the 1970s and 1980s, the present-day entre-
preneurial self is compelled to contribute its subjectivity and is
concerned to efface once again the boundaries between work and
private life. The aim of the self-realisation that was supposed to
have been fulfilled in the past by breaking up encrusted structures
has now been transformed into a requirement, into ‘institutiona-
lized expectations inherent in social reproduction’ whose intrinsic
purpose has been lost.26 It is now a long-established practice to
understand one’s work as an expression of intrinsic interests and
to show that one does not work because one has to, but because
one wants to. In this way, the concept of alienation acquires a new
meaning: to perform alienated work, to be alienated from one’s
work, is no longer a social condition that is vulnerable to the
critique of capitalism, because the expectation to become one
with one’s own work is one of the impositions of the present.
Today individual resistance seems to reside precisely in the act of
not identifying too strongly with one’s work. In therapy, burnout
patients learn to restore precisely that strangeness that should
loosen the identification with work and to look for other sources
of recognition outside of work.
25
Luc Boltanski and Ève Chiapello. The New Spirit of Capitalism, trans. Gregory Elliott (New
York: Verso, 2005).
26
See Honneth, ‘Organized Self-Realisation’, p. 467.
1 Introduction 15
Interdisciplinary Perspectives
This interdisciplinary essay collection explores the complex connections
between psychological, sociological, and biologic theories of exhaustion.
Examining the status of exhaustion symptoms in medical, psychological,
sociological, historical, and literary accounts, it analyses the interplay
between the processes involved in the production of mental health diag-
noses, socio-cultural transformations, and subjective illness experiences.
The volume is divided into five themed sections. It opens with a
section on historical models of exhaustion. Adopting a cultural-historical
perspective, Anna Katharina Schaffner argues that exhaustion is not at all
a modern preoccupation, nor the specific bane of our age of techno-
capitalism, as many critics argue, but that anxieties about exhaustion and
its psychological, physical, and social effects have always been with us.
She shows that theories of exhaustion and its corrosive effects can be
found in many historical periods, including Greek antiquity and the
Middle Ages. The symptoms of mental and physical exhaustion were
considered to be among the core symptoms of melancholia, theorised in
the broader framework of humoural theory by the physician Galen. An
alternative model of exhaustion emerged in Late Antiquity and blos-
somed in the Middle Ages: the notion of sloth, or acedia. Just like
melancholia, acedia included various symptoms of mental and physical
exhaustion among its core indicators, such as weariness, torpor, apathy,
lethargy, sleepiness, irritability, cognitive impairment, and hopelessness.
Yet, unlike melancholia, which was treated and defined by physicians,
sloth fell under the remit of theologians such as St Thomas Aquinas. It
was understood not as an organic disease, but rather as a spiritual and
moral failing.
The Swiss historian Patrick Kury analyses the emergence of nine-
teenth-century neurasthenia and ‘managerial disease’, a pre-cursor of
burnout associated with stressful jobs, as well as cardiovascular and
psychosomatic lifestyle diseases, and which was frequently diagnosed
in the 1950s and 1960s in Germany. Investigating the cultural-historical
factors that led to the rapid spread of these ‘diseases of civilisation’, Kury
pays close attention to the knowledge transfers between the United
States and Germany that characterise these fatigue and stress discourses.
16 S. Neckel et al.
Manager disease was driven by the anxiety that there was a worryingly
high mortality rate among Germany’s overtaxed (and mainly male)
elites, who were physically and mentally exhausted by the enormous
task of rebuilding the country’s economy after the Second World War,
and often paid the price for driving forward the German ‘economic
miracle’ with their own lives. It was only in the 1970s that the concept of
psycho-social stress took hold in German public and medical debates.
Kury argues that the neurasthenia and managerial disease diagnoses, just
like stress and burnout, ‘are often regarded positively, and appear in
phases of rapid social and economic change’.
The second section of this collection is dedicated to the role of
exhaustion symptoms in specific contemporary syndromes, in particular
burnout, CFS, and depression. Contributions in this section are written
by clinical experts, including psychiatrists and psychologists. Johanna
Doerr und Urs Nater investigate the different ways in which medically
unexplained fatigue-like symptoms have been treated, focussing on
difficulties in differentiating between different conditions. They begin
by relating the development and variations of the neurasthenia diagno-
sis, investigating the overlap of this diagnosis with depression diagnoses.
Following this, a comparison is made with East Asian diagnostic prac-
tices regarding medically unexplained fatigue, and the changes that have
occurred in this context. The focus of the essay then switches to the
second half of the twentieth century, to the developments of diagnoses
of CFS and of ME. Diagnostic criteria for the various conditions are
examined and found seriously to overlap, with arguments made as to
why one diagnosis may be given rather than another. At this point the
previously discussed conditions, and depression, are all considered in the
light of criteria commonly given for burnout. The conclusion is reached
that differential diagnoses for similarly presenting fatigue conditions is at
best an inexact science, and may lack medically stable grounds.
The Dutch work and organisational psychologist Wilmar Schaufeli
explores the historical roots of burnout as well as the specific socio-
cultural factors that led to its emergence. Addressing the question of
whether the major symptoms of burnout are ubiquitous or context-
specific, he analyses how they relate to similar syndromes, such as
neurasthenia and depression. Have burnout-like phenomena been
1 Introduction 17
observed in the past as well, and is it a typically Western phenomenon?

Schaufeli’s chapter concludes with a discussion of differences in the ways
the diagnosis is used and understood in North America and Europe.
The following essay explores this idea further. Torsten and Linda
Heinemann investigate German and American academic and popular
media sources in order to analyse different conceptions of burnout in
these cultures. Tracing a development that begins with Freudenberger’s
introduction of the term and that ends with the present day, they show
that a surge in media interest, especially in the last decade, is noticeable
in Germany. In the United States, by contrast, the term remains con-
fined to specific professions, and is not generally considered a culturally
all-embracing condition. Torsten and Linda Heinemann also explore the
specific nature of public discussions of burnout, and draw attention to
the comparatively individualistic conception of the disease in the United
States, which contrasts with what the German media present as pre-
dominantly a social crisis.
Section three of this essay collection explores the link between exhaus-
tion and self-realisation, primarily with recourse to sociological and
cultural-theoretical models and theories. The French sociologist Alain
Ehrenberg, author of The Weariness of the Self: Diagnosing the History of
Depression in the Contemporary Age (1998), reflects on the anthropology
of adversity in individualist societies in his contribution. He argues that
in societies in which autonomy is the supreme value, mental health
‘functions as a discursive space in which many of the core tensions and
conflicts of neo-liberal subjectivity are negotiated’. Mental health, he
writes, ‘is the name individualistic society has given to our style of
dealing with passions, the social and moral equivalent of magical rites
for the modern autonomous individual’. Conditions such as depression
and burnout may thus be seen as a reaction against adversity and
contingency, and constitute forms of psycho-social suffering that are
caused by the idea of inadequacy. Ehrenberg concludes that ‘we have
seen a change in the social status of psychic suffering, and an extension
of its uses, particularly in the political sphere’.
The Swedish sociologists Elin Thunmann and Marcus Persson con-
tribute a narrative analysis, interpreting interviews with exhausted
Swedish workers. These public service workers were found to share
18 S. Neckel et al.
common characteristics, initially all working in environments presenting

an inexhaustible number of tasks. Workplace change served only to
exacerbate these, and the subjects were found to respond with both
pride at their sterling efforts, and shame at their inabilities to achieve
the impossible. Various self-justification tactics by the interviewees are
examined, which leads to a discussion of internal as opposed to external
factors among the exhausted. The demands of the work sphere are found
to lead to societal expectations to present an ‘authentic’ self, which can
partly be held responsible for the pathologies outlined in the interviews.
Frankfurt sociologist Greta Wagner explores the self-medication with
amphetamines by students in Germany and the United States. In both
countries, there has been an alarmist media debate in recent years about
the increasing use of stimulants as ‘study drugs’. Based on interviews with
users of attention-deficit hyperactivity disorder prescription drugs, she
shows that it is not primarily the cognition-enhancing effect that makes
students take them, but rather the increase in wakefulness, alertness, and
motivation. A closer look at the history of amphetamines reveals that
since their discovery in 1887, they have been prescribed to ‘treat’ exhaus-
tion syndromes and ‘misused’ to fight feelings of exhaustion.
Section four, dedicated to discourse and metaphor analysis, as well as
to literary representations of exhaustion, features contributions from
sociologists and literary scholars. Ulrich Bröckling from the University
of Freiburg studies burnout with a view to treating it ‘as a symptom in its
own right’; as a discourse which holds a mirror to its society, rather than
as a thing in itself. Bröckling specifically analyses the verbal imagery
associated with burnout, seizing on basic images of catching light, of
being on fire, before moving on to depleted batteries, robotic imagery,
and the salmon and the hamster, which are used to describe different
aspects of the social role of the burnout diagnosis. These various objec-
tifications and animisms create a confused picture of modernity; faced
with competing explanations from biology and culture, self-help and
social entrapment, the burnout diagnosis is itself seen as only the
beginning of a complex of recommendations and demands.
The English literary scholar Michael Greaney explores a range of late
nineteenth-century and early twentieth-century literary texts that directly
engage with exhaustion. Aesthetic representations of states of exhaustion,
1 Introduction 19
he writes, have the power to ‘provide us with vicarious access to the first-
person experience of what it feels like to be exhausted, an experience that
cannot be measured or quantified, but that can be conjured up in words
and transmitted and shared in literary texts’. Moreover, attention to
literary images of exhaustion ‘can enable us to shift our focus from
exhaustion as an impersonal object of scientific scrutiny to exhaustion
as a subjective experience, the affective content of which has an internal
history that is inaccessible to blood tests and brain scans’. However,
Greaney also argues that the texts he discusses are not only written
about exhaustion but also performatively enact exhaustion at the level of
style and language. ‘In the formal strategies of many modernist texts’, he
writes, ‘we can observe an ambivalent sense of exhaustion as both a
physical ordeal and an aesthetic opportunity for the writer’. There is,
then, a positive and productive side to exhaustion, which in various texts
functions as aesthetic resource and impetus for stylistic renewal.
The final section is dedicated to the link between social suffering,
growth, and exhaustion. The sociologist Iain Wilkinson’s contribution
explores the precise role of ‘the social’ in the construction of fatigue
syndromes, and the ways in which embodied experiences of social life
may become manifest both in physical symptoms and in theoretical
discourses. He argues that although there is now a renewed recognition
of the social determination of our bodily and emotional health, there is
still a lack of consensus on how we should practically manage and
respond to illnesses shaped by social experience. Moreover, the social
component of human health has become ‘ever more politically conten-
tious’, as is particularly evident in the cases of neurasthenia and CFS.
‘The agony of “the social”’, Wilkinson writes, ‘is not only encountered
in the morbid effervescence that emanates from the poor quality of
peoples’ moral-social lives, it also encompasses the social as a vexed
matter for debate in connection with the conditions that are most
conducive to the promotion of human health’.
Sighard Neckel and Greta Wagner characterise burnout as a form of
social suffering generated by the current regime of economic growth. In
our competitive society individuals are compelled permanently to moni-
tor and optimise their own performance. At the same time, they exert
themselves more and more in an attempt to achieve professional and
20 S. Neckel et al.
personal fulfilment, a process which often results into self-exploitation.

Yet, in recent years, the critique of the abuse of subjectivity in contem-
porary capitalism has become so strong that the discourse of exhaustion
might trigger the emergence of a new order of justification which
promises to use subjective resources more sparingly. Following Weber
and his claim that capitalism has always used external orders of justifica-
tion, Neckel and Wagner argue that we may be witnessing the emer-
gence of a Buddhist spirit of capitalism. Buddhist practices such as
mindfulness, that are increasingly being implemented in large corpora-
tions, are highly individualised strategies for preventing exhaustion.
Parts of this introduction were translated by Ciaran Cronin
References
S. E. Abbey and P. E. Garfinkel, ‘Neurasthenia and Chronic Fatigue
Syndrome: The Role of Culture in the Making of a Diagnosis’, American
Journal of Psychotherapy 148 (1991), 1638–46.
BKK Gesundheitsreport, Gesundheit fördern – Krankheit versorgen – mit
Krankheit leben, 2012, online at: www.bkk.de/fileadmin/user_upload/
PDF/Arbeitgeber/gesundheitsreport/Gesundheitsreport_2012/
Gesundheitsreport_2012.pdf) (accessed January 2013).
Luc Boltanski and Ève Chiapello, The New Spirit of Capitalism, trans. Gregory
Elliott (New York: Verso, 2005).
Centres for Disease Control and Prevention (CDC) web information on CFS,
online at: http://www.cdc.gov/cfs/causes/risk-groups.html (accessed January
2015).
Peter Conrad, The Medicalization of Society: On the Transformation of Human
Conditions into Treatable Disorders (Baltimore: The John Hopkins
University Press, 2007).
Alain Ehrenberg, The Weariness of the Self: Diagnosing the History of Depression in
the Contemporary Age, trans. David Homel et al. (Montreal: McGill-Queens’s
University Press, 2010a).
———, ‘Depression: Unbehagen in der Kultur oder neue Formen der Sozialität’,
in Kreation und Depression: Freiheit im gegenwärtigen Kapitalismus, ed.
Christoph Menke and Juliane Rebentisch (Berlin: Kadmos, 2010b),
pp. 52–62.
1 Introduction 21
Wilhelm Erb, Über die wachsende Nervosität unserer Zeit (Heidelberg:

Hörning, 1894).
R. Freeman and A. L. Komaroff, ‘Does the Chronic Fatigue Syndrome Involve
the Autonomic Nervous System?’, American Journal of Medicine 102 (1997),
357–64.
Herbert J. Freudenberger and Geraldine Richelson, Burnout: The High Cost of
High Achievement (New York: Anchor, 1983).
Stephen T. Holgate, Anthony L. Komaroff, Dennis Mangan, and Simon
Wessely, ‘Chronic Fatigue Syndrome: Understanding a Complex Illness’,
Nature 12 (2011), 539–44.
Axel Honneth, ‘Organized Self-Realization: Some Paradoxes of Indivdualization’,
European Journal of Social Theory 7: 4 (2004), 463–78.
Institute of Medicine, ‘Beyond Myalgic Encephalomyelitis/Chronic Fatigue
Syndrome: Redefining an Illness’, report released in February 2015, online
at: http://www.nationalacademies.org/hmd/Reports/2015/ME-CFS.aspx
(accessed September 2016).
Emil Kraepelin, Psychiatrie. Ein Lehrbuch für Studierende und Ärzte, vol. 1
(Leipzig: Barth Verlag, 1900).
Richard L. Kradin, Pathologies of the Mind/Body Interface: Exploring the Curious
Domain of the Psychosomatic Disorders (New York: Routledge, 2013).
Patrick Kury, ‘Von der Neurasthenie zum Burnout – eine kurze Geschichte von
Belastung und Anpassung’, in Leistung und Erschöpfung: Burnout in der
Wettbewerbsgesellschaft, ed. Sighard Neckel and Greta Wagner (Berlin:
Suhrkamp Verlag, 2013), pp. 107–28.
A. L. Landay, C. Jessop, E. T. Lennettee, and J. A. Levy, ‘Chronic Fatigue
Syndrome: Clinical Conditions Associated with Immune Activation’, Lancet
338 (1991), 707–12.
A. M. Lerner, C. Lawrie, and H. S. Dworkin, ‘Repetitively Negative Changing
T Waves at 24-H Electrocardiographic Monitors in Patients with Chronic
Fatigue Syndrome’, Chest 104 (1993), 1417–21.
Steffen Mau, Inequality, Marketization and the Majority Class: Why Did the European
Middle Classes Accept Neo-Liberalism? (New York: Palgrave Pivot, 2015).
Robin McKie, ‘Chronic Fatigue Syndrome Researchers Face Death Threats
from Militants’, The Observer (August 2011), online at: (http://www.the
guardian.com/society/2011/aug/21/chronic-fatigue-syndrome-myalgic-
encephalomyelitis) (accessed March 2016).
Meinhard Miegel, Stefanie Wahl, Martin Schulte, and Elias Butzmann,
Altering Attitudes: From a Culture of Consumerism to a Culture of Prosperity
(Bonn: Denkwerk Zukunft – Stiftung kulturelle Erneuerung, 2011).
22 S. Neckel et al.
Sighard Neckel and Greta Wagner (eds), Leistung und Erschöpfung: Burnout in
der Wettbewerbsgesellschaft (Berlin: Suhrkamp, 2013).
J. A. Richman and L. A. Jason, ‘Gender Biases Underlying the Social
Construction of Illness States: The Case of Chronic Fatigue Syndrome’,
Current Sociology 49 (2001), 15–29.
Harmut Rosa, ‘Wettbewerb als Interaktionsmodus: Kulturelle und sozialstrukturelle
Konsequenzen der Konkurrenzgesellschaft’, Leviathan 34: 1 (2006), 82–104.
Anna Katharina Schaffner, Exhaustion: A History (New York: Columbia
Wolfgang Schmidbauer, ‘Mehr Hofnarr als Hofrat. Über die Krisen der
Psychotherapie’, Kursbuch 170 ‘Krisen lieben’ (2012), 150–73.
Michael Sharpe, ‘Chronic Fatigue Syndrome’, The Psychiatric Clinics of North
America 19: 3 (1996), 549–73.
Edward Shorter, From Paralysis to Fatigue: A History of Psychosomatic Illness in
the Modern Era (New York: The Free Press, 1992).
Elaine Showalter, Hystories: Hysterical Epidemics and Modern Media (New York:
Columbia University Press, 1998).
David Tuller, ‘Re-Examining Chronic Fatigue Syndrome: Research and
Treatment Policy’, online at: http://healthaffairs.org/blog/2016/02/04/reex
amining-chronic-fatigue-syndrome-research-and-treatment-policy/
(accessed September 2016).
N. C. Ware and A. Kleinman, ‘Culture and Somatic Experience: The Social
Cause of Illness in Neurasthenia and Chronic Fatigue Syndrome’,
Psychosomatic Medicine 54 (1992), 546–60.
Max Weber, ‘“Objectivity” in Social Science and Social Policy’, in The
Methodology of the Social Sciences, trans. Edward A. Schils and Henry A.
Finch (Glencoe, IL: Free Press, 1949), pp. 49–112.
Simon Wessely, Matthew Hotopf and Michael Sharpe, Chronic Fatigue and Its
Symptoms, rev. ed. (Oxford: Oxford University Press, 1999).
M. M. Zeineh, J. Kang, S. W. Atlas, M. M. Raman, A. L. Reiss, J. L. Norris,
I. Valencia, and J. G. Montoya, ‘Right Arcuate Fasciculus Abnormality in
Chronic Fatigue Syndrome’, Radiology 274: 2 (2015), 517–26.
Sighard Neckel is Professor of Sociology at the University of Hamburg. He

has published almost 180 articles and several academic volumes which cover a
wide range of sociological topics in the fields of cultural sociology, social
inequality, economic sociology, sociology of emotions, and social theory.
1 Introduction 23
Anna Katharina Schaffner is Reader in Comparative Literature and Medical

Humanities at the University of Kent, UK. She has published on the histories
of exhaustion, sexology and psychoanalysis, Dada, the film director David
Lynch, and various modern writers. Her most recent monograph, Exhaustion:
A History, was published by Columbia University Press in 2016.
Greta Wagner is Research Associate at the Institute of Sociology at the

Goethe-University Frankfurt am Main, Germany. She has published on stra-
tegies of self-optimisation, especially the self-medication with cognitive enhan-
cing drugs, and on burnout.
Part I
Cultural-Historical Perspectives
2
Pre-Modern Exhaustion: On Melancholia
and Acedia
Anna Katharina Schaffner
Many historians, sociologists, and cultural critics argue that the rapid
spread of exhaustion syndromes such as neurasthenia, depression,
chronic fatigue syndrome, and burnout are intricately tied up with
the advent of modernity and its many discontents.1 They claim that
these phenomena are primarily sociogenic in origin, and the result of
processes such as urbanisation, industrialisation, bureaucratisation, and
acceleration. More recently, the social changes resulting from the
transformation of manufacturing into service and finance economies,
1
See, for example, Jonathan Crary, 24/7: Capitalism and the End of Sleep (London and New York:
Verso, 2013); Sighard Neckel and Greta Wagner (eds), Leistung und Erschöpfung. Burnout in der
Wettbewerbsgesellschaft (Frankfurt am Main: Suhrkamp, 2013); Patrick Kury, Der Überforderte
Mensch. Eine Wissensgeschichte vom Stress zum Burnout (Frankfurt am Main and New York:
Campus, 2012); Alain Ehrenberg, The Weariness of the Self: Diagnosing the History of Depression in
the Contemporary Age, trans. David Homel et al. (Montreal and London: McGill-Queen’s University
Press, 2010); Richard Sennett, The Corrosion of Character (New York: W. W. Norton, 1998); and
Hans Selye, Stress without Distress (London and Toronto: Hodder and Stoughton, 1975).
A.K. Schaffner (*)


DOI 10.1007/978-3-319-52887-8_2
28 A.K. Schaffner
intensified competition in the context of globalised neo-liberal capital-

ism, the subjectivisation of work, a 24/7 consumer culture, as well as
new communication technologies and their associated psycho-social
stressors have been singled out as exhaustion generators. All of these
arguments are based on the idea that human energy levels have basically
remained static throughout history, while the cognitive, emotional, and
temporal demands on the modern subject have increased so sharply that
a chronic deficit of inner resources ensues.
Moreover, as exhaustion is a phenomenon generated by a complex
interplay of mind, body, and society, arguments about the causes of and
cures for a chronic lack of energy are often combined with a critique of
specific social and cultural developments. Many current commentators
on burnout, for example, hold the spread of neo-liberal techno-capitalism
responsible for the proliferation of exhaustion-related diseases, and
frequently appear to long for a return to an (often idealised) less
energy-draining and more humane past.2 Similarly, in the wake of
the neurasthenia epidemic at the end of the nineteenth century, com-
mentators singled out various social changes which they proposed as
causes for the chronic energy depletion of the modern subject, and
which included the emancipation of women, the spread of capitalist
competition, various technological inventions, the erosion of traditional
values, the loss of the influence of the church and the community, and
various others.3
While the emergence of specific symptom clusters and their accom-
panying aetiological narratives are indeed historically specific and reflect
dominant cultural anxieties and preoccupations at a given moment, I
argue that the experience of states of exhaustion is not bound to a
particular time and place. Exhaustion and its psycho-social effects have
preoccupied physicians, theologians, philosophers, cultural critics, and
2
See, for example, Leistung und Erschöpfung; Ehrenberg, The Weariness of the Self; and Crary, 24/7.
3
See George M. Beard, A Practical Treatise on Nervous Exhaustion (Neurasthenia): Its Symptoms,
Nature, Sequences, Treatment (New York: W. Wood, 1880); and American Nervousness: Its Causes
and Consequences. A Supplement to Nervous Exhaustion (Neurasthenia) (New York: G. P. Putnam
Sons, 1881); Richard von Krafft-Ebing, Über Gesunde und Kranke Nerven, Fourth edition
(Tübingen: Verlag der H. Laupp’schen Buchhandlung, 1898); and Wilhelm Erb, Über die
wachsende Nervosität unserer Zeit (Heidelberg: J. Hörning, 1884).
psychologists since classical antiquity. The specific ways in which

exhaustion and its effects are theorised, however, can act as barometers
for medical and wider social paradigm changes, and can reveal insights
into the ways in which the relationship between mind, body, and society
was imagined, as well as about dominant conceptions of human agency
and will power.
I understand exhaustion as an individual physical, mental, or spiritual
state, and also as a broader cultural phenomenon. Physically, exhaustion
manifests itself as fatigue, lassitude, lethargy, and weakness. On an affective,
emotional, and spiritual level, the symptoms of exhaustion include weari-
ness, disillusionment, apathy, hopelessness, and a lack of motivation.
Exhaustion can also result in restlessness and irritability. Medically speak-
ing, the symptoms of exhaustion feature prominently in various historical
and current diagnostic categories including melancholia, acedia, nervous-
ness, neurasthenia, depression, CFS, and burnout. Yet these diagnoses
are, of course, not simply synonymous with exhaustion: all of them
combine the physical and mental symptoms of exhaustion with a range
of other symptoms. Sometimes, exhaustion is seen as the consequence of
other symptoms; sometimes, it is thought to be their cause. However, in
one way or another, the key symptoms of exhaustion feature at the very
heart of all of these fatigue syndromes.
There are already many excellent sociological, historical, and psycho-
logical studies of exhaustion syndromes and their accompanying narra-
tives in the nineteenth, twentieth, and twenty-first centuries, ranging in
their subjects from neurasthenia to burnout. However, the pre-modern
history of exhaustion is less well explored. In the following chapter, pace
the critics who claim that exhaustion is a disease of modernity caused by
acceleration, rapid social and technological changes, and so on, I seek to
demonstrate that exhaustion is a ubiquitous and timeless experience.
Many ages have battled with its demons and, moreover, presented
themselves as the most exhausted period in history.
*
The symptoms of exhaustion were first discussed as indicators of mel-
ancholia by physicians working in the humoural tradition. Humour
theory was introduced to medicine by Hippocrates in the fifth century
30 A.K. Schaffner
BC, and further developed by the Greek physician Galen of Pergamum

(AD 129–c. 216). Galen’s version of humour theory was so influential
that it remained the dominant medical paradigm until the advent of
modern medicine in the nineteenth century.4 One of the central tenets
of this theory is the importance of a balance between the four bodily
humours: blood, yellow bile, black bile, and phlegm. Within this frame-
work, all illnesses – be they chronic or acute, mental or physical – can be
explained by the relative excess or insufficiency of one or more of the four
humours.
In Galen’s writings, we encounter exhaustion primarily in the guise of
lethargy, torpor, weariness, sluggishness, and lack of energy. Moreover,
all of these were thought to be typical symptoms of melancholia, which
thus features some of the key symptoms of physical and mental exhaus-
tion among its core indicators. Other indicators of melancholia included
fear and sorrow. Like neurasthenia, this diagnosis often encompasses a
plethora of associated complaints ranging from irritability, restlessness,
mania, hallucinations, and paranoia to misanthropy and self-loathing.5
In On the Affected Parts (composed after AD 192), Galen argues that
melancholia is triggered by a surplus of black bile. He distinguishes two
types of melancholia. In the first kind, the entire blood supply of an
individual becomes atrabilious, the melancholic humour thickening and
slowing the blood, rendering the patient lethargic, slow, and prone to
stupor.6 Interestingly, a general slowing of the patient’s movement and
speech and the impairment of their cognitive faculties are still considered
4
For more general literature on Galen, see, for example, Christopher Gill, Naturalistic Psychology
in Galen and Stoicism (Oxford: Oxford University Press, 2010); Christopher Gill, Tim
Whitmarsh, and John Wilkins (eds), Galen and the World of Knowledge (Cambridge:
Cambridge University Press, 2009); and R. J. Hankinson (ed.), The Cambridge Companion to
Galen (Cambridge: Cambridge University Press, 2008).
5
See Jennifer Radden’s introduction to her anthology The Nature of Melancholy: From Aristotle to
Kristeva (Oxford: Oxford University Press, 2000), pp. 3–51, for an overview of the historical
transformations of the concept and the ways in which the condition was theorised from classical
antiquity to the present day. See also Matthew Bell, Melancholia: The Western Malady
(Cambridge: Cambridge University Press, 2014) and Clark Lawlor, From Melancholia to Prozac:
A History of Depression (Oxford: Oxford University Press, 2012).
6
Galen, Selected Works, trans. P. N. Singer (Oxford and New York: Oxford University Press,
1997), pp. 339–41.
some of the behavioural signs of depression today.7 Galen proposes that,

as a result of the denser texture of the black-bile-infected blood, it either
does not reach the brain at all, as it travels more slowly and is often
obstructed on the way, or else damages the brain’s functions by clogging
up its pathways. The cure for this kind of melancholia entails blood-
letting, so as to purge the excess of bilious fluids from the body and to
reinvigorate the sluggish bloodstream.
The second kind of melancholia that Galen describes in On the
Affected Parts originates in the stomach, and can be caused by inflamma-
tion, indigestion, heartburn, and certain types of food. In order to fight
these disturbances in the fluid economy, the body attempts to burn the
excess of melancholic humours accumulating in the stomach. However,
the ashes of the burned black bile rise to the brain in the form of a black
vapour that subsequently clouds the sufferer’s judgement and feelings:
As some kind of sooty and smoke-like evaporation or some sort of heavy

vapors are carried up from the stomach to the eyes, equally and for the
same reason the symptoms of suffusion occur, when an atrabilious eva-
poration produces melancholic symptoms of the mind by ascending to the
brain like a sooty substance or a smoky vapor.8
Ostensibly figurative expressions still in use today, such as ‘clouded

judgement’ or ‘black mood’, are thus rooted in what in ancient medical
theory was actually thought to be the case, namely the assumption that
the brain and its cognitive and affective functions were literally clouded
and dulled by black vapours. A strand in current depression research still
focuses on the role of negative attention and memory biases in the
thought processes of the depressed, that is, the selective and often
7
For an analysis of the symptoms of depression, see Alain Ehrenberg, The Weariness of the Self:
Diagnosing the History of Depression in the Contemporary Age. For a discussion of the parallels
between ancient melancholia and modern depression, see also Stanley W. Jackson, Melancholia &
Depression: From Hippocratic Times to Modern Times (New Haven and London: Yale University
Press, 1990).
8
Galen, On the Affected Parts, ed. and trans. Rudolph E. Siegel (London and New York: S. Karger,
1976), pp. 92–3.
32 A.K. Schaffner
exclusive attention to and memory of negative information, which can

be considered as forms of clouded judgement.
Galen believes that the soul is embodied, and that it is directly
affected by bodily processes: ‘All of the best physicians and philosophers
agree that the humours [krâseis] and actually the whole constitution of
the body change the activity of the soul.’9 He does not conceive of the
soul as an autonomous entity, but repeatedly emphasises that it is a ‘slave
to the mixtures of the body’, and that the body thus has the ability to
deprive the soul of its energy:10
So one is bound to admit, even if one wishes to posit a spare substance for
the soul, at least that it is a slave to the mixtures of the body: these have the
power to separate it, to make it lose its wits, to destroy its memory and
understanding, to make it more timid, lacking in confidence and energy,
as happens in cases of melancholy [ . . . ].11
The idea that the soul, moods, and even specific behaviours are essen-
tially determined by physical processes starkly contrasts with later med-
ical thinking, which frequently divides phenomena into those that
pertain either to the mind or to the body, and which leaves little room
for theorising the complex interactions between the two entities. There
are parallels here to the arguments of researchers who believe in the
purely biomedical origins of depression, that is, the idea that chemical
processes in the brain, the ‘mixtures of the body’, are the exclusive
determiners of our moods.12
According to Galen, melancholic exhaustion thus originates at a
physical, almost proto-biochemical level, and only in a second step
9
Ibid., p. 93.
10
He also discusses this idea in his treatise On the Doctrines of Hippocrates and Plato and in his late
pamphlet The Faculties of the Soul Follow the Mixtures of the Body. See Piereluigi Donini,
‘Psychology’, in The Cambridge Companion to the Hellenistic World, ed. Glenn R. Bugh
(Cambridge: Cambridge University Press, 2006), pp. 184–209 (p. 184).
11
Galen, Selected Works, p. 155.
12
In some texts he goes even further, suggesting that the soul is, in fact, identical to the organs in
which it is seated, and, in particular, that the soul might be identical to the cerebral pneuma. See
Donini, ‘Psychology’, p. 201.
proceeds to impact adversely on the mind and the spirit by slowing or

blocking the movement of the blood, or by literally clouding the spirit.
The causes of exhaustion symptoms such as weariness, lethargy, and
torpor, as explained in the humoural framework, then, are essentially
physiological in nature: it is the body that adversely affects the mind, and
not, as twentieth-century psychosomatic theorists would argue, the other
way round. Consequently, Galen also believes that doctors rather than
philosophers should be charged with the improvement of the intellectual
and moral qualities of the soul.13 Yet curiously, there appears to be no
room in Galen’s model for the notion that purely mental processes can
influence bodily reactions and result in physical symptoms, for example,
that faulty reasoning and irrationally pessimistic interpretations of phe-
nomena and experiences might become manifest in a physical lack of
energy. Although Galen very briefly mentions ‘excessive worrying’ and
grief as potentially melancholia-enhancing phenomena, he never theo-
rises further how these psychological factors might actually interact with
and impact on the physical body.
While the humoural model of melancholia offers a theory of the ways
in which the body impacts on the spirit, it centres on the idea that the
mind and soul are pure and pristine, and that it is the body that acts as
the corrupting force. Yet might not the mind also impact on the body in
a comparable way? Galen does not comment on this possibility. In
contrast, many twenty-first-century biomedical researchers investigating
the chemical makeup of depressed brains admit that they are not at all
certain whether reduced serotonin levels are a consequence of depression
or its cause. This matter is still essentially considered an unresolved
‘chicken and egg’ question.
*
While the symptoms of mental and physical exhaustion were considered
to be among the core symptoms of melancholia until it was replaced by
the concept of depression in the twentieth century, an alternative model
of theorising states of exhaustion emerged in Late Antiquity and
13
See ibid., p. 196.
34 A.K. Schaffner
blossomed in the Middle Ages: the notion of sloth or acedia. Just like
melancholia, acedia included various symptoms of mental and physical
exhaustion among its core indicators, such as weariness, torpor, apathy,
lethargy, sleepiness, irritability, cognitive impairment, and hopelessness.
Yet unlike melancholia, which was treated and theorised by physicians,
sloth fell into the remit of the theologians. It was understood not as an
organic disease, but rather as a spiritual and moral failing.
From the fourth century AD sloth featured prominently in theologi-
cal treatises cataloguing what would later become the Seven Deadly Sins.
Indeed, it was often considered to be the most severe of the cardinal
vices, a fundamental spiritual failing manifest in a bad attitude towards
divine grace that gave rise to the sibling sins of envy, gluttony, lust,
wrath, pride, and avarice. Yet the mediaeval concept of sloth is not
simply to be equated with our modern understanding of the term as an
aversion to effort and an undue attachment to repose, pleasure, and
leisure: mediaeval sloth entailed an all-important spiritual dimension
that is now lost, and was much more complex than the secular concep-
tion of laziness as a lack of willpower, drive, and discipline.
The concept of acedia, the technical term for sloth and often used in
the place of its Latin cognates such as inertia, pigritia, desidia, socordia,
and ignavia in the Middle Ages, denotes a condition that shares various
psychological, physical, and behavioural symptoms with melancholia,
depression, and even burnout, but places these in a theological frame-
work. Acedia is derived from the ancient Greek word for indifference,
listlessness, or apathy. Literally it denotes a ‘state of non-caring’ (speci-
fically about divine matters), and has also been described as ‘weariness of
the heart’. As a theological version of melancholia, acedia was originally
associated with monks and the monastic lifestyle, until it was extended
to lay people in the tenth and eleventh centuries.14
The concept emerged in the fourth century in the Egyptian desert near
Alexandria among the Desert Fathers, a cluster of monks who lived as
14
The following account of the history of acedia in the Middle Ages is indebted to two excellent
studies on the subject: Siegfried Wenzel, The Sin of Sloth: Acedia in Medieval Thought and
Literature (Chapel Hill: University of North Carolina Press, 1967) and Werner Post, Acedia –
Das Laster der Trägheit. Zur Geschichte der siebten Todsünde (Freiburg and Vienna: Herder, 2011).
hermits in the wilderness. It was first theorised by the monk and theologian
Evagrius Ponticus (346–399).15 In the Antirrhetikos he drew up a list of
eight fundamental ‘bad thoughts’ or ‘demonic temptations’, which he
considered to be the cause of all sinful behaviour, and which would later
constitute the basis for the Seven Deadly Sins. His list includes gluttony,
fornication (or lust), avarice, hubris (or pride), sadness, wrath, boasting
(or vainglory), and acedia. Evagrius defines the latter as mental and spiritual
exhaustion manifest in listlessness, apathy, boredom, restlessness, dejection,
irritability, and hatred of the anachoretic lifestyle. Acedia, he writes, entices
monks to abandon their spiritual calling, to leave their cells, and to neglect
their spiritual duties. He associates acedia with the ‘noonday demon’, who
attacks at midday when the heat is at its most oppressive and the monks are
particularly vulnerable. This demon, Evagrius explains, not only entices the
monk to sleep during the day but also
makes the sun appear sluggish and immobile, as if the day had fifty hours.
Then he causes the monk continually to look at the windows and forces him
to step out of his cell and to gaze at the sun to see how far it still is from the
ninth hour, and to look around, here and there, whether any of his brethren
is near. Moreover, the demon sends him hatred against the place, against life
itself, and against the work of his hands, and makes him think he has lost the
love among his brethren and that there is none to comfort him. If during
those days anybody annoyed the monk, the demon would add this to
increase the monk’s hatred. He stirs the monk also to long for different
places in which he can find easily what is necessary for his life and can carry
on a much less toilsome and more expedient profession. [ . . . ] To these
thoughts the demon adds the memory of the monk’s family and of his former
way of life. He presents the length of his lifetime, holding before the monk’s
eyes all the hardships of his ascetic life. Thus the demon employs all his wiles
so that the monk may leave his cell and flee from the race-course.16
15
For more information on Evagrius Ponticus, see, for example, A. M. Casiday, Evagrius Ponticus:
The Early Church Fathers (Oxon and New York: Routledge, 2006); and George Tsakiridis,
Evagrius Ponticus and Cognitive Science: A Look at Moral Evil and the Thoughts (Eugene,
Oregon: Wipf and Stock, 2010).
16
Quoted in Wenzel, The Sin of Sloth, p. 5.
36 A.K. Schaffner
Evagrius’s definition of acedia thus includes not only the exhaustion

symptoms of sleepiness, lethargy, irritability, and hopelessness but also
impatience and agitation, which are manifest in various unproductive
displacement activities. Just like neurasthenics and the burned-out, those
afflicted by acedia vacillate between sluggishness and restlessness, states
marked by too little energy or else by aimless, non-productive activities
that waste energy. In most cases of melancholia and depression, in
contrast, there tends not to be much energy available to waste in such
non-productive dissipation activities. According to Evagrius, acedic
lethargy and restlessness are caused by an external, demonic agent and
an internal moral disposition.17 He believes, however, that it is within
human power to resist this temptation – indeed, that defying it is the
monk’s spiritual duty. Appropriate defences against this demon are a
vigorously renewed diligence and an earnest dedication to one’s spiritual
tasks: practising endurance and patience, insistent prayer, reading and
the recitation of psalms, as well as meditation on Scripture.18 Yet the
rigorous regime Evagrius proposes as cure is, of course, among the causes
that instigated the state of exhaustion in the acedic monks in the first
place, and it is questionable whether the prescription of more steadfast-
ness and fortitude yielded the required results.
The second early Christian author to write on acedia was John
Cassian (360–435). Cassian lived in a monastery in Bethlehem before
visiting the hermit colonies in Egypt in 386, where he met Evagrius and
was influenced by his teachings. He dedicates an entire chapter to acedia
in The Monastic Institutes (ca. 425), a practical handbook for monks that
draws on the wisdom and practices of the Desert eremites. Book X of
The Monastic Institutes explores the vice of acedia, which he defines as
‘weariness or distress of heart’: Acedia
is akin to dejection, and is especially trying to solitaries, and a dangerous

and frequent foe to dwellers in the desert; and especially disturbing to a
monk about the sixth hour, like some fever which seizes him at stated
17
Ibid., p. 14.
18
See ibid., p. 5.
times, bringing the burning heat of its attacks on the sick man at usual and
regular hours. Lastly, there are some of the elders who declare that this is
the ‘midday demon’ spoken of in the ninetieth Psalm.19
Like Evagrius, Cassian argues that those in the grips of acedia feel disgust
with the cell and contempt for their brothers. He describes a concaten-
ation of sins in that one follows from the other: the brothers long to
be elsewhere, and are unable to read, to concentrate, to pray, or to do
undertake any productive activity. It makes the monk ‘lazy and sluggish
about all manner of work which has to be done within the enclosure of
his dormitory’.20 Moreover, the state of mental lethargy and unproduc-
tive hyperactivity is followed by the symptoms of extreme bodily exhaus-
tion and starvation, accompanied by mental confusion:
Then the fifth or sixth hour brings him such bodily weariness and longing
for food that he seems to himself worn out and wearied as if with a long
journey, or some very heavy work, or as if he had put off taking food
during a fast of two or three days. Then besides this he looks about
anxiously this way and that, and sighs that none of the brethren come
to see him, and often goes in and out of his cell, and frequently gazes up at
the sun, as if it was too slow in setting, and so a kind of unreasonable
confusion of mind takes possession of him like some foul darkness, and
makes him idle and useless for every spiritual work, so that he imagines
that no cure for so terrible an attack can be found in anything except
visiting some of the brethren, or in the solace of sleep alone.21
Here, Cassian describes the physical symptoms of acedia in terms of

what we would now call post-exertion malaise, a bodily fatigue that is as
intense as that experienced after prolonged fasting, hard labour, or
19
John Cassian, The Monastic Institutes, trans. Edgar C.S. Gibson, in A Select Library of Nicene
and Post-Nicene Fathers of the Christian Church, ed. Henry Wace and Philip Schaff, 14 vols.
(Oxford: James Parker and Company; New York: The Christian Literature Company, 1894), vol.
XI, pp. 183–641 (p. 266).
20
Ibid., p. 267.
21
Ibid.
38 A.K. Schaffner
extended walking, and which results in a craving for sustenance. Like

Evagrius, he also describes the symptoms of hopelessness, restlessness, an
inability to concentrate, a search for human company, and a desire for
sleep. Ultimately, the monk thus harassed by the demon of acedia
is disturbed, until, worn out by the spirit of accidie, as by some strong

battering ram, [the victim] either learns to sink into slumber, or, driven
out from the confinement of its cell, accustoms itself to seek for consola-
tion under these attacks in visiting some brother, only to be afterwards
weakened the more by this remedy which it seeks for the present.22
Thus ensues a vicious circle: monks become ever more unable to med-
itate and contemplate things of a spiritual nature, and their ill-chosen
strategies for restoring their energy reserves aggravate their condition
further, just like a weary twenty-first-century sufferer who is unable to
concentrate might constantly check their email, Facebook, or Twitter.
Thus ‘the solider of Christ becomes a runaway from His service, and a
deserter, and “entangles himself in secular business”, without at all
pleasing Him to whom he engaged himself’.23
Although Cassian describes in detail the physical, mental, and beha-
vioural symptoms of acedia, he ultimately sees it as a moral and spiritual
problem, one that pertains to the soul:
All the inconveniences of this disease are admirably expressed by David in

a single verse, where he says, ‘My soul slept from weariness’, that is, from
accidie. Quite rightly does he say, not that his body, but that his soul slept.
For in truth the soul which is wounded by the shaft of this passion does
sleep, as regards all contemplation of the virtues and insight of the
spiritual senses.24
Rather than conceiving of the various symptoms of exhaustion as having

a physical cause, both Evagrius and Cassian think of it as a spiritual
22
Ibid.
23
Ibid.
24
Ibid., pp. 267–8.
failing caused by a lack of willpower or a moral defect. The behavioural

effects of the weariness of the soul are idleness or else restless over-
activity: either acedic monks remain lethargically in their cells without
making any spiritual progress, or they wander about aimlessly, in search
of idle chatter and refreshments.25 Interestingly, Cassian also considers
acedia as infectious in nature, a danger to the community that had to be
contained like a virus. He quotes Paul, who deploys vivid medical
imagery to illustrate his warning:
And so he bids them withdraw from those who will not make time for
work, and to cut them off like limbs tainted with the festering sores of
leisure: lest the malady of idleness, like some deadly contagion, might
infect even the healthy portion of their limbs, by the gradual advance of
infection.26
Paul is gravely concerned by those who do not work: ‘For we have heard
that some among you walk disorderly, working not at all, but curiously
meddling.’27 Those who do not work, the Apostle sternly proclaims,
shall not eat. Work is also Cassian’s antidote to acedia: he believes that
manual labour is the panacea that is able to prevent the disease of acedia
from wreaking havoc in the monastic communities. The medical meta-
phors which he frequently employs when commenting on acedia are
particularly striking in the following quotation, which presents idleness
as the root cause of acedia:
The cause of all these ulcers, which spring from the root of idleness, he
heals like some well-skilled physician by a single salutary charge to work;
as he knows that all the other bad symptoms, which spring as it were from
the same clump, will at once disappear when the cause of the chief malady
has been removed.28
25
Ibid., p. 268.
26
Ibid., p. 269.
27
Ibid., p. 271. See Thessalonians 3:11.
28
Ibid, p. 271.
40 A.K. Schaffner
Cassian reports that the desert communities in Egypt never allowed

monks, and especially not the younger ones, to be idle, ‘estimating the
purpose of their hearts and their growth in patience and humility by
their diligence in work’.29 The historian Siegfried Wenzel points out
that regulated and fairly distributed manual labour is more important in
a monastic context than in a desert cell, as monastic life depends on the
organised participation of all its members. In a tight-knit community
such as a monastery, those who refuse to perform their assigned role pose
a threat to social cohesion.30 It is interesting that Evagrius’s cure for
acedia differs so drastically from Cassian’s: Evagrius first described acedia
in the context of anchorites, where the social component was not yet so
important, and proposes an intensification of prayer and meditation as
acedia’s antidotes. There might, then, well be a practical dimension to
Cassian’s alternate proposal, which posits work as the ultimate cure for
acedia, and which shows a shift of emphasis to the social consequences of
spiritual failure, that is, a concern with combating the risk of the failure
of the group at large. Wenzel’s argument can, in fact, be extended
further, to society as a whole: the more complex social structures
become, the more those who do not contribute their share endanger
the smooth functioning of the system. It is worth remembering that the
establishment of the canon of the Seven Deadly Sins was generally
driven not just by abstract theological reasoning but also by very prag-
matic social considerations – sloth, such as wrath, avarice, gluttony, lust,
pride, and jealousy, can breed resentment and prove to be very harmful
to the social fabric. Similarly, the overworked, overstretched, and
exhausted of our age pose an economic and social risk too: sick leave
owing to stress, depression, and burnout costs billions in lost earnings
each year, and the strain these conditions put on public health services
continues to rise dramatically.
Drawing on both Evagrius’s and Cassian’s works, Pope Gregory the
Great (540–604) finally compiled a list of seven cardinal vices that were
to become the Seven Deadly Sins in the form we know them today.
29
Ibid., p. 274.
30
See Wenzel, The Sin of Sloth, p. 22.
Gregory folded sorrow (tristitia) into acedia, and vainglory into pride,
and also added envy to Evagrius’s earlier list of ‘demonic temptations’.
Sloth (socordia) and acedia were often treated as synonymous, until
socordia replaced acedia altogether.31
In On the Sacraments of the Christian Faith the mystic scholar Hugh of
Saint Victor (1096–1141) seeks to establish the difference between vice
and sin:
vices are corruptions of the soul, out of which, if they are not checked by
reason, sins, that is, acts of injustice arise. Now when consent is offered to
the temptation of vice, there is an act of injustice which is called a sin. So
vice is the weakness of spiritual corruption, but sin arising from corrup-
tion through consent is an act of iniquity. And so vice without consent is
weakness, to which in so far as there is weakness mercy is due, but in so far
as it is checked from an act of iniquity a reward and a crown are due.32
This distinction is of considerable importance in the history of exhaus-

tion: while vice is a given predilection, a psychological or characterolo-
gical weakness, for which one cannot be held responsible, sin is a
behaviour and can therefore be influenced and controlled. According
to Hugh of Saint Victor’s logic, it is in our gift not to act on our
weaknesses, to control them through reason and willpower, and thus
to take responsibility for our behaviour and actions.33 A predilection
towards sluggishness and torpor, according to this argument, would
therefore be a vice and thus a spiritual weakness that can be forgiven,
while consenting to this predilection and succumbing to exhaustion
would be considered a sin.
Hugh of Saint Victor’s definition of dejection is of interest, too:
‘Despair is sadness born from confusion of the mind, or weariness and
immoderate bitterness of the spirit by which spiritual enjoyment is
31
However, the current ‘Catechism of the Catholic Church’ still lists the sins in Latin as ‘superbia,
avaritia, invidia, ira, luxuria, gula’ and as ‘pigritia seu acedia’ (laziness or acedia).
32
Hugh of Saint Victor, On the Sacraments of the Christian Faith (De Sacramentis), trans. Roy J.
Deferrari (Cambridge, MA: The Mediaeval Academy of America, 1951), p. 375.
33
Ibid., p. 376.
42 A.K. Schaffner
extinguished, and by a kind of beginning of desperation the mind is

overthrown within itself.’34 The idea that confused reasoning and a
weariness of the spirit can lead to a mind being ‘overthrown within
itself’ anticipates psychoanalytical models, according to which a sadistic
superego might lash against the ego. It also evokes the cognitive beha-
vioural notion of endlessly looping negative thoughts, a self-destructive
kettle-logic that uses up all of one’s energy and from which there seems
to be no escape. A follower of Hugh of Saint Victor defines ‘tristitia seu
acedia’ (sorrow or acedia) as ‘an anguish of the mind that is perturbed by
the frustration of its desire through something contrary, or, the weari-
ness [taedium] to perform a good deed well’.35 Again, this definition
evokes either conflicting internal desires that wear out the sufferer, or
else external impediments that prevent a desire from being fulfilled.
The thirteenth-century Italian theologian Thomas Aquinas
(1225–1274) defines acedia further in his famous Summa Theologiae
(written between 1265 and 1274), in which he draws up the core
Christian taxonomy of sins, distinguishing between the cardinal and
the venial sins, and arranging them hierarchically. In Aquinas’s scholas-
tic system, every cardinal sin is opposed to a cardinal virtue. He defines
acedia as a ‘sorrow’ that is opposed to spiritual joy and charity.
According to Aquinas, charity is our relationship with God. Acedia is
a ‘sadness about spiritual good’.36 In other words, acedia is a form of
spiritual apathy that is, if consented to, manifest in the rejection of the
effort required to commit oneself to God, and to all that is good. Faith
requires ongoing work and effort, a constantly renewed commitment.
Yet Aquinas attributes this shirking away from a union with God not
primarily to laziness or sadness as such, but rather to perverted forms of
sadness, that is, uncontrolled sadness or sadness directed at the wrong
‘object’, and above all at good things. This is why Aquinas considers
acedia a cardinal spiritual failing. Physical weariness, sluggishness, and
34
Ibid., p 375.
35
Quoted in Wenzel, The Sin of Sloth, p. 34.
36
St Thomas Aquinas, Summa Theologiae: A Concise Translation, ed. Timothy McDermott
(London: Eyre and Spottiswoode, 1989), p. 365.
torpor are not the actual crime but rather the effects of a failing that is
spiritual in nature: acedia, according to Aquinas, is ultimately caused by
human pride that is manifest in a perverted loathing of good things.
Moreover, Aquinas defines acedia by proposing a behavioural model
with a psychological cause, and one which is based on specific concep-
tions of agency:
Apathy [acedia] is a sort of depression which stops us doing anything, a

weariness with work, a torpor of spirit which delays getting down to anything
good. Spiritual goods are real goods, and taking no joy in them is bad in itself;
and it is bad in its effects if it so depresses a man as to keep him back from
good works. Apathy [acedia] then is doubly wrong. Sadness as such merits
neither praise nor blame; what we praise is a controlled sadness at evil, what
we blame is sadness that is either uncontrolled or is sad about good.37
The mental sadness or apathy about good things prevents the acting out
of good things, an acting out that in return would reward us with joy,
which is the opposite of sadness. It is because of this vicious circle that
Aquinas considers acedia a cardinal spiritual failing that has as its
ultimate cause, like all sins, human pride. He argues that acedia is a
mortal sin,
saddened by the very goodness of God in which charity rejoices. Sins that
by definition exclude the love of charity are of their nature fatal. Since joy
in God necessarily follows on charity, and apathy [acedia] is sadness about
spiritual good as a facet of God’s goodness, apathy [acedia] is of its nature
fatal.38
Like Hugh of Saint Victor, however, Aquinas distinguishes between the

existence of a natural predilection towards acedia, on the one hand, and
voluntary intellectual consent to give in to that predilection, on the
other: the former is not as grave a sin as the latter; one is a sin of the flesh
37
Ibid.
38
Ibid.
44 A.K. Schaffner
(i.e. sense-appetites, which Hugh of Saint Victor would have described

as vice), while the other is a sin of the spirit (i.e. perverted reasoning):
But sins are completed only when reason consents to them, and if apathy
[acedia] arises in our sense-appetites – the flesh rebelling against the spirit –
but does not get at our reason – by turning into horror and loathing of
God’s goodness – then the sin is incomplete and non-fatal.39
In Aquinas’s view, then, it is the spiritual dimension of acedia, the

aversion to all that is good, which constitutes the truly sinful core of the
condition. In secular terms, this aversion could be described as a form of
loathing, ungratefulness, and contemptuousness – an actively negative
attitude towards the world that is stronger than mere hopelessness.
Again like Hugh of Saint Victor, Aquinas strongly believes in volition
and personal responsibility – giving in to spiritual exhaustion attests not
only to a bad attitude towards divine goodness but also to a lack of
willpower. Human beings are by their very nature rational, and are
capable of sin precisely because of their powers of reasoning and their
ability to choose not to follow reason. If we were not able to act
reasonably, we would not be able to sin:40
Ignorance is a wound in reason’s response to truth, wickedness in will’s

response to good; weakness wounds the response of our aggressive emo-
tions to challenge and difficulty, and disordered desire our affections’
reasonable and balanced response to pleasure. All sins inflict these four
wounds, blunting reason’s practical sense, hardening the will against good,
increasing the difficulty of acting well and inflaming desire.41
It is precisely this notion of agency and personal responsibility, the

conviction that everyone endowed with the gift of reason can at all
times choose not to give in to the temptation of acedic weariness, which
renders the theological conception of exhaustion distinct from medical,
39
Ibid., p. 365.
40
Ibid., p. 269.
41
Ibid, p. 270.
psychological, and psychoanalytical models. Mediaeval acedia is above

all a moral and a spiritual failing, as according to the scholastics it is
always within our powers as rational beings to resist spiritual weariness
that expresses itself in consenting to temptation and in disinvesting in
the good, including not doing good works. In most medical models, in
contrast, agency and willpower do not have the authority to influence
any of the processes that are understood to be organic in nature –
regardless of whether they are thought to be caused by humours, nerves,
viruses, infections, or immune deficiencies. Freud, moreover, dealt a
further blow to the notion of purely rational human agency and ration-
ally based moral responsibility when he revealed the extent of the power
our unconscious drives, formative childhood experiences, and murky
desires hold over us.
It is interesting that in current debates about the role of willpower and
agency in dealing with certain problems such as addiction, obesity, and
even depression, burnout, and CFS, it tends to be people leaning to the
right of the political spectrum who embrace views similar to that of
Aquinas’: they, too, postulate the ultimate primacy of willpower, reason,
and full personal responsibility for one’s actions, and consequently
believe that not taking measures to improve one’s own mental or
physical welfare constitutes a morally reprehensible failing. The British
Prime Minister David Cameron, for example, has recently proposed that
disability benefits for the obese and for drug and alcohol addicts be cut if
they fail to engage with programmes designed to help them overcome
their conditions.42
*
The case studies discussed above reveal that concerns about the effects of
exhaustion on the mind and the body of the individual, as well as on the
wider social community, are by no means a modern phenomenon. The
mental, physical, and spiritual symptoms of states of exhaustion have
been theorised since classical antiquity, and appear, under different
42
Rowena Mason, ‘David Cameron Calls on Obese to Accept Help or Risk Losing Benefits’, The
Guardian, 14 February 2015, online at: http://www.theguardian.com/politics/2015/feb/14/david-
cameron-obese-addicts-accept-help-risk-losing-benefits (accessed February 2015).
46 A.K. Schaffner
names and labels, as common denominators in an ever-shifting historical

regime of exhaustion-related syndromes.
All exhaustion theories address either implicitly or explicitly
questions of responsibility, agency, and willpower. In some accounts
(most notably mediaeval theological ones centred on the notion of
sin, but also more recent neo-liberal ones which attempt to redirect
responsibility for the management of the subject’s physical and men-
tal well-being to the individual), exhaustion is represented primarily
as a form of weakness and lack of willpower, and even as a grave
spiritual or characterological failing manifest in a bad mental attitude.
Some theorists following in Galen’s footsteps firmly believe in the
organic causes of exhaustion, such as a surplus of black bile that
wreaks havoc with the bodily humoural economy, a lack of nerve-
power (e.g. George M. Beard), the chronic overstrain of the cognitive
system by too many external stimuli and stressors (e.g. Richard
von Krafft-Ebing, Wilhelm Erb, and Hans Selye), the weakening of
the immune system by viral infections (a specific school of CFS
researchers), or various forms of biochemical imbalance (exclusively
biomedically oriented psychiatrists). Within this category, the ex-
hausted individual may be seen either as an innocent victim afflicted
by parasitical external agents, or as having inherited bad genetic materi-
als, or else they may be seen as at least partly responsible for their
exhaustion by having engaged in energy-depleting behaviours, such as
working too hard, eating the wrong food, worrying too much, not
getting enough rest and sleep, or overindulging in sexual activities.
Other exhaustion theorists allow for the possibility that character
traits, individual mental states and attitudes, as well as wider cultural
psycho-social pressures can trigger bodily responses: they assume that
qualities such as optimism, engagement, contentedness, resilience, and
also insights into our psychological patterns and desires translate directly
into the amount of energy we have at our disposal. Whether exhaustion
is theorised as pertaining to the will, the mind, the body, or to wider
social developments, shapes the ways in which the exhausted are per-
ceived and, as a consequence, treated. The exhausted may be perceived
as innocent victims deserving care and support, or dismissed as shirkers
and slackers; they may be categorised as mentally or physically ill; or they
may be considered casualties of wider socio-political developments and

technological transformations.
While it is possible to detect historically specific theorisations of the
agents that cause exhaustion, and a tendency to look back nostalgically
to other historic periods and to relate the current depletion of human
energies to very specific technological and socio-cultural changes, it is
also possible to diagnose the recurrent production of theories about the
loss of energy as expressions of timeless anxieties that concern the natural
process of ageing, the dangers of the waning of engagement, and death.
Theorising exhaustion and, crucially, proposing cures and therapeutics
for its effects is a tactic to counteract the awareness of our helplessness
and terror in the face of our mortality. It is, in other words, a terror
management strategy designed to hold at bay our most existential
fears.43 These anxieties are increasingly commercially exploited not
only by the cosmetics industry promising cures that halt and even reverse
the physical signs of aging but also by the rapidly growing wellness and
mindfulness industries and the ever-expanding array of energy drinks,
energy supplements, stimulants, neuro-enhancers, and mood-lifters.
Whether the age of modernity, and more specifically our own age,
really is the most exhausted is impossible either to prove or to disprove.
It is, however, highly unlikely. Even the quantifiable proliferation of
discourses on exhaustion, or the rapid increase in the number of people
who are being diagnosed with exhaustion-related syndromes, is not
necessarily an indicator that our own subjective experiences of exhaus-
tion are more numerous or more intense than those experienced by our
ancestors in earlier periods. It might simply be more acceptable now to
articulate and to seek remedies for one’s feelings of stress, weariness, and
hopelessness. It is impossible to measure and compare the exact amount
of energy spent and effort experienced by a twenty-first-century office
43
Sheldon Solomon, Jeff Greenberg, and Tom Pyszczynski have recently demonstrated that
almost all our individual and broader cultural activities are a response to death and designed to
hold our mortal terror at bay. However, this impulse is, of course, particularly clearly discernible
in attempts to combat ageing, illness, and to counteract the general depletion of our energies. See
Sheldon Solomon, Jeff Greenberg, and Tom Pyszczynsky, The Worm at the Core: On the Role of
Death in Life (London: Allen Lane, 2015).
48 A.K. Schaffner
worker with that of a nineteenth-century factory worker, or a farmer

ploughing his fields in the early modern period, or a mother of 10
starving children in the Middle Ages. Moreover, most discourses on
the chronic forms of exhaustion that cannot be explained in terms of
illness or extreme physical exertion tend to focus on the experiences of
predominantly middle- and upper-class ‘brain workers’, with a concen-
tration not so much on the effects of external threats such as viral
infections, wars, hunger, violence, or very hard physical labour, but
rather on psycho-social stressors.
A frequently repeated argument of the exhaustion theorists, especially
in the modern period, is that the technologies that have made our lives
physically easier, that have accelerated travel and communication, and
that should help us save both time and energy come with their own set
of new psycho-physical pressures, shaping both our public and our
private lives in new, insidious ways, thereby undoing their beneficial
effects. It is, of course, important not just to accept technological
progress and economic growth as values in themselves but to keep asking
critical questions about the wider cultural and psychological effects of
social and technological changes. Exhaustion theories have traditionally
functioned as vehicles for precisely such forms of cultural critique. At the
same time, it is also worth remembering that, as Frank Kermode put it,
We think of our own crisis as pre-eminent, more worrying, more interesting

than other crises. [ . . . ] It is commonplace to talk about our historical
situation as uniquely terrible and in a way privileged, a cardinal point in
time. But can it really be so? It seems doubtful that our crisis [ . . . ] is one of
the important differences between us and our predecessors. Many of them
felt as we do. If the evidence looks good to us, so it did to them.44
Kermode neatly sums up a strategy that most cultural commentators

writing on exhaustion tend to deploy, and which entails a nostalgic
glorification of the past paired with an ahistorical exaggeration of the
perceived evils of one’s own time.
44
Frank Kermode, The Sense of an Ending: Studies in the Theory of Fiction (Oxford: Oxford
University Press, 1968), pp. 94–5.
References
George M. Beard, A Practical Treatise on Nervous Exhaustion (Neurasthenia): Its
Symptoms, Nature, Sequences, Treatment (New York: W. Wood, 1880).
George M. Beard, American Nervousness: Its Causes and Consequences. A Supplement
to Nervous Exhaustion (Neurasthenia) (New York: G. P. Putnam Sons, 1881).
Matthew Bell, Melancholia: The Western Malady (Cambridge: Cambridge
A. M. Casiday, Evagrius Ponticus: The Early Church Fathers (Oxon and New
York: Routledge, 2006).
John Cassian, The Monastic Institutes, trans. Edgar C.S. Gibson, in
A Select Library of Nicene and Post-Nicene Fathers of the Christian
Church, Henry Wace and Philip Schaff, 14 vols (Oxford: James
Parker and Company; New York: The Christian Literature Company,
1894), vol. XI, pp. 183–641.
Jonathan Crary, 24/7: Capitalism and the End of Sleep (London and New York:
Verso, 2013).
Piereluigi Donini, ‘Psychology’, in The Cambridge Companion to the Hellenistic
World, ed. D. Glenn and R. Bugh (Cambridge: Cambridge University Press,
2006), pp. 184–209.
Alain Ehrenberg, The Weariness of the Self: Diagnosing the History of Depression
in the Contemporary Age, trans. David Homel et al. (Montreal and London:
McGill-Queen’s University Press, 2010).
Wilhelm Erb, Über die wachsende Nervosität unserer Zeit (Heidelberg:
J. Hörning, 1884).
Galen, On the Affected Parts, ed. and trans. Rudolph E. Siegel (London and
New York: S. Karger, 1976).
Galen, Selected Works, trans. P. N. Singer (Oxford and New York: Oxford
Christopher Gill, Tim Whitmarsh, and John Wilkins (eds.), Galen and the
World of Knowledge (Cambridge: Cambridge University Press, 2009).
Christopher Gill, Naturalistic Psychology in Galen and Stoicism (Oxford: Oxford
R. J. Hankinson (ed.), The Cambridge Companion to Galen (Cambridge:
Cambridge University Press, 2008).
Hugh of Saint Victor, On the Sacraments of the Christian Faith (De
Sacramentis), trans. Deferrari Roy J. (Cambridge, MA: The Mediaeval
Academy of America, 1951).
50 A.K. Schaffner
Stanley W. Jackson, Melancholia & Depression: From Hippocratic Times to

Modern Times (New Haven and London: Yale University Press, 1990).
Frank Kermode, The Sense of an Ending: Studies in the Theory of Fiction
(Oxford: Oxford University Press, 1968).
Richard Von Krafft-Ebing, Über Gesunde und Kranke Nerven, Fourth edition
(Tübingen: Verlag der H. Laupp’schen Buchhandlung, 1898).
Patrick Kury, Der Überforderte Mensch. Eine Wissensgeschichte vom Stress zum
Burnout (Frankfurt am Main and New York: Campus, 2012).
Clark Lawlor, From Melancholia to Prozac: A History of Depression (Oxford:
Oxford University Press, 2012).
Rowena Mason, ‘David Cameron Calls on Obese to Accept Help or Risk
Losing Benefits’, The Guardian, 14 February 2015, online at: http://www.
theguardian.com/politics/2015/feb/14/david-cameron-obese-addicts-
accept-help-risk-losing-benefits (accessed 18 February 2015).
Sighard Neckel and Greta Wagner (eds), Leistung und Erschöpfung. Burnout in
der Wettbewerbsgesellschaft (Frankfurt am Main: Suhrkamp, 2013).
Werner Post, Acedia – Das Laster der Trägheit. Zur Geschichte der siebten
Todsünde (Freiburg and Vienna: Herder, 2011).
Jennifer Radden, ‘Introduction’, in The Nature of Melancholy: From Aristotle to
Kristeva, ed. Jennifer Radden (Oxford: Oxford University Press, 2000), pp. 3–51.
Hans Selye, Stress without Distress (London and Toronto: Hodder and
Stoughton, 1975).
Richard Sennett, The Corrosion of Character (New York: W. W. Norton, 1998).
Sheldon Solomon, Jeff Greenberg and Tom Pyszczynsky, The Worm at the
Core: On the Role of Death in Life (London: Allen Lane, 2015).
St Thomas Aquinas, Summa Theologiae: A Concise Translation, ed. Timothy
McDermott (London: Eyre and Spottiswoode, 1989).
George Tsakiridis, Evagrius Ponticus and Cognitive Science: A Look at Moral Evil
and the Thoughts (Eugene, Oregon: Wipf and Stock, 2010).
Siegfried Wenzel, The Sin of Sloth: Acedia in Medieval Thought and Literature
(Chapel Hill: University of North Carolina Press, 1967).

Humanities at the University of Kent, UK. She has published on the histories of
exhaustion, sexology and psychoanalysis, Dada, the film director David Lynch,
and various modern writers. Her most recent monograph, Exhaustion: A History,
was published by Columbia University Press in 2016.
3
Neurasthenia and Managerial Disease
in Germany and America: Transnational
Ties and National Characteristics
in the Field of Exhaustion 1880–1960
Patrick Kury
A History of Knowledge at the Interface

Between Nature, Culture, and Society
In his essay Nous n’avons jamais été modernes (1991), the French philosopher,
sociologist, and cultural anthropologist Bruno Latour criticised the strict
separation of nature and culture in the modern era.1 Latour assumed that –
paradoxically and unexpectedly – the epistemological distinction between
nature and culture has resulted in so-called hybrids, ‘creatures between nature
and culture’.2 These are entities such as the ozone hole, global warming,
or genetically modified corn, which cannot simply be assigned either to the
1
Bruno Latour, Nous n’avons jamais été modernes. Essai d’anthropologie symétrique (Paris: éditions
La Découverte, 1991).
2
Bruno Latour, Wir sind nie modern gewesen. Versuch einer symmetrischen Anthropologie (Frankfurt
a.M: Fischer, 2008), p. 19.
P. Kury (*)
University of Lucerne, Lucerne, Switzerland
e-mail: patrick.kury@hist.unibe.ch

DOI 10.1007/978-3-319-52887-8_3
52 P. Kury
realm of objects or to the human domain.3 The hybrids emerge over and
again from the interdependencies and transformations of these domains,
which develop their own potentialities.
A particularly strong link between scientific artefacts and cultural
interpretations can be found in the diseases of civilisation. According
to Volker Roelcke:
The term ‘civilization disease’ is used for a wide range of health problems
that are attributed to the conditions of life in the modern age. It implies a
criticism of the current state of society. The development of the concept
and the strategies derived for combating diseases of civilization correlate
with each specific historical and political context.4
Lifestyle diseases are accordingly the product of the cultural interpreta-

tions available in a given era, as well as the specific social conditions then
prevailing. Roelcke thus recommends integrating ‘history and society
directly in the medical conceptualization’.5
The postulate of analysing the interaction between society, culture,
health, and disease when exploring so-called lifestyle diseases or diseases
of civilisation is directly relevant to the historical analysis of fatigue and
stress disorders. The approaches of Latour and Roelcke allow us to tackle
the complexity of this subject in its historicity, and also to analyse
current meanings and functions.
Analysing the social and cultural interdependencies of lifestyle diseases
also implies investigating transnational knowledge transfers. Transfers
between the stress discourses in North America and Europe are parti-
cularly common. This applies not only to today’s omnipresent burn-
out syndrome, which was first described by the German-American
psychotherapist Herbert Freudenberger in 1974. It became from
the mid-1990s one of the most frequently diagnosed workplace and
3
Ibid., pp. 67–8.
4
Volker Roelcke, ‘Zwischen individueller Therapie und politischer Intervention. Strategien gegen
“Zivilisationskrankheiten” zwischen 1920 und 1960’, Gesundheitswesen 57 (1995), 443–51 (443).
5
Volker Roelcke, Krankheit und Kulturkritik. Psychiatrische Gesellschaftsdeutungen im bürgerlichen
Zeitalter (1790–1914), (Frankfurt a. M.: Campus, 1999), p. 13.
3 Neurasthenia and Managerial Disease in Germany and America . . . 53
stress-related conditions in German-speaking countries. Yet the active

exchange between American and European discourses is also evident in
earlier literature on stress phenomena, such as neurasthenia, which,
coming from the United States, began its triumphal march through
Europe from 1880 onwards.
In the early 1930s, the German-Hungarian physician and biochemist
Hans Selye emigrated to the United States. He achieved scientific fame in
Canada, where he established himself as a master of stress research.
Nazism drove a large number of scientists and researchers across the
Atlantic, resulting in North America becoming a focal centre in the fields
of endocrinology and competitive knowledge. This essay highlights some
of these American-German and German-American exchanges between
1870 and 1950. It concentrates on two lifestyle diseases, neurasthenia and
managerial disease. This focus shows how knowledge transfers bring
national peculiarities to the fore, while revealing an entangled history of
ordinary and imaginary forced transfers.
Nerves Under Stress: The Genealogy

of Neurasthenia
The conjunction of modern lifestyles, new medical concepts of illness,
and the thematisation of health in the last third of the nineteenth
century explains why the literature generally describes neurasthenia as
the first disease of civilisation.6 Originating in the United States, the
concept of neurasthenia spread widely and rapidly in Central and
Western Europe in the early 1880s, notably in Germany and Austria.7
Neurasthenia, defined in terms of a vast range of symptoms, reached its
heyday before 1900.8 Doctors, psychiatrists, and patients assumed that
modern conditions of life, technical innovation, new modes of transport
6
Ibid., pp. 112–21.
7
Ibid., pp. 122–3.
8
Hans-Georg Hofer, Nervenschwäche und Krieg. Modernitätskritik und Krisenbewältigung in der
österreichischen Psychiatrie 1880–1920 (Vienna and Weimar: Böhlau, 2004), p. 56.
54 P. Kury
and communication, and the growing tempo of life weakened and put a
strain on the nervous system more than in the past. Neurasthenia was
seen as epitomising the modern age.9 However, under completely dif-
ferent social, economic, and cultural conditions after the First World
War the neurasthenia concept soon waned in importance.
In the late eighteenth and early nineteenth centuries, the notion of
nerves as sinew and muscle-like networks had slowly given way to the
idea of a delicate plexus for the transmission of stimuli; the decisive
impulse for the debate over nervousness then came, in about 1880, from
the United States.10 American research had hitherto ‘played virtually no
role in strongholds of European medicine’, according to Hans-Georg
Hofers.11 After this, however, it was the American neurologist Georg M.
Beard who gave a detailed description of the symptomatology and
pathogeny of ‘neurasthenia’ or ‘nervous exhaustion’ and established
neurasthenia as a diagnosis of the times.12 In A Practical Treatise on
Nervous Exhaustion (1880) and American Nervousness (1881), Beard,
who worked outside academia as an electrotherapist and neurologist,
was to become one of the best-known representatives of the field in the
United States and beyond.13
Social and Cultural Distinctions

By neurasthenia or nervousness, Beard understood the ‘functional dis-
eases of the nervous system’ caused by a ‘lack of nerve force’ that
manifested itself in a wide range of symptoms.14 These included
9
Hofer, Nervenschwäche, pp. 14–22.
10
Roelcke, Krankheit und Kulturkritik, pp. 112–21; Hofer, Nervenschwäche, pp. 45–88.
11
Ibid., p. 46, pp. 48–9.
12
Ibid., p. 46.
13
George M. Beard, A Practical Treatise on Nervous Exhaustion (Neurasthenia): Its Symptoms,
Nature, Sequences, Treatment (New York: William Wood & Company, 1880); George M. Beard,
American Nervousness: Its Causes and Consequences, A Supplement to Nervous Exhaustion
(Neurasthenia) (New York: Putnam’s Son, 1881).
14
Beard, American Nervousness, p. iv. On the difficulty of distinction between the terms, see
Hofer, Nervenschwäche, p. 16.
headaches, noises in the ears, a weak voice, morbid irritability, mental

depression, morbid fears (agoraphobia, claustrophobia, astraphobia; also
fear of responsibility), restlessness, insomnia, tenderness of the teeth,
nervous dyspepsia, desire for stimulants and narcotics, abnormally dry
skin, heaviness in the loins and limbs, shaking, tremulous and variable
pulse, local spasms of the muscles, sensitiveness to changes in the
weather, a feeling of weakness, cold extremities, men’s and women’s
diseases, yawning, a youthful appearance, and so forth.15
In addition, clinically distinct variants of neurasthenia were identified,
for example, spinal, cerebral, and sexual neurasthenia, or that of the
digestive tract.16 Beard was clearly aware of the seemingly arbitrary range
of symptoms when he remarked that the condition could affect all
functions and organs.17 He accordingly stressed that, in diagnosing
neurasthenia, it was to be remembered that the symptoms were not
structural or organic in nature but functional.18
Although to an extent Beard judged the sufferings of neurasthenics to
be serious and attributed the increase in the condition to modern
lifestyles, he did not regard it as a sign of misguided societal and tech-
nical developments, let alone as an expression of genetic degeneration.
Probably, the most important reason for his attitude was the symbolic
power of nervousness and neurasthenia for society: Beard ascribed
the illness primarily to members of the urban middle and upper classes
in the North and East of the United States, to so-called brainworkers:
businessman, lawyers, scientists, engineers, journalists, politicians, doc-
tors, and clergymen.19 In this sense, as Hans-Georg Hofer notes, Beard
saw neurasthenia as a sign of ‘national superiority’, as ‘a strategy of
distinction [ . . . ] to safeguard the elite status in society’ of the ‘male
American middle classes and upper classes’ over ‘blacks from the
15
Beard, American Nervousness, pp. 7–8.
16
Ibid., p. 56.
17
George M. Beard, Die Nervenschwäche (Neurasthenia). Ihre Symptome, Natur, Folgezustände und
Behandlung, trans. M. Neisser (Leipzig: Verlag von F.C.W. Vogel, 1883), p. 23.
18
Beard, American Nervousness, pp. 15–17; Beard, Practical Treatise, p. 118.
19
Beard, Nervenschwäche (Neurasthenia), p. 15; Beard, American Nervousness, p. 205.
56 P. Kury
southern states and white construction workers’ from the outlying dis-
tricts of New York.20
With the concept of neurasthenia, Beard also drew a distinction
between Europe and America.21 As far as the causes of nervousness and
neurasthenia were concerned, Beard was convinced that it was the living
conditions of the technologised modern age with its new modes of
transport and communication, and the mass media, thus mainly accel-
erative technologies and phenomena, that put the human nervous system
under greater strain than in the past. In American Nervousness, he wrote:
The chief and primary cause of this development and very rapid increase
of nervousness is modern civilisation, which is distinguished from the
ancient by these five characteristics: steam power, the periodical press, the
telegraph, the sciences, and the mental activity of women.22
Accordingly, the nervous system was subject to much greater stress in

modern urban centres than in rural areas and in past ages.23 Beard fails
to explain why he believed that the intellectual activity of women was a
cause of the increase in neurasthenia. However, again in American
Nervousness, he stressed that women are basically more nervous than
men: ‘in civilized lands, women are more nervous, immensurably, than
men, and suffer more from general and special nervous disease [ . . . ]’.24
Yet he sees the reason for American women being ‘weak’ and ‘tender’
(and presumably therefore more vulnerable to nervous conditions) as
lying not in biological but in social differences: ‘The weakness of woman
is all modern, and it is pre-eminently American. Among the Indians the
girls, like the boys, are brought up to toil and out-door life [ . . . ]. So
different are the squaws from the tender and beautiful women of the
white races, that they seem to belong to another order of creatures.’25
20
Hofer, Nervenschwäche, p. 57 and 59.
21
Beard, Nervenschwäche (Neurasthenia), p. 21.
22
Beard, American Nervousness, p. vi and 96.
23
Ibid., p. vii and pp. 133–138.
24
Ibid., p. 207.
25
Ibid., p. 185.
Despite the apparent prevalence of neurasthenia among women, Beard

in A Practical Treatise on Nervous Exhaustion cites fewer case studies of
women than men.26 In American Nervousness when discussing the rela-
tion between nervousness and beauty, clothes, child-bearing, and breast-
feeding, the examples he gives primarily concern women.27
Drawing on the technical knowledge of his time, Beard compared
people to electric batteries exhausted by unusual effort. Just as electrical
power under conditions of poor conductivity meets with greater resis-
tance, the nerves, too, react with greater resistance to unusual strain. To
overcome this resistance more energy or nerve force is required, which
means that reserves are used up and people tire.28 The aim of treatment
for people suffering from weak nerves is therefore twofold: ‘to widen the
margin of nerve-force, and to teach the patient how to keep from
slipping over the edge’.29
An American Disease Makes the Grade

in Germany
The scientific concept of neurasthenia hits the nerve of its time, provid-
ing a direct, scientific, but vague relationship between external causes
and diseases. Neurasthenia permitted a medical interpretation of many
types of strain experienced in the modern age, giving a social explanation
for individual conditions. As Volker Roelcke points out, during the
entire nineteenth century the question of the external causes of mental
illness had been the ‘central topos [ . . . ] of psychiatric theory build-
ing’.30 In modernity industrialisation and urbanisation favoured the
establishment and rapid acceptance of the concept of neurasthenia
from the 1880s onwards. As Roelcke also stresses, neurasthenia was
26
27
Beard, American Nervousness, pp. 65–78 and p. 52.
28
Ibid., pp. 10–12 and pp. 98–9.
29
Beard, American Nervousness, p. 13.
30
Roelcke, Krankheit und Kulturkritik, p. 205.
58 P. Kury
defined in pathogenic terms with ‘modern civilization’ being a necessary

and specific cause for the newly defined disease. For the first time, Beard
had thus defined, in a manner relevant for reception history, a distinct
and specific clinical syndrome as a disease of civilisation.31
The pathogenic definition and the variety of symptoms were des-
cribed by the famous German neurologist Wilhelm Erb, the most
influential of Beard’s German exponents, as follows:32
The immeasurable increase in traffic, worldwide networks of telegraph

and telephone have completely transformed conditions in trade and
commerce: haste and agitation reign, the night is used for travel, the day
for business, even the pleasure trips are a strain on the nervous system;
major political, industrial, and financial crises involve far greater sections
of the population in their commotion than in the past; participation in
political life has become general: political, religious, social struggles, the
buzz of party and electoral activities, the immense growth in societies and
associations fire the mind, demand ever greater effort, depriving people of
the time for recreation, sleep and rest; life in the big city has become more
and more sophisticated and restless.33
This quotation shows paradigmatically how the concept of neurasthenia

was strongly concerned with social and technological progress, with the
lifestyle of the urban middle-class elites, with achievement orientation,
and with the medicalisation of political and leisure culture.
In both the scientific community and for popular science, Beard’s
concept of neurasthenia found immediate acceptance and spread almost
explosively in Western and Central Europe, particularly in Germany.34
Given the country’s rapid economic growth and the rapid urbanisation
of the metropolis Berlin, Germany seems to have been particularly
susceptible to the notion of neurasthenia. There, as in the Austrian
31
Ibid., p. 120. Roelcke adds that from ‘the perspective of Beard and his contemporaries [ . . . ]
this disease “had” an ontological status, because it existed independently of the perception and
discursive theory of physicians. The neurasthenia was so “discovered” [ . . . ]’. Ibid., p. 121.
32
Hofer, Nervenschwäche, p. 69.
33
Wilhelm Erb, Über die wachsende Nervosität unserer Zeit (Heidelberg: Koester, 1894), p. 20.
34
Roelcke, Krankheit und Kulturkritik, pp. 122–3; Hofer, Nervenschwäche, pp. 64–73.
capital Vienna, neurasthenia attracted a great deal of attention in the

media. Not only neurologists, psychiatrists, and physicians but also
politicians, writers, intellectuals, and bohemians took an interest in the
new disease.
The literature has seen Max Weber as a kind of ideal-typical German
neurasthenic. Practically throughout his life, Weber suffered from
overwork, exhaustion, depression, sexual disorders, troubled sleep, and
eating disorders. Again and again he switched between ergomania and
extensive spa treatments, including visits to the Monte Verità ‘life refor-
mers’. Weber thus more or less incorporated in himself the tensions
experienced by an entire era.35
The literature explains the rapid spread of the concept of neurasthenia
in Germany first in terms of the socio-historical factors mentioned, such
as industrialisation, mechanisation, urbanisation, and a general accelera-
tion.36 While Joachim Radkau sees these socio-historical factors as the
cause of the actual increase in neurasthenic disorders in the late nine-
teenth century, Roelcke sees ‘the boom of the interpretive paradigm
neurasthenia as the expression of a historically specific, middle-class self-
and world interpretation [ . . . ], which, however, permits no direct
conclusions in the sense of retrospective epidemiology’.37 Hofer argues
in the same vein: ‘Of course, the subjective sufferings of people at the
turn of the century must be taken seriously, but as diagnosis, neurasthe-
nia and nervousness belonged to a medico-scientific explanatory system
that lent their experience a name and plausibility without capturing it
“authentically” or describing it “objectively.” ’ Hofer concludes that ‘the
diagnostic labels of medicine are to be regarded as historically contingent
35
Joachim Radkau, Max Weber. Die Leidenschaft des Denkens (Munich: Carl Hanser, 2005),
pp. 240–351. Responses to the negative side effects of modernity brought by the turn of the
century produced different, also non-academic movements that sought to reform living conditions
perceived as problematic, and accordingly the movements were called life reform movements.
Presenting an outstanding example of a place for reform, without being a real centre, was the
Monte Verità above Ascona. Max Weber was among those attracted by the magic and eroticism of
this Southern Alpine resort.
36
Joachim Radkau, Das Zeitalter der Nervosität. Deutschland zwischen Bismarck und Hitler
(Munich: Carl Hanser, 1998), pp. 173–262; Roelcke, Krankheit und Kulturkritik, p. 66.
37
Roelcke, Ibid., p. 26.
60 P. Kury
cultural achievements, which cannot reflect the sufferings of individuals

or at best only fragmentarily’.38
Furthermore, Roelcke and Hofer point out that the success of the
paradigm needs to be seen in the context of the crisis the (German)
educated classes were then experiencing, and the development of the
fledgling discipline of neurology within science.39 Thus, in the face of
this crisis, neurasthenia posited a link between life circumstances per-
ceived as stressful and ‘previously unclassifiable feelings of ill health’.40 At
the same time, a diagnosis of neurasthenia allowed patients to interpret
their condition as lying outside of their responsibility.
With regard to neurasthenia displacing older diagnoses such as hypo-
chondria, hysteria, and nervousness, Hofer agrees with the Canadian
medical historian Edward Shorter that the term neurasthenia had a
euphemistic function and served as a ‘fig leaf’, especially for middle-
and upper-class patients, to spare the feelings of patients and their
families alike.41 Hofer also refused to see any direct link between a
reputedly collective nervous emotional state in the late nineteenth- and
early twentieth-century Germany and the outbreak of the First World
War, as postulated by Radkau.42
After the First World War, the prominence the neurasthenia syndrome
had attained after 1880 declined just as fast as it had been growing, despite
the increasing importance psychiatry had achieved during the Great War.
The biological interpretation of mental disorders developed by pathologist
Emil Kraepelin had been a major factor from 1904 onwards: yet the too
open, too broad aetiology of neurasthenia weakened the concept, and
socio-economic conditions certainly also played a role in its decline.
It can be assumed that after 1918 large section of the middle classes
had neither the time nor the money for treatment. Against the backdrop
of economic crisis, unemployment, and hyperinflation, the male elite
38
39
Roelcke, Krankheit und Kulturkritik, p. 26 and pp. 122–137; Hofer, Nervenschwäche, pp. 18–9.
40
Ibid., p. 211 and 125.
41
Ibid., p. 160.
42
Ibid., pp. 26–28; Radkau, Zeitalter, pp. 447–64.
could no longer afford the luxury of neurasthenia. The experience of tens

of thousands of war veterans who had become the victims of material
struggles and often of severe traumatisation made lifestyle diseases such
as neurasthenia a negligible condition. It was only in the difficult
economic times after the Second World War that widespread disorders
once again became an issue among those in leading positions.
Lifestyle Diseases After 1950:

Managerial Disease
In the early 1950s, a socio-medical term appeared in Germany and
Austria, and later under other circumstances in Switzerland, that add-
ressed physical and mental stress; Managerkrankheit, managerial disease.
Doctors in German-speaking countries turned their attention to the
pressure of work on men in leading positions, to their diseases and causes
of death. For about a decade, the concept of managerial disease enjoyed
great popularity, not least in the media and in fiction. The medical experts
who addressed the phenomenon of managerial disease focused primarily
on cardiovascular conditions. Yet various psychosomatic disorders and
symptoms were soon subsumed under this name, disorders that today
would be understood as consequences of stress; in the 1950s to be ‘burnt
out’ meant to be suffering from managerial disease.43
The specialists believed the cause of the exhaustion and overwork
condition to lie in the socio-economic and cultural circumstances of
the 1950s. In West Germany and Austria, the first two decades after
the Second World War were devoted to reconstruction, to improving
the disastrous housing situation, to restoring a functioning economy,
expanding the social market economy, re-establishing democratic struc-
tures, creating politically independent media, and integrating millions of
returning soldiers, refugees, and displaced persons into society. All these
tasks presented enormous social, economic, and political challenges.
43
See eds. Herbert Gross et al., Intelligenz – zu Tode gehetzt (Munich: Allianz-Versicherung,
1958), p. 1.
62 P. Kury
The Marshal Plan and burgeoning economic growth in the Western

world helped cope with them.44
As far as is known, the term Managerkrankheit first appeared in the
1950s. One of the first to broach the subject was Michael Bauer, ministerial
counsellor, professor, and president of the German Spa Association.45 In the
prestigious Münchener Medizinische Wochenschrift, he wrote in 1953 of the
‘managerial disease that now attracts so much attention’. As a leading health
practitioner and therapist, Bauer was at the interface between medicine,
therapy, popular science, and society. Thus, it is hardly surprising that he
described managerial disease as a disease of civilisation (without using this
term directly). He saw in the condition the ‘best testimony’ for the different
‘ills of civilisation’ that had so strongly increased since the Second World
War.46 Bauer put the blame on ‘overstrain to the point of exhaustion, a lack
of sleep and real relaxation, overtaxation of one’s capabilities, a lack of
exercise, and the excessive use of stimulants of all sorts’; in brief, on the
new work and consumer behaviour of the post-war period.47
Like Bauer, the internist Max J. Halhuber of the Innsbruck University
Hospital drew attention to the growing public interest in managerial
disease, which ‘had become one of the most popular medical topics in
illustrated weeklies and the daily press’.48 In Ars Medici, a Swiss journal for
medical practitioners, Halhuber pointed to ‘a disturbing socio-medical
experience: namely the striking increase in sudden circulatory deaths in
relatively young businessmen and politicians’.49 Bauer and Halhuber were
two among many to note this situation. The editors of the journal
44
Hans-Ulrich Wehler, Deutsche Gesellschaftsgeschichte, vol. 5, Bundesrepublik und DDR
1949–1990 (Munich: C. H. Beck, 2008), pp. 73–6; Herfried Münkler, Die Deutschen und ihre
Mythen (Berlin: Rowohlt, 2009), pp. 455–76.
45
The contemporary physicians Max Hochrein, Friedrich Dittmar, and Otto Graf assumed that it
was Michael Bauer who had used the concept of manager disease for the first time.
46
Michael Bauer, ‘Das Deutsche Bäderwesen und seine Organisation im Dienste der Vorbeugung.
Behandlung und Behebung von Krankheiten und Krankheitsfolgen’, Jubiläumsausgabe: 100
Jahre Münchner Medizinische Wochenschrift (Jubiläumsausgabe: 100 Jahre MMW) 95 (1953),
126–28 (127).
47
Bauer, ‘Bäderwesen und seine Organisation’, p. 127.
48
Max J. Halhuber, ‘Begriff und Bedeutung der Managerkrankheit’, Ars medici. Das Organ des
praktischen Arztes 43:1 (1953), 462–66 (462).
49
Ibid.
Medizinische Klinik had thus described the term Managerkrankheit as a

‘buzzword’ as early as 1954.50
Since then doctors have thematised the pressure to perform to which
men in leading positions are subject, and which may even result in illness
and death. The term managerial disease ascribed overwork and exhaus-
tion chiefly to the economic and political, mainly male, elite. From a
medical point of view, managerial disease was primarily understood as a
cardiovascular condition, but many doctors soon came to interpret it as a
psychosomatic lifestyle disease encompassing a wide range of ailments
and symptoms, and began to attribute it to the socio-economic and
cultural situation of the 1950s.51
Real and Imagined Transfers

According to contemporary experts, the neologism Managerkrankheit,
introduced in the 1950s into the German-speaking world, was a transla-
tion of the American ‘managerial disease’. Although internist Halhuber
was convinced that ‘excess mortality’ among the male elite since the 1948
currency reform was behind the emergence of the new term, he and his
Viennese colleague Rudolf Wenger assumed James Burnham’s book The
Managerial Revolution to be the source of the word and concept,52 which
appeared in New York in 1941.53 Burnham had attempted a sociological
typology that classified managers in terms of functional criteria, postulat-
ing that capitalist society was in transition to a new, so-called managerial
order in which managers constituted the ‘ruling class’.54 He claimed that
it was increasingly managers who controlled access to the means of
50
Medizinische Klinik, 49, p. 1608.
51
Halhuber, ‘Begriff und Bedeutung’, p. 462.
52
Ibid., pp. 462–4.
53
James Burnham, The Managerial Revolution: What is Happening in the World (New York: John
Day, 1941).
54
Burnham assumed that the ‘economic system which will ensure the social management of the
manager, [ . . . ] is based on the state ownership of the means of production’. James Burnham, Das
Regime der Manager (Stuttgart: Union Deutsche Verlagsgesellschaft, 1948), p. 92.
64 P. Kury
production and the distribution of products.55 According to Halhuber,

Burnham’s book introduced the term ‘managerial disease’ into the
United States, leading to ‘premature vascular sclerosis’ being classified
in the United States as an occupational disease.56
Whether Wenger and Halhuber were right cannot be answered con-
clusively at this point. However, the term managerial disease is nowhere
to be found in the titles of American books or articles in the early 1950s,
and although it came to be used somewhat more frequently in the 1960s,
there is no comparing its currency with that of Managerkrankheit in
German-speaking countries. Doubts about Wenger and Halhuber’s
hypothesis that a precursor of the concept of managerial disease is to
be sought in the United States are also fuelled by a 1958 marginal note
by the American political scientist Herbert J. Spiro; after studying in
West Germany between 1953 and 1955 he published a monograph
on codetermination in post-war Germany at Harvard, in which he has
this to say about trade-union leaders in the German steel and mining
sectors:
Among these are several mayors of sizeable cities, members of the

Bundestag, of state parliaments and municipal councils. These men,
once more, as many of the works council chairmen, are very busy indivi-
duals, and some of them suffer from what the Germans call ‘managerial
disease’, which in Germany seems to manifest itself as circulatory disorders
rather than stomach ulcers.57
The American Spiro thus ascribed the term ‘managerial disease’ entirely
to German medical discourse. It is therefore plausible to assume that
the term Managerkrankheit was not imported as a translation of
the American term ‘managerial disease’, but that the terminology trans-
fer took place in precisely the opposite direction. It can, however, be
55
Ibid., p. 115 and 117.
56
Halhuber, ‘Begriff und Bedeutung’, p. 462. The term managerial disease is not found in
Burnham’s book Managerial Revolution.
57
Herbert J. Spiro, The Politics of German Codetermination (Cambridge, MA: Harvard University
Press, 1958), p. 105.
assumed that the impetus for the concept came from the United States.
Apart from contemporary references to Burnham by German physicians,
there is further evidence that this was the case; in the United States, too,
the proliferation of cardiovascular disease in middle- and upper-class
men was under discussion in medical circles in the early 1950s, a debate
that had attracted attention in West Germany.58
In contrast to Germany and Austria, where managerial disease had
been associated not only with economic growth and new lifestyles in
the consumer society but also directly with the efforts and privations
demanded by reconstruction, the debates in the United States inter-
preted the increase in cardiovascular diseases mainly as a question of
lifestyle. As the American journalist Barbara Ehrenreich has shown, there
was speculation in the United States about the psychosocial causes of
cardiovascular diseases in such media as Life magazine and the men’s
magazine Playboy, which first appeared in 1953. Men’s lifestyles and
their role as the breadwinner were criticised.59 However, there was still
no evidence that only the professional and social elite were affected.
Medical Interpretations of the Challenges

of the Post-war Period
The discourse on stress and the popular scientific concept of managerial
disease opened the way for a broad discussion and medical interpreta-
tions regarding the presumed physical and mental consequences of
reconstruction, and the ‘economic miracle’, in Germany. The concept
of managerial disease directly linked social change in the post-war era
with a perceived increase in physical and mental stress. Although the
condition stood for the morbid excesses of reconstruction and growth, it
was also inextricably associated with the success story of the Federal
58
For the American debates on cardiovascular diseases, see Barbara Ehrenreich, Die Herzen der
Männer. Auf der Suche nach einer neuen Rolle (Reinbek bei Hamburg: Rowohlt, 1984), p. 77–98,
translated as The Hearts of Men: American Dreams and the Flight from Commitment (New York:
Pluto, 1983). I thank Wolfgang Fach for pointing this out.
59
Ibid., pp. 51–60 and 80–3.
66 P. Kury
Republic, the currency reform, the Economic Miracle, and the integra-
tion of the Federal Republic into the Western Alliance.
When in the late 1950s major progress in reconstruction and in trade-
union protection for the workforce had been achieved, the vague and
scientifically untenable term Managerkrankheit rapidly lost its impor-
tance and disappeared from the medical literature as fast as it had
surfaced a decade earlier. In the popular mind, however, the concept
survived well beyond the 1950s. The preoccupation with managerial
disease, which in the 1950s had led to the publication of a number of
health guides, built bridges for German doctors who had made a career
before 1945. Scientists concerned with the strains of civilisation could
look back on work done under the National Socialist regime on perfor-
mance and fatigue, without these German experts having to draw on
bio-chemical medicine and stress research in the English-speaking world
and Scandinavia.
Forced Transfers and Missing Links

The popularity of diagnoses of managerial disease in the Federal
Republic of Germany in the 1950s and early 1960s can also be explained
by the standstill in knowledge transfers under the Nazi rule. Under the
Nazi racial and extermination policies, the Second World War and its
aftermath had put an end to Germany’s leading position in the field of
endocrinology. The destruction of knowledge in the natural sciences and
medicine following 1933 was not equally drastic in all fields of scientific
research and medicine, but in endocrinology the loss was particularly
striking. The loss of biochemical knowledge within the medical research
community had consequences for German science. Experts previously
occupied with questions of exhaustion did not take part in the upcoming
stress research. Rather, they dealt with the Managerkrankheit theory,
which leant upon neurasthenia research. Besides, in Germany the
Managerkrankheit concept had a greater plausibility.
In 1953, Arthur Jores addressed the question of this loss. Jores, who is
remembered above all as well-known psychosomatic researchers of the
1960s and 1970s, was until well into the 1960s one of the leading
endocrinologists in Germany.60 As a critic of the Nazis, he had had to

abandon his university career after their seizure of power, and spent
several months in prison. After the Second World War, he became head
of internal medicine at the University Hospital Hamburg-Eppendorf. In
1953, he was co-founder of the German Society of Endocrinology and
its first president from 1953 to 1963. On the occasion of the first
symposium of the German Society of Endocrinology in 1953, Jores
discussed the state of endocrinology in Germany at that time. Without
directly mentioning the background of Nazi science and racial policy,
Jores had the following to say:
The German-speaking world was the birthplace of endocrinology. Biedl

produced the first textbook on the subject, and in 1929 Hirsch brought
out the first manual with almost only German authors contributing. The
focus of endocrinological research today is in America. In Germany there
are only few who still address this important discipline. It is the hope of
the founders of this society that it will provide new impetus for reviving
endocrinological research in Germany.61
The issue raised by Jores of the loss of importance of German and

European endocrinology caused by the massive forced emigration of
scientists, or their murder by the National Socialists, has yet to be
systematically investigated. A number of outstanding Jewish scientists,
such as the Hungarian endocrinologist Károly Gyula David who worked
in the circle around Laqueur for the pharmaceutical company Organon
founded in Amsterdam in 1923 (and who succeeded in isolating testos-
terone in 1935), or the chemist Salomon Kober who also working at
Organon (who had developed a biological process for detecting the
hormone estrone), were murdered by the Nazis at Mauthausen and
60
For Arthur Jores, see Gerhard Bettendorf (ed.), Zur Geschichte der Endokrinologie und
Reproduktionsmedizin (Berlin: Springer, 1995), pp. 268–9. In his habilitation thesis in the
1930s, he provided evidence that melanophore hormone (a hormone that controls body colour-
ing) is formed as an independent hormone in the pituitary gland.
61
Arthur Jores, ‘Vorwort’, in Zentrale Steuerung der Sexualfunktion. Die Keimdrüsen des Mannes, 1.
Symposium der Deutschen Gesellschaft für Endokrinologie, ed. Henryk Nowakowski (Berlin:
Springer, 1955).
68 P. Kury
Auschwitz-Birkenau.62 Numerous other endocrinologists saved their

lives only by emigrating.63 As a rule, emigrating scientists settled in the
United States, with some in Switzerland, for instance Manes Kartagener,
who worked at the Swiss Federal Institute of Technology in Zurich.64
Other eminent scientists such as Ernst Laqueur, professor of pharma-
cology, director of the pharmacotherapeutic laboratory at the University of
Amsterdam, and co-founder of Organon, were banned from entering their
own institutes.65 The emigration and flight of many leading scientists from
Germany, Austria, and other parts of Europe explains why the United States
became the centre of endocrinological research from the late 1940s. The
resulting loss of expertise in the field of endocrinology in Germany may have
been a reason why stress research (whether in endocrinology, in psychiatry,
or in psychosomatic medicine) in Germany attracted little attention before
1970. The decline of endocrinology in Germany after 1945 was partly
reflected in the academic career of Arthur Jores, who turned to psycho-
somatic medicine after the Second World War. Exchanges with patients
after the experience of the Second World War caused him to take this step.66
At the same time, Jores continued in the 1950s to work for the revival of
German endocrinology and to bring psychosomatics and endocrinology
together. The Fifth Symposium of the German Society of Endocrinology in
Freiburg in 1957, on the topic ‘Hormones and Psyche’, sought to address
Jores’ concerns. For the time being, however, this endeavour remained a
marginal consideration in Germany.67
62
For Károly Gyula David and Salomon Kober, see Bettendorf, Endokrinologie, p. 99 and
pp. 320–1.
63
The following scholars were brought to safety before the Nazi’s takeover: Ludwig Adler
(1876–1958), Selmar Aschheim (1878–1965), Bernhard Aschner (1883–1960), Maximilian,
Richard Ehrenstein (1899–1968), Erich Fels (1897–1981), Ludwig Fraenkel (1870–1951), Alfred
Fröhlich (1871–1953), Ernst Gräfenberg (1881–1957), Franz Josef Kallmann (1897–1965), Manes
Kartagener (1897–1975), Ernst Laqueur (1880–1947), Walter Siegfreid Loewe (1884–1963), Otto
Loewi (1873–1961), Robert Meyer (1864–1947), Karl Heinrich Slotta (1895–1987), and Bernhard
Zondek (1891–1966).
64
For Manes Kartagener, see ibid., p. 294.
65
For Ernst Laqueur, see ibid., pp. 330–331.
66
Ibid., p. 269.
67
Henryk Nowakowski, Hormone und Psyche. Die Endokrinologie des Alterns, 5. Symposium der
Deutschen Gesellschaft für Endokrinologie (Berlin: Springer, 1958).
Belated Interest in Psychosocial Stress

In 1958, an article by the Linz physician and later senior medical officer
Helmut Paul entitled Über den Psycho-Stress appeared in the Munich
journal Psychologie und Praxis.68 In the history of German psychology,
this article is generally considered to signal the beginning of the concern
with stress in Germany.69 Paul sought to make the German public
acquainted with the latest findings of contemporary stress research in
the English-speaking world. He laid particular emphasis on the work of
Hans Selye, Abram Kardiner, Roy R. Grinker and John P. Spiegel, and
Reuben Hill. With reference to Hans Selye, Paul, who had investigated,
among other things, the function of hormones in fatigue, pointed out
that it was initially clear that physiological stresses such as in inflamma-
tion, and psychological stress, did not run fully parallel to one other.
However, psychological stress did have a task similar to physiological
stress, namely to deal with the damage caused by the reason for stress.70
Paul gave no explicit definition of psychological stress. Rather, he
distinguished between endogenous stress, where the source lies within
the individual himself, and exogenous stress, where the cause is to be
sought in the environment. Paul focused on exogenous stress. At the
same time, he noted that in practice these two forms of stress could
usually not be kept clearly separate, since mental stress usually involves
both predisposition and reaction to the environment.71 Both forms of
stress took the course described by Selye, from an alarm reaction via the
resistance stage to the exhaustion stage, from which under favourable
conditions it will proceed to the recovery stage.72
68
Helmut Paul, ‘Über den Psycho-Stress’, Psychologie und Praxis. Wirtschaft, Industrie,
Verwaltung, Zeitschrift für die Anwendungsgebiete der Psychologie 2: 1 (1958), 1–13.
69
Wolfgang Schönpflug, ‘Beanspruchung und Belastung bei der Arbeit – Konzepte und
Theorien’, in Arbeitspsychologie, ed. Uwe Kleinbeck and Joseph Rutenfranz (Göttingen: Verlag
für Angewandte Psychologie, 1987), pp. 130–84 (p. 134).
70
All quotations are from Paul, ‘Über den Psycho-Stress’, p. 1.
71
Ibid.
72
Ibid., p. 2.
70 P. Kury
Paul also distinguished between acute and chronic psychological stress.73

In both cases, they mostly involve a ‘threat to the psychological domain
[ . . . ] that includes self-preservation’.74 In acute psychological stress, this is
caused by sudden stress situations such as earthquakes, air raids, or even
(unjustified) criticism, a transfer, or dismissal. Chronic psychological stress
involves a summation of individual stimuli that act over a longer period.75
Paul appears to have drawn on Abram Kardiner and Herbert Spiegel’s 1947
publication War Stress and Neurotic Illness, transferring their treatment of
the wartime situation to civilian life. With his distinction between acute
and chronic psychological stress, Paul also appears to have anticipated
Thomas H. Holmes and Richard H. Rahe’s concept of a ‘life event’, and
Allen D. Kanner and Richard S. Lazarus’s notion of ‘daily hassles’.
One striking aspect of Paul’s remarks is that he relates the various
aspects of psychological stress, which he attributes to war experience,
only to American soldiers and civilians during the Second World War
and the Korean War. Writing in 1958, he has nothing to say about
corresponding experiences in Germany or Austria during the Second
World War. The focus on the US war situation can be explained at least
partially by his choice of research literature. Further to this, however, the
early Federal Republic did not offer a suitable terrain for appreciating the
psychosomatic and psychosocial findings of North American stress
research, by Harold G. Wolff and others.
While the medical profession and the general public in West Germany
and Austria discussed managerial disease as the physical and psychological
consequence of reconstruction and economic growth, they did not
associate it to the same degree with war and persecution. The emotional
overload typical of West German post-war society, due to external and
internal factors, stood in the way of adopting innovative psychosomatic
approaches from the United States. It was not until the mid-1970s that
science and the media in Germany and Austria, too, began to concern
themselves intensively with psychosocial stress research.
73
Ibid., pp. 3–5.
74
Ibid., p. 4.
75
Ibid., pp. 3–4.
Major impulses for the medical study of the later consequences of war and
persecution came not from Germany but from Denmark, Holland, and later
Israel – but chiefly from the English-speaking world. Of the 14 conferences
dealing with the health consequences of persecution and war between 1954
and 1964, only one took place in Germany.76 New York developed into a
centre for the study of the psychological consequences of war and persecu-
tion, notably under prominent psychoanalysts such as Kurt R. Eissler,
William G. Netherlands, and others. William Netherlands, who had studied
in Würzburg and worked in Berlin and Gailingen, had fled Germany in
1934.77 He eventually immigrated to the United States in 1940, where he
held a chair of psychiatry at the State University in New York. At the same
time, he worked as medical officer at the German Consulate General in
New York. He published a number of scientific papers on the later effects
of persecution from the early 1960s, partly in collaboration with the psy-
chiatry professor Henry Krystal, himself a survivor of the Shoah. William
Netherlands resigned as medical officer at the German Consulate General in
1973 after a dispute with the German compensation authorities.78
In the long term, the commitment of this New York psychiatrist paid off
in dealing with war-related traumatic disorders among American soldiers.
Yet it required the debate on the Vietnam War in the United States to bring
a general recognition of post-traumatic stress disorder, as a health problem.
The history of neurasthenia and Managerkrankheit show the inter-
weaving between the United States and Germany in the field of exhaus-
tion research, long before stress and burnout research attained popularity.
As exhaustion illnesses the earlier two are founded both on mechanical
images of the body, against which stress and burnout, which operate with
dynamic sources, are based. Above all, these health disturbances have
in common the fact that they are often regarded positively, and appear in
phases of rapid social and economic change.
76
Christian Pross, Wiedergutmachung. Der Kleinkrieg gegen die Opfer (Frankfurt a. M.: Hamburger
Institut für Sozialforschung, 1988), pp. 361–64.
77
For G. Niederland, see Wenda Focke, ‘Niederland, William (Wilhelm) G.’, Neue Deutsche
Biographie 19 (1998), 223–24, online at: http://www.deutsche-biographie.de/artikelNDB_n19-
223-01.html (accessed April 2010).
78
Pross, Wiedergutmachung, p. 140.
72 P. Kury
References
Michael Bauer, ‘Das Deutsche Bäderwesen und seine Organisation im Dienste
der Vorbeugung. Behandlung und Behebung von Krankheiten und
Krankheitsfolgen’, Jubiläumsausgabe: 100 Jahre Münchner Medizinische
Wochenschrift (Jubiläumsausgabe: 100 Jahre MMW) 95 (1953), 126–8.
Symptoms, Nature, Sequences, Treatment (New York: William Wood &
Company, 1880).
———, American Nervousness: Its Causes and Consequences, A Supplement to
Nervous Exhaustion (Neurasthenia) (New York: Putnam’s Son, 1881).
———, Die Nervenschwäche (Neurasthenia). Ihre Symptome, Natur, Folgezustände
und Behandlung, trans. M. Neisser (Leipzig: Verlag von F.C.W. Vogel, 1883).
Gerhard Bettendorf (ed.), Zur Geschichte der Endokrinologie und
Reproduktionsmedizin (Berlin: Springer, 1995).
James Burnham, The Managerial Revolution. What is Happening in the World
(New York: John Day, 1941).
———, Das Regime der Manager (Stuttgart: Union Deutsche
Verlagsgesellschaft, 1948).
Barbara Ehrenreich, Die Herzen der Männer. Auf der Suche nach einer neuen
Rolle (Reinbek bei Hamburg: Rowohlt, 1984).
Wilhelm Erb, Über die wachsende Nervosität unserer Zeit (Heidelberg: Koester,
1894).
Wenda Focke, ‘Niederland, William (Wilhelm) G.’, Neue Deutsche Biographie
19 (1998), 223–4, online at: http://www.deutsche-biographie.de/
artikelNDB_n19-223-01.html (accessed April 2010).
Herbert Gross et al. (eds.), Intelligenz – zu Tode gehetzt (Munich: Allianz-
Versicherung, 1958).
Max J. Halhuber, ‘Begriff und Bedeutung der Managerkrankheit’, Ars medici.
Das Organ des praktischen Arztes 43: 1 (1953), 462–6.
Hans-Georg Hofer, Nervenschwäche und Krieg. Modernitätskritik und
Krisenbewältigung in der österreichischen Psychiatrie 1880–1920 (Vienna
and Weimar: Böhlau, 2004).
Arthur Jores, ‘Vorwort’, in Zentrale Steuerung der Sexualfunktion. Die Keimdrüsen
des Mannes, 1. Symposium der Deutschen Gesellschaft für Endokrinologie, ed.
Henryk Nowakowski (Berlin: Springer, 1955).
Bruno Latour, Nous n’avons jamais été modernes. Essai d’anthropologie symétrique
(Paris: éditions La Découverte, 1991).
———, Wir sind nie modern gewesen. Versuch einer symmetrischen Anthropologie
(Frankfurt a. M.: Fischer, 2008).
Herfried Münkler, Die Deutschen und ihre Mythen (Berlin: Rowohlt, 2009).
Henryk Nowakowski, Hormone und Psyche. Die Endokrinologie des Alterns, 5.
Symposium der Deutschen Gesellschaft für Endokrinologie (Berlin: Springer, 1958).
Helmut Paul, ‘Über den Psycho-Stress’, Psychologie und Praxis. Wirtschaft,
Industrie, Verwaltung, Zeitschrift für die Anwendungsgebiete der Psychologie
2: 1 (1958), 1–13.
Christian Pross, Wiedergutmachung. Der Kleinkrieg gegen die Opfer (Frankfurt a. M.:
Hamburger Institut für Sozialforschung, 1988).
Joachim Radkau, Das Zeitalter der Nervosität. Deutschland zwischen Bismarck
und Hitler (Munich: Carl Hanser, 1998).
———, Max Weber. Die Leidenschaft des Denkens (Munich: Carl Hanser, 2005).
Volker Roelcke, ‘Zwischen individueller Therapie und politischer Intervention.
Strategien gegen “Zivilisationskrankheiten” zwischen 1920 und 1960’,
Gesundheitswesen 57 (1995), 443–51.
———, Krankheit und Kulturkritik. Psychiatrische Gesellschaftsdeutungen im
bürgerlichen Zeitalter (1790–1914) (Frankfurt a. M.: Campus, 1999).
Wolfgang Schönpflug, ‘Beanspruchung und Belastung bei der Arbeit – Konzepte
und Theorien’, in Arbeitspsychologie, ed. Uwe Kleinbeck and Joseph Rutenfranz
(Göttingen: Verlag für Angewandte Psychologie, 1987), pp. 130–84.
Herbert J. Spiro, The Politics of German Codetermination (Cambridge, MA:
Harvard University Press, 1958).
Hans-Ulrich Wehler, Deutsche Gesellschaftsgeschichte, vol. 5, Bundesrepublik und
DDR 1949–1990 (Munich: C. H. Beck, 2008).
Patrick Kury is Senior Lecturer in Swiss and General Contemporary History at

the University of Lucerne and at the Distance Learning University of Switzerland.
He is also co-curator and project leader of the exhibition 14/18 – Switzerland and
the Great War. His most recent books include In Step with Time: From Swiss
Industries Fair to MCH Group (Basel 2016), edited with Esther Baur; 14/18
La Suisse et la Grande Guerre (Baden 2014), edited with Roman Rossfeld and
Thomas Buomberger; and Der überforderte Mensch. Eine Wissensgeschichte vom
Stress zum Burnout (Frankfurt and New York, 2012).
Part II
Exhaustion Syndromes
4
Exhaustion Syndromes: Concepts
and Definitions
Johanna M. Doerr and Urs M. Nater
Introduction
Fatigue is a very common complaint and a normal part of human
experience.1 It can be defined as a ‘sense of exhaustion’,2 or as ‘tiredness,
weakness, and lack of energy’.3 Fatigue and exhaustion are often used
interchangeably; however, in the medical and psychological literature,
authors prefer the term fatigue. The term fatigue will thus be used
in this chapter. Comparable to pain, fatigue is a subjective phenomenon
1
T. Pawlikowska et al., ‘Population Based Study of Fatigue and Psychological Distress’, BMJ 308
(1994), 763–6.
2
W. T. Riley et al., ‘Patient-Reported Outcomes Measurement Information System (PROMIS)
Domain Names and Definitions Revisions: Further Evaluation of Content Validity in IRT-Derived
Item Banks’, Quality of Life Research 19 (2010), 1311–21 (1318).
3
R. Schwarz, O. Krauss, and A. Hinz, ‘Fatigue in the General Population’, Onkologie 26
(2003), 140.
J.M. Doerr (*) U.M. Nater

University of Marburg, Marburg, Germany
e-mail: johannamdoerr@gmail.com; nater@uni-marburg.de

DOI 10.1007/978-3-319-52887-8_4
78 J.M. Doerr and U.M. Nater
and as such is commonly reported by self-assessment measures.4 It reaches

clinical relevance when it cannot be alleviated by measures of rest, or
presents itself at such an intensity that it interferes with daily life and well-
being.5 Clinically relevant fatigue is defined as ‘prolonged’ when it lasts
longer than one month and ‘chronic’ if it persists for at least six months.6
Chronic fatigue can be found in patients suffering from cancer,7 multiple
sclerosis,8 human immunodeficiency virus infections,9 and other illnesses. If
no sufficient somatic explanation for fatigue can be found with today’s
medical knowledge, it is referred to as ‘medically unexplained’.
Chronic medically unexplained fatigue as a core symptom of various
syndromes has puzzled many commentators throughout history (for a com-
prehensive overview, see Edward Shorter,10 Karin Johannisson,11 and
Stephanie S. Leone)12 and across cultures. This chapter analyses different
attempts at and possibilities of naming and classifying chronic fatigue con-
ditions, each in the context of their historical and cultural background.13
4
A. J. Dittner, S. C. Wessely, and R. G. Brown, ‘The Assessment of Fatigue: A Practical Guide for
Clinicians and Researchers’, Journal of Psychosomatic Research 56 (2004), 157–70.
5
W. T. Riley et al., ‘Patient-Reported Outcomes Measurement Information System (Promis)
Domain Names and Definitions Revisions: Further Evaluation of Content Validity in Irt-Derived
Item Banks’, Quality of Life Research 19 (2010), 1318.
6
K. Fukuda et al., ‘The Chronic Fatigue Syndrome: A Comprehensive Approach to Its Definition
and Study. International Chronic Fatigue Syndrome Study Group’, Annals of Internal Medicine
121 (1994), 953–9; L. A. Jason et al., ‘A Community-Based Study of Prolonged Fatigue and
Chronic Fatigue’, Journal of Health Psychology 4 (1999), 9–26.
7
A. Barsevick et al., ‘I’m So Tired: Biological and Genetic Mechanisms of Cancer-Related
Fatigue’, Quality of Life Research 19 (2010), 1419–27.
8
F. Bethoux, ‘Fatigue and Multiple Sclerosis’, Annales de Réadaptation et de Médecine Physique
49 (2006), 355–60.
9
J. Barroso, ‘A Review of Fatigue in People with HIV Infection’, Journal of the Association of
Nurses in AIDS Care 10 (1999), 42–9.
10
Edward Shorter, ‘Chronic Fatigue in Historical Perspective’, in Chronic Fatigue Syndrome –
Ciba Foundation Symposium 173, ed. Gregory R. Bock and Julie Whelan (Chichester, England:
John Wiley, 1993), pp. 6–16.
11
Karin Johannisson, ‘Modern Fatigue: A Historical Perspective’, in Stress in Health and Disease
(Weinheim, Germany: Wiley-VCH Verlag, 2006), pp. 3–19.
12
S. S. Leone et al., ‘Two Sides of the Same Coin? On the History and Phenomenology of
Chronic Fatigue and Burnout’, Psychology and Health 26 (2011), 449–64.
13
This book chapter is based on an updated literature search for a German review paper which we
published in 2013: J. M. Doerr and U. M. Nater, ‘Erschöpfungssyndrome – Eine Diskussion
First, the case of neurasthenia is discussed as the most prominent example

of how historical and cultural factors influence the definitions and
diagnoses of fatigue. Next, the controversial case of chronic fatigue
syndrome or myalgic encephalomyelitis (CFS/ME) will be described.
After this the most recent new fatigue syndrome, burnout, is discussed.
We compare the specific criteria for each condition and also discuss the
latter two concepts in relation to depression.
Neurasthenia
The initial description of neurasthenia is often regarded as the first
attempt to classify a fatigue condition. In 1869, the New York-based
physician George Beard described a syndrome that was defined by a
‘want of nervous force’, and introduced the term ‘neurasthenia’ for this
phenomenon.14 Criteria for the syndrome, described in his book, com-
prised in addition to fatigue a wide array of emotional, cognitive, and
somatic symptoms (such as hopelessness, morbid fears, deficient mental
control, general and local itching, and cold feet and hands).15 As the
diagnosis of neurasthenia comprised such a wide array of divergent
symptoms, it became the most diagnosed neuro-psychiatric disorder
around 1900. As such, the diagnosis may be regarded as a ‘wastebasket’
for otherwise unexplained symptoms and is not necessarily comparable
to what we would classify as a medically unexplained CFS today.16
However, using different criteria (but keeping fatigue as the main
symptom), neurasthenia can still be found as a diagnostic category in the
International Classification of Diseases in its 10th revision (ICD-10,
verschiedener Begriffe, Definitionsansätze und klassifikatorischer Konzepte’, Psychotherapie,

Psychosomatik, Medizinische Psychologie 63 (2013), 69–76.
14
George Beard, ‘Neurasthenia, or Nervous Exhaustion’, Boston Medical and Surgical Journal
3 (1869), 217–21.
15
George Beard, A Practical Treatise on Nervous Exhaustion (Neurasthenia), third edition
(New York: 5 Cooper Union, 1894).
16
Edward Shorter, ‘Chronic Fatigue in Historical Perspective’, in Chronic Fatigue Syndrome –
Ciba Foundation Symposium 173, ed. by Gregory R. Bock and Julie Whelan (Chichester, England:
John Wiley, 1993), pp. 6–16 (p. 12).
code F48.0).17 The ICD-10 describes neurasthenia as a condition presenting

with two overlapping subtypes: one with increased fatigue after mental effort,
and one with feelings of bodily or physical weakness and exhaustion after
minimal effort. Further, muscular pain, dizziness, tension headaches, sleep
disturbance, inability to relax, irritability, and dyspepsia (indigestion) are
described as symptoms (see Table 4.1). This diagnosis is excluded if the
patient suffers from a current depressive episode, anxiety disorder, or neuro-
logical disorder. Due to these exclusion criteria, neurasthenia as defined by
the ICD-10 criteria may be seen as a ‘secondary’ diagnosis that can only be
used if there is no other psychiatric disorder present.18 Further, by a mere
comparison of the criteria it seems likely that a patient qualifying as being
neurasthenic would also meet the criteria for at least a mild depressive episode
(see Table 4.1), or a somatic symptom disorder as defined by the fifth edition
of the Diagnostic and Statistical Manual of Mental diseases (DSM-5), thus
making the diagnosis of neurasthenia obsolete.19 Indeed, this diagnosis seems
very unpopular in Western societies;20 it was removed from the DSM in its
third revision in 1980,21 and its removal from the ICD in its upcoming 11th
revision has also been suggested.22 Interestingly, there has been very little
recent research on the ICD-10 criteria. However, as neurasthenia is a
common diagnosis in non-Western cultures and the ICD is an international
classificatory system, it has legitimately not been removed so far.
In East Asian cultures such as Japan and China, neurasthenia under-
went developments that differed from the fate of the diagnosis in
Western culture. In China, neurasthenia was introduced in the early
17
World Health Organization, The ICD-10 Classification of Mental and Behavioural Disorders –
Clinical Descriptions and Diagnostic Guidelines (1992), pp. 19; pp. 134–5.
18
V. Starcevic, ‘Neurasthenia: Cross-Cultural and Conceptual Issues in Relation to Chronic
Fatigue Syndrome’, General Hospital Psychiatry 21 (1999), 249–55 (251).
19
American Psychiatric Association, DSM-5 Diagnostic and Statistical Manual of Mental Disorders –
Fifth Edition (Arlington, VA: American Psychiatric Publishing, 2013), pp. 309–15.
20
B. Bankier, M. Aigner, and M. Bach, ‘Clinical Validity of ICD-10 Neurasthenia’,
Psychopathology 34 (2001), 221–36.
21
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, third
edition (Washington: American Psychiatric Association, 1980).
22
J. Zielasek et al., ‘Assessing the Opinions and Experiences of German-Speaking Psychiatrists
Regarding Necessary Changes for the 11th Revision of the Mental Disorders Chapter of the
International Classification of Disorders (ICD-11)’, European Psychiatry 25 (2010), 437–42.
Table 4.1 Fatigue Syndromes
Criteria
Neurasthenia CFS (Fukuda ME (Carruthers Burnout (Maslach Depressive Major depres-
(World Health et al. 1994) et al. 2011) and Jackson episode sion (American
Organization 1981) (World Health Psychiatric
1992) Organization Association
1992) 2013)
Fatigue Increased Persistent of Post-exertional Overwhelming Increased Fatigue or loss of
fatigue after relapsing neuroimmune (emotional) fatiguability energy
mental effort, chronic fatigue, exhaustion exhaustion
or persistent Post-exertional
and distressing malaise
complaints
of bodily
weakness and
exhaustion
after minimal
effort
Time frame At least At least Not specified Not specified For at least 2 For at least
3 months 6 months weeks 2 weeks nearly
every day
New or
definite onset
Cognitive Dizziness Impairment in Neurocognitive Sense of Reduced Diminished
symptoms short-term impairments ineffectiveness concentration ability to
memory or (difficulty and lack of and attention think or
4 Exhaustion Syndromes: Concepts and Definitions
concentration processing accomplishment concentrate, or

information, indecisiveness
short-term
memory loss)
81
(continued )
Table 4.1 (continued)
82
Criteria
Pain Feelings of Sore throat, Significant pain
muscular aches muscle pain, in muscles,
and pains multijoint pain muscle–tendon
without joint junctions,
swelling or joints,
redness abdomen or
chest
Tension Headaches of Headaches
headaches new type,
pattern, or
severity
J.M. Doerr and U.M. Nater
Sleep Sleep Unrefreshing Sleep distur- Disturbed sleep Insomnia/

disturbance sleep bance hypersomnia
(disturbed
sleep pattern or
unrefreshed
sleep)
Motor Neurosensory, Psychomotor Psychomotor
symptoms perceptual and agitation or agitation/
motor inhibition retardation
disturbances
Other Dyspepsia Tender cervical Immune, gastro-
physical or axillary intestinal and
symptoms lymph nodes genitourinary
impairments
Energy
production/
transportation
impairments
Mood Irritability, Feelings of Depressed mood Depressed mood
inability to cynicism and
relax detachment
from the job
(depersonalisa-
tion)
Loss of interest Loss of interest
and enjoyment or pleasure
Reduced Feelings of
self-esteem and worthlessness
self-confidence or excessive or
Bleak and inappropriate
pessimistic guilt
views of the
future
Ideas or acts of Recurrent
self-harm or thoughts of
suicide death, suicidal
ideation,
suicide
attempt, or a
specific plan for
committing
suicide
Appetite Diminished Weight gain/loss,
appetite increase/
decrease in
4 Exhaustion Syndromes: Concepts and Definitions
appetite
Note: Main criteria are presented in bold.
83
twentieth century as part of a scientific exchange with Western cultures

(mainly the USA).23 After the formation of the People’s Republic of
China and as part of a series of strong Soviet influences (and with it
Pavlovian theories of health and pathology), neurasthenia became one of
the priorities of the health plan employed by the communist party,
which fostered Chinese research on this matter. In the early 1960s, the
political relationship between China and the Soviet Union deteriorated,
and Chinese health-care providers began to re-visit traditional Chinese
medicine concepts, which led to the use of the term shenjing shuairuo
(‘weakness of nerves’) for neurasthenia. Neurasthenia became so popular
that it served as an umbrella term that comprised almost every psychia-
tric diagnosis, other than psychotic disorders, until the 1980s. Given
that (a) the causes of neurasthenia were thought to be somatic rather
than mental and (b) neurasthenia was seen as a disease above all affecting
brain workers or intellectuals, it was seen as less stigmatising than, for
example, diagnoses of a depressive disorder. Consequently, it was the
most common psychiatric diagnosis in China for a long time.24
In the 1980s, because of increasing international exchanges and the
restructuring of psychiatric diagnostic systems, the diagnosis of neurasthe-
nia was aligned with Western systems. As traditional Chinese medicine
forms a holistic approach, which does not include the hierarchisation of
symptoms or a differentiation between mental and physical states, the
introduction of Western classification systems (DSM and ICD) was both
literally and figuratively foreign. Bearing in mind these clear differences, a
study by Arthur Kleinman in 1982 showed that 87% of Chinese neur-
asthenia cases could also be diagnosed with major depression and benefit
from tricyclic antidepressants.25 Therefore, a critical re-thinking of the
neurasthenia concept seemed warranted. Pharmaceutical marketing addi-
tionally fuelled this development. In line with these developments, the
23
S. X. Liu, ‘Neurasthenia in China: Modern and Traditional Criteria for Its Diagnosis’, Culture,
Medicine and Psychiatry 13 (1989), 163–86.
24
P. Cheung, ‘Adult Psychiatric Epidemiology in China in the 80s’, Culture, Medicine and
Psychiatry 15 (1991), 479–96.
25
A. Kleinman, ‘Neurasthenia and Depression: A Study of Somatization and Culture in China’,
Culture, Medicine and Psychiatry 6 (1982), 117–90.
popularity of the diagnosis has decreased in China in urban areas, but the
diagnosis can still often be found in rural areas. Especially in elderly people or
people of a low educational background, it is still notably less associated
with stigmatisation than other psychiatric diagnoses.26 In order to diagnose
neurasthenia according to the Chinese Classification of Mental Disorders,
three out of the following five symptoms must be present: weakness, emo-
tional instability, agitation, neuralgia, and sleep disturbances.27 Evidently,
these criteria are still broader compared to the ICD-10 criteria.
In Japan, being diagnosed with neurasthenia (shinkeisuijaku) remains
more common than in Western cultures, but less common than in China.
The neurasthenia diagnosis was introduced in Japan around the same time
as in China. In the 1920s, Morita Shoma identified the term ‘neurasthe-
nia’ as too broad and used the term shinkeishitsu for a sub-group of
neurasthenia patients. Shinkeishitsu encompasses a set of symptoms that
would in current Western terms most likely qualify as anxiety symptoms,
and is characterised by the patient being caught in a vicious cycle between
sensitivity to physical and mental changes, and anxiety.28 In the early
1940s, the diagnosis of neurasthenia was widely used in Japan. The
Japanese consensus was that four different sub-groups of neurasthenia
can be distinguished: (a) genuine neurasthenia (in Beard’s sense),
(b) reactive neurasthenia (defined by a temporary exhaustion, sleep
disturbance, or irritability due to a physical or psychological stressor),
(c) pseudo-neurasthenia (a prodromal or residual sign of another illness),
and (d) Morita’s shinkeishitsu.29 After the Second World War, neurasthe-
nia was replaced by the term ‘neurosis’ as a result of strong US influences,
and from then on decreased even further in popularity.30 Tsung-Yi Lin
26
S. Lee and A. Kleinman, ‘Are Somatoform Disorders Changing with Time? The Case of
Neurasthenia in China’, Psychosomatic Medicine 69 (2007), 846–9 (848).
27
Chinese Medical Association, Chinese Classification of Mental Disorders, ed. Hunan Medical
University (Changsha, China, 1990).
28
K. Kitanishi et al., ‘Diagnostic Consideration of Morita Shinkeishitsu and DSM-III-R’,
Psychiatry and Clinical Neurosciences 56 (2002).
29
T. Y. Lin, ‘Neurasthenia Revisited: Its Place in Modern Psychiatry’, Culture, Medicine and
Psychiatry 13 (1989), 105–29.
30
T. Suzuki, ‘The Concept of Neurasthenia and Its Treatment in Japan’, Culture, Medicine and
Psychiatry 13 (1989).
observes that neurasthenia (in the sense of Beard) was not used anymore,
and that the diagnosis of shinkeishitsu was narrowed down to cases of
social phobia and agoraphobia in Japan in the late 1970s/early 1980s.
However, the diagnosis ‘neurasthenia’ had, because of its wide acceptance
in Japanese society, gained popularity as a camouflage diagnosis to protect
patients from ‘shock’ or stigmatisation when presenting with mental
disorders such as schizophrenia and affective disorders.31
Conclusions on Neurasthenia
Neurasthenia can thus be regarded as a historical construct of Western
societies that was retained as a diagnostic category in the current ICD-10
primarily owing to its popularity in East Asian cultures. This popularity
seems to stem from its ability to serve as a ‘camouflage’ for other psychia-
tric disorders that are seen as providing more of a stigma.32 However,
because of international cross-traffic and the alignment of diagnostic
systems, the diagnosis of neurasthenia is also becoming less common in
East Asian cultures. Although it may entirely lose its significance as a
diagnosis in the near future, it is still important to bear these Asian
specificities in mind when discussing and comparing fatigue syndromes,
as they exemplify cultural and historical influences on fatigue diagnoses.
Chronic Fatigue Syndrome/Myalgic

Encephalomyelitis
During the second half of the twentieth century, further attempts to find
a name for medically unexplained chronic fatigue in Western society
were made. These terms were mostly based on the assumed cause of the
symptoms. As chronic fatigue was observed after infections with
Lin, ‘Neurasthenia Revisited’, 112.

31
P. Y. Schwartz, ‘Why Is Neurasthenia Important in Asian Cultures?’, Western Journal of

32
Medicine 176 (2002), 257–8.

mononucleosis (or Epstein-Barr Virus, EBV), terms such as ‘chronic

mononucleosis’ or ‘chronic EBV infection’ were used in the 1960s for
those who reported being chronically fatigued. However, a clear con-
nection to mononucleosis could not be validated empirically.33 After
multiple cases of medically unexplained fatigue were observed in the
Royal Free Hospital in London in 1955, the terms ‘benign encephalo-
myelitis’ (benign inflammation of the central nervous system) and
‘myalgic encephalomyelitis (ME)’ (muscle pain with inflammation of
the central nervous system) were coined. The involvement of the central
nervous system has been seen as likely due to sensorimotor symptoms.
As many symptoms resembled those observed in patients with muscular
inflammation, the term ‘myalgic’ seemed appropriate.34 In line with
this, the diagnosis ‘postviral fatigue syndrome’ including ‘benign ME’
can still be found in the ICD-10 under ‘diseases of the nervous system’
(G93.3), without further specifications.35 This diagnosis, next to the
possibility of classifying the syndrome as an undifferentiated somato-
form disorder (F45.1), is often chosen by health-care providers when
patients present with CFS/ME.36
In the late 1980s, the Centers for Disease Control and Prevention
(CDC) published criteria for so-called chronic fatigue syndrome.37
These criteria were revised in 1994 (see Table 4.1) and have been used
widely for research and treatment purposes.38 However, the term ‘CFS’
has not been accepted by several patient organisations because of fears of
stigmatisation, and because of the possibility of CFS being regarded as a
33
N. E. Soto and S. E. Straus, ‘Chronic Fatigue Syndrome and Herpesviruses: The Fading
Evidence’, Herpes 7 (2000), 46–50.
34
N. D. Compston, ‘An Outbreak of Encephalomyelitis in the Royal Free Hospital Group,
London, in 1955’, Postgraduate Medical Journal 54 (1978), 722–4.
35
World Health Organization, The ICD-10 Classification of Mental and Behavioural Disorders –
Clinical Descriptions and Diagnostic Guidelines (1992), p. 233.
36
Ibid., p. 130.
37
G. P. Holmes et al., ‘Chronic Fatigue Syndrome: A Working Case Definition’, Annals of
Internal Medicine 108 (1988), 387–9.
38
K. Fukuda et al., ‘The Chronic Fatigue Syndrome: A Comprehensive Approach to Its
Definition and Study. International Chronic Fatigue Syndrome Study Group’, Annals of
Internal Medicine 121 (1994).
purely mental disorder. As such, the term ‘myalgic encephalomyelitis’ has

been preferred by many patient advocacy groups. In 2003 clinical criteria
for CFS/ME,39 and in 2011 international consensus criteria for ME, were
published;40 since then, using the umbrella term ‘CFS/ME’ or ‘ME/CFS’
has been common in the literature, although there is still disagreement
concerning the underlying aetiology of the condition. Common comor-
bidities (additional diseases) that overlap with CFS, but are still distinct
disorders, are depressive episodes or fibromyalgia, a syndrome characterised
mainly by chronic pain.41 The cause of CFS/ME remains unclear.42
Present research promotes a more integrated view, in which stress experi-
ences43 as well as changes in immune functioning44 work in concert and
thus play an important role in the pathogenesis, maintenance, and exacer-
bation of symptoms. As these factors are closely inter-related and cannot be
strictly categorised into dichotomous somatic/mental categories, a more
holistic view that integrates research from both mind and body studies
might be beneficial for patients, practitioners, and researchers. However,
the discussion about the categorisation of CFS/ME as either a mental or a
somatic disorder, and ultimately about its ‘correct’ name, is still ongoing.
A recent report of the US-American Institute of Medicine (IOM) has
proposed new criteria, as well as a re-naming for the syndrome as
‘systemic exertion intolerance disease’ (SEID).45 The SEID criteria
39
B. M. Carruthers et al., ‘Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome: Clinical
Working Case Definition, Diagnostic and Treatment Protocols’, Journal of Chronic Fatigue
Syndrome 11 (2003), 7–36.
40
B. M. Carruthers et al., ‘Myalgic Encephalomyelitis: International Consensus Criteria’, Journal
of Internal Medicine 270 (2011), 327–38.
41
Fukuda et al., ‘The Chronic Fatigue Syndrome’.
42
Board on the Health of Select Populations Institute of Medicine, ‘Beyond Myalgic
Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness’ (2015).
43
C. Heim et al., ‘Childhood Trauma and Risk for Chronic Fatigue Syndrome: Association with
Neuroendocrine Dysfunction’, Arch Gen Psychiatry 66 (2009), 72–80; and U. M. Nater, C. Heim,
and W. C. Reeves, ‘The Role of Stress in Chronic Fatigue Syndrome’, International Journal of
Medical and Biological Frontiers 16 (2010), 869–84.
44
R. Patarca, ‘Cytokines and Chronic Fatigue Syndrome’, Annals of the New York Academy of
Sciences 933 (2001), 185–200; and N. G. Klimas and A. O’Brien Koneru, ‘Chronic Fatigue
Syndrome: Inflammation, Immune Function, and Neuroendocrine Interactions’, Current
Rheumatology Reports 9 (2007), 482–87.
45
Institute of Medicine, ‘Beyond Myalgic Encephalomyelitis’.
propose that post-exertional malaise and unrefreshing sleep be regarded

as main symptoms, next to chronic fatigue. Further, pain, immune
impairment, and other symptoms such as gastrointestinal impairment
and sore throat are seen as supporting a diagnosis of SEID.
The report has led to a great deal of discussion in the research
community, among practitioners, and in patient advocacy groups. The
most obvious criticism of the SEID criteria concerns potential exclu-
sionary criteria; Peter D. White, for example, points out that the lack of
a mental state examination (as well as the lack of an evaluation of other
possible explanations of the experienced fatigue, both of which were
dropped from the SEID criteria) might foster misdiagnoses and the loss
of important information that may lead to a better understanding of the
condition and better treatment for the individual patient.46 Indeed,
initial analyses suggest that by using the newly proposed IOM criteria
the prevalence of CFS multiplies 2.8 times, compared to the CDC CFS
criteria.47 White further points out that the term ‘SEID’ concentrates on
post-exertional malaise as the core symptom, whereas other symptoms
are just as (or even more) common.48 He also critiques that the report
does not sufficiently appreciate the fact that there are safe and effective
treatments available for CFS/ME (although there has been some debate
about the study he bases this statement on).49 Although the name
change from ‘syndrome’ to ‘disease’ was supposed to be welcomed by
patient advocacy groups, an initial survey shows that this might not
be the case at all; 62%50 of the surveyed persons (patients, advocates,
and other stakeholders) rated the proposed name change to SEID as
46
P. D. White, ‘Chronic Fatigue Syndrome: Right Name, Real Treatments’ (2015), online at:
http://www.medscape.com/viewarticle/841289 (accessed August 2015).
47
L. A. Jason et al., ‘Unintended Consequences of Not Specifying Exclusionary Illnesses for
Systemic Exertion Intolerance Disease’, Diagnostics 5 (2015), 272–86.
48
P. D. White, ‘Chronic Fatigue Syndrome: Right Name, Real Treatments’.
49
P. D. White and others, ‘Comparison of Adaptive Pacing Therapy, Cognitive Behaviour
Therapy, Graded Exercise Therapy, and Specialist Medical Care for Chronic Fatigue Syndrome
(Pace): A Randomised Trial’, Lancet, 377 (2011). One of the most prominent critics of PACE is
David Tuller, who points out various flaws in the study. See D. Tuller, ‘Trial by Error: The
Troubling Case of the Pace Chronic Fatigue Syndrome Study’, (2015).
50
L. Petrison, ‘Evaluating a Proposed Name to Replace ‘ME/CFS’: A Community Survey Project
Conducted by Lisa Petrison, Ph.D.’ (2015).
‘pretty bad’ or ‘very bad’ (for a discussion see also Leonard A. Jason).51 It
remains to be seen if the IOM report will have a lasting impact and
ultimately leads to changes in health-care systems that will be helpful for
affected patients. For the time being, it is expected that the terms CFS/
ME will continue to be in use for the next few years.
Differentiating CFS/ME from Depression

The presence of fatigue is a major criterion for a depressive episode according
to ICD-10 and, therefore, the question arises if CFS and depression can be
differentiated.52 Indeed, there is a danger of missing a CFS/ME diagnosis if a
comorbid depression is present, or of falsely diagnosing CFS/ME as depres-
sion. The literature suggests that about 50–75% of all people suffering from
CFS/ME also suffer from a depressive episode during their lifetime.53 In a
study using the CDC criteria, 22% of all CFS patients also currently
qualified as having a depressive episode.54 One might deduce from these
findings that the risk of a depressive episode is heightened in CFS/ME
patients, but more longitudinal research is needed to bolster this assumption.
Further evidence that CFS/ME and depression are different illnesses
stems from research regarding hormone levels, which has shown that
heightened cortisol concentrations can be found in patients with depres-
sive disorders, whereas lower than average cortisol levels are observed in
patients with CFS/ME.55 In a literature review on the differences
51
L. A. Jason et al., ‘Reflections on the Institute of Medicine’s Systemic Exertion Intolerance
Disease’, Polskie Archiwum Medycyny Wewnetrznej 125 (2015), 576–81 (579).
52
World Health Organization, pp. 99–102.
53
N. Afari and D. Buchwald, ‘Chronic Fatigue Syndrome: A Review’, American Journal of
Psychiatry 160 (2003), 221–36 (p. 225).
54
U. M. Nater et al., ‘Psychiatric Comorbidity in Persons with Chronic Fatigue Syndrome
Identified from the Georgia Population’, Psychosomatic Medicine 71 (2009), 557–65.
55
A. J. Cleare et al., ‘Contrasting Neuroendocrine Responses in Depression and Chronic Fatigue
Syndrome’, Journal of Affective Disorders 34 (1995), 283–9; L. V. Scott and T. G. Dinan, ‘Urinary
Free Cortisol Excretion in Chronic Fatigue Syndrome, Major Depression and in Healthy Volunteers’,
Journal of Affective Disorders 47 (1998), 49–54; and U. M. Nater et al., ‘Attenuated Morning Salivary
Cortisol Concentrations in a Population-Based Study of Persons with Chronic Fatigue Syndrome and
Well Controls’, Journal of Clinical Endocrinology and Metabolism 93 (2008), 703–9.
between depressive disorders and CFS/ME, James P. Griffith and Fahd

A. Zarrouf conclude that often flu-like symptoms (such as a sore throat,
tender lymph nodes, and so on) are expressed by CFS/ME patients, but not
by depressive patients.56 A further difference is the response to physical
activity – whereas this leads to symptom exacerbation in CFS/ME patients,
it leads to symptom reduction (i.e. mood improvement) in depressive
patients. Further, a more recent study shows that mood-related symptoms
(depressed mood, anhedonia, loss of motivation) are more specific for
patients suffering from depression than for patients with CFS/ME.57
Differentiating CFS/ME from Neurasthenia

By the mere comparison of CFS/ME and neurasthenia as defined in the
ICD-10, the two syndromes can hardly be differentiated. The most pro-
minent difference seems to be the time criterion (three months for neur-
asthenia, six months for CFS/ME, see Table 4.1). Further, neurasthenia
can only be diagnosed if affective disorders and a variety of anxiety disorders
can be excluded as a diagnosis. Confusingly, even CFS (G93.3) is listed as
an exclusionary condition.58 For CFS/ME, on the other hand, anxiety
disorders do not preclude the diagnosis, and using the CDC criteria or the
newly proposed IOM criteria a depressive episode does not need to be
excluded either.59 In the literature, the terms ‘chronic fatigue syndrome’
and ‘neurasthenia’ are often used synonymous,60or otherwise CFS seems to
56
James P. Griffith and Fahd A. Zarrouf, ‘A Systematic Review of Chronic Fatigue Syndrome:
Don’t Assume It’s Depression.’, Journal of Clinical Psychiatry 10 (2008), 120–8.
57
B. K. Bennett et al., ‘Characterization of Fatigue States in Medicine and Psychiatry by
Structured Interview’, Psychosomatic Medicine 76 (2014), 379–88.
58
World Health Organization, p. 233.
59
Fukuda et al., ‘The Chronic Fatigue Syndrome’; B. M. Carruthers et al., ‘Myalgic Encephalomyelitis:
International Consensus Criteria’, Journal of Internal Medicine 270 (2011); and Board on the Health of
Select Populations Institute of Medicine (2015), ‘Beyond Myalgic Encephalomyelitis/Chronic Fatigue
Syndrome: Redefining an Illness’.
60
A. Sharpley et al., ‘Do Patients with “Pure” Chronic Fatigue Syndrome (Neurasthenia) Have
Abnormal Sleep?’, Psychosomatic Medicine 59 (1997), 592–6; and B. K. Bennett et al.,
‘Characterization of Fatigue States in Medicine and Psychiatry by Structured Interview’,
Psychosomatic Medicine 76 (2014).
be regarded as a modern version of neurasthenia.61 Indeed, there is

almost no research that intends to differentiate between CFS/ME
and neurasthenia.62 In one study, an overlap of 97% was found
when no exclusion criteria were used for neurasthenia.63 This overlap
was reduced to 40% when exclusion criteria were considered. Thus,
almost all patients that qualify as having CFS/ME also meet the
criteria for neurasthenia. However, this does not hold true for the
opposite, because CFS/ME criteria are more clearly put into opera-
tion and researched, and as such describe a more homogenous group
of patients.
Conclusion on CFS/ME
CFS/ME is a highly debilitating syndrome that presents with medically
unexplained fatigue as its core symptom. Its classification, choice of
name, and adequate treatment are still controversial; an important
reason for such a controversy is due to experiences and fear of stigma-
tisation among patients. A more holistic mind–body view may improve
communication between researchers, health-care providers, and patients,
and should be promoted in both research and clinical care. Depression is
more prevalent in CFS/ME patients than in the general population, but
it should be seen as a different disorder.
61
D. B. Greenberg, ‘Neurasthenia in the 1980s: Chronic Mononucleosis, Chronic Fatigue
Syndrome, and Anxiety and Depressive Disorders’, Psychosomatics 31 (1990), 129–37;
R. Arcari and H. D. Crombie, ‘Mark Twain and His Family’s Health: Livy Clemens’
Neurasthenia in the Gilded Age and Chronic Fatigue Syndrome of Today’, Connecticut
Medicine 67 (2003), 293–6.
62
V. Starcevic, ‘Neurasthenia: Cross-Cultural and Conceptual Issues in Relation to Chronic
Fatigue Syndrome’, General Hospital Psychiatry 21 (1999).
63
A. Farmer et al., ‘Neuraesthenia Revisited: ICD-10 and DSM-III-R Psychiatric Syndromes in
Chronic Fatigue Patients and Comparison Subjects’, British Journal of Psychiatry 167 (1995),
503–6.
Burnout
Parallel to developments in medicine and psychology, research focusing on
working conditions has examined a phenomenon called ‘burnout’ – a term
that has been coined as an attempt to define criteria for fatigue that
is caused by prolonged job-related stress.64 The term burnout was
first prominently used in the 1970s by the psychoanalyst Herbert
Freudenberger when he observed that several employees in his clinic,
including himself, suffered from an impairing exhaustion. As those who
had formerly been very engaged in their work (or had ‘burnt’ for their
work) were particularly affected, he called this phenomenon being ‘burnt
out’. His article ‘Staff Burn-Out’, describing the condition and also dis-
cussing prevention and treatment, is often seen as the starting point of
research on burnout.65 Nowadays, the term is used for describing a
syndrome as well as a process (to burn out).66 Referring to the most
prominent criteria as described by Christina Maslach, the burnout syn-
drome is defined by three symptoms (also called the ‘burnout triad’): (1)
emotional exhaustion (feeling weak, tired, and worn out); (2) depersona-
lisation /cynicism (an increased feeling of distance towards the job and/or
clients); and (3) a sense of ineffectiveness and lack of accomplishment
(subjectively or objectively decreased accomplishment).67
Initially, the major focus of burnout research was on those working in
helping professions, but more recently burnout has also been described in
other professions (such as IT specialists and athletes).68 However, Wilmar
B. Schaufeli and Toon W. Taris stress that the term should only be used in
64
C. Maslach, W. Schaufeli, and M. P. Leiter, ‘Job Burnout’, Annual Review of Psychology
52 (2001), 397–422.
65
H. J. Freudenberger, ‘Staff Burn-Out’, Journal of Social Issues 30 (1974), 159–65.
66
A. Weber and A. Jaekel-Reinhard, ‘Burnout Syndrome: A Disease of Modern Societies?’,
Occupational Medicine (London) 50 (2000), 512–17.
67
C. Maslach and Susan E. Jackson, ‘The Measurement of Experienced Burnout’, Journal of
Occupational Behaviour 2 (1981), 99–113; and C. Maslach, W. Schaufeli, and M. P. Leiter, ‘Job
Burnout’, Annual Review of Psychology 52 (2001).
68
Anja Gerlmeier, ‘Stress und Burnout bei IT-Fachleuten – Auf der Suche nach Ursachen. Stress
and Burnout in It Professionals – Searching for the Causes’, in Burnout in der IT-Branche.
Ursachen und betriebliche Prävention (Kroening: Asanger, 2011), 53–89; and Kate Goodger
et al., ‘Burnout in Sport: A Systematic Review’, The Sport Psychologist 21 (2007), 127–51.
occupational contexts.69 It has been a matter of controversy whether burnout

can be used as a diagnostic category for clinical purposes (i.e. to allow patients
to gain access to health-care provisions and burnout-specific treatments).70
There is little consensus as to how to operationalise the aforementioned triad
of burnout criteria. Cutoff values for clinically relevant burnout have been
suggested, utilising the widely used Maslach Burnout Inventory-General
Survey (MBI-GS), but the authors of this survey stress that these criteria
are probably only useful for the Dutch populace, because of differences in
symptom expression between the populations of different countries.71
Interestingly, the authors define clinically relevant burnout as ‘job-related
neurasthenia’ and use the ICD-10 criteria of neurasthenia as well as sub-
jective job perception for confirmation of the diagnosis. This can be con-
sidered while bearing in mind that there are no clear guidelines that are
regarded as binding by researchers or practitioners.
Although the Maslach criteria are used most frequently, there is also
criticism regarding their validity. Tage S. Kristensen and his colleagues, for
example, point out that the three burnout criteria described above cannot be
seen as symptoms as such.72 Only emotional exhaustion really qualifies as a
symptom, whereas depersonalisation might be seen as a coping strategy, and
the sense of ineffectiveness may be the result of prolonged stress. Renzo
Bianchi argues that burnout should not be used as a diagnostic category
because (a) it cannot be validly differentiated from depression; (b) the three-
dimensional structure of its diagnostic criteria is incoherent; and (c) the job-
perception criteria is not suitably discriminatory in classifying the disease.73
69
W. Schaufeli and T. W. Taris, ‘The Conceptualization and Measurement of Burnout:
Common Ground and Worlds Apart’, Work and Stress 19 (2005), 256–62.
70
R. Bianchi, I. S. Schonfeld, and E. Laurent, ‘Burnout-Depression Overlap: A Review’, Clinical
Psychology Review 36 (2015), 28–41.
71
Wilmar Schaufeli et al., ‘Maslach Burnout Inventory – General Survey’, in The Maslach Burnout
Inventory – Test Manual, third edition, ed. Christina Maslach, Suzan Jackson, and Michael Leiter
(Palo Alto: Consulting Psychologists Press, 1996); W. Schaufeli et al., ‘On the Clinical Validity of
the Maslach Burnout Inventory and the Burnout Measure’, Psychology and Health 16 (2001),
565–82; and W. Schaufeli and T. W. Taris, ‘The Conceptualization and Measurement of
Burnout: Common Ground and Worlds Apart’, Work and Stress 19 (2005).
72
T. S. Kristensen et al., ‘The Copenhagen Burnout Inventory: A New Tool for the Assessment of
Burnout’, Work and Stress 19 (2005), 192–207.
73
R. Bianchi, I. S. Schonfeld, and E. Laurent, ‘Is It Time to Consider the “Burnout Syndrome” a
Distinct Illness?’, Front Public Health 3 (2015), 158.
In sum, including burnout as a distinct disorder in upcoming classi-

ficatory systems is generally not recommended. However, burnout has
already been included in the ICD-10 as a ‘factor influencing health
status and contact with health services’ (Z73.0).74 There, it is simply
defined as a ‘state of vital exhaustion’. Although this definition does not
seem very helpful in clinical practice, the use of burnout as a diagnosis
has become quite common in Western societies (e.g. it is one of the five
most common diagnoses in Sweden).75
From a patient perspective, being diagnosed with burnout can be
experienced as relieving and de-stigmatising because of the implication
of having exerted oneself beyond one’s boundaries. In particular, any
causes that might have led to the burnout are restricted to the workplace,
that is, they can be attributed externally instead of internally. Further, it
might be a helpful concept in patient–doctor communication when
explaining the pathogenesis of, for example, a current depressive epi-
sode.76 However, because of the conceptually and scientifically proble-
matic nature of the construct, as described above, the term ‘burnout’
should always be used with care. Using the term ‘burnout’ for a specific
sub-group of depressive patients, for example, may stigmatise those
depressive patients who do not meet the criteria.
Differentiating Between Burnout

and Depression
As mentioned earlier, there seems to be a strong conceptual overlap
between burnout and depression (for an overview, see Renzo
Bianchi and colleagues).77 Furthermore, there is research suggesting
74
World Health Organization, p. 244; and A. Weber and A. Jaekel-Reinhard, ‘Burnout
Syndrome: A Disease of Modern Societies?’, Occupational Medicine (London), 50 (2000).
75
T. Friberg, ‘Burnout: From Popular Culture to Psychiatric Diagnosis in Sweden’, Culture,
Medicine and Psychiatry, 33 (2009), 538–58.
76
A. Hillert and M. Marwitz, ‘Burnout: Eine kritische Analyse mit therapeutischen
Implikationen’, Ärztliche Psychotherapie 4 (2008), 235–41.
77
R. Bianchi, I. S. Schonfeld, and E. Laurent, ‘Burnout-Depression Overlap: A Review’, Clinical
Psychology Review 36 (2015).
that a depressive episode may be a logical consequence of the burnout

process.78 For example, the risk of developing a depressive episode is
estimated as being as high as 50% when having high burnout values,
according to the MBI-GS.79 It was also shown that burnout and depres-
sion were associated with each other bi-directionally.80 D.C. Glass and
J.D. McKnight concluded in their systematic review that the root of the
overlap between burnout and depression lies in the symptom of fatigue.
In line with this, Birgit Reime and Irene Steiner found considerable
correlation between measured depression and emotional exhaustion,
but less of a correlation between depersonalisation and a sense of ineffec-
tiveness.81 One may conclude that depression and burnout are distinct
phenomena, but it has yet to be kept in mind that burnout as a construct
per se stands on shaky grounds. As there is a lack of consensus on the
diagnostic criteria for burnout, the overlap of and differentiation between
burnout and depression cannot be assessed satisfactorily.82
Differentiation Between Burnout and CFS/ME

Because of cognitive impairment, it is likely that CFS/ME patients also
feel a lack of accomplishment which would, in addition to fatigue,
constitute an overlap of symptoms between burnout and CFS/ME (see
Table 4.1). Depersonalisation or cynicism may, however, be specific to
burnout. Yet there has been little empirical effort made to investigate the
78
L. Hallsten, ‘Burning Out: A Framework’, in Professional Burnout: Recent Developments in
Theory and Research, ed. W. Schaufeli, C. Maslach, and T. Marek (Washington, DC: Taylor and
Francis, 1993), pp. 95–113.
79
K. Ahola et al., ‘The Relationship between Job-Related Burnout and Depressive Disorders –
Results from the Finnish Health 2000 Study’, Journal of Affective Disorders 88 (2005), 55–62.
80
Ibid.; and S. Toker and M. Biron, ‘Job Burnout and Depression: Unraveling Their Temporal
Relationship and Considering the Role of Physical Activity’, Journal of Applied Psychology 97
(2012), 699–710.
81
B. Reime and I. Steiner, ‘Burned-Out or Depressive? An Empirical Study Regarding the
Construct Validity of Burnout in Contrast to Depression’, Psychotherapie, Psychosomatik,
Medizinische Psychologie 51 (2001), 304–7.
82
Bianchi, Schonfeld, and Laurent. ‘Is It Time to Consider the “Burnout Syndrome” a Distinct
Illness?’.
comparison of CFS/ME and burnout. Marcus J.H. Huibers and collea-

gues found that the most prominent difference between burnout and
CFS cases is the way they explain the origins of their symptoms.83
Whereas patients classified as CFS cases attributed a somatic cause to
their symptoms, burnout cases attributed a psychological cause to their
symptoms. However, it should be mentioned that this study did not
include a comprehensive set of measures (in that it included no biolo-
gical measures). In another study, Stephanie S. Leone and colleagues
found that prolonged fatigue (independently of the job context) and
burnout resulted in each other, across time.84 However, ultimately the
same problem as with comparing burnout to depression occurs when
comparing burnout to CFS/ME. As long as there is no clear and
accepted operationalisation of a ‘burnout syndrome’ and as long as
there is still doubt if it should even be a diagnostic category, a compar-
ison of syndromes can hardly be realised, and the attempts to do so are
difficult to interpret. Here close attention should instead be paid to how
the different concepts are conceptualised and measured.
Conclusions on Burnout
Burnout describes the phenomenon of job-related fatigue that is fre-
quently present in modern societies. We would advise against using this
term as a diagnostic category, but from a clinical perspective it may serve
its purpose in physician–patient communication. Research on the over-
lap between burnout and other syndromes is difficult to interpret in light
of the vagueness of burnout criteria. This vagueness might also bring the
risk that burnout as a diagnosis shares some features with neurasthenia,
83
M. J. Huibers et al., ‘Fatigue, Burnout, and Chronic Fatigue Syndrome among Employees on
Sick Leave: Do Attributions Make the Difference?’, Occupational and Environmental Medicine
60 (Suppl. 1) (2003), 26–31.
84
S. S. Leone et al., ‘The Temporal Relationship between Burnout and Prolonged Fatigue: A 4-Year
Prospective Cohort Study’, Stress and Health 25 (2009), 365–74; and U. Bultmannand et al.,
‘Measurement of Prolonged Fatigue in the Working Population: Determination of a Cutoff Point
for the Checklist Individual Strength’, Journal of Occupational Health Psychology 5 (2000), 411–16.
in that it serves as a camouflage for other (psychiatric) disorders or as a

wastebasket for otherwise unexplained symptoms (see above).
Overall Conclusion
Clinically relevant fatigue is a prevalent problem in modern society. Fatigue
is not specific to a certain disease, but occurs in a number of diseases, and
can also occur under conditions regarding which no medical explanation
can be found. As yet, there is no objective medical test that can measure
fatigue. The diagnosis of syndromes presenting with fatigue thus relies
mainly on the subjective reports of patients, including thorough histories,
and assessing certain exclusionary medical and psychiatric conditions.
Classifying syndromes in which fatigue is the main symptom has been
and probably will be a matter of controversy for the foreseeable future.
By comparing the different fatigue syndromes, as we did in this
chapter, it becomes obvious that differentiation is not an easy under-
taking, as the historical and cultural backgrounds of patients, health-care
providers, and researchers fundamentally shapes the use of diagnoses (see
also Olaug S. Lian and Hilde Bondevik).85 One problem is that clear-cut
somatic diseases are generally perceived as more legitimate than mental
disorders, which leads patients (and clinicians) to prefer one diagnosis
over another (such as neurasthenia instead of other psychiatric disorders
prevalent in Asian cultures), or preferring one term for a diagnosis over
another (such as MME instead of CFS in CFS/ME patients), or at least
feeling the need to give a de-stigmatising pathogenesis of symptoms
(as in the cases of burnout and depression). These and other uncertain-
ties lead to insecurities in patients (e.g. helplessness and fear of stigma-
tisation when faced with medically unexplained symptoms), and in
health-care providers (e.g. reluctance in making a possibly stigmatising
diagnosis, or prescribing unnecessary medical procedures).86 Ultimately,
85
O. S. Lian and H. Bondevik, ‘Medical Constructions of Long-Term Exhaustion, Past and
Present’, Sociology of Health and Illness 37 (2015), 920–35.
86
S. Gupta, ‘More Treatment, More Mistakes’, New York Times 31 July 2012, p. 23.
promoting a more holistic mind–body view in both research and clinical

practice, and also in society in general, would help to address at least
some of these issues.
References
N. Afari and D. Buchwald, ‘Chronic Fatigue Syndrome: A Review’, American
Journal of Psychiatry 160 (2003), 221–36.
K. Ahola et al., ‘The Relationship between Job-Related Burnout and
Depressive Disorders – Results from the Finnish Health 2000 Study’,
Journal of Affective Disorders 88 (2005), 55–62.
American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Third Edition (Washington: American Psychiatric Association,
1980).
American Psychiatric Association, DSM-5: Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (Arlington, VA: American Psychiatric
Publishing, 2013).
R. Arcari and H. D. Crombie, ‘Mark Twain and His Family’s Health: Livy
Clemens’ Neurasthenia in the Gilded Age and Chronic Fatigue Syndrome
of Today’, Connecticut Medicine 67 (2003), 293–6.
B. Bankier, M. Aigner and M. Bach, ‘Clinical Validity of ICD-10
Neurasthenia’, Psychopathology 34 (2001), 134–9.
J. Barroso, ‘A Review of Fatigue in People with HIV Infection’, Journal of the
Association of Nurses in AIDS Care 10 (1999), 42–9.
A. Barsevick et al., ‘I’m So Tired: Biological and Genetic Mechanisms of
Cancer-Related Fatigue’, Quality of Life Research 19 (2010), 1419–27.
George Beard, ‘Neurasthenia, or Nervous Exhaustion’, Boston Medical and
Surgical Journal 3 (1869), 217–21.
George Beard, A Practical Treatise on Nervous Exhaustion (Neurasthenia), Third
Edition (New York: 5 Cooper Union, 1894).
B. K. Bennett et al., ‘Characterization of Fatigue States in Medicine and
Psychiatry by Structured Interview’, Psychosomatic Medicine 76 (2014),
379–88.
F. Bethoux, ‘Fatigue and Multiple Sclerosis’, Annales de Réadaptation et de
Médecine Physique 49 (2006), 265–71, 355–60.
R. Bianchi, I. S. Schonfeld, and E. Laurent, ‘Burnout-Depression Overlap:
A Review’, Clinical Psychology Review 36 (2015a), 28–41.
R. Bianchi, I. S. Schonfeld, and E. Laurent, ‘Is It Time to Consider the “Burnout

Syndrome” a Distinct Illness?’, Frontiers in Public Health 3 (2015b), 158.
Board on the Health of Select Populations Institute of Medicine, Beyond
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness
(Washington, DC: The National Academies Press, 2015). Online at:
http://www.iom.edu/mecfs.
U. Bultmannand et al., ‘Measurement of Prolonged Fatigue in the Working
Population: Determination of a Cutoff Point for the Checklist Individual
Strength’, Journal of Occupational Health Psychology 5 (2000), 411–16.
B. M. Carruthers et al., ‘Myalgic Encephalomyelitis/Chronic Fatigue Syndrome:
Clinical Working Case Definition, Diagnostic and Treatment Protocols’,
Journal of Chronic Fatigue Syndrome 11 (2003), 7–36.
B. M. Carruthers et al., ‘Myalgic Encephalomyelitis: International Consensus
Criteria’, Journal of Internal Medicine 270 (2011), 327–38.
P. Cheung, ‘Adult Psychiatric Epidemiology in China in the 80s’, Culture’,
Chinese Medical Association, Chinese Classification of Mental Disorders, ed.
Hunan Medical University (Changsha,: China, 1990).
A. J. Cleare et al., ‘Contrasting Neuroendocrine Responses in Depression and
Chronic Fatigue Syndrome’, Journal of Affective Disorders 34 (1995), 283–9.
N. D. Compston, ‘An Outbreak of Encephalomyelitis in the Royal Free Hospital
Group, London, in 1955’, Postgraduate Medical Journal 54 (1978), 722–4.
A. J. Dittner, S. C. Wessely, and R. G. Brown, ‘The Assessment of Fatigue:
A Practical Guide for Clinicians and Researchers’, Journal of Psychosomatic
Research 56 (2004), 157–70.
J. M. Doerr, and U. M. Nater, ‘Erschöpfungssyndrome – Eine Diskussion
Verschiedener Begriffe, Definitionsansätze Und Klassifikatorischer Konzepte’,
Psychotherapie, Psychosomatik, Medizinische Psychologie 63 (2013), 69–76.
A. Farmer et al., ‘Neuraesthenia Revisited: ICD-10 and DSM-III-R Psychiatric
Syndromes in Chronic Fatigue Patients and Comparison Subjects’, British
Journal of Psychiatry 167 (1995), 503–6.
H. J. Freudenberger, ‘Staff Burn-Out’, Journal of Social Issues 30 (1974), 159–65.
T. Friberg, ‘Burnout: From Popular Culture to Psychiatric Diagnosis in
Sweden’, Culture Medicine and Psychiatry 33 (2009), 538–58.
K. Fukuda et al., ‘The Chronic Fatigue Syndrome: A Comprehensive Approach
to Its Definition and Study. International Chronic Fatigue Syndrome Study
Group’, Annals of Internal Medicine 121 (1994), 953–9.
Anja Gerlmaier, ‘Stress und Burnout bei IT-Fachleuten — Auf der Suche nach
Ursachen. Stress and Burnout in IT Professionals – Searching for the Causes’,
in Burnout in Der IT-Branche. Ursachen und betriebliche Prävention, ed. Anja
Gerlmaier and Erich Latniak (Kroening: Asanger, 2011), pp. 53–89.
Kate Goodger et al., ‘Burnout in Sport: A Systematic Review’, The Sport
Psychologist 21 (2007), 127–51.
D. B. Greenberg, ‘Neurasthenia in the 1980s: Chronic Mononucleosis,
Chronic Fatigue Syndrome, and Anxiety and Depressive Disorders’,
Psychosomatics 31 (1990), 129–37.
James P. Griffith and Fahd A. Zarrouf, ‘A Systematic Review of Chronic
Fatigue Syndrome: Don’t Assume It’s Depression’, Journal of Clinical
Psychiatry 10 (2008), 120–8.
S. Gupta, ‘More Treatment, More Mistakes’, New York Times, (31 July 2012), 23.
L. Hallsten, ‘Burning Out: A Framework’, in Professional Burnout: Recent
Developments in Theory and Research, ed. W. Schaufeli, C. Maslach and
T. Marek (Washington, DC: Taylor and Francis, 1993), pp. 95–113.
C. Heim et al., ‘Childhood Trauma and Risk for Chronic Fatigue Syndrome:
Association with Neuroendocrine Dysfunction’, Archives of General Psychiatry
66 (2009), 72–80.
A. Hillert and M. Marwitz, ‘Burnout: Eine kritische Analyse mit therapeu-
tischen Implikationen’, Ärztliche Psychotherapie 4 (2008), 235–41.
G. P. Holmes et al., ‘Chronic Fatigue Syndrome: A Working Case Definition’,
Annals of Internal Medicine 108 (1988), 387–9.
M. J. Huibers et al., ‘Fatigue, Burnout, and Chronic Fatigue Syndrome among
Employees on Sick Leave: Do Attributions Make the Difference?’, Occupational
and Environmental Medicine 60 Suppl 1 (2003), 26–31.
L. A. Jason et al., ‘A Community-Based Study of Prolonged Fatigue and
Chronic Fatigue’, Journal of Health Psychology 4 (1999), 9–26.
L. A. Jason et al., ‘Reflections on the Institute of Medicine’s Systemic Exertion
Intolerance Disease’, Polskie Archiwum Medycyny Wewnetrznej 125 (2015a),
576–81.
L. A. Jason et al., ‘Unintended Consequences of not Specifying Exclusionary
Illnesses for Systemic Exertion Intolerance Disease’, Diagnostics 5 (2015b),
272–86.
Karin Johannisson, ‘Modern Fatigue: A Historical Perspective’, in Stress in
Health and Disease, ed. B. B. Arnetz and R. Ekman (Weinheim, Germany:
Wiley-VCH Verlag, 2006), pp. 3–19.
A. Kleinman, ‘‘Neurasthenia and Depression: A Study of Somatization and

Culture in China’, Culture Medicine and Psychiatry 6 (1982), 117–90.
N. G. Klimas and A. O’Brien Koneru, ‘Chronic Fatigue Syndrome:
Inflammation, Immune Function, and Neuroendocrine Interactions’,
Current Rheumatology Reports 9 (2007), 482–7.
T. S. Kristensen et al., ‘The Copenhagen Burnout Inventory: A New Tool for
the Assessment of Burnout’, Work and Stress 19 (2005), 192–207.
S. Lee and A. Kleinman, ‘Are Somatoform Disorders Changing with Time? The
Case of Neurasthenia in China’, Psychosomatic Medicine 69 (2007), 846–9.
S. S. Leone et al., ‘The Temporal Relationship between Burnout and Prolonged
Fatigue: A 4-Year Prospective Cohort Study’, Stress and Health 25 (2009),
365–74.
S. S. Leone et al., ‘Two Sides of the Same Coin? On the History and
Phenomenology of Chronic Fatigue and Burnout’, Psychology and Health
26 (2011), 449–64.
O. S. Lian and H. Bondevik, ‘Medical Constructions of Long-Term Exhaustion,
Past and Present’, Sociology of Health and Illness 37 (2015), 920–35.
T. Y. Lin, ‘Neurasthenia Revisited: Its Place in Modern Psychiatry’, Culture
S. X. Liu, ‘Neurasthenia in China: Modern and Traditional Criteria for Its
Diagnosis’, Culture Medicine and Psychiatry 13 (1989), 163–86.
C. Maslach and Susan E. Jackson, ‘The Measurement of Experienced Burnout’,
Journal of Occupational Behaviour 2 (1981), 99–113.
C. Maslach, W. Schaufeli, and M. P. Leiter, ‘Job Burnout’, Annual Review of
Psychology 52 (2001), 397–422.
U. M. Nater, C. Heim, and W. C. Reeves, ‘The Role of Stress in Chronic
Fatigue Syndrome’, International Journal of Medical and Biological Frontiers
16 (2010), 869–84.
U. M. Nater et al., ‘Attenuated Morning Salivary Cortisol Concentrations in a
Population-Based Study of Persons with Chronic Fatigue Syndrome and
Well Controls’, The Journal of Clinical Endocrinology and Metabolism
93 (2008), 703–9.
U. M. Nater et al., ‘Psychiatric Comorbidity in Persons with Chronic Fatigue
Syndrome Identified from the Georgia Population’, Psychosomatic Medicine
71 (2009), 557–65.
R. Patarca, ‘Cytokines and Chronic Fatigue Syndrome’, Annals of the New York
Academy of Sciences 933 (2001), 185–200.
T. Pawlikowska et al., ‘Population Based Study of Fatigue and Psychological

Distress’, BMJ 308 (1994), 763–6.
L. Petrison, ‘Evaluating a Proposed Name to Replace “ME/CFS”:
A Community Survey Project Conducted by Lisa Petrison, Ph.D.’ (2015).
B. Reime and I. Steiner, ‘Burned-out or Depressive? An Empirical Study
Regarding the Construct Validity of Burnout in Contrast to Depression’,
Psychotherapie, Psychosomatik, Medizinische Psychologie 51 (2001), 304–7.
W. T. Riley et al., ‘Patient-Reported Outcomes Measurement Information
System (PROMIS) Domain Names and Definitions Revisions: Further
Evaluation of Content Validity in IRT-Derived Item Banks’, Quality of
Life Research 19 (2010), 1311–21.
Wilmar Schaufeli et al., ‘Maslach Burnout Inventory – General Survey’, in The
Maslach Burnout Inventory – Test Manual, third edition, ed. Christina
Maslach, Suzan Jackson and Michael Leiter (Palo Alto: Consulting
Psychologists Press, 1996).
W. Schaufeli et al., ‘On the Clinical Validity of the Maslach Burnout Inventory
and the Burnout Measure’, Psychology and Health 16 (2001), 565–82.
W. Schaufeli and T. W. Taris, ‘The Conceptualization and Measurement of
Burnout: Common Ground and Worlds Apart’, Work and Stress 19 (2005),
256–62.
P. Y. Schwartz, ‘Why Is Neurasthenia Important in Asian Cultures?’, Western
Journal of Medicine 176 (2002), 257–8.
R. Schwarz, O. Krauss and A. Hinz, ‘Fatigue in the General Population’,
Onkologie 26 (2003), 140–4.
L. V. Scott and T. G. Dinan, ‘Urinary Free Cortisol Excretion in Chronic
Fatigue Syndrome, Major Depression and in Healthy Volunteers’, Journal of
Affective Disorders 47 (1998), 49–54.
A. Sharpley et al., ‘Do Patients with “Pure” Chronic Fatigue Syndrome
(Neurasthenia) Have Abnormal Sleep?’, Psychosomatic Medicine 59 (1997),
592–6.
Edward Shorter, ‘Chronic Fatigue in Historical Perspective’, in Chronic Fatigue
Syndrome – Ciba Foundation Symposium 173, ed. Gregory R. Bock and Julie
Whelan (Chichester, England: John Wiley, 1993), pp. 6–16.
N. E. Soto and S. E. Straus, ‘Chronic Fatigue Syndrome and Herpes viruses:
The Fading Evidence’, Herpes 7 (2000), 46–50.
V. Starcevic, ‘Neurasthenia: Cross-Cultural and Conceptual Issues in Relation to
Chronic Fatigue Syndrome’, General Hospital Psychiatry 21 (1999), 249–55.
S. Toker and M. Biron, ‘Job Burnout and Depression: Unraveling Their

Temporal Relationship and Considering the Role of Physical Activity’,
Journal of Applied Psychology 97 (2012), 699–710.
D. Tuller, ‘Trial by Error: The Troubling Case of the Pace Chronic Fatigue
Syndrome Study’ (2015), online at: www.virology.ws/2015/10/21/trial-by-
error-i/ (accessed December 2016).
A. Weber, and A. Jaekel-Reinhard, ‘Burnout Syndrome: A Disease of Modern
Societies?’, Occupational Medicine (London) 50 (2000), 512–17.
P. D. White et al., ‘Comparison of Adaptive Pacing Therapy, Cognitive
Behaviour Therapy, Graded Exercise Therapy, and Specialist Medical
Care for Chronic Fatigue Syndrome (Pace): A Randomised Trial’, Lancet
377 (2011), 823–36.
P. D. White, ‘Chronic Fatigue Syndrome: Right Name, Real Treatments’
(2015), online at: http://www.medscape.com/viewarticle/841289 (accessed
August 2015).
World Health Organization, The ICD-10 Classification of Mental and
Behavioural Disorders – Clinical Descriptions and Diagnostic Guidelines
(Geneva: World Health Organization, 1992).
J. Zielasek et al., ‘Assessing the Opinions and Experiences of German-Speaking
Psychiatrists Regarding Necessary Changes for the 11th Revision of the
Mental Disorders Chapter of the International Classification of Disorders
(ICD-11)’, European Psychiatry 25 (2010), 437–42.
Johanna M. Doerr completed her Ph.D. about the relationship between fatigue
and stress in 2016, supervised by Urs M. Nater. She works as a Research Associate
at the Department of Clinical Biopsychology in Marburg, Germany, studying the
interconnectedness of somatic complaints and stress, and their biological under-
pinnings. She is also training as a Cognitive Behavioral Therapist. Before her Ph.D.
and therapist training, she studied Psychology in Münster and Marburg, Germany.
Urs M. Nater is the Lichtenberg Professor of Clinical Biopsychology at the

Department of Psychology at the Philipps University of Marburg, Germany. He
received his Ph.D. from the University of Zurich, Switzerland, in 2004. His
research focuses on identifying the underlying mechanisms that translate stress
into fatigue. He serves on the editorial boards of International Journal of Behavioral
Medicine, BMC Psychology, Psychoneuroendocrinology, Stress, and others. He is also
the President-elect of the International Society of Behavioral Medicine.
5
Burnout: A Short Socio-Cultural History
Wilmar B. Schaufeli
The term ‘burnout’ was first used in a clinical sense in the early 1970s
by Herbert Freudenberger, a practicing American psychologist.1 The
concept was developed further by the academic researcher and social
psychologist Christina Maslach, who subsequently developed the most
widely used questionnaire for assessing burnout. From the beginning,
two more or less independent streams of activities can be observed in the
field of burnout studies: (1) a practice-based approach focused on
burnout cures, which resulted in the emergence of a veritable ‘burnout
industry’ offering workshops, training programmes, counselling,
1
Christina Maslach and Wilmar Schaufeli, ‘Historical and Conceptual Development of
Burnout’, in Professional Burnout: Recent Developments in Theory and Research, ed. Wilmar
Schaufeli, Christina Maslach, and Tadeausz Marek (Washington, DC: Taylor & Francis,
1993), pp. 1–16.
W.B. Schaufeli (*)

Utrecht University, Utrecht, The Netherlands
KU Leuven, Belgium
e-mail: w.schaufeli@uu.nl

DOI 10.1007/978-3-319-52887-8_5
106 W.B. Schaufeli
psychotherapy, organisational consultancy, and so on; and (2) academic

research, which produced thousands of scientific publications (75,000
according to Google Scholar and 10,000 according to PsychInfo in
March 2017).
Interestingly, there is not much interaction between these two fields.
Very few practical burnout intervention measures, for example, have
been scientifically evaluated; a systematic review of burnout prevention
programmes identified only 25 studies, of which 14 were randomised
controlled trials.2 In a more recent study, Laurentiu Maricuţoiu, Florin
Sava, and Oana Butta focus on all types of burnout intervention
programmes, rather than restricting themselves to prevention pro-
grammes, in their meta-analyses.3 They found that a controlled inter-
vention was performed in only 6% of the 913 intervention studies they
originally identified, and eventually only 47 studies are included in their
meta-analysis. The results of this meta-analysis show modest but lasting
positive effects of interventions in reducing burnout.
This chapter seeks to explore the historical roots of burnout as well
as the socio-cultural factors that led to its emergence. Significantly,
burnout did not develop in a historical vacuum; in addition to a
subjective experience, it is also a multi-faceted socio-cultural pheno-
menon. In the first part of this chapter, I discuss the academic
discovery of burnout and why it emerged in the final decades of
the twentieth century. Next, I address the question of how far the
major symptoms of burnout are independent of time and place, and
how they relate to other similar concepts. Have burnout-like phe-
nomena been observed in earlier times, and is it a typically Western
phenomenon? And how do the symptoms of burnout and those of
depression relate to each other? In the final section, I discuss differ-
ences in the ways the diagnosis is used and understood in North
America and Europe.
2
Wendy Awa, Martina Plaumann, and Ulla Walter, ‘Burnout Prevention: A Review of
Intervention Programs’, Patient Education and Counseling 78 (2010), 184–90.
3
Laurentiu Maricuţoiu, Florin Sava, and Oana Butta, ‘The Effectiveness of Controlled Interventions
on Employees’ Burnout: A Meta-Analysis’, Journal of Occupational and Organizational Psychology, 89
(2016), 1–27.
The Discovery of Burnout

The term burnout was first used as an informal, everyday term.4 Indeed,
Freudenberger borrowed it from the illicit drug scene where it colloqui-
ally referred to the devastating effects of chronic drug abuse.5 He used
the term to describe the gradual emotional depletion, loss of motivation,
and reduced commitment among volunteers of the St Mark’s Free Clinic
in New York’s East Village, whom he observed as a consulting psycho-
logist. Such free clinics for drug addicts and homeless people had
grown out of the counter-cultural movement, whose protagonists were
dissatisfied with the establishment. Not unimportantly, Freudenberger
himself fell victim to burnout twice, increasing his credibility when spread-
ing the message of burnout. His writings on the subject were strongly
autobiographical and his impact is illustrated by the fact that he received
the Gold Medal Award of the American Psychological Association, for life
achievement in the practice of psychology in 1999. Rather than a scholar,
Freudenberger was a psychoanalytically trained practitioner who was pri-
marily interested in preventing and combatting burnout, rather than in
understanding and investigating its underpinnings.
Independently and simultaneously, Maslach and her colleagues came
across the same term in California when interviewing a variety of human
services workers. As a social psychology researcher at the University of
California at Berkeley, Maslach was interested in how these workers coped
with emotional arousal while performing their demanding jobs. As a result
of these interviews, she learned that these workers often felt emotionally
exhausted, that they developed negative perceptions and feelings about
4
For a more detailed discussion, see Schaufeli and Maslach, ‘Historical and Conceptual Development
of Burnout’, and Wilmar Schaufeli, Michael Leiter, and Christina Maslach, ‘Burnout: 35 Years of
Research and Practice’, Career Development International 14 (2009), 204–20.
5
Herbert Freudenberger, ‘Staff Burnout’, Journal of Social Issues 30 (1974), 159–65.
Although Freudenberger is credited for coining the term burnout, it was first used in a publication
by Bradley (H. Bradley, ‘Community-Based Treatment for Young Adult Offenders’, Crime and
Delinquency 15 (1969), 359–70), who described a community-based treatment program for young
offenders (Enzmann and Kleiber, 1989). The term burnout is mentioned in quotation marks only
once, when a particular time schedule is discussed that should prevent it from occurring among the
staff that run the programme. Although no further explanation or description is provided, it illustrates
that the notion of ‘burnout’ was in the air by the end of the 1960s in the US.
108 W.B. Schaufeli
their clients or patients, and that they experienced crises in professional

competence as a result of this emotional turmoil.6 Following the self-
descriptions of workers’ symptoms, the practitioners referred to this psy-
chological condition as ‘burnout’. Maslach and her colleagues subsequently
developed an accessible and easy-to-use self-reporting questionnaire for
assessing burnout, which became known as the Maslach Burnout
Inventory (MBI).7 This went on to become the most widely used assess-
ment tool for burnout.
Initially, the scientific community deemed burnout a ‘pseudoscienti-
fic’ or ‘fad’ concept and denounced it as ‘pop psychology’, but this soon
changed after the introduction of the MBI, which triggered a wave of
empirical burnout research.8 Cindy and Donald McGeary documented
an exponential increase in burnout publications starting from the
moment the MBI was introduced; from the 1980s to the 1990s, pub-
lications increased by 64%, and from the 1990s to the 2000s by 150%.9
Originally, burnout was described and discussed as a phenomenon
that was specific to the human service sector, and especially in health
care, education, social work, psychotherapy, legal services, and law
enforcement. Indeed, the original version of the MBI could only be
employed in these fields because of its content and the wording of its
questions. Until the mid-1990s, when a general version was published,
burnout was more or less a phenomenon restricted to the so-called
caring professions.10 Yet why was this the case?
6
Christina Maslach, ‘Burned-Out’, Human Behavior 9 (1976), 16–22, and Christina Maslach,
‘Burnout: A Multidimensional Perspective’, in Professional Burnout: Recent Developments in Theory
and Research, ed. Wilmar Schaufeli, Christina Maslach, and Tadeusz Marek (Washington, DC:
Taylor & Francis, 1993), pp. 19–32.
7
Christina Maslach and Suzan Jackson, ‘The Measurement of Experienced Burnout’, Journal of
Occupational Behavior 2 (1981), 99–113.
8
Schaufeli and Maslach, ‘Historical and Conceptual Development of Burnout’.
9
Cindy McGeary and Donald McGeary, ‘Occupational Burnout’, in Handbook of Occupational
Health and Wellness, ed. Robert Gatchel and Izabella Schultz (New York: Springer, 2012),
pp. 181–200.
10
Wilmar Schaufeli et al., ‘Maslach Burnout Inventory – General Survey’, in The Maslach Burnout
Inventory – Test Manual, third ed., ed. Christina.Maslach, Suzan Jackson, and Michael Leiter
(Palo Alto: Consulting Psychologists Press, 1996).
Why Did Burnout Emerge at the End

of the Twentieth Century in the Human
Services Sector?
It has been argued that the emergence of the burnout concept is related
to several broader social, economic, and cultural developments of the
1960s in America.11 Three specific developments may have contributed
to the emergence of burnout in the human services sector. First, from
the early 1960s onwards, the War on Poverty in the US led to a large
influx of idealistically motivated young people into human services
professions. However, after struggling to eradicate poverty for a decade
or so, they found themselves increasingly disillusioned. Their frustrated
idealism was a defining quality of the burnout experience, gradually
turning into despair and cynicism.
Second, from the 1950s onwards, the human services underwent
rapid professionalisation and bureaucratisation as a result of greater
government and state influence. Small-scale traditional agencies, where
work was considered a calling, transformed into large modern organisa-
tions with formalised job descriptions. Viewed from this perspective,
burnout represents the price paid for professionalising the helping
professions from callings into modern occupations. One may speculate
that the frustration and disillusionment arising from a widespread
institutionalised clash of utilitarian organisational values with the pro-
viders’ personal or professional values promoted burnout.
Third, the cultural revolution of the 1960s significantly weakened the
professional authority of doctors, nurses, teachers, social workers, and
police officers. The traditional prestige of these professionals was no
longer accepted as a given, and ever more empowered and demanding
recipients expected much more than in the past. As a consequence,
recipients’ demands for care, service, empathy, and compassion intensi-
fied. From the perspective of social exchange, a discrepancy grew
between the professionals’ efforts and the rewards they received in
11
Wilmar Schaufeli, Michael Leiter, and Christina Maslach, ‘Burnout: 35 Years of Research and
Practice’, Career Development International 14 (2009), 204–20.
110 W.B. Schaufeli
terms of recognition and gratitude. This ‘lack of reciprocity’ is known to

foster burnout.12
These three factors are more or less specific to the human services
sector, but there were also additional, more general socio-cultural devel-
opments that seem to have contributed to the emergence of burnout in
the last quarter of the twentieth century. Since the Second World War the
importance and roles of traditional social communities and networks such
as the church, the neighbourhood, and the family have gradually been
eroded. According to Richard Sennett, this is the result of the emergence
of ‘flexible capitalism’, a system that replaced traditionally rigid, homo-
geneous, and predictable social institutions with more flexible, heteron-
ymous, and continuously changing ones.13 This development encourages
social fragmentation and what Sennett calls ‘the corrosion of character’, a
notion akin to burnout.
Simultaneously, a ‘narcissistic culture’ developed, characterised by tran-
sient, unrewarding, and even combative social relationships that produced
self-absorbed, manipulative individuals demanding the immediate gratifi-
cation of their desires, but remaining perpetually unsatisfied.14 As Barry
Farber noted, the combination of this more radical process of individua-
lisation and narcissism produced ‘a perfect recipe for burnout’; the former
generates stress and frustration, whereas the latter undermines people’s
resources for coping.15
In conclusion, then, it seems that some specific socio-cultural conditions
existed in the US in the final decades of the twentieth century that might
have fostered the emergence of burnout as a social problem. However, as it
is also a psychological phenomenon, it is highly unlikely that the experience
of burnout exclusively occurred in this particular time window. Hence, in
the following sections, the historical roots of burnout are discussed.
12
Wilmar Schaufeli, ‘The Balance of Give and Take: Toward a Social Exchange Model of
Burnout’, The International Review of Social Psychology 19 (2006), 87–131.
13
Richard Sennett, The Corrosion of Character: The Personal Consequences of Work in the New
Capitalism (New York: Norton, 1998).
14
Christoffer Lasch, The Culture of Narcissism: American Life in an Age of Diminishing Returns
(New York: Norton, 1979).
15
Barry Farber, ‘Introduction: A Critical Perspective on Burnout’, in Stress and Burnout in the
Human Services Professions, ed. Barry Farber (New York: Pergamon, 1983), pp. 1–20 (p.11).
Is Burnout Specific to the Late

Twentieth Century?
Although, as noted earlier, ‘burnout’ was first used in relation to work
done in the last century, the term has a longer history that dates back to
the end of the sixteenth century, when William Shakespeare wrote in the
seventh poem of The Passionate Pilgrim (1599):16
She burn’d with love, as straw with fire flameth

She burn’d out love, as soon as straw outburneth
The phrase ‘burn’d out’ is used here, probably for the first time, in a
psychological sense, that is, to describe a process of energy exhaustion in
relation to love.17
There are numerous other examples of descriptions of burnout symp-
toms avant-la-lettre, in the sense that they document mental exhaustion
and disengagement in people who used to be very dedicated and com-
mitted. Matthias Burisch argues that burnout cases can already be found in
the Bible, such as with the prophet Elijah who, after winning several
victories and performing miracles in the name of the Lord, breaks down
in the face of an impending defeat, plunging into deep despair and falling
into a deep sleep.18 This mental condition subsequently became known
among priests as ‘Elijah’s fatigue’, and includes symptoms such as intense
but exhausting commitment to a cause, disappointment, and social disen-
gagement, all of which strongly resemble modern descriptions of burnout.
Another example of a burnout case from the Bible is Moses, who at some
point during the flight from Egypt becomes disillusioned because he has
given so much, yet his people are still not satisfied and continue demanding
more (including meat instead of manna).
16
The authorship of many of the poems in this collection, which is attributed to Shakespeare, is
disputed.
17
Dirk Enzmann and Dieter Kleiber, Helfer-Leiden: Streβ und Burnout in psychosozialen Berufen
(Heidelberg: Asanger, 1989), p. 18.
18
Matthias Burisch, Das Burnout-Syndrome, fourth ed. (Heidelberg: Springer, 2010).
112 W.B. Schaufeli
Early examples of burnout symptoms can also be found in literary

texts. For instance, it appears that Senator Thomas Buddenbrook, one of
the protagonists in Thomas Mann’s novel Buddenbrooks (1901), suffers
from burnout.19 Above all, he feels exhausted by his political work and
business ventures in Lübeck, and the way Thomas Buddenbrook is
portrayed by Mann is strongly reminiscent of a present-day case descrip-
tion of burnout, as it includes mental exhaustion, disillusionment, and
the loss of interest and drive (i.e. the impoverishment and desolation of
his inner life, the ‘Verarmung und Verödung seines Inneren’).
Probably, the best-known fictional example of a burnout-sufferer
avant-la-lettre is the world-famous architect Querry, the main character
in Graham Greene’s 1960 novel A Burnt-Out Case, who moves to Africa
to live in a leper colony, with whom he identifies in various ways.
Querry has gloom-filled thoughts, is disillusioned, and suffers from
fatigue, apathy, and cynicism. The similarities to Freudenberger’s drug
addicts are striking: Like drug addicts, lepers become emaciated by their
illnesses. Both Freudenberger and Dr Collin, the character who diag-
noses Querry as a burntout case in Greene’s novel, transpose a metaphor
that is basically physical in nature (i.e. being literally consumed by
narcotics or by a physical illness) into the mental domain. Greene’s
novel appeared in 1960, before most of the developments commenced
that are associated with the emergence of burnout in the 1970s, such as
the influx of young human services professionals, the professionalisation
of the human services, and the counter-cultural revolution. Hence,
Querry can be considered a true burnout case avant-la-lettre.
The same applies to the much-cited case study of the psychiatric nurse
Miss Jones, by Morris Schwarz and Gwen Will, which is considered to
be the first publication on burnout in a professional journal.20 Although
the authors do not use the term burnout, their in-depth case description
fits very well with the present-day notion of burnout. This case study not
only describes the process of burning out that gradually takes place in
19
Burisch, Das Burnout-Syndrome.
Morris Schwartz & Gwen Will, ‘Low Morale and Mutual Withdrawal on a Mental Hospital
20
Ward’, Psychiatry: Interpersonal and Biological Processes 16 (1953), 337–53.

Miss Jones but also documents the hospital staff’s low morale and its
effects on patient care. By noting patients’ responses to Miss Jones’
cynicism and low morale, the key dynamic of burnout is aptly captured.
The authors describe a vicious circle of Miss Jones’s alienation from her
patients, leading to the patients’ alienation, and subsequently to the even
greater alienation of Miss Jones. Seen from this perspective, burnout is a
maladaptive strategy, an attempt to cope with the emotional demands of
the job. This description resembles Maslach’s, who argues that increas-
ing emotional demands are the root causes of burnout that lead to
exhaustion.21 Depersonalisation – or mental distancing – aggravates
this process, and is considered an inappropriate attempt to cope with
these emotional demands.
Taken together, the examples above illustrate that the psychological
condition that is characterised by loss of energy and motivation, and
which has been branded as burnout in the mid-1970s, is not unique to
that particular era. In addition, many other earlier cases have been
described that fit the current descriptions of burnout, including loss of
energy (i.e. feeling exhausted, weak, used-up, worn-out, and overbur-
dened) and loss of motivation (in particular, disillusionment, poor mor-
ale, disengagement, withdrawal, cynicism, depersonalisation, and the loss
of drive and interest). Moreover, the burnout metaphor itself has been
used previously to denote the mental condition that is characterised by
loss of energy and drive. In short, the experience of burnout symptoms is
not specific to the late twentieth century. A compelling case that illus-
trates this point and deserves special attention is that of neurasthenia.
Neurasthenia: Nineteenth-Century Burnout?

The American neurologist George Miller Beard described a new illness
in 1869 which he labelled neurasthenia, and which centred on the
notion of a somatic depletion of nervous energy caused by a faster
pace of life. The hallmark of this new illness – which literally means
21
Maslach, ‘Burnout: A Multidimensional Perspective’.
114 W.B. Schaufeli
‘nerve weakness’ – is severe debilitating mental and physical fatigue arising

after even minimal effort. Beard was active in promoting neurasthenia
through his publications, and soon his ideas took root in Europe, most
notably in Germany, France, Britain, and the Netherlands, and after the
First World War also in Japan and China.22
Beard understood neurasthenia primarily as a disorder of modernity,
caused by the fast pace of urban life. Accelerated modern life, he argued,
puts excessive demands on peoples’ brains, which, in turn, weakens and
depletes their nerve force, thus causing neurasthenic symptoms such as
exhaustion, anxiety, despair, insomnia, indigestion, palpations, and
migraines. In addition to mental overload resulting from an excessively
demanding or pressured job, neurasthenia may also result from physical
strain caused, for instance, by a prolonged viral infection. For this
reason, Leone et al. not only see parallels between neurasthenia and
burnout but also between neurasthenia and chronic fatigue syndrome:23
‘Beard’s neurasthenia combined features of both modern burnout and
modern fatigue syndromes.’24 What are the symptoms that are shared
between neurasthenia and burnout?
First, mental exhaustion is considered the defining symptom of both
conditions. This is exemplified by the fact that in the 1896 edition of his
famous Textbook of Psychiatry, Emil Kraepelin classifies neurasthenia as a
‘disorder of exhaustion’.25 Second, both neurasthenia and burnout have
been considered maladies of their times. Freudenberger states that
burnout is ‘a demon, born of the society and times we live in and our
ongoing struggle to invest our lives with meaning’.26 This statement
could likewise apply to neurasthenia and Beard’s time. Neurasthenia was
22
Marijke Gijswijt-Hofstra, ‘Introduction: Cultures of Neurasthenia from Beard to the First
World War’, in Cultures of Neurasthenia from Beard to the First World War, ed. Marijke
Gijswijt-Hofstra and Roy Porter (Amsterdam: Rodopi, 2001), pp. 1–30.
23
Stephany Leone et al., ‘The Sides of the Same Coin? On the History and Phenomenology of
Chronic Fatigue and Burnout’, Psychology & Health 26 (2011), 449–64.
24
Leone et al., ‘The Sides of the Same Coin?’, p. 451.
25
Gijswijt-Hofstra, ‘Introduction: Cultures of Neurasthenia from Beard to the First World War’,
p. 11.
26
Herbert Freudenberger and Geraldine Richelson, Burnout: How to Beat the High Costs of Success
(New York: Bantam Books, 1980), p. 6.
understood as the product of rapid social and technological changes,

which resulted from the transformation of an agricultural into an
industrial society. In a similar vein, burnout was seen as the product of
the social and cultural changes that resulted from the transformation of
an industrial society into a post-industrial service-oriented society.27
This is exemplified by the fact that neurasthenia appeared first among
the icons of the new industrial era – the dynamic businessmen – whereas
analogously burnout appeared first among the icons of the new service
era – the human services professionals.
Third, neurasthenia, like burnout, offered an explanation for an
ordinary, rather than a pathological, trouble and affliction. In the nine-
teenth century, neurasthenia was clearly separated from mental disease
and offered an alternative for the then popular diagnoses of hysteria and
hypochondria.28 In a similar vein, the popularity of burnout as a
diagnosis has been explained by pointing to its ‘non-medical nature’.29
Instead of as a mental disorder, burnout is usually considered a normal
response to an abnormal situation; sometimes, it is even a diagnosis
worn with pride, almost as a badge of honour (‘I’ve exhausted myself by
going to the limit’).
Fourth, initially neurasthenia was very much an affliction of the
educated elite rather than the labouring classes. However, ‘What started
off as a more or less fashionable disease of the elites later on became to a
certain extent “desocialized” and “democratized.”’30 Burnout also started
as a typical complaint of higher educated human services professionals.
It took more than a decade after its discovery before it was acknowledged
that burnout could also occur among the lower educated and those with
less prestigious jobs, such as blue-collar workers.
Finally, the emergences of both the neurasthenia and the burnout
diagnoses have brought in their wake attempts to exploit commercially
these conditions. Marijke Gijswijt-Hofstra writes: ‘One could even speak
27
Schaufeli, Leiter, and Maslach, ‘Burnout: 35 Years of Research and Practice’.
28
Gijswijt-Hofstra, ‘Introduction: Cultures of Neurasthenia from Beard to the First World War’.
29
Schaufeli and Maslach, ‘Historical and Conceptual Development of Burnout’.
30
Gijswijt-Hofstra, ‘Introduction: Cultures of Neurasthenia from Beard to the First World War’,
p. 23.
116 W.B. Schaufeli
of a “neurasthenia market”, a market where medical advice, technology,

remedies and cures were advertised and sold, thus creating and playing on
the demands from potential patients.’31 Currently, a similar burnout
market seems to exist that produces training courses, e-health pro-
grammes, self-help books, prevention programmes, workshops, counsel-
ling, psychotherapy, organisational consultancy, and so on.
The neurasthenia diagnosis began to disappear after the First World
War. Gradually, the diagnosis became out-dated, except in Japan and
China, where it still enjoys popularity. The main reason for the disappear-
ance of neurasthenia was that it came to encompass too many symptoms,
which rendered it too baggy and unspecific as a diagnostic tool. Stephanie
Leone et al. argue that CFS and burnout are the heirs of the physical and
psychological symptoms of neurasthenia.32 Seen from this perspective,
neurasthenia could, indeed, be considered the nineteenth-century forerun-
ner of burnout. In spite of the fact that – at least initially – the notion of
neurasthenia was firmly rooted in physiology, the parallels with burnout are
striking, not only regarding their common core symptom (exhaustion) but
also regarding their explanatory models, which blame external socio-
cultural developments for the spread of the conditions.
On the Difference Between Depression

and Burnout
A parallel exists between the pervasiveness of neurasthenia at the end of
the nineteenth century and the omnipresence of depression at the end of
the twentieth century. As Allan Horwitz and Jerome Wakefield argue,
the apparent present-day epidemic of depression is primarily owing to
how psychiatrists often understand and classify normal human sadness
as an abnormal experience.33 Since the publication of the DSM-III
31
Ibid., p. 25.
32
Leone et al., ‘The Sides of the Same Coin?’.
33
Allan Horwitz and Jerome Wakefield, The Loss of Sadness: How Psychiatry Transformed Normal
Sorrow into Depressive Disorder (New York: Oxford University Press, 2007).
(the Diagnostic and Statistical Manual of Mental Disorders published by

the American Psychiatric Association) in 1980, professionals began to
diagnose depression based on such general symptoms as a depressed
mood, loss of interest, and fatigue, all of which have to persist for at
least two weeks.34 According to Horwitz and Wakefield, this approach is
fundamentally flawed because it fails to take into account the context in
which the symptoms occur. This context may, for instance, be the work
context and, as a consequence, considerable overlap might occur between
burnout and depression because both share at least one core symptom,
namely exhaustion.
Freudenberger already noted the close link between burnout and
depression when he observed that, at least initially, the symptoms of
burnout tend to be job related and situation specific rather than general
and pervasive, as in the case of depression.35 In his view, work-specific
burnout symptoms could generalise across all situations and spheres of
life, hence leading to a ‘real depression’. This theory is supported by a
more recent three-wave study spanning seven years, which demonstrated
that high levels of burnout constitute a risk factor for the development of
future depressive symptoms.36 Another study showed that burnout at
the baseline predicted increased fatigue four years later, and the reverse
was also observed.37 This led the authors to conclude that burnout and
prolonged fatigue seem to influence each other mutually over time in the
manner of a ‘downward spiral’. Combining the results of both these
34
The DSM describes major depressive disorders as follows: ‘The essential feature of a major
depressive episode is a period of at least 2 weeks during which there is either depressed mood or
the loss of interest or pleasure in nearly all activities. [ . . . ] The individual must also experience at
least four additional symptoms drawn from a list that includes changes in appetite or weight, sleep,
and psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking,
concentrating, or making decisions; or recurrent thoughts of death or suicidal ideation or suicide
plans or attempts.’
35
Herbert Freudenberger and Geraldine Richelson, Burnout: How to Beat the High Costs of Success
(New York: Bantam Books, 1980).
36
Jari Hakanen and Wilmar Schaufeli, ‘Do Burnout and Work Engagement Predict Depressive
Symptoms and Life Satisfaction? A Three-Wave Seven-Year Prospective Study’, Journal of Affective
Disorders 141 (2012), 415–24.
37
Stephanie Leone et al., ‘The Temporal Relationship between Burnout and Prolonged Fatigue:
A 4-year Prospective Cohort Study’, Stress & Health 25 (2009), 365–74.
118 W.B. Schaufeli
studies, one may conclude that increased exhaustion is responsible

for the generalisation of context-specific burnout into context-free
depression.
Despite earlier claims of a distinction between burnout and depres-
sion, based on the results of a meta-analysis that involved 18 studies,38 a
more recent comprehensive review concludes that the empirical evidence
for their distinction is somewhat inconsistent.39 More specifically, and
based on a set of 92 studies on burnout and depression, this review
concludes that: (1) symptoms of burnout and depression overlap, and
most burned-out workers also exhibit depressive symptoms; (2) burnout
and depression levels are moderately to highly correlated, particularly so
far as the exhaustion component of burnout is concerned; (3) results
regarding the causal link between burnout and depression are hetero-
geneous; (4) somatic and biological levels of analysis seem to suggest
some degree of distinctiveness; and (5) burnout and depression are
found to differ in regard to their links to both job-specific (burnout),
and to generic (depression), factors. Overall, the distinction between
burnout and depression is partly supported by the empirical research.
However, the authors also note that the comparison between depression
and burnout is hampered by the heterogeneity of the spectrum of
depressive disorders and by a lack of consensual diagnostic criteria for
burnout. Therefore, a final conclusion regarding the overlap between
burnout and depression cannot be given, although it seems that exhaus-
tion constitutes the primary link.
Is Burnout a Western Phenomenon?

After its emergence in the US in the 1970s, in the 1980s the concept of
burnout spread to Western Europe, particularly to the UK, Germany,
the Low Countries (Holland and Belgium), and the Nordic countries
38
Arnold Glass and John Knight, ‘Perceived Control Depressive Symptomatology, and
Professional Burnout: A Review of the Evidence’, Psychology & Health 11 (1996), 23–48.
39
Renzo Bianchi, Irvin Sconfield, and Eric Laurent, ‘Burnout-Depressive Overlap: A Review’,
Clinical Psychology Review 36 (2015), 28–41.
(Scandinavia and Finland), as well as to Israel. From the mid-1990s

onwards, burnout was also observed in the rest of Western, Middle-, and
Eastern Europe, Asia, the Middle East, Latin America, Australia, and
New Zealand. After the turn of the last century, research on burnout
also spread to Africa, China, and to the Indian subcontinent. It is
interesting to note that, very generally speaking, the order in which
the interest in burnout seems to have spread corresponds to the socio-
economic development of the countries involved.
It has been suggested that globalisation, privatisation, and liberalisation
cause rapid changes in modern working life, such as the necessity to acquire
new skills, the need to adopt new types of work, the imperative to achieve
ever higher productivity, general acceleration, and increased temporal
pressures, which, in their turn, may produce burnout.40 In addition, as
discussed above, socio-cultural developments such as social fragmentation,
individualisation, and the rise of the ‘me culture’ are pervasive not only in
the US and Europe but also in other countries. Although the notion of
burnout seems to have spread around the globe, it yet remains to be seen
whether or not it is essentially a Western phenomenon.
Most studies on burnout that have been conducted in non-Western
countries use similar conceptualisations of burnout; burnout is predomi-
nantly assessed with the MBI. Further, the specific cultural contexts tend
not to be taken into account in these non-Western studies. Basically, non-
Western burnout studies are replications of those that have been conducted
in Western countries. Only a small number of studies have compared
the prevalence of burnout across two or more countries. But even these
comparative studies have lacked a truly cross-cultural perspective, because
the differences in prevalence of burnout are merely described, and not
explained in terms of socio-cultural differences.
In her review of cross-cultural and anthropological studies on burn-
out, Ina Rösing only found four exceptions to the weakness described
above.41 The most notable one is Victor Savicki’s study, which
40
Schaufeli, Leiter, and Maslach, ‘Burnout: 35 Years of Research and Practice’.
41
Ina Rösing, Ist die Burnout-Forschung ausgebrannt? Analyse und Kritik der internationalen
Burnout-Forschung (Heidelberg: Asanger, 2003).
120 W.B. Schaufeli
investigated burnout among child and youth-care workers across 13

different countries.42 He found that the prevalence of burnout symp-
toms seems, indeed, to be dependent on cultural factors. More specifi-
cally, burnout levels of child and youth-care workers were higher in
countries where people feel uncomfortable with uncertainty and ambi-
guity, and where they accept and expect that power is distributed
unequally, as well as in countries that value career success over quality
of life. In addition, across all countries burnout was correlated to high
job demands and coping styles driven by avoidance.
Rösing also criticises the concept of burnout as such on a more
fundamental level as being ethnocentric.43 Burnout, she argues, is
inherently linked to a job or profession. Indeed, the public discourse
surrounding and almost all research are about job or professional burn-
out, rather than about burnout as a universal experience. However, the
very notions of ‘job’ and ‘profession’ are culture-specific constructs and
exist only in modern industrialised societies and not in traditional, rural,
agricultural communities. Therefore, job/occupational burnout is intrin-
sically intertwined with the former and not with the latter.
As far as the various components of the MBI burnout questionnaire
are concerned, Rösing also argues that depersonalisation and reduced
personal accomplishment are ethnocentric concepts. Depersonalisation
presupposes a Western personality conception, which emphasises a sharp
distinction between ‘me’ and ‘you’, who then enter both – as separate
entities – into a ‘personal’ relationship. In a similar vein, personal
accomplishment presupposes a Western conception of achievement,
that is, one that links achievement to the ‘self’; achievement is seen as
personal achievement. This is typical for Western, individualised cul-
tures, whereas in collectivistic cultures achievement is considered to
result from group efforts.
By contrast, the core symptom of burnout – emotional exhaustion –
seems to occur universally. For example, Rösing describes ‘burnout’
42
Victor Savicki, Burnout across Cultures: Stress and Coping in Child and Health Care Workers
(Westpoint, CT: Preager, 2002).
43
Rösing, Ist die Burnout-Forschung ausgebrannt?
among the Quechua and Aymarai Indians from the Andes (Bolivia) and
among the Ladakhs in the Himalaya (Tibet), calling it a ‘loss of soul’, in
which exhaustion plays an important role, together with feelings of
meaninglessness and emptiness.
To sum up, despite the fact that the concept of burnout has spread
around the globe, virtually no investigation has been carried out that
takes cultural differences between countries into account. There is only
one study so far to show that such differences matter. At a more basic
level, it seems that at least two of the three burnout components
(depersonalisation and reduced personal accomplishment) are ethno-
centric Western concepts that cannot be applied in traditional societies.
This can also be said to apply to the entire concept of job and occupa-
tional burnout. In contrast, context-free emotional exhaustion is likely
to be a universal experience. Hence, for the time being, it seems that the
concept of burnout is restricted to modern, industrialised, and urbanised
societies.
The Global Reception of Burnout

As noted above, the concept of burnout originated in the US in the
1970s, before rapidly spreading to other countries around the world. Its
quickly growing popularity in the US has been explained by its non-
medical nature.44 Initially, the term burnout was not used as a medical
diagnosis. Rather, it was considered an almost inevitable process that
would occur among highly motivated human services workers (i.e. a
normal response to an abnormal situation). However, burnout was also
considered as a particular negative psychological state manifest in various
symptoms, described as the ‘burnout syndrome’. Wilmar Schaufeli and
Dirk Enzmann demonstrated that, from the outset, academic authors
used both process-oriented and state-oriented definitions of burnout.45
44
Maslach and Schaufeli, ‘Historical and Conceptual Development of Burnout’.
45
Wilmar Schaufeli and Dirk Enzmann, The Burnout Companion to Study and Research: A Critical
Analysis (London: Taylor & Francis, 1998), pp. 31–7.
122 W.B. Schaufeli
In crossing the Atlantic Ocean the meaning of burnout changed, and

gradually expanded from a psychological phenomenon into a medical
diagnosis. This happened, particularly, in European countries such as
Sweden and the Netherlands, and has to do with the way their social
security systems operate; in these countries social security systems cover
sickness and work incapacity pensions for employees who suffer from
burnout.46 This means that the gatekeepers of these systems need
assessment tools for identifying those who suffer from burnout. In this
sense, these social security systems reflect commonly held social values
about job stress and compensation for psychosocial risks at work. In
contrast to the US (and also many other European countries), Sweden
and the Netherlands have a long tradition of being sensitive to employ-
ees’ stress at work, and in compensating for its adverse effects.
Yet a burned-out employee in Sweden or the Netherlands is only
eligible for financial compensation (in the form of sick leave or disability
payments) when officially diagnosed by a medical professional. The
medical professional thus acts as a gatekeeper, using officially sanctioned
diagnostic criteria. The problem in the case of burnout is precisely
the lack of such criteria. Burnout is not included in the DSM-V.
In the ICD-10 (the World Health Organization’s International
Classification of Diseases), burnout (code Z73.0) is placed in the ‘pro-
blems related to life management difficulty’ category and loosely
described as ‘a state of vital exhaustion’, without further elaboration.
This leaves much room for interpretation by medical professionals.
It thus follows that, if burnout is to be considered a mental condition
that renders sufferers eligible for financial compensation, specific diag-
nostic criteria should be developed.
For this reason in 2005 the Swedish National Board of Health
and Welfare added ‘exhaustion disorder’ (utmattningssyndrom) to the
national version of the ICD-10.47 In a similar vein, in the Netherlands
46
It should not be disregarded that other European countries have similar social security systems.
However, detailed information on these is only available in the local languages, which are beyond
the comprehension of this author.
47
Torbjörn Friberg, ‘Diagnosing Burn-Out: An Anthropological Study of a Social Concept in
Sweden’ (unpublished doctoral thesis, Lund University, 2006), pp. 69–72.
the Royal Dutch Medical Association in 2000 issued guidelines for

assessing and treating stress-related disorders in occupational and pri-
mary health care.48 The diagnostic classification in these guidelines
distinguished between three levels of stress-related disorders at work:
(1) mild distress (relatively minor symptoms that lead to minimal or
only partly impaired occupational functioning); (2) serious distress
(major distress symptoms which cause temporal loss of the entire occu-
pational role); and (3) burnout (work-related neurasthenia and long-
term loss of the occupational role).49
In essence, then, the degree to which a professional role can be
fulfilled is the defining characteristic that differentiates between these
three types of stress-related disorders. ‘Burnout’ is defined as the final
stage of a chronic exhaustion process that prevents employees from
fulfilling their occupational roles. It is treated as a serious medical
diagnosis that generates access to financial compensation, treatment,
and rehabilitation. The very fact that burnout as a medical diagnosis is
associated with these benefits has increased its social acceptance in the
Netherlands.
The reason why the understanding of burnout in the Netherlands
differs from its original meaning in the US has to do with the fact
that an alternative term already existed when ‘burnout’ entered the
scene in the 1980s. For decades, both the lay public and professionals
had used the notion of overspannenheid (literally, ‘overstrain’) to
denote a psychological state that is similar to what was known as
‘burnout’ in the US. Since the 1950s Dutch physicians had been
using ‘overstrain’ (or its French equivalent surmenage) as an official
48
Jacques van der Klink and Frank van Dijk, ‘Dutch Practice Guidelines for Managing
Adjustment Disorders in Occupational and Primary Health Care’, Scandinavian Journal of
Work Environment and Health 29 (2003), 478–87.
49
The diagnostic criteria are physiological and/or mental symptoms of exhaustion for at least two
weeks, an essential lack of psychological energy, and symptoms such as difficulties in concentrat-
ing, a decreased ability to cope with stress, irritability or emotional instability, sleep disturbances,
muscle pain, dizziness, or palpitations. These symptoms have to occur every day during a two-
week period and must cause significant suffering leading to an impaired work capacity. Finally, the
symptoms must be related to work but not to other psychiatric or medical diagnoses, or to
substance abuse.
124 W.B. Schaufeli
diagnostic label, albeit one that was not restricted to the work
context. When ‘burnout’ was introduced, it was used to indicate a
severe psychological disorder rather than a mild form of distress;
more precisely, the final stage of a long-term process of exhaustion
from which it is very difficult to recover.
The popularity of ‘burnout’ in North America can be explained by
the fact that ‘burnout’ is a non-medical, socially accepted label that
carries very little stigma. Paradoxically, the reverse seems to be true in
some countries in Europe: burnout is very popular because it is an official
medical diagnosis that opens the gates of the welfare state, with its
compensation claims and treatment programmes.
Conclusion
Two types of conclusions can be drawn regarding the historical and
socio-cultural context of burnout. First, the core symptom of burnout –
exhaustion – is a context-free, universal, psychological experience, which
neither seems restricted to a particular historical era nor to a particular
culture. The importance of the exhaustion symptom further seems to
link burnout with depression, which also counts exhaustion among its
core symptoms. The most telling historical example of burnout avant-la-
lettre is nineteenth-century neurasthenia, but burnout-like phenomena
have also been observed in non-Western cultures among indigenous
peoples from the Andes and the Himalaya.
Second, burnout, as it has been ‘discovered’ in the US in the 1970s,
seems to be rather specific to modern, advanced societies that are
characterised by social fragmentation and individualisation. Moreover,
burnout is equated with occupational burnout (i.e. a work-related and
context-bound condition), and therefore is a culture-specific notion.
This means that it occurs by definition exclusively in those cultures in
which ‘jobs’, ‘occupations’, and ‘professions’ exist. Yet even within
Western culture ‘burnout’ can mean different things in different coun-
tries, ranging from mild psychological distress to a medically diagnosed
incapacity to work.
It can be argued that the specificity of burnout, which lies in the

combination of exhaustion with other symptoms such as mental distan-
cing (depersonalisation, cynicism) and reduced personal accomplish-
ment, is lost when it is reduced to mere exhaustion. This would lead
to the final conclusion that, indeed, burnout is a psychological condition
that is rooted in a specific historical and socio-cultural context.
References
Wendy Awa, Martina Plaumann, and Ulla Walter, ‘Burnout Prevention:
A Review of Intervention Programs’, Patient Education and Counseling
78 (2010), 184–90.
Renzo Bianchi, Irvin Sconfield, and Eric Laurent, ‘Burnout-Depressive
Overlap: A Review’, Clinical Psychology Review 36 (2015), 28–41.
H. Bradley, ‘Community-Based Treatment for Young Adult Offenders’, Crime
and Delinquency 15 (1969), 359–70.
Matthias Burisch, Das Burnout-Syndrome, fourth edition (Heidelberg: Springer,
2010).
Dirk Enzmann and Dieter Kleiber, Helfer-Leiden: Streβ und Burnout in psycho-
socialen Berufen (Heidelberg: Asanger, 1989).
Barry Farber, ‘Introduction: A Critical Perspective on Burnout’, in Stress and
Burnout in the Human Services Professions, ed. Barry Farber (New York:
Pergamon, 1983), pp. 1–20.
Herbert Freudenberger, ‘Staff Burnout’, Journal of Social Issues 30 (1974), 159–65.
Herbert Freudenberger and Geraldine Richelson, Burnout: How to Beat the
High Costs of Success (New York: Bantam Books, 1980).
Torbjörn Friberg, ‘Diagnosing Burn-Out: An Anthropological Study of a Social
Concept in Sweden’ (unpublished doctoral thesis, Lund University, 2006).
Marijke Gijswijt-Hofstra, ‘Introduction: Cultures of Neurasthenia from Beard
to the First World War’, in Cultures of Neurasthenia from Beard to the First
World War, ed. Marijke Gijswijt-Hofstra and Roy Porter (Amsterdam:
Rodopi, 2001), pp. 1–30.
Arnold Glass and John Knight, ‘Perceived Control Depressive Symptomatology,
and Professional Burnout: A Review of the Evidence’, Psychology & Health 11
(1996), 23–48.
Graham Greene, A Burnt-Out Case (Harmonthworth: Penguin, 1960).
126 W.B. Schaufeli
Jari Hakanen and Wilmar Schaufeli, ‘Do Burnout and Work Engagement
Predict Depressive Symptoms and Life Satisfaction? A Three-Wave Seven-
Year Prospective Study’, Journal of Affective Disorders 141 (2012), 415–24.
Allan Horwitz and Jerome Wakefield, The Loss of Sadness: How Psychiatry
Transformed Normal Sorrow into Depressive Disorder (New York: Oxford
Christoffer Lasch, The Culture of Narcissism: American Life in an Age of
Diminishing Returns (New York: Norton, 1979).
Stephanie Leone et al., ‘The Temporal Relationship between Burnout and
Prolonged Fatigue: A 4-year Prospective Cohort Study’, Stress & Health
25 (2009), 365–74.
Stephanie Leone et al., ‘The Sides of the Same Coin? On the History and
Phenomenology of Chronic Fatigue and Burnout’, Psychology & Health 26
(2011), 449–64.
Laurentiu Maricuţoiu, Florin Sava, and Oana Butta, ‘The Effectiveness of
Controlled Interventions on Employees’ Burnout: A Meta-Analysis’,
Journal of Occupational and Organizational Psychology 89 (2016), 1–27.
Christina Maslach, ‘Burned-Out’, Human Behavior 9 (1976), 16–22.
Christina Maslach, ‘Burnout: A Multidimensional Perspective’, in Professional
Burnout: Recent Developments in Theory and Research, ed. Wilmar Schaufeli,
Christina Maslach, and Tadeusz Marek (Washington, DC: Taylor &
Francis, 1993), pp. 19–32.
Christina Maslach and Suzan Jackson, ‘The Measurement of Experienced
Burnout’, Journal of Occupational Behavior 2 (1981), 99–113.
Christina Maslach and Wilmar Schaufeli, ‘Historical and Conceptual Development
of Burnout’, in Professional Burnout: Recent Developments in Theory and Research,
ed. Wilmar Schaufeli, Christina Maslach, and Tadeausz Marek (Washington,
DC: Taylor & Francis, 1993), pp. 1–16.
Cindy McGeary and Donald McGeary, ‘Occupational Burnout’, in Handbook
of Occupational Health and Wellness, ed. Robert Gatchel and Izabella Schultz
(New York: Springer, 2012), pp. 181–200.
Ina Rösing, Ist die Burnout-Forschung ausgebrannt? Analyse und Kritik der
internationalen Burnout-Forschung (Heidelberg: Asanger, 2003).
Victor Savicki, Burnout across Cultures: Stress and Coping in Child and Health
Care Workers (Westpoint, CT: Preager, 2002).
Wilmar Schaufeli, ‘The Balance of Give and Take: Toward a Social Exchange
Model of Burnout’, The International Review of Social Psychology 19 (2006),
87–131.
Wilmar Schaufeli and Dirk Enzmann, The Burnout Companion to Study and
Research: A Critical Analysis (London: Taylor & Francis, 1998).
Wilmar Schaufeli, Michael Leiter, and Christina Maslach, ‘Burnout: 35 Years
of Research and Practice’, Career Development International 14 (2009),
204–20.
Wilmar Schaufeli et al., ‘Maslach Burnout Inventory – General Survey’, in The
Maslach Burnout Inventory – Test Manual, third ed., ed. Christina Maslach,
Suzan Jackson and Michael Leiter (Palo Alto: Consulting Psychologists
Press, 1996).
Morris Schwartz and Gwen Will, ‘Low Morale and Mutual Withdrawal on a
Mental Hospital Ward’, Psychiatry: Interpersonal and Biological Processes 16
(1953), 337–53.
Richard Sennett, The Corrosion of Character: The Personal Consequences of Work
in the New Capitalism (New York: Norton, 1998).
Jacques Van Der Klink and Frank Van Dijk, ‘Dutch Practice Guidelines for
Managing Adjustment Disorders in Occupational and Primary Health
Care’, Scandinavian Journal of Work Environment and Health 29 (2003),
478–87.
Wilmar B. Schaufeli is distinguished research professor at Leuven University,

Belgium and full Professor of Work and Organizational Psychology at Utrecht
University, The Netherlands (www.wilmarschaufeli.nl). In addition, he is also
visiting professor at Loughborough Business School, UK, and Jaume I Universitat,
Castellon, Spain. In 2014, he was awarded ‘Highly Cited Researcher’ by Thomson
Reuters in recognition of ranking among the top 1% of most cited researchers in
the fields of psychology and psychiatry. Initially, his research interests were job
stress and burnout, but in the last decade his focus shifted towards positive
occupational health psychology. He is a fellow of the European Academy of
Occupational Health Psychology, a licensed occupational health psychologist,
and also works part-time as an organizational consultant (www.3ihc.nl).
6
Burnout: From Work-Related Stress
to a Cover-Up Diagnosis
Linda V. Heinemann and Torsten Heinemann
Introduction
In the summer of 2012, we were fortunate enough to spend 3 months at
the Brocher Foundation. It is located in an elegant nineteenth-century villa
in a park-like private property with green lawns and old trees on the south
shore of Lake Geneva, with direct access to the water. The place is a
researcher’s paradise as it offers the opportunity to work in a relaxed,
We thank the editors for their instructive criticism and helpful comments on an earlier version of
this chapter, as well as Alan Connor who copy-edited the text. We also thank the Brocher
Foundation for their funding of our research stay.
L.V. Heinemann (*)

Goethe University, Frankfurt, Germany
e-mail: heinemann@med.uni-frankfurt.de
T. Heinemann
University of Hamburg and University of California, Berkeley, CA, USA
e-mail: torsten.heinemann@uni-hamburg.de

DOI 10.1007/978-3-319-52887-8_6
130 L.V. Heinemann and T. Heinemann
tranquil environment without the distractions of everyday life. It is quite

the opposite of a place to be exhausted in; it allows one to be productive, yet
almost feels like one is on vacation. However, we were there to study the
history of the burnout syndrome and its social and ethical implications.
Every evening colleagues would meet for dinner to discuss their research,
exchange ideas, and support each other. When we talked about our project
on the first evening we got some funny looks from our colleagues. This was
not so much due to the fact that our topic did not seem to match the
environment – though we received a few comments on this as well – but
rather owing to the fact that there seemed to be a plethora of different
understandings of the term burnout and its meaning in circulation. When
we described the heated debate on the ‘burned out society’ in Germany,
our colleagues from Australia, Denmark, New Zealand, the United
Kingdom, and the United States had a hard time believing we were
speaking about the same burnout phenomenon they had heard about.
For some of them, burnout was a health risk and indeed an occupational
risk only for a particular profession; for others, burnout was mostly related
to social class, and still others understood burnout to be a distinct mental
state of our age, comparable, for example, to neurasthenia in the late
nineteenth and early twentieth centuries. We were already aware of some
cultural differences regarding burnout, but it was at this moment that we
realised the profound differences in the understanding and conceptualisa-
tion of the burnout syndrome in cultural discourses and their respective
national public health systems.
In this chapter, we examine the burnout syndrome and its use in
different cultural and national contexts, particularly in the United States
and in Germany. The aim is to compare how the burnout concept is
used and understood in these two countries. We argue that in the
United States, and more generally in Anglo-Saxon contexts, burnout is
mostly used with its original meaning, that is, it describes a normal
psychological reaction to abnormal pressure resulting from work-related
stress particularly among health professionals, teachers, and professional
athletes. In Germany, in contrast, the term is used to denote a whole
host of different exhaustion symptoms and mental problems supposedly
related to the neoliberal Zeitgeist. In other words, it serves as an umbrella
term that encompasses mental disorders as diverse as depression or
6 Burnout: From Work-Related Stress to a Cover-Up Diagnosis 131
personality disorders, but also simple feelings of exhaustion or being

overwhelmed by everyday life without distinctive clinical relevance. Due
to this conceptual ambiguity, burnout serves as a cover-up diagnosis that
allows people to call in sick without being stigmatised as mentally ill,
and with the opportunity successfully to return to the workplace.
In order to analyse the burnout syndrome and its use in today’s
society, we begin by providing a brief overview of the historical devel-
opment of burnout in the early 1970s.1 We outline when and how it was
first described in the academic literature and how it was taken up in a
larger discourse both in the United States and in Germany. In the next
section, we look at the recent epidemic of use of the burnout syndrome
term in Germany, in contrast to the more narrow and cautious under-
standing of this concept in the United States. In order to explain these
significant cultural differences, we conclude by outlining three factors
that may contribute to them. The argument is based on an extensive
literature review of scientific publications, as well as a media analysis of
the popular press in Germany and in the United States.2
The Historical Development

of the Burnout Concept
The burnout syndrome was first described in two scientific articles pub-
lished in 1974, one by Herbert Freudenberger and one by Sigmund
Ginsburg.3 In subsequent years, it was Freudenberger, a German-born
1
For a detailed account of the history of burnout, see also Schaufeli in this volume.
2
In order to analyse the scientific literature on this topic, we conducted an extensive literature
search in the PubMed database and reviewed more than 1400 scientific articles on burnout
published between 1974 and 2015. The media analysis was done on leading US-American and
German daily newspapers and magazine such as The New York Times, The Wall Street Journal,
USA Today, Newsweek, Time, The New Yorker, Frankfurter Allgemeine Zeitung, Frankfurter
Rundschau, Süddeutsche Zeitung, Die Zeit, and Der Spiegel.
3
Herbert J. Freudenberger, ‘Staff Burn-Out’, Journal of Social Issues 30: 1 (1974), pp. 159–65;
Sigmund G. Ginsburg, ‘The Problem of the Burned-out Executive’, Personnel Journal 48: 8
(1974), 598–600.
American psychologist and psychoanalytic psychotherapist, who

made the term popular in a number of further publications.4 He is
therefore widely considered to be the founding father of the concept.
However, it should be noted that Freudenberger did not invent the
term. Instead, he deserves credit for systematically describing and
analysing a mental condition he observed in some of his colleagues
and that he also experienced himself, and which was referred to by
his colleagues as being ‘burned out’.
In his original 1974 article, Freudenberger describes the state
of being burned out as ‘becoming exhausted by making excessive
demands on energy, strength, or resources’ in the workplace.5
According to Freudenberger, burnout is characterised by physical
symptoms such as exhaustion, fatigue, frequent headaches and gastro-
intestinal disturbances, sleeplessness, and shortness of breath.
Behavioural signs are frustration, anger, a suspicious attitude, a feeling
of omnipotence or overconfidence, excessive use of tranquilisers and
barbiturates, cynicism, and signs of depression. Freudenberger not
only described the symptoms of burnout but also argued that it is
primarily ‘the dedicated and the committed’ who are most likely to
burn out.6 It is important to note that his account of burnout was
based on observations and introspection in a particularly demanding
working environment; a free clinic in New York City. More generally
speaking, for him, burnout occurs in contexts that require a significant
amount of emotional work and empathy, personal involvement, and
intrinsic motivation. At the same time, this type of work is often not
very well paid and exhausting; working conditions typical not only in
the health-care sector but also in social work and education.
4
Herbert J. Freudenberger, ‘The Staff Burn-out Syndrome in Alternative Institutions’,
Psychotherapy: Theory, Research & Practice 12: 1 (1975), 73–82; Herbert J. Freudenberger,
‘Burn-out: Occupational Hazard of the Child Care Worker’, Child Care Quarterly 6: 2 (1977),
90–9; Herbert J. Freudenberger, ‘Burn-out: The Organizational Menace’, Training and
Development Journal 31: 7 (1977), 26–7; Herbert J. Freudenberger and Geraldine Richelson,
Burn-out: The High Cost of Achievement (Garden City, NY: Anchor Press/Doubleday, 1980).
5
Freudenberger, ‘Staff Burn-Out’, p. 159.
6
Ibid., p. 161.
Freudenberger did not just describe the burnout syndrome, he

also suggested preventive measures. As he believed that burnout is parti-
cularly linked to specific working environments and organisational con-
texts, he proposed intervening at the organisational rather than just the
individual level. His recommendations included shorter working hours,
regular job rotation, and frequent supervision and staff training.
Freudenberger’s initial work was followed by a significant number of
psychological and medical studies, starting with research by Christina
Maslach and her colleagues in the late 1970s and early 1980s.7 In contrast
to Freudenberger’s qualitative, almost auto-ethnographic account, the
social psychologist Maslach focused on the measurement of burnout.
Based on the three dimensions of burnout – exhaustion, cynicism, and
inefficacy – she developed the Maslach Burnout Inventory (MBI), which
is still the most widely used questionnaire for measuring burnout today.8
The MBI marked a turning point in burnout research, as it was now
possible to easily measure this mental state in different populations and
professions. The burnout phenomenon was now investigated in further
occupations – particularly in education, but also in sports, and service
providers. Furthermore, it was systematically described in relationship to
established concepts in industrial-organisational psychology such as job
stress, job satisfaction, and organisational commitment.9 One aspect that
should be highlighted is the fact that ‘from the beginning, burnout was
studied not so much as an individual stress response, but in terms of an
individual’s relational transactions in the workplace’.10 As shall be demon-
strated, this assumption has changed over time, particularly in its German
context since the late noughties.
7
Christina Maslach, ‘Burned-Out’, Human Behavior 5: 1 (1976), 16–22; Ayala Pines and
Christina Maslach, ‘Characteristics of Staff Burnout in Mental Health Settings’, Hospital &
Community Psychiatry 29: 4 (1978), 233–7; Christina Maslach and Susan E. Jackson, ‘The
Measurement of Experienced Burnout’, Journal of Organizational Behavior 2: 2 (1981), 99–113.
8
Maslach and Jackson, ‘The Measurement of Experienced Burnout’.
9
C. Maslach, W. Schaufeli, and M. P. Leiter, ‘Job Burnout’, Annual Review of Psychology
52 (2001), 397–422.
10
Ibid, p. 400.
The Disorder of the Passionate

and the Dynamic in the Helping Professions
As previously mentioned, the term burnout was already in use in every-
day life to describe feelings of work-related exhaustion in a particular
setting, even before it was systematically and scientifically described
and studied. The term seemed to be a literal description of people’s
experience, portraying the lack of fire to fuel them in their daily work. In
addition, it was not a phenomenon of the ‘happy-go-lucky individual’
but of ‘dynamic, charismatic, goal-oriented men or women’.11 Burnout
was understood and later conceptualised as a multi-factor phenomenon
that was not only related to the individual but, to a significant extent,
influenced by their work environment. Burnout was not one’s own fault
but dependent on organisational factors. Thus while burnout was cer-
tainly not something one would aim for, it was also not the worst of all
possible mental disorders. Rather, it was a condition to which one could
relate without needing to fear stigmatisation, because it was mostly
related to environmental factors and personality traits that are generally
perceived as desirable.
Despite this history and the increasing scientific interest in the topic,
it took five years before the media picked up on the supposedly new
phenomenon and a broader public debate arose. The New York Times
was one of the first major news outlets to report on the topic in 1979.12
Interestingly, the article describes teachers, not health-care workers, who
suffer from depression, exhaustion, anxiety, and anger in combination
with diffuse physical symptoms. This mysterious illness is called ‘tea-
chers “burnout”’. The article especially cites external factors as causes of
this new disease, most notably ‘inadequate professional preparation for
the realities of today’s schools, poor organizational structures within the
schools, and in working with supervisors who are burned out them-
selves’.13 Consequently, solutions suggested to overcome these problems
11
Freudenberger and Richelson, Burn-out: The High Cost of Achievement, p. 19.
12
Sally Reed, ‘Teacher “Burnout”: A Growing Hazard’, New York Times, 7 January 1979.
13
Ibid.
mostly relate to organisational measures or interventions at a societal

level, such as raising the status of teachers as a professional field.
The article also cites an industrial psychologist who treats ‘burned-out
[business] executives’, but leaves no doubt that burnout is mostly related
to ‘helping professions – teachers, counsellors, and social workers’.14
Shortly after its appearance in The New York Times similar articles were
published about the second burnout ‘high-risk’ group, that is, nurses.
The general argument in these articles is similar; nurses as well as
teachers have jobs with high responsibilities yet a lack of recognition
and social approval.
In the space of only three years, however, reporting on the phe-
nomenon began to change. In a New York Times article from 1982, a
New York psychiatrist is quoted as saying:
Some people, seeking approval from almost everyone, may use work as a
primary method to enhance self-esteem and gain social approval. Unable
to say no to demands of others, these individuals cultivate few activities
that bring pleasure or satisfaction to themselves. They eventually become
burdened with fatigue, which in turn leads to decreased effectiveness.15
Now the focus is on the individual and no longer on environmental

factors. Another important shift relates to the occupational groups that
are prone to burnout. The article still mentions helping professions as
being particularly vulnerable, but other groups come into focus too. The
article specifically mentions ‘a growing number of women [ . . . ] as they
try to juggle careers and the traditional demands of a home and family
without compromising either’.16 It goes on to say that:
Children, too, are subject to burnout, especially those with exploita-

ble talents or an overly strong academic drive. Talented young ath-
letes, dancers and musicians, among others, may flounder because
14
Ibid.
15
Jane E. Brody, ‘Personal Health’, New York Times, 6 October 1982.
16
Ibid.
they are pushed too hard too fast and denied the time to play and
interact normally with their peers.
These two changes between the reports are interrelated and have
consequences for the understanding of burnout. Suddenly, it is the
individual who is responsible for dealing with work-related stress and
exhaustion and ensuring that one does not burn out. ‘Self-awareness is
probably the best defence against burnout. [ . . . ] The single most
important step is to avoid making work the sole determinant of self-
esteem.’17 The article does not list a single intervention or preventive
measure on the organisational or societal level.
In part, this shift – that is, the idea that burnout can affect everyone
and that it is related to personality traits – is also reflected in burnout
research. As mentioned before, the MBI made it possible to measure
burnout simply and on a larger scale, so it was studied in more and more
occupations. It comes as no surprise that, once one starts to measure
exhaustion and fatigue in different work-related contexts and to describe
it as a burnout syndrome, one is likely to find people who suffer from it,
especially as its underlying concept was not particularly selective in
contrast to other mental disorders such as depression.18
Interestingly, the individualisation described in the New York Times
article is not so well founded on scientific research on the burnout
syndrome, at least not on the typical research of the 1980s. At that
time, most research articles still largely portrayed burnout as a multi-
faceted syndrome that was not triggered only by a particular personality
type. The shift away from this can be explained by the dominance of
some actors in the public discourse around that time, most notably
Freudenberger, who started to focus increasingly on individual factors.
In the early 1980s, researchers in Germany had already started to pick
up on the concept of burnout, and engaged in international discussions
on the topic. The first article on the topic in a German scientific journal
17
Brody, ‘Personal Health’.
18
Scott T. Meier, ‘The Construct Validity of Burnout’, Journal of Occupational Psychology 57:
3 (1984), 211–19.
was published in 1981 and dealt with the phenomenon in nurses.19

Over the following years, several more articles were published on the
subject in the same journal, and in 1986 burnout among teachers also
became a matter of scientific interest.20 Interestingly, though, it was not
until almost 10 years after the first article appeared in The New York
Times that burnout became of interest to the media and popular press in
Germany. The first published article found in the German mass media
dates to 1988.21 Here, burnout is described as a ‘mysterious mental
illness’ that mostly affects helping professions. Explicit reference is made
to Freudenberger and his studies in the 1970s as well as to other pioneers
of burnout research. This is not, however, the whole story. The article
also quotes German ‘burnout experts’ such as Matthias Burisch, who
explains that burnout mostly affects people who are very passionate
about their jobs. These people experience a lack of approval in the
workplace or realise that they can no longer achieve important personal
goals. This, in turn, may very well result in burnout symptoms, espe-
cially between the ages of 40 and 50. Even though it is not explicitly
mentioned, the underlying idea is that burnout can affect almost anyone
in any profession. The article also cites a US-based therapist and man-
agement consultant who states that ‘it is not the people who are crazy
but the organizational structures they work in’.22 Yet, instead of further
elaborating on the exhausting and demanding structural features of
work, the article closes with remarks on the personal component, thus
individualising the phenomenon. In the end, it is the individual’s
responsibility to take care of his or her mental and physical health.
This individualisation of mental health risks, and particularly of exhaus-
tion and fatigue in the workplace, that can be observed in the subsequent
public debate are important prerequisites for the new meaning attrib-
uted to burnout in Germany in the noughties, as will be shown in the
next section.
19
J. Knoblauch, ‘Playing a Trick on Stress: Recipe Against Burnout in the Hospital Routine’,
Krankenpflege Journal 19: 11 (1981), 7–10.
20
K. Biener, ‘Stress in Teachers’, Fortschritte der Medizin 104: 20 (1986), 405–8.
21
‘Nichts als Ruhe’, Der Spiegel, 26 December 1988, 162–4.
22
Der Spiegel, ‘Nichts als Ruhe’, 164.
It is also remarkable that while German researchers started to become

interested in burnout at a very early stage, the media were very slow to
cover this topic. It suggests that this particular type of exhaustion was
simply not an issue that was worth reporting at that time. This certainly
does not mean that exhaustion and fatigue were not a topic of public
debate at all, but even if one searches for alternative terms and concepts
in the popular press there are few references to clinically relevant
phenomena. This shows that workers did not want to speak about
their feelings to the extent we observe today, and there was possibly
not even an awareness that it was worth talking about. Others may well
have feared stigmatisation because of their mental challenges and
problems.
Burned-Out Society: Exhaustion

and Fatigue Are Everywhere
During the 1990s and early 2000s, numerous scientific articles were
published on burnout, its causes, associated factors, its symptoms, its
prevalence in different occupational groups, psychometric studies, and on
intervention and prevention programmes. However, the number of these
publications remained fairly low compared to other mental states such as
depression or other forms of work-related stress and exhaustion, rarely
exceeding more than 40 publications a year until the mid-noughties.23
Likewise, there are very few media reports on the burnout syndrome
during that time, and it seems that few people took any notice of this
phenomenon.
In Germany this changed dramatically at the beginning of the 2010s,
when burnout turned into a Volkskrankheit (widespread disease). Hardly
a week went by without a new report on the increasing number of
burnout cases all over the country and in various professions. The
23
Linda V. Heinemann and Torsten Heinemann, ‘Die Etablierung einer Krankheit? Wie Burnout in
den modernen Lebenswissenschaften untersucht wird’, in Leistung und Erschöpfung: Burnout in der
Wettbewerbsgesellschaft, ed. Sighard Neckel and Greta Wagner (Berlin: Suhrkamp, 2013), 129–47.
reports usually told the story of people who were passionate about and
successful in their jobs, who worked excessively, and one day finally
collapsed.24 Interestingly, the articles did not cover doctors, nurses, or
social workers, but lawyers, business executives, and members of the
higher social classes. The only classic target group of burnout still
regularly mentioned were teachers. Apart from them, it was the young
and successful that were exhausted by the increasing pace of business and
social life. Suddenly, burnout was everywhere and could supposedly
affect everyone. Journals and newspapers, respectively, declared ‘The
Burn-Out-Society’ and ‘The Burned-Out Republic’.25 Magazines asked
on their title pages whether there was still ‘Anyone without Burnout?’.26
Even health insurance companies published reports on the increasing
number of burnout patients. For example, the Deutsche Angestellten
Krankenkasse, one of the major German health insurers, included a
chapter on the burnout syndrome in its annual health report.27 It stated
that if burnout was an accepted diagnosis it would be one of the most
prevalent mental health diagnoses after affective, neurotic, stress-related,
and somatoform disorders.
The rise of the use of ‘burnout’ in Germany comes at a time char-
acterised by a perceived acceleration of society and social life as well as a
series of economic and social crises.28 The development of new and
the advancement of existing information technologies and devices,
particularly since the last decade of the twentieth century, has blurred
the boundaries between working hours and leisure time. They increase
the feeling of instant and permanent availability for the employer.
Simultaneously, this crisis of the new economy was soon followed by a
seemingly even more dramatic and far-reaching crisis, the so-called
global financial crisis. This produced a profound uncertainty and
24
See, for example, Jörg Blech, ‘Schwermut ohne Scham’, Der Spiegel, 6 February 2012, 122–31.
25
‘Die Burn-out-Gesellschaft’, Focus, 8 March 2010; Sven Astheimer, ‘Volkskrankheit Burnout:
Die Ausgebrannte Republik’, Frankfurter Allgemeine Zeitung, 1 February 2012.
26
‘Noch jemand ohne Burnout?’, Die Zeit, 1 December 2011.
27
IGES Institut GmbH, DAK-Gesundheitsreport 2013 (Hamburg, February 2013).
28
Hartmut Rosa, Social Acceleration: A New Theory of Modernity, trans. Jonathan Trejo-Mathys
(New York, NY: Columbia University Press, 2015).
feelings of insecurity in societies around the world, including in

Germany. This is not to say that these feelings were always objectively
justified; but they gave rise to increased stress in the workplace and in
private life, as well as feelings of exhaustion and depression. Social
scientists have since concluded that we live in an age of depression.29
Nadine Teuber shows in her comprehensive study on depression in
Germany that this diagnosis is ‘female’.30 She argues convincingly that
symptoms for depression correspond with stereotypes of femininity.
Burnout, in contrast, can be associated with characteristics that are
typically attributed to men: hard working, ignoring physical symptoms,
transgressing physical and psychological boundaries, and using drugs, for
example. As shown below, even the way of coping with this mental state
is often portrayed as a ‘male’ story of success in a double sense. First, it is
often men that are the subjects of media reports. Second and more
importantly, the way they overcome burnout is a story of fighting,
power, and getting stronger and becoming resilient by the end. It is
this particular connotation that contributed to the rise of burnout in
Germany at this very specific historical time; successful men, and poten-
tially women with male traits, in the noughties would not suffer from
depression; they would burn out and overcome it.
The burnout discourse and the widespread use of this term were
particularly fuelled by several public figures and celebrities who claimed
to be suffering from burnout. One of the most relevant media reports in
this context was the case of one of the youngest university professors in
Germany at that time, Miriam Meckel. At the age of 43, she experienced
a physical and psychological breakdown due to her immense workload
over the previous 15 years. Meckel spent five weeks at a psychological
rehabilitation clinic. After her convalescence, she wrote a non-fiction
book about her experiences entitled Letter to My Life: Experiences with
29
Alain Ehrenberg, The Weariness of the Self: Diagnosing the History of Depression in the
Contemporary Age (Montreal: McGill-Queen’s University Press, 2010); Charlotte Jurk, Der
Niedergeschlagene Mensch. Depression – Geschichte und gesellschaftliche Bedeutung einer Diagnose
(Münster: Westfälisches Dampfboot, 2008).
30
Nadine Teuber, Das Geschlecht der Depression: ‘Weiblichkeit’ und ‘Männlichkeit’ in der
Konzeptualisierung depressiver Störungen (Bielefeld: Transcript, 2011).
Burnout.31 The book was an enormous success and widely discussed in

the media.32 Her case, as well as a significant number of similar reports,
contributed to the intense public discussion on the burnout syndrome in
the following years, as outlined above. Meckel’s lifestyle and her way of
coping with burnout can perfectly be described by male attributes.
The list of German celebrities suffering from burnout is long. Even
before Miriam Meckel publicised her burnout case, one of the first
celebrities to do so was the famous and successful ski jumper Sven
Hannawald. He claimed to have suffered from burnout in 2004.
Others that followed were Ralf Rangnick, a soccer coach, Tim Mälzer,
a television chef, and book author Frank Schätzing. Soccer professionals
such as Sebastian Deisler and Robert Enke were also often referred to in
the media as having burnout though, in both cases, the official term that
was used in press releases and public statements was ‘depression’. These
were only a few examples of the growing popularity of burnout in
Germany. Burnout became a fashionable diagnosis without actually
being a ‘real’, that is, a medically accepted, diagnosis.33
On the one hand, the headlines as well as the book publications
suggest that burnout is a disease which can affect any gender or profes-
sion, including high achievers such as Miriam Meckel. ‘Only those who
burn, can also burn out’ is a literal translation of a statement that several
articles refer to or at least present as a general idea.34 In this way,
burnout is almost presented as a badge of honour: ‘Look how hard I
worked!’ On the other hand, the articles struggle to explain exactly what
burnout is. They do not provide a coherent description despite there
being some established scientific definitions. One reason for this is that
burnout is not an officially recognised diagnosis in the standard classi-
fication systems and is, therefore, not sufficient for medical treatment in
31
Miriam Meckel, Brief an mein Leben: Erfahrungen mit einem Burnout (Reinbek bei Hamburg:
Rowohlt, 2010).
32
Sandra Kegel, ‘Diagnose: Totale Erschöpfung’, Frankfurter Allgemeine Zeitung, 10 March 2010;
Sabrina Pfauth, ‘Frau Nimmersatt und ihr Burn-out’, Süddeutsche Zeitung, 16 March 2010.
33
Wolfgang P. Kaschka, Dieter Korczak, and Karl Broich, ‘Burnout: A Fashionable Diagnosis’,
Deutsches Ärzteblatt International 108: 46 (2011), 781–7.
34
See Blech, ‘Schwermut ohne Scham’.
most countries around the world, including in Germany. Another and

more important reason is that journalists could not tell their stories in
the manner they do if they would subscribe to a narrower definition of
burnout. Their articles are about people who show symptoms that could
be described as depressive, bi-polar, panic or anxiety disorders; and are
sometimes even explicitly mentioned as such. The writers use the term
burnout to summarise all these cases in such a way that there appears to
be no doubt that burnout actually exists as a distinct mental disorder.
Due to this ambiguity, namely, the fact that it is not a proper psychiatric
diagnosis yet seems established enough to relate to without any further
explanation, it proves particularly appealing. As suggested in some
articles, people can acknowledge that they have certain mental problems
without the fear of stigmatisation, as is the case with depression and
other mental disorders. In other words, burnout covers up mental
disorders and lets them appear as a minor bump in an otherwise
successful career. Meckel is an excellent example for this, in that she
used her burnout ‘diagnosis’ for her further success by relieving it in a
book about her experiences with this mental state.
Burnout is associated with everyday struggles related to life in a
neoliberal society and having a successful career. Thus, it became and
was made an umbrella term and a cover-up diagnosis for all kinds of
physical and psychological symptoms which may reduce productivity.
Suffering from burnout is presented as being not as devastating as a
major depression or a panic disorder. This and the above-described male
connotations of burnout, in a society that is still largely dominated by
men particularly in the business and public administration worlds,
contribute to the popularity of this concept in Germany.
In contrast to the wide media coverage of the burnout syndrome and
the ubiquitous use of the term in Germany, burnout has hardly made it
to the headlines of US-American newspapers or magazines such as The
New York Times, The Wall Street Journal, USA Today, or Newsweek,
since 2000. For example, USA Today only published four articles with
the term burnout in the headline between 2010 and 2015. In the same
period, the Frankfurter Allgemeine Zeitung published some 50 articles
using the term in its title, and more than 500 articles mention burnout
at some point. On this quantitative level, there is already a striking
difference between the two countries. Clearly, burnout is much more in

favour in Germany than in the US media.
The differences do not end there. The US media certainly report on
burnout, but their articles differ significantly from those in German
newspapers and magazines. One difference concerns the use of the
term. In the US media, burnout is used in two different ways. In most
cases, it is a literal description of a certain emotion or feeling without
an attempt to label a new and distinct disease which has to be treated.
That does not mean that the problem is not to be taken seriously; it
just seems to be handled less emotionally and more descriptively than
in Germany.
Burnout is used to describe an almost natural state of breakdown as a
consequence of ‘twenty years of manic working’, states Mary Lou
Quinlan, whose case is described in a 2002 article.35 After having
fantasised about being hurt in a car accident to finally achieve some
‘peace and quiet’ in a hospital, she realised that a change in her lifestyle
was both necessary and inevitable. After a five-week sabbatical she quit
her job as a chief executive in a Manhattan ad agency and started her
own business. In this context, burnout is not presented as a new disease,
but as the consequence of a distinct working lifestyle and organisational
factors which, taken together, put her into a state in which she had
burned all her fuel.36
If burnout is used as a diagnosis at all, which is the second way of
using the term, it is mostly used with its original meaning, that is to say,
to describe people who suffer from work-related stress in the health-care
sector.37 Other articles deal with burnout among teachers and elite
35
Melinda Ligos, ‘Executive Life; To Conquer Burnout, Think Smaller’, New York Times,
12 April 2002.
36
Organisational factors can be long working hours with poor payment and little approval as is the
case in some health-care and social professions, including teachers, nurses, and social workers.
37
Pauline W. Chen, ‘The Widespread Problem of Doctor Burnout’, The New York Times, 23
August 2012; Pauline W. Chen, ‘Easing Doctor Burnout With Mindfulness’, The New York
Times, 26 September 2013; Jane E. Brody, ‘Aiding the Doctor Who Feels Cancer’s Toll’, The
New York Times, 26 November 2012; Janice Lloyd, ‘Nearly Half of Doctors Report
Symptoms of Burnout; Study’s Findings Raise Concerns about Effects of Health Care
Reform’, USA Today, 21 August 2012, B5.
athletes.38 However, as mentioned earlier, most articles do not discuss the

question as to whether burnout is a ‘real’ new disease, or if it just covers up
‘old’ diseases such as depression or anxiety. Instead, the conditions which
lead to the loss of energy in teachers or medical staff are described as a
distinct phenomenon, a combination of individual and organisational
factors, and following this possible solutions are discussed.
Another striking difference is that burnout seems to be less popular
among celebrities, high-profile executives, and managers in the United
States. Whereas there are plenty of reports about burned-out musicians,
popular athletes, or successful managers in the German media, this has
not been the case in the US media over the last 10 years.
Cultural Differences in the Use and Meaning

of the Term Burnout
Our analysis reveals distinct differences in the use and meaning of the term
burnout in German and US popular media. These differences have not
gone unnoticed by others. Benedict Carey already noted in 2010 that ‘in
recent years, psychiatrists in Europe have been diagnosing what they call
“burnout syndrome”, the signs of which include “vital exhaustion”’.39
However, Carey does not provide a convincing explanation regarding
the reasons for this development and the differences in the use of the
concept. It may be surmised that there are two aspects to be taken into
consideration.
The first relates to the way burnout is described and used in psychol-
ogy and medicine. To date most burnout research has been circular,
relying on questionnaires that measure symptoms that are not yet clearly
or strictly defined. The lack of knowledge about burnout and its related
diagnostic criteria trigger new research that is equally problematic, using
38
Jacques Steinberg, ‘Giving the Teacher Balm for Burnout’, The New York Times, 1 July 2001;
Pat Borzi, ‘Spreading Joy of Swimming, Ex-Olympian Finds It Again’, The New York Times,
28 June 2012; Brian Homewood and Pritha Sarkar, ‘Anxiety, Depression “Highly Prevalent”
in Football, Says Study’, The New York Times, 2 April 2014.
39
Benedict Carey, ‘On the Verge of “Vital Exhaustion”?’, The New York Times, 31 May 2010.
as it does the same debatable measures to identify supposed sufferers

from burnout, and examining their states of mind. A close investigation
of medical and psychological studies on burnout shows that, instead of
providing further clarification of the concept, this type of research
actually contributes to the indefinite status of the burnout syndrome.40
There is no consensus among researchers and clinicians on what burnout
actually is, and whether or not it is useful to classify it as a distinct and
distinguishable diagnosis that the media as well as the public can use in
different ways. Yet there is also scientific evidence that suggests that
burnout is indeed a relevant and distinct diagnosis with very high
prevalence rates in various professions. This allows the media and the
public to speculate about a burnout epidemic, with some reporting up to
a 31% rate of burnout cases among medical students.41 There are also
several studies that report a significant overlap between burnout and
other diagnoses such as depression, and thus justify the use of burnout as
an umbrella term. Yet, at the same time, there are numerous studies
suggesting that burnout is particularly prevalent in certain professions,
or that argue against the usefulness of the burnout diagnosis altogether.
Whatever position one chooses to adopt it can be backed by scientific
evidence, thus allowing for a narrow use in the United States and a more
general understanding of the syndrome in Germany.
The question, however, remains as to why burnout became such a
popular subject and a ubiquitous term in the last decade in Germany,
while it did not have such a career in the United States. This is the second
aspect which can be explained by some recent economic developments
and cultural traditions in the two countries. It is no surprise that burnout
became a topic of debate and public interest during a period of economic
crises. This had started already with the crisis of the new economy at the
turn of the millennium, and gained momentum with the so-called global
financial crises since 2008. From a German and, for that matter, con-
tinental European perspective, the origin of both crises lay in the United
40
Linda V. Heinemann and Torsten Heinemann, ‘The Social Construction of a Contested
Diagnosis: The Case of Burnout’ (Under Review).
41
Sally A. Santen et al., ‘Burnout in Medical Students: Examining the Prevalence and Associated
Factors’, Southern Medical Journal 103: 8 (2010), 758–63.
States and its mode of capitalism. The United States is perceived as the
posterchild of capitalism, neoliberalism, flexible labour conditions, and
of ‘social acceleration’.42 Basically, burnout can be said to be a response to
these developments. As outlined above, the term is used to describe a state
of exhaustion among successful people who can no longer keep up with
the pace of life in a supposedly increasingly complex and high-pressure
society. It is a symbol for excessive misuse of a person’s mental and
physical resources. If a person can no longer keep up with the speed of
work, she or he will eventually suffer from burnout. More importantly,
the term is not translated into German and used with its counterpart
ausgebrannt sein, but as an English term. Thus, the English term becomes
a metaphor for all those aspects associated with the perceived challenges
of neoliberalism and seems to capture or incorporate them in a single
word. At the same time, the syndrome is not only negative. It also
includes the successful return, the positive story of managing one’s own
feelings, emotions, and bodily conditions, and returning to where one
dropped out before, sometimes becoming even more successful. This is
the other side of the perceived ‘American way of life’ that is attributed to
this concept and its connotations.
In the US debate, by contrast, at least some of the societal challenges
associated with burnout in Germany are not considered relevant or
worth problematising. They are part of everyday life and therefore
taken for granted. Thus, there is no need to use the concept of burnout
in the particularly Germanic way or, at least, not as excessively. For
example, there is not a single article in The New Yorker that uses
‘burnout’ in its headline. This certainly does not mean that The New
Yorker does not discuss stress, fatigue, and exhaustion as well as the
societal, individual, and health-related challenges in the age of neoliber-
alism. Quite the contrary, these topics regularly appear in this magazine,
but they are not discussed together with burnout as in Germany.
To conclude, the term burnout is used in a very different way
depending on the cultural context. In Germany the term is still popular
whereas in the United States its use diminished after the term was
42
Rosa, Social Acceleration: A New Theory of Modernity.
successfully transferred to Germany. We argue that the different devel-

opments of the term are the result of an interplay of several factors. The
scientific vagueness of the term, which allows it to be used to cover a
broad spectrum, means it can be applied to certain historic circum-
stances, such as the economic crisis in 2008, and can cover cultural
differences in the way modern capitalism is applied. This may also be an
explanation for the possibility of the much more emotional use of the
term burnout in the German media. In the United States, burnout has
remained pretty much what it was since it was first mentioned in 1974; a
reaction to a stressful and overloaded working life with little recognition.
When used as a psychological diagnosis, the burnout syndrome has
remained fuzzy and diffuse up to the present day. This is true for both
the cultural contexts this chapter has examined. What differs is the way
burnout appears in public discussion, that is, in the media. In the United
States, burnout is seen as a specific issue in particular occupations, while
in Germany it is understood as the ultimate response to a perceived ever-
increasing acceleration of today’s society, and of our mode of existing.
References
Sven Astheimer, ‘Volkskrankheit Burnout: Die Ausgebrannte Republik’,
Frankfurter Allgemeine Zeitung, 1 February 2012. Online at: http://www.faz.
net/aktuell/wirtschaft/volkskrankheit-burnout-die-ausgebrannte-republik-
11627772.html (accessed 23 February 2017).
K. Biener, ‘Stress in Teachers’, Fortschritte der Medizin 104: 20 (1986), 405–8.
Jörg Blech, ‘Schwermut ohne Scham’, Der Spiegel, 6 February 2012, 122–31.
Pat Borzi, ‘Spreading Joy of Swimming, Ex-Olympian Finds It Again’, The
New York Times, 28 June 2012, B11.
Jane E. Brody, ‘Personal Health’, New York Times, 6 October 1982, C12.
———, ‘Aiding the Doctor Who Feels Cancer’s Toll’, The New York Times,
26 November 2012, D7.
Benedict Carey, ‘On the Verge of “Vital Exhaustion”?’, The New York Times,
31 May 2010, D1.
Pauline W. Chen, ‘The Widespread Problem of Doctor Burnout’, The New York
Times, 23 August 2012. Online at: http://well.blogs.nytimes.com/2012/08/
23/the-widespread-problem-of-doctor-burnout/ (accessed 23 February 2017).
———, ‘Easing Doctor Burnout With Mindfulness’, The New York Times, 26
September 2013. Online at: http://well.blogs.nytimes.com/2013/09/26/easing-
doctor-burnout-with-mindfulness/ (accessed 23 February 2017).
Alain Ehrenberg, The Weariness of the Self: Diagnosing the History of Depression in
the Contemporary Age, trans. David Homel et al. (Montreal: McGill-Queen’s
Focus, ‘Die Burn-out-Gesellschaft’, 8 March 2010.
Herbert J. Freudenberger, ‘Staff Burn-Out’, Journal of Social Issues 30:
1 (1974), 159–65.
———, ‘The Staff Burn-out Syndrome in Alternative Institutions’,
Psychotherapy: Theory, Research & Practice 12: 1 (1975), 73–82.
———, ‘Burn-out: Occupational Hazard of the Child Care Worker’, Child
Care Quarterly 6: 2 (1977a), 90–9.
———, ‘Burn-out: The Organizational Menace’, Training and Development
Journal 31: 7 (1977b), 26–7.
Herbert J. Freudenberger and Geraldine Richelson, Burn-out: The High Cost of
Achievement (Garden City, NY: Anchor Press/Doubleday, 1980).
Sigmund G. Ginsburg, ‘The Problem of the Burned-out Executive’, Personnel
Journal 48: 8 (1974), 598–600.
Linda V. Heinemann and Torsten Heinemann, ‘Die Etablierung einer
Krankheit? Wie Burnout in den modernen Lebenswissenschaften untersucht
wird’, in Leistung und Erschöpfung: Burnout in der Wettbewerbsgesellschaft ed.
Sighard Neckel and Greta Wagner (Berlin: Suhrkamp, 2013), pp. 129–47.
———, ‘Burnout research: Emergence and scientific investigation of a con-
tested diagnosis’, Sage Open January–March (2017), 1–12. doi:10.1177/
2158244017697154 (accessed 23 February 2017).
Brian Homewood and Pritha Sarkar, ‘Anxiety, Depression “Highly Prevalent” in
Football, Says Study’, Reuters Online, 2 April 2014. Online at: http://www.
reuters.com/article/us-soccer-health-fifpro-idUSBREA3111N20140402
(accessed 23 February 2017).
IGES Institut GmbH, DAK-Gesundheitsreport 2013 (Hamburg, February
2013).
Charlotte Jurk, Der Niedergeschlagene Mensch. Depression – Geschichte und gesellschaf-
tliche Bedeutung einer Diagnose (Münster: Westfälisches Dampfboot, 2008).
Wolfgang P. Kaschka, Dieter Korczak, and Karl Broich, ‘Burnout: A Fashionable
Diagnosis’, Deutsches Ärzteblatt International 108: 46 (2011), 781–7.
J. Knoblauch, ‘Playing a Trick on Stress: Recipe Against Burnout in the
Hospital Routine’, Krankenpflege Journal 19: 11 (1981), 7–10.
Melinda Ligos, ‘Executive Life; To Conquer Burnout, Think Smaller’, New

York Times 12 April 2002, section 3, 12.
Janice Lloyd, ‘Nearly Half of Doctors Report Symptoms of Burnout; Study’s
Findings Raise Concerns about Effects of Health Care Reform’, USA Today,
21 August 2012, B5.
Christina Maslach, ‘Burned-Out’, Human Behavior 5: 1 (1976), 16–22.
Christina Maslach and Susan E. Jackson, ‘The Measurement of Experienced
Burnout’, Journal of Organizational Behavior 2: 2 (1981), 99–113.
C. Maslach, W. Schaufeli, and M. P. Leiter, ‘Job Burnout’, Annual Review of
Psychology 52 (2001), 397–422.
Miriam Meckel, Brief an mein Leben: Erfahrungen mit einem Burnout (Reinbek
bei Hamburg: Rowohlt, 2010).
Scott T. Meier, ‘The Construct Validity of Burnout’, Journal of Occupational
Psychology 57: 3 (1984), 211–19.
Sandra Kegel, ‘Diagnose: Totale Erschöpfung’, Frankfurter Allgemeine Zeitung,
10 March 2010, 29.
Sabrina Pfauth, ‘Frau Nimmersatt und ihr Burn-out’, Süddeutsche Zeitung,
16 March 2010, 10.
Ayala Pines and Christina Maslach, ‘Characteristics of Staff Burnout in Mental
Health Settings’, Hospital & Community Psychiatry 29: 4 (1978), 233–7.
Sally Reed, ‘Teacher “Burnout”: A Growing Hazard’, New York Times,
7 January 1979, 163.
Hartmut Rosa, Social Acceleration: A New Theory of Modernity, trans. Jonathan
Trejo-Mathys (New York, NY: Columbia University Press, 2015).
Sally A. Santen et al., ‘Burnout in Medical Students: Examining the
Prevalence and Associated Factors’, Southern Medical Journal 103:
8 (2010), 758–63.
Der Spiegel, ‘Nichts als Ruhe’, 26 December 1988, 162–4.
Jacques Steinberg, ‘Giving the Teacher Balm for Burnout’, The New York
Times, 1 July 2001, section 4A, 24–7.
Nadine Teuber, Das Geschlecht der Depression: ‘Weiblichkeit’ und
‘Männlichkeit’ in der Konzeptualisierung depressiver Störungen (Bielefeld:
transcript, 2011).
Die Zeit, ‘Noch jemand ohne Burnout?’, 1 December 2011.
Linda V. Heinemann is a clinical psychologist and psychotherapist. Her

research interests are in gender and mental health and the sociology of
diagnosis.
Torsten Heinemann is a Professor of Sociology at the University of Hamburg

as well as a Marie Curie Fellow at the Institute for the Study of Societal Issues at
the University of California, Berkeley. His research interests are in social
theory, social studies of science and technology with a particular focus on
biomedicine and biotechnologies, medical sociology, and social problems.
Part III
Exhaustion and Self-Realisation
7
What We Talk About When We Talk
About Mental Health: Towards
an Anthropology of Adversity
in Individualistic Society
Alain Ehrenberg
One should neither laugh nor cry at the world, but understand it.
Baruch Spinoza
Reports on mental health published by health and political organisations

generally indicate that about 20–25% of the population of any modern
society is affected by a ‘mental illness’, mostly by anxiety and depression.
It thus comes as no surprise from this number of people affected that the
This was the subject Albert O. Hirschman had to deal with in philosophy for the French
Baccalauréat he took in Berlin in 1932. Quoted by Cass Sunstein, ‘An Original Thinker of our
Time’, The New York Review of Books, May 23 (2013).
To recall Haruki Murakami’s What I Talk About When I Talk About Running (London: Vintage,
2009), and in tribute to Raymond Carver’s short story, ‘What We Talk About When We Talk About
Love’, in Where I’m Calling From: Selected Short Stories (New York: Vintage, 1989), pp. 138–51.
A. Ehrenberg (*)
Centre national de la recherche scientifique, Paris, France
e-mail: alain.ehrenberg@parisdescartes.fr

DOI 10.1007/978-3-319-52887-8_7
154 A. Ehrenberg
resulting costs to society are enormous (ca. 3–4% of the GDP of

European Union countries). Today mental health certainly is a central
public health issue, but contrary to a disease such as cancer, for example,
it functions as a discursive space in which many of the core tensions and
conflicts of neo-liberal subjectivity are negotiated. One has to elaborate
further about the central place it has come to occupy in our way of life.
Most of the problems grouped under the heading ‘mental health’ –
depression and other exhaustion-related syndromes, addictions, atten-
tion-deficit hyperactivity disorder, and other conditions – tend to be
systematically subjected to social and political concerns about what is
right, fair, unfair, good, or bad; they tend to be objects of intense and
ongoing social controversy. The controversies revolve around the argu-
ment that these conditions are in fact not only illnesses requiring
treatment but also social ills involving values and ideals inherent to
our way of life. At stake are the values we attach to our social relations –
at school, in the family, at the workplace, and by extension, in society as a
whole. Although these conditions affect people individually, they also
manifest a common ill that is social, even socio-political in nature. This
question of the value of social relations, of their human value, cannot be set
aside: it is an intrinsic characteristic of these subjects, it belongs to their
grammar.
In ‘Understanding a Primitive Society’, the philosopher Peter Winch
explains that the magical rites of the Azandes (as observed by the
anthropologist Edward Evans-Pritchard) ‘express an attitude to contin-
gencies; one, that is, which involves recognition that one’s life is subject
to contingencies, rather than an attempt to control these’. These rites
‘emphasize the importance of certain fundamental features of their
life . . . We have a drama of resentment, evil-doing, revenge, expiation,
in which there are ways of dealing (symbolically) with misfortunes and
their disruptive effects on man’s relations with his fellows, with ways in
which life can go on despite such disruption’.1
1
Peter Winch ‘Understanding a Primitive Society’, American Philosophical Quarterly 1: 4 (1964),
307–24. The article consists of a discussion with anthropologist Edward Evans-Pritchard and
philosopher Alasdair McIntyre regarding magical rites practiced by Azandes.
7 What We Talk About When We Talk About Mental Health . . . 155
I argue in this chapter that the centrality of emotional and mental health
problems in our society (including depression, stress, burnout, and other
exhaustion-related syndromes) can be described as a form of ‘obligatory
expression’, which characterises an attitude towards contingency or adver-
sity in a global context where autonomy is our supreme value. Here I refer
to the article by Marcel Mauss, ‘The Obligatory Expression of Emotions’
(1921) – ‘obligatory’ meaning ‘expected’, rather than ‘compelled’. Mental
health is approached as a major individualistic way of dealing with what the
ancients called passions; it is the name individualistic society has given to
our style of dealing with passions, the social and moral equivalent of
magical rites for the modern autonomous individual.
I develop this idea in three steps. In part one, I outline the debate on
the workplace and mental health in French society. The second part
presents the main features of autonomy today and their relations to
mental health. In the third part, I argue that mental health may be seen
as an attitude towards adversity resulting from social relationships that
links individual and common ills.
The French Debate on the Workplace

and Mental Health
Starting in the 1980s and developing into the 1990s, gloomy phrases began
to crop up in the writings of many French psychoanalysts, sociologists, and
philosophers. They began to speak of a ‘new psychic economy’, of an
increasing prevalence of borderline personalities symbolising ‘anthropolo-
gical mutation’ and the ‘melancholisation of social ties’ – referring in these
various ways to a malaise, afflicting both society and the individual, whose
core is autonomy and whose victim is life in common (what the French
call the vivre-ensemble, or living together). On these different levels, mental
health is taken to raise the question of the fate of social ties in democratic
societies dominated by mass individualism and globalised capitalism. These
worries have been crystallised by the rise of autonomy, which has divided
French society, where it tends to represent an abandonment of the individual
and society to market forces.
156 A. Ehrenberg
France is a society in which politics is of a particularly high value2 – la

question sociale (the social question) was at the core of the French
Revolution.3 The cost of autonomy is a topos of the national narrative.
Autonomy divides French society, in which it resembles a Kantian
imperative – a ‘you must’ – whereas, by contrast, it unifies the United
States where the self-motivated individual is considered a supreme
value.4 Specifically, when speaking of France, what is meant is not
only among academics, as in the United Kingdom, Germany, or the
United States, where these questions are an intellectual routine, but also
and above all in French society at large, in which anti-liberalism is a
common conviction, part of a system of collective beliefs anchored in the
old Jacobin tradition, according to which the State sets society in motion
and frees individuals from their private dependencies. The State is the
instituteur du social (the State institutes the social), an expression which
connotes both the notion of institution and an idea of the State as a sort
of primary-school teacher (instituteur is French for ‘schoolteacher’), an
idea that contrasts starkly with American individualism, in which the
government is often seen as the main danger to ‘rugged’ individualism –
the division of American society regarding Obama’s healthcare reform
being the latest episode of this history.
With the French Revolution, a political concept of the social was
born, which incarnates what historian François Furet, using a formula
from Marx, has called the ‘illusion of politics’: ‘it inaugurates a world in
which any social change is due to known, listed, living phenomena. Like
mythical thought, it invests the objective universe with subjective wills,
that is, either people responsible to blame or scapegoats, as you like it.
Action never meets obstacles or limits, but only opponents.’5 The
Jacobin tradition has been renewed in the new context of globalisation,
2
See Louis Dumont, German Ideology: From France to Germany and Back (Chicago: The
University of Chicago Press, 1994).
3
See Hannah Arendt, On Revolution (New York: Viking Press, 1963), and François Furet, Penser
la Révolution française (Paris: Gallimard, 1978).
4
For a comparison between French and American social ideas and values regarding the shift from
Oedipus to Narcissus, see Alain Ehrenberg, La Société du malaise (Paris: Odile Jacob, 2010).
5
Furet, Penser la Révolution française, p. 43.
flexible work, unemployment, and precariousness: many people think

that the tidal waves of neo-liberalism and globalisation must be resisted,
which have resulted in the steep rise of exhaustion-related complaints
such as stress, depression, and burnout.
In France, generally speaking, the word ‘liberalism’ is preceded by the
prefix ‘ultra’, while ‘individualism’ is accompanied by the adjective
‘frenzied’; ‘autonomy’ is considered a danger for our life in common.
For example, a book by John Dewey entitled Liberalism and Social
Action (1935) was translated last year into French with the title Après
le Libéralisme, as if it were impossible for French people to associate
liberalism with social action – despite the fact that there are several types
of liberalism and several neo-liberalisms.6 It might be added that even a
small dose of Dewey’s pragmatism would not harm French socio-poli-
tical thought – on the contrary.
Among protagonists and observers alike, the widespread malaise in
society is expressed and understood in terms of the idea that social ties
are getting weaker and that, as a result, the individual is increasingly
obliged to rely on himself, on his personal abilities, his subjectivity, and
his interiority. The individual seems overloaded with responsibilities and
ordeals he has not met before. As I have argued in The Weariness of the
Self, this widespread psychic suffering is distinguished by the idea of not
being able to live up to social expectations, and frequently results in
depression, chronic exhaustion, and its related syndromes. It shows fear
of loss, of insufficiency regarding social ideals, and is also related to
narcissism and self-esteem.7 This reflects a threefold process involving
the deinstitutionalisation, psychologisation, and privatisation of human
6
John Dewey, Après le Libéralisme. Ses impasses, son avenir (Paris: Flammarion, 2014).
7
If this seems a typical picture of depression today, the history of depression goes much beyond
that of social causes of psychic suffering. In La Fatigue d’être soi. Depression et société (Paris: Odile
Jacob, 1998), depression has been approached more in terms of accompanying transformations of
ideals or collective representations than of power relationships, that is, a Durkheimian rather than
Foucaldian orientation. As Allan Young wrote in his foreword to the English translation, ‘the book
will be “unfamiliar” to most Anglophone readers’. ‘Foreword’, in The Weariness of the Self:
Diagnosing the History of Depression in the Contemporary Age, trans. David Homel et al.
(Montreal and London: McGill-Queens University Press, 2010), p. xi. I sum up the connecting
thread of the book in a box at the end of this chapter.
158 A. Ehrenberg
existence. These various ‘-isations’ are taken to indicate one thing above
all: namely, the nostalgic notion that a truly ‘genuine’ society is what
existed in the past. Present suffering is viewed as being caused by this
disappearance of a true society, that is, of a society with genuine jobs and
families, genuine schools and policies, a society in which we were
dominated, perhaps, but also protected; neurotic, perhaps, but also
structured.
I would summarise French social ideas, the French consensus on these
questions, as follows: we have seen a shift from a social model where
individuals made up society – they stood together – to a liberal or neo-
liberal one, where this is no longer the case. This is the core expression of
the French malaise. The concept of social or psychosocial suffering is
supposed to be a major symptom of this breakdown of the social fabric.
The widespread notion of ‘social suffering’ encapsulates the idea of
the damaging effects of neo-liberalism and globalisation. Around the
year 2000, the rise of two topics related to exhaustion and the workplace –
psychic suffering caused by flexible work (i.e. overwork), and moral
harassment – symbolised this shift from a social to a liberal model.
Starting in the 1980s, the French have gradually come to group these
diverse problems under the concept of social suffering, a notion of people
unified in their sufferings that can be considered to stem from Jacobinism
in the context of modern mental health. The Americans, for their part,
have generated rather a multitude of syndromes within the DSM, the
Diagnostic Manual of the American Psychiatric Association.
However, there is something missing in the Jacobin conversation
about psychic suffering in the workplace; namely, the sociological
dimension. Indeed, if one wants to discuss work and employment
today in terms of public policies, one must expand the picture to include
both the sociology of organisations and of work. Approaching these
problems without having a sociological description of management
practices, which can vary tremendously, there is a risk of giving an overly
general picture of what goes on within organisations; the risk is the
‘craving for generalisation’ (Wittgenstein). Problems of social suffering
greatly depend on these differences in practice. Without an empirical
sociology of management, the sociology of depression, anxiety, and
psychosocial suffering in the workplace overlooks a fundamental
descriptive step: flexible work raises various types of problems different

from those related to Taylorian/Fordian work. Indeed, the steep rise of
exhaustion and work-related syndromes such as stress and burnout, and
the ‘quality of working life’, are the subject of a large body of research at
the European level. They show a marked increase in work effort in which
the long-term health effects of increased pressure are likely to be particu-

larly severe among the low-skilled. This is because the impact of work
pressure is mediated by the degree of control that employees can exercise
over the work task. Where people are allowed initiative to make decisions
about how to plan and carry out their work, they prove to be substantially
more resilient [ . . . ]. It is jobs that combine high demand with low control
that poses the highest health risks.8
This is the point that should be highlighted. Building social dialogue

between employers and employees takes time, implies a definition of
methods, the elaboration of a shared diagnosis by stakeholders, and so
on. These are the only means to find the way for action for change. This
is a much more difficult and demanding political task than general
jeremiads on neo-liberalism.
New social risks also require public policies regarding investment in the
skills of individuals from an early age (in preschool, for example), adapting
and securing professional trajectories, accommodating critical life course
transitions, and so on.9 This is the pathway to be taken if the wish were
really to improve the world, and not only denounce its social ills.
The central axiom of my analysis is, then, that the idea that society
causes psychic suffering is itself a social idea, and consequently should
itself be an object for sociology, that is, an object for sociology to analyse
and investigate. This goes together with recognising that mental health
cannot be approached solely as a public health issue, nor solely as a
8
Gøsta Esping-Andersen, with Duncan Gallie, Anton Hemerijck, and John Myles, Why We Need
a New Welfare State (New York: Oxford University Press, 2001) pp. 105–6.
9
Ibid. See also this synthesis in Anton Hemerijk, Bruno Palier, and Frank Vandenbroucke, ‘For a
Social Investment Pact in Europe’, Books and Ideas, 15 June 2011. Online at: http://www.
booksandideas.net/For-a-Social-Investment-Pact-in.html (accessed February 2016).
160 A. Ehrenberg
domain of pathology (though, of course, it is also both of these). It does

not constitute a distinct reality that can be ‘cut out’ from social life, nor
can it be summed up in a list of problems to be solved. In its very
essence, it characterises an attitude towards adversity and suffering in a
global context in which ideas, values, and norms of autonomy are the
supreme value.
Autonomy, Mental Health, and Emotion

The concept of autonomy today designates a number of aspects of social
life, and has to be described historically in two steps. Autonomy first
emerged as a collective aspiration in Western societies between the end
of the Second World War and the 1970s: it entailed liberty of choice,
based on self-ownership, and thus normative diversity regarding life-
styles and achievements. New populations – minorities – gained access
to individuality, that is, they were considered equal individuals.
Between the 1970s and the 1980s, autonomy became the common
condition and pervaded social relationships: individual initiative became
highly valued, notably in the transformations of the workplace, where
flexible work implies a worker’s autonomy. All these changes modify the
relationships between the agent and his or her actions: they increase the
responsibility of the agent regarding his or her own actions. The conse-
quence is that everything which is about individual behaviour – the
mobilisation of personal dispositions, notably the ability of the individual
to change by herself or himself, to be the agent of their own change – is
now a major social and political preoccupation.
We have been faced with new life trajectories and new ways of living
affecting the family, employment, education, relationships between gen-
erations, and so on. Along with this, we have witnessed the end of the
welfare state of the twentieth century. This change indicates a life in a type
of sociality where all have to invest themselves personally in numerous
and heterogeneous social situations; this is partly responsible for the steep
rise in exhaustion-related syndromes The individual capability to act as an
autonomous self has become a major point of reference. It embodies our
ideals of personal accomplishment.
This is a change in what can be called the ‘personal equation’. In the

former discipline-based system, the aim of behaviour regulation was the
docile individual, and values of autonomy, such as choice or individual
initiative, were subordinated: the personal equation was weak. In the
current autonomy-based system, the aim of regulation is personal initia-
tive, and everybody has to choose and adopt a line of conduct: the
personal equation is strong. Think, for instance, of the shift from
qualifications in the Taylorian/Fordian workplace to skills in the flexible
workplace, and notably social skills alongside which an emotional
dimension has emerged, related to increased self-control. These skills
condition the possibility of adopting a line of conduct, as a form of the
management of the workforce, where the problem is not any longer how
to coordinate action from a centralised management, but rather how to
get people to cooperate with one another. In the discipline-based system,
the regulation of action consists in a discipline of the body, while in the
flexible organisation it consists of mobilising personal commitment. In
both cases, the individual has to ‘self-control’, to ‘self-regulate’, but the
style of social expectations is different. Today, the source of efficiency in
the workplace is both the relationship and the individual. These capa-
cities are required at every level of hierarchy, faced with a type of
temporality characterised by uncertainty. In this context, emotional
expression and control are major skills: and, of course, skills that require
the perpetual investment of mental energy, often so much so that
individuals feel chronically drained and exhausted as a consequence.
The meaning of discipline itself has changed: now it is subordinated
to the goal of generating individual initiative, thus abilities to self-
motivate and self-activate. It tends towards self-discipline. Whereas in
the past the problem was to render the individual docile and useful, as
Foucault put it, now it is to develop abilities both to activate and to
control the self. The aim of discipline is not primarily obedience; it is a
means to develop the abilities of empathy and self-reliance.
Self-motivation, self-activation, self-control, self-discipline, self-regu-
lation; there is, of course, a strong relationship between these notions
and the significance of mental health in contemporary social life. All
these techniques of the self require substantial energy – more energy
than many possess. The point to be made here is that many phenomena
162 A. Ehrenberg
that we would normally assign to the domain of personality are not

primarily psychological in nature. Rather, they pertain to the normative
changes to ways of acting in society, and thus about new forms of
socialisation and their consequences with regards to inequality and
poverty today. In this sociality, individual subjectivity has become a
major issue, a common question, because it emphasises problems of self-
structuring. Without self-structuring, it is difficult to act by oneself in an
appropriate manner. This was never a central concern in the past society
of mechanical discipline. The consequence of the shift from discipline to
autonomy is a demand for an increased capacity for self-expression and
self-control. At the same time, our social relationships are ever more
frequently formulated in a language of affects and emotions, vacillating
between the positive value of mental health and the negative value of
psychic suffering. Mental health has become a space where core tensions
of our individualism can be represented and find solutions.
Individual Afflictions and Social

Relationships: Towards an Anthropology
of Adversity in Individualistic Society
I would like to take the discussion a step further to address more
fundamental problems of anthropology and sociology. I will attempt
to outline a global sociological framework, which will enable the clar-
ification of the status of psychological symptoms today, and to shed light
on what we talk about when we talk about mental health issues.
Sociologically speaking, the preoccupation with causal explanations
needs to be replaced by the recognition that mental suffering today has
been extended, from a personal problem to be treated by psychologists
and physicians to a reason for attempting to alter disturbed social
relationships and societal forms of organisation. In other words, we
have seen a change in the social status of psychic suffering, and an extension
of its uses, particularly in the political sphere. It has acquired a value that
extends well beyond the area of psychopathology – this being clearly
confirmed by the notions of social or psychosocial suffering.
There are cogent reasons for this situation, which are related to the
core features of mental pathologies: they are functional pathologies in the
sense that they are illnesses pertaining to ideas and moral feelings
necessary to civilisation, such as guilt and shame, without which there
would be no society at all. To be able to feel guilty in certain contexts is
right, and a good thing, while having excessive feelings of guilt is
pathological: obsessional behaviour is valued, but obsessional symptoms
are pathological. They are both values of civilisation and its symptoms.
This is why we speak of social pathologies.
There are two intersecting uses of the idea of social pathology that
need to be differentiated in sociological terms: (1) a use which allows the
analysis of the causes and reasons for a problem and the means to act on
them; this use is practical and singularising (this person’s depression
results from poor interpersonal relations within this department); (2) a
use expressing a wider social malaise. In this latter sense, depression,
burnout, stress, and addictions are reactions to or forms of resistance
towards such things as competition, flexibility, and the excessive sub-
jective commitment required by the management of organisations. In
this latter case, the use is rhetorical and universalising: mental suffering is
approached from the viewpoint of a malaise in society.
This is why the combination of social and moral evil, illness, and
misfortune have transformed the traditional Freudian theme of
‘discontent’ in civilisation or culture into a vision focused on con-
temporary pathologies of individualistic, democratic societies, as well
as having drawn attention to political and moral issues concerning
the human values of the social order. In this way, issues of mental
health become central questions for political philosophy and the
anthropology of democratic societies, the core concerns of which
involve strong social cohesion. The conversion of the Freudian
theme into a question of political philosophy occurred on the ground
of narcissistic pathologies, which became the basis for a questioning
of the modes of ‘living together’ (vivre-ensemble) in the 1970s. The
political idea that ‘society’ causes psychic suffering should be replaced
by the sociological idea according to which psychic suffering has
been extended to social issues and must be approached as an expected
expression of social malaises. Hence, my proposition to approach
164 A. Ehrenberg
mental health issues as expressing a common attitude regarding

adversity produced by social relationships.
This new morbidity, which is not only the subject matter of a
particular area of mental illness but, above all, of the general field of
social life, has been instituted as a major issue in the workplace, in
education, and in the family. The main difference between traditional
psychiatry and modern mental health can be expressed very simply:
psychiatry is a local idiom, specialised in the identification of particular
problems. Mental health, because of its very large spectrum, is a global
idiom enabling the formulation of the multiple tensions and conflicts of
contemporary modern life, and providing answers for acting on them,
that is, identifying problems generally linked to social relationships,
attributing reasons to them, and finding solutions to them. Today
mental health is not only about the struggle against mental illness; it is
also a way of addressing multiple problems in ordinary sociality – in the
family, work and workplace, in couples, education, etc. Mental health
concerns not only health but also the socialisation of the modern
individual. It challenges the essential elements of individualist society,
such as self-value, the opposition between responsibility and illness, the
ability to succeed in life, and so on. It raises moral questions concerning
good and evil, justice and injustice, dignity and shame.
This conclusion highlights two major changes. The first change is the
status of the symptom: the mental disorder is an expression of difficulties
related to socialisation in one way or another, and criteria related to
social functioning have become essential. The second change is related to
a new kind of unhappiness: the feeling of not being able to be good
enough, of not being able to mobilise oneself to do things, is at the core
of this evil; the inability to act and to project oneself into the future is at
the core of the difficulties of the subject.
Two examples, in the United States and in the United Kingdom, will
illustrate the intertwining between mental health and socialisation. The
evolution of American paediatrics is representative of the first change
outlined above. In 1975, the American Academy of Pediatrics intro-
duced the concept of ‘new morbidity’ to designate non-infectious pro-
blems which affect children and families, the prevalence of which was on
the rise. In 1991, it released a report on the role of paediatrics in the
future. Its first sentence asserts that ‘societal changes have engendered
significant changes in the delivery of health care’, in which social
dimensions have a central place.10 The new morbidity is behavioural,
and the concept of behavioural health has gained a new value, from
toddlers to young adults. Now, social, developmental, and behavioural
problems are at the core of the profession of paediatrics. Two other
reports followed, in 2001 and 2012, which went in the same direction.
This new morbidity represents a ‘shift in the understanding of what has
an impact on children and families’ health’.11 Disparities, claims the
2012 report, ‘threaten the democratic ideals of our country in weakening
the national creed of equality of opportunity’.12 This is a ‘significant
change of paradigm’: Through developmental approaches, which aim at
reducing pathologies of adulthood with early interventions in childhood,
a shift has occurred from a sick-care model to a health-care one.
In a nutshell, the new morbidity and the new health relate to beha-
viour, and behaviour is determined by individual autonomy. It is less
disobedience which counts than a lack of empathy for others and a lack
of self-reliance, which are disclosed by the behaviour, and which have
long-term negative consequences for socialisation. The accent put on
early intervention and on developmental approaches highlights a funda-
mental element of autonomy: the relationship with time. As mental
health deals with pathologies of relational life that disable individual
freedom, it seems to be an ensemble of practices in which personal
transformations form a key value, or, in other words, practices conceived
of as, in relation to time, centred on uncertain and unstable futures.
Changes in our relationship to time and the increase in the concern for
emotional and drive control are closely connected.
10
American Academy of Pediatrics Task Force, ‘Report on the Future Role of the Pediatrician in
the Delivery of Health Care’, Pediatrics 87: 3 (March 1991), 401–9 (401).
11
American Academy of Pediatrics: Committee on Psychosocial Aspects of Child and Family
Health, ‘The New Morbidity Revisited: A Renewed Commitment to the Psychosocial Aspects of
Pediatric Care’, Pediatrics 108: 5 (November 2001), 1227–30 (1229).
12
Jack Shonkoff et al., ‘The Lifelong Effects of Early Childhood Adversity and Toxic Stress’,
Pediatrics 129: 1 (January 2012), 232–46 (233).
166 A. Ehrenberg
Regarding the most common disorders (mainly depression, stress,

burnout, and anxiety), let us explore some examples from the United
Kingdom to illustrate the idea of a global idiom in which emotional self-
control and autonomy are intertwined. For example, the famous report
on depression published by the economist Richard Layard in 2006
claims that anxiety and depression disorders are the main social issues
today and that the primary cause of misery is not poverty but ‘mental
illness’.13 The report proposed recruiting 10,000 therapists specialising
in cognitive behavioural therapy to alleviate this new social scourge. In
their follow-up to the report, the National Health Service launched the
Initiative to Increase Access to Psychotherapy initiative which has cre-
ated several thousand therapists’ positions. The same year, the Institute
for Public Policy Research (IPPR), a progressive British think tank,
published Freedom’s Orphans, which ‘used two large surveys that fol-
lowed young people born in 1958 and 1970, and shows that in just over
a decade, personal and social skills became 33 times more important in
determining relative life chances.’14 Several reports were published in the
United Kingdom on the topic of ‘character capabilities’ as targets for
early intervention public policy against child poverty. For instance, there
is Demos, which published Character Inquiry in 2011:
The aim of The Character Inquiry is to investigate the potential of

focusing on character, and character development, to help achieve greater
levels of wellbeing in society and among individuals [ . . . ]. The capabil-
ities that enable individuals to live ethically responsible and personally
fulfilling lives [ . . . ] consist of the ability to apply oneself to tasks, to
empathize with others and to regulate one’s emotions.15
Focus, empathy, and self-control are three key words related to

autonomy.
13
The London School of Economics: The Center for Economic Performance’s Mental Health Policy
Group, Depression Report: A New Deal for Depression and Anxiety Disorders, June 2006. Online at:
http://cep.lse.ac.uk/pubs/download/special/depressionreport.pdf (accessed February 2016).
14
Julia Margo and Mike Dixon, Freedom’s Orphans: Raising Youth in a Changing World (London:
Institute for Public Policy Research, 2006), p. 20.
15
Jen Lexmond and Matt Grist, The Character Inquiry (London: Demos, 2011), p. 10.
Another report published by IPPR in 2009 is about personal advisers

who play a pivotal role in the welfare-to-work programme entitled Now
It’s Personal: Personal Advisers and the New Work Public Service. Notably,
the report underlines ‘evidence that new training techniques such as the
Cognitive Behavioral Interviewing technique can encourage a more open
and productive dialogue between adviser and client, enabling discussions
to move onto employment related goals more quickly’.16 The same year
a report published by the director of the NHS, Carol Black, proposed
changing concepts of fitness and disability at work from a sick to a ‘fit for
work’ model. As a follow-up to these various reports and recommenda-
tions, a new plan for developing psychotherapy training and access was
launched in 2010. As the Minister for the Care Service put it in his
foreword, ‘talking therapies are a major element of our cross-government
mental health strategy’.17
This example highlights how psychotherapy has been extended to
social problem-solving, that is, has become a form of coaching: social
functioning is added to and intertwined with psychopathology. The
solutions are conceived of as forms of empowerment to develop indivi-
duals in their capacities to rely on themselves, helping people to help
themselves through support, for the purpose of making them agents of
their own change. Mental health issues are at the core of public policies,
which have larger targets than strictly psychiatric problems. They are
about how to achieve socialisation in a world where the ability to decide
and act by oneself pervades social relationships, and is the common
condition. Mental health acts on our mores and habits. The policies
seem like the concept of Rousseau’s civil religion in the Social Contract:
they are about mores, they ‘foster feeling[s] of sociability’. This might be
the point of these practices. The expanded use of the concept of psychic
suffering and transformations in psychotherapy go hand with hand in
the society of generalised autonomy.
16
Claire McNeil, Now It’s Personal: Personal Advisers and the New Work Public Service (London:
Institute for Public Policy Research, 2009), p. 6.
17
Department of Health, Ministry for Care Services, Talking Therapy: A Four Year Plan of Action
(London: Crown, 2010), p. 2.
168 A. Ehrenberg
Conclusion: Individual Afflictions

and Social Relationships
Mental health can no longer be considered to be only a particular sector
dominated by psychiatry and clinical psychology. It has become a cross-
sectional concern of society as a whole, one with implications for the overall
political agenda and for diverse institutions and professions, including in
the realms of business, medicine, family, school, and the judicial system.
This new vision obviously implies that mental health practices deal with the
relations between individual afflictions and social relationships.
Mental health and psychic suffering are connected to the autonomy-
based system as follows: Changes in our ways of acting in society, symbo-
lised by the notion of autonomy, correspond to changes in our ways of
being affected, symbolised by the notion of psychic suffering. Autonomy
consists in an emphasis on the activity of the individual, but, at the same
time, it is something to which one is subjected, which one has to put up
with: Affect, affection, passion, passivity – all of these words are related to
the fact of being subjected to or affected by something.
The focus on autonomy brings out an affective and emotional dimension
that used to have a secondary value, occupying only a subordinate place in a
system centred on discipline. Mental health concerns both our ways of being
affected by our ways of acting, as well as how we are acted upon in relation to
these afflictions. The value granted today to mental health, psychic suffer-
ing, affect, and emotions is the fruit of a context through which injustice,
failure, deviance, dissatisfaction, and so on tend to be appraised according
to their impact on individual subjectivity and the capacity to lead an
autonomous life. In this sense mental health, as currently conceived, is a
major individualistic way of dealing with the passions; it offers a social form
adopted both to name and to deal with passions when norms and values are
entirely oriented towards individual action.
Exhaustion, misfortune, unhappiness, distress, mental illness, and also all
manners of physical discomfort – all these are elements in a language game
that expresses various contingencies of a genuine individualistic drama. This
language has its grammar and its rhetoric; it governs meanings and regulates
affects. It does, after all, enable the expression of complaints – and whenever
a complaint is expressed, it is a speech act, even if it is not merely that. This

means, of course, that it is addressed to someone, to someone who must
understand it and if need be act on it. In this sense, the domain of mental
health (unlike aspects of classic psychopathology or psychiatry) belongs
among the general phenomenon of collective existence.
Thus, mental health is more than the antonym of an illness; it is the
equivalent of good socialisation, because being in good mental health is to
be able to act by oneself in an appropriate manner in most situations of
life. It is possible now that a good life might be defined by the best score in
the Global Assessment of Functioning of the DSM: ‘91 – 100. No
symptoms. Superior functioning in a wide range of activities, life’s pro-
blems never seem to get out of hand, is sought out by others because of his
or her many positive qualities.’ I do not know how many of us reach such
a score, but I suspect that most of us would be more in tune with
Nietzsche’s claim in The Twilight of the Idols: ‘Nothing has become
more unfamiliar than what once seemed so desirable: “peace of mind”.’18
On the anthropological level, my hypothesis in The Weariness of the Self:

Diagnosing the History of Depression in the Contemporary Age was that
contemporary depression is the encounter between traditional melancholy
of the sixteenth century, which affected the exceptional man, and the
modern individualistic democratic dynamic for which everyone can become
exceptional. It has accompanied what I have called the democratisation of
the exceptional.
On the socio-historical level, I read the history of depression in the
twentieth century through the history of the opposition between Freud’s
conflict model, in which symptoms have a moral dimension pertaining to
guilt and are a compromise, a way for the individual to get out of his
dilemma, but by reproducing them disguised, and the deficit model of
Janet’s ‘mental disinfection’, which compensates for the lacking will of
the patient by spiritual direction (‘direction de conscience’).
Beginning with the invention of electroshock therapy, I have described
two periods in the contemporary history of depression. From the 1940s to
the beginning of the 1970s, there were complementarities between the
18
Friedrich Nietzsche, Crépuscule des idoles (Paris: Gallimard, 1889), p. 34. My translation. ‘Rien
ne nous est devenu plus étranger que ce qui semblait autrefois si désirable: “la paix de l’âme.”’
170 A. Ehrenberg
two models of illness, and depression was considered as a subfield of

neurosis – even the more biologically oriented French psychiatrists recog-
nised how much they were indebted to Freud’s analysis of (unconscious)
conflicts – ECT, then neuroleptics and antidepressants driving the develop-
ment of psychotherapies, considered as the ‘in-depth treatment’ (traitement
de fond).19 The disconnection between the two models during the 1970s
and the autonomisation of depression disorder has led to the domination of
the deficit model over the guilt model, and neurosis has been embedded in
depression. Depression today is the posthumous revenge of the Janetian
mental disinfection on Freudian guilt conflict.
These two periods have been analysed as corresponding to two ages
of individualism. Neurosis is a tragedy of guilt, because its underlying ques-
tion is: What am I allowed to do? Depression, in contrast, is a tragedy of
inadequacy, because its core question is: Am I able to do it?
References
American Academy of Pediatrics Task Force, ‘Report on the Future Role of the
Pediatrician in the Delivery of Health Care’, Pediatrics 87: 3 (March 1991),
401–9.
American Academy of Pediatrics: Committee on Psychosocial Aspects of Child
and Family Health, ‘The New Morbidity Revisited: A Renewed Commitment
to the Psychosocial Aspects of Pediatric Care’, Pediatrics 108: 5 (November
2001), 1227–30.
Hannah Arendt, On Revolution (New York: Viking Press, 1963).
Raymond Carver, ‘What We Talk About When We Talk About Love’, in Where
I’m Calling From: Selected Short Stories (New York: Vintage, 1989), pp. 138–51.
Department of Health, Ministry for Care Services, Talking Therapy: A Four
Year Plan of Action (London: Crown, 2010).
John Dewey, Après le Libéralisme. Ses impasses, son avenir (Paris: Flammarion,
2014).
19
The comparison of Japan and France, and of both countries to the United States, shows a
singular French line in articulating pharmacotherapy and psychotherapy. Even the psychoanalyst
André Green gave an interpretation of the action of neuroleptics in terms of ‘Lacanian graphs’ at
the beginning of the 1960s. On Japan, see Junko Kitanaka, Depression in Japan: Psychiatric Cures
for a Society in Distress (Princeton: Princeton University Press, 2012), pp. 119–20; on France, see
Ehrenberg, La Société du malaise, chapters 2 and 3.
Louis Dumont, German Ideology: From France to Germany and Back (Chicago:
The University of Chicago Press, 1994).
Alain Ehrenberg, La Société du malaise (Paris: Odile Jacob, 2010a).
———, The Weariness of the Self: Diagnosing the History of Depression in the
Contemporary Age, trans. David Homel et al. (Toronto: McGill-Queen’s
University Press, 2010b), 44.
Gøsta Esping-Andersen, with Duncan Gallie, Anton Hemerijck, and John
Myles, Why We Need a New Welfare State (New York: Oxford University
Press, 2001).
François Furet, Penser la Révolution française (Paris: Gallimard, 1978).
Anton Hemerijk, Bruno Palier, and Frank Vandenbroucke, ‘For a Social
Investment Pact in Europe’, Books and Ideas, 15 June 2011. Online at:
http://www.booksandideas.net/For-a-Social-Investment-Pact-in.html
(accessed February 2016).
Junko Kitanaka, Depression in Japan: Psychiatric Cures for a Society in Distress
(Princeton: Princeton University Press, 2012).
Jen Lexmond and Matt Grist, The Character Inquiry (London: Demos, 2011).
The London School of Economics: The Center for Economic Performance’s
Mental Health Policy Group, Depression Report: A New Deal for Depression
and Anxiety Disorders, June 2006. Online at: http://cep.lse.ac.uk/pubs/down
load/special/depressionreport.pdf (accessed February 2016).
Julia Margo and Mike Dixon, Freedom’s Orphans: Raising Youth in a Changing
World (London: Institute for Public Policy Research, 2006).
Claire McNeil, Now It’s Personal: Personal Advisers and the New Work Public
Service (London: Institute for Public Policy Research, 2009).
Friedrich Nietzsche, Crépuscule des Idoles (Paris: Gallimard, 1889).
Jack Shonkoff et al. ‘The Lifelong Effects of Early Childhood Adversity and
Toxic Stress’, Pediatrics 129: 1 (January 2012), 232–46.
Cass Sunstein, ‘An Original Thinker of our Time’, The New York Review of
Books, May 23 2013.
Peter Winch, ‘Understanding a Primitive Society’, American Philosophical
Quarterly 1: 4 (1964), 307–24.
Alain Ehrenberg is research director emeritus at the National Center for

Scientific Research (CNRS), Paris. Among many other books, he is the author
of the widely acclaimed monograph La fatigue d’être soi: Dépression et société
(1998, published in English in 2009 as The Weariness of the Self: Diagnosing the
History of Depression in the Contemporary Age).
8
Self-Realisation Through Work
and Its Failure
Elin Thunman and Marcus Persson
Exhaustion Syndromes and Work in Sweden

Psychological conditions such as burnout, chronic fatigue, and depression
have become the main reasons for longer sick leave in several Western
countries.1 In Sweden, the increased rate of sick leave in general, and the
rise in people who are on sick leave due to psychological diagnoses in
particular, has caused a widespread debate during the past few years. In a
recent OECD report, the authors conclude that about 5 percent of the
population suffer from severe mental disorders, while 15 percent are
troubled by more moderate psychic disorders.2 The existing information,
particularly from Statistics Sweden’s national standard of living survey,
1
Max Henderson et al., ‘Work and common psychiatric disorders’, Journal of the Royal Society of
Medicine 104: 5 (2011), 198–207; OECD, Sick on the Job? Myths and Realities about Mental
Health and Work (Paris: OECD Publishing, 2012).
2
OECD, Mental Health and Work: Sweden (Paris: OECD Publishing, 2013).
E. Thunman (*) M. Persson

Uppsala University, Uppsala, Sweden
e-mail: elin.thunman@soc.uu.se; marcus.persson@soc.uu.se

DOI 10.1007/978-3-319-52887-8_8
174 E. Thunman and M. Persson
indicates that the prevalence of psychological disorders is at about the

same level in Sweden as in other OECD countries.3
Since 2006 the most common causes of long-term sick leave from
work in Sweden have been psychological ailments.4 Depression is a
syndrome within the main diagnostic group ‘mental disorders’, while
burnout and chronic fatigue are included in the sub-group ‘stress reac-
tions and anxiety disorders’. In the 2000s, the proportion of psychiatric
diagnoses leading to long-term sick leave increased drastically in Sweden.
Between 1999 and 2003, the proportion of long-term sick leave owing
to psychological diagnoses grew from 18 percent to 30 percent. Between
2005 and 2010, the ubiquity of psychiatric diagnoses decreased, but
since 2011 they have noticeably increased again. In 2014, the number of
people taking long-term sick leave for mental diagnoses reached a record
high of 35 percent. Together with depression, the most common psy-
chiatric diagnoses are stress reactions and anxiety disorders. Taken
together, these diagnoses constitute 94% of all mental-health-related
sick leave in Sweden.
The link between adverse psychosocial work environments and mental-
disorder sick leave is clearly apparent both in Sweden and in the other
Western countries, a finding which is supported by numerous international
studies. It is also evident that the risks of sick leave differ between occupa-
tional groups.5 Swedish studies show that both men and women working in
professions with close contact with help receivers, in different types of welfare
services including the health, education, and social care services, have a
significantly higher risk of being on sick leave with psychiatric diagnoses.6
3
The Swedish Insurance Office, ‘Sjukfrånvaro i psykiska diagnoser. En studie av Sveriges befolkning
16–64 år’ [‘Sick-leave in Psychiatric Diagnoses. A Study of the Swedish Population 16–64 Years’],
Social Insurance Report 4 (2014).
4
According to the Swedish Insurance Office’s definition, sick-leave that is longer than 60 days is
defined as ‘long-term sickness’.
5
Swedish Council on Health Technology Assessment and Assessment of Social Services,
‘Arbetsmiljöns betydelse för symtom på depression och utmattningssyndrom. En systematisk
litteraturöversikt’ [‘The Significance of the Work Environment for Symptoms of Depression and
Chronic Fatigue Syndrome. A Systematic Literature Review’] (Stockholm: Swedish Council on
Health Technology Assessment, 2014).
6
Swedish Work Environment Authority, Work-related Disorders 2014 (Stockholm: Swedish Work
Environment Authority, 2014), p. 27.
In this chapter, we focus on the micro-level by examining how

employees working in public services think and feel about their situa-
tion, and what the factors are that, according to their experiences, lead to
the development of exhaustion symptoms. More specifically, we deploy
narrative analysis tools to examine how Swedish public service workers
with exhaustion symptoms use language to explain their subjective
experiences with exhausting work and perceived demands. By doing
so, our aim is to contribute to the body of knowledge about the
processes preceding the development of exhaustion symptoms.
Talking with Swedish Public Service Workers

The empirical material in this essay consists of interviews conducted
with workers at four public workplaces: an elementary school, an upper
secondary school, an employment office, and an elderly care centre. The
sample is based on Swedish occupational groups with statistically high
levels of exhaustion syndromes. Common symptoms reported by the
interviewed workers are burnout, chronic fatigue, and depression. The
interviews were performed according to a semi-structured design in
order to capture how the participants think, feel, talk, and attempt to
render their experiences about exhausting work meaningful.7
Out of the total number of 28 interviewees, 3 people from 3 separate
work sites were selected as illustrative samples to represent the voices of
the other study participants. Even bearing in mind individual variety, all
narratives share specific elements, strategies, and functions. One repre-
sentative has been chosen from each public service sector: education,
health-care, and public employment services. Finally, the three narrators
were chosen to reflect the age and gender groups of the total sample. The
three employees we follow throughout the essay, and who were given
fictitious names, are Alex, Belinda, and Claudia, and they will be pre-
sented in more detail in the next section.
7
Robert Merton, Marjorie Fiske, and Patricia Kendall, The Focused Interview. A Manual of
Problems and Procedures (New York: Free Press, 1990 [1956]), p. 16.
The formal analytical process was performed in three steps, according

to Elliot Mishler’s typology for narrative analysis.8 The first step was to
identify recurrent narrative elements in the stories, such as themes, events,
and emotions. The next step was to identify the narrative strategies, such
as excuses and justifications, used by the narrators to construct their
narratives. In the third and final step of the analysis, we focused on the
function of the narratives within the societal and cultural systems of
meaning in which the interview participants live and work. The chapter
follows these three analytical steps.
Portraits of the Narrators

Alex is in his fifties and was diagnosed with burnout. He has worked for
more than 10 years as an administrator at a Swedish public employment
services office. Before Alex started to work there, he worked in the
engineering industry, but thought it too tedious to work with ‘dead
things’, as he puts it. He subsequently started to work at the employ-
ment service office in order to help people get back to work.
Originally, a traditional agency with a citizenship ethos, the Swedish
Public Employment Service, has increasingly become a customer- and
result-oriented service agency. Its most important task is to meet
the labour market requirements of effectively ‘matching’ job seekers
with employers, prioritising those who are outside the labour market.9
A common basic service to streamline efforts for clients was introduced
in 2011, involving the monitoring of enrolees’ search activities in
standardised ways and the establishment of individual action plans.
Alex works at a public employment services’ office located in an area
with many applicants who find it particularly hard to get a job, due to
language difficulties and low education levels. As an effect of the service’s
enhanced focus on results and goal attainment in terms of successful
8
Elliot Mishler, ‘Models of Narrative Analysis: A Typology’, Journal of Narrative & Life History
5 (1995), 87–123.
9
Swedish Code of Statutes (SFS), Enactment with Instruction for the Swedish Public Employment
Service (Stockholm: Fritzes, 2007), p. 1030.
matching, the officers’ work has shifted from the traditional emphasis on
supplying jobs to a growing focus on documentation, through automated
computerised information systems, of search activities and action plans.
Alex developed the symptoms of burnout when he worked with long-
term unemployed people who no longer have a right to public insurance,
that is, a group of people for whom it is particularly difficult to find their
way back into work:
The lives of those I met were often in chaos, they felt ashamed of not
being able to provide, or even take care, of their children, and I encoun-
tered a lot of anxiety. I also met people with more or less explicitly
expressed suicidal thoughts and feelings of despair and so on. Of course
it affects you.
Trying to help these people demanded too much effort from Alex.
Today he still works at the employment office, but in a new part-time
position that he calls a ‘fall-back’. ‘I still want to do this [work] but I
need to lick my wounds a bit. It’s a really fun job but I . . . uh . . . well, I
hit the wall, so to speak.’
Belinda is in her thirties and has been diagnosed with chronic fatigue
and depression. She has worked as a teacher (grades one to three) for
2 years since she graduated in education. It was at her former workplace
(another school) that she became ill.
The Swedish education system is currently undergoing major restruc-
turing. During the 1990s, the state promoted school choice and com-
petition through legislation and the funding of independent (private)
schools, even though education in Sweden has traditionally been a
public venture and pupils have always enrolled in the (municipal) school
in the area in which they live. In addition, the Swedish education system
is today characterised by high demands for the attainment of goals and
results, and the evaluation of pupils’ achievements.10
At the elementary school where Belinda works the teachers’ work
has been altered from the traditional prominence given to teaching
10
The Swedish National Agency for Education, Curriculum for Compulsory School, Preschool Class
and the Leisure-Time Centres 2011 (Stockholm: Fritzes, 2011).
to an increased emphasis on the documentation of pupils’ learning

outcomes. The heightened documentation demands have been intro-
duced along with new technologies such as an Internet-based
platform for the standardised registration of results and evaluations.
The amplified documentation was introduced as a way of achieving
better learning outcomes, through which the school can achieve
more of its goals. The number of pupils in need of extra support
has increased due to language difficulties and diagnoses such as
attention-deficit hyperactivity disorder, while the resources for sup-
port have decreased.
Belinda describes how at first she never took breaks, but that she is
now aware of the need for personal strategies in order not to become ill
again. Her colleagues have told her to ‘leave your work here at school
when you go home for the day so you can come back with renewed
energy’. ‘Otherwise’, Belinda says, ‘one could work indefinitely, because
there are constantly things to arrange, phone calls to make, written
assessments to be put out, and attendance sheets to sign every day’.
Belinda is considering a change of career because she doubts her ability
to cope with what she experiences as exhausting work conditions until
retirement: ‘I do not think I can work as a teacher forever, because I
think it’s a pretty tough environment and there is so much to do. I don’t
think it is worth risking my health for my work; it is better I do
something else.’
Claudia is in her fifties and has not formally been diagnosed with any
exhaustion syndromes. However, due to symptoms including headaches,
nausea, and feelings of numbness, all of which are connected to experi-
ences of exhausting work, we have included her in the analysis. She
moved from Macedonia to Sweden 16 years ago. During her first years
in Sweden Claudia stayed at home with her small children, but for the
last 10 years she has worked as a health-care assistant at a short-term
home for elderly people.
In 2009, a law about freedom of choice for recipients regarding
elderly care was implemented in Sweden. Exposed to competition,
several municipalities declared their future goal was to be a ‘world-
class’ elderly care provider. In 2011 a ‘dignity assurance’, based on a
‘national value system’ was introduced to secure the daily care quality for
elderly care users in Sweden.11 The assurance implies an increased focus

on the results of operations, and follow-up through individual imple-
mentation plans and national instruments for needs assessment, in order
to facilitate a systematic and more uniform approach.
At the elderly care home where Claudia works, the increased customer
and results orientations and the exposure to competition are manifest in
the implementation of a value system based on the requests of users, as a
way to reach the overarching goal of offering ‘world-class’ elderly care. In
accordance with these objectives, the nurses’ and assistant nurses’ work
has changed from the traditional emphasis on care to an intensified
attention to documentation of accomplishments in relation to individual
users. The increased demand to keep records and to document progress
was initiated as a way of improving and safeguarding user satisfaction in
line with the new value system. In order to improve efficiency and
results, the amount of care each ‘customer’ needs is estimated in
advance.
Claudia describes her job at the short-term home as stimulating,
because she constantly meets new people, but also as exhausting – she
is one of only four staff members. Claudia describes her exhausting
work-day and the symptoms it gives rise to in the following terms:
Most days at work are very stressful. In the evening when I finish my shift
I often have a strong headache and feel nauseous. I go home and just
crash. At the same time, I cannot quite let go of the thoughts of the elderly
when I’m at home. Sometimes, when it has been particularly busy at
work, and after trying to make everyone happy, I feel so much pain in my
body that I can hardly move the next day. I feel completely empty,
stunned. I walk like a zombie.
In the future, Claudia plans to educate herself and to become a nurse in

order to acquire more control over her work and, as she says, hopefully
also to achieve a less exhausting workday.
11
Swedish Government Official Reports (SOU), A Dignified Life in the Elderly Care. Petition of the
Dignity Investigation (Stockholm: Fritzes, 2008), p. 51.
Pride, Shame, and Work Evaluation

How do Alex, Belinda, and Claudia evaluate the processes at work
preceding the development of their experiences of exhaustion? The
element of evaluation involves the emotional side of the narratives,
and provides information about how the narrators express feelings in
connection to their experiences. First, Alex, Belinda, and Claudia all
declare a strong commitment to and engagement with their work. For
instance, Alex expresses a deep social engagement and holds a profound
belief in the social and political mission his organisation aims to fulfil:
I think it’s a very exciting work environment. The meeting between the
microcosm and the macrocosm. We have a social duty, a political mission.
To promote the production flow, so that inflation does not become too
high, that we do not create bottlenecks, and that people get jobs, because I
believe they want to work and that they feel good about themselves when
they do.
In the stories of our three study participants, we find several examples of

positive emotions in relation to their work. For example, Claudia feels
‘great when I am satisfied with my job. Because, somehow I think that
when you’re working with something you have to like it, otherwise you
won’t do a good job. I like my job. I want to do the best’. Belinda
explains that she finds it ‘extremely rewarding to work with children, to
be part of a class that I can influence in any way, and it gives me a lot of
pleasure to know that I can contribute to the pupils’ future’.
Alex, Belinda, and Claudia express feelings of pride when they talk
about the meaning and value of helping people and contributing some-
thing through their work. However, in situations when it is difficult to
do their jobs successfully, the expressed feelings in the three stories shift
from positive to negative. Claudia, for example, states:
I feel so happy when I say to the patient: “Sleep well!” and they say in
return: “Hope you sleep well, too!” It’s emotional, really, and I feel so
content and go home without any feelings of guilt. But many times they
just say: “Oh well”, and that doesn’t feel right, you know.
In this quotation, we can see how Claudia shifts between positive and
negative feelings depending on whether she considers herself successful or
unsuccessful in her relationships with her patients. Indeed, the most frequent
expressions of feelings we find in the narratives are negative feelings asso-
ciated with experiences of failure and inadequacy. As Alex puts it:
This feeling that you don’t do enough. To go home every day with that
feeling. And then be yelled at for not have time on top of that . . . that’s
what is so hard. It drags you down and steals all of your energy. That’s
probably what has been hardest, to always feel inadequate whatever I do.
When Alex feels inadequate for not being able to do his job properly, the
feelings of worthlessness are not far away: ‘It’s like . . . damn, I’m bad;
why can’t I manage?’. Belinda expresses herself in a similar way when she
talks about how she felt when she first became ill: ‘In the beginning I
tried to hide and avoid people because I thought I was bad. My
colleagues seemed to manage their job and why couldn’t I? What was
wrong with me? I worked all the time but it was not enough. I felt like I
was useless.’
The negative feelings that can be observed in Alex, Belinda, and
Claudia’s narratives can be associated with categories of feelings such
as meaninglessness, alienation, sadness, frustration, and worthlessness.
They can all be understood within the wider category of feelings of
shame, which have been observed in several studies about exhausting
work and exhaustion syndromes. This has often been dealt with as an
emotional response, of the personal experience of failure for not being
able to meet increasing or conflicting demands of today’s working life.12
According to Thomas Scheff, shame arises in fundamental situations
of threat to a bond; it signals trouble in a relationship.13 Shame develops
when one feels one has failed to live up to one’s standards – that is,
internalised social expectations – that are held in common with others in
12
Ulla-Britt Eriksson, Bengt Starrin, and Staffan Jansson. Utbränd och emotionellt utmärglad
[Burnout and Emotional Emaciation] (Lund: Studentlitteratur, 2003), pp. 75–8; Arlie
Hochschild, The Managed Heart (Berkeley, CA: University of California Press, 1983).
13
Thomas Scheff, ‘Shame in Self and Society’, Symbolic Interaction 26: 2 (2003), 239–62 (254).
private and professional life. Scheff argues that feelings of shame serve a
universal social function to ensure conformity, which is individuals’
adjustments to group or societal rules and standards, with the aim of
gaining recognition and acceptance.14 Following Scheff, when Alex,
Belinda, and Claudia express feelings of shame, they have tried to
adapt to what they regard as the correct standards for their work, but
without succeeding.
In order further to examine the exact character of Alex, Belinda, and
Claudia’s standards, we take a closer look at how they explain what they
perceive as their shameful failures. We do this by analysing how Alex,
Belinda, and Claudia use narrative strategies when they account for their
experiences of exhaustion.
Justifying the Exhausted Self

Listening to how Alex, Belinda, and Claudia are telling their stories, that
is, which strategies they adopt for constructing their stories, it is clear that
all of them are keen to accept responsibility for becoming exhausted.
None of them try to blame staff cutbacks, reorganisations, organisational
conspiracies, or ‘evil’ managers. Claudia, for example, takes full responsi-
bility for her exhaustion by referring to the demands she puts on herself:
This morning I talked to the nurse [her supervisor] and she said: “You
have to take it easy”. But how am I supposed to take it easy? When I see
that it does not work . . . I’ve been away for a while now [and] when I
come back it’s completely different. And even the residents say: “Now
there will be order again.” They notice who is taking more responsibility.
They also need to know who they can turn to. Not the one who says: “No,
no I don’t have the time.” They always turn to me: “Can you help?”
I want it to work out well, and that the residents feel safe when I am here.
No one has told me that I should take more responsibility, but I do it
myself. It’s me, it’s my fault.
14
Thomas Scheff, ‘Shame and Conformity: The Defence-Emotion System’, American Sociological
Review 53: 3 (1988), 395–7.
Belinda describes in a similar way how she blames her own too strong
commitment to her work and loyalty towards her pupils for making her ill:
When I started working, I had such big and great ideas, and I wanted to
do this and that. I wanted to teach them everything I could and that they
should get a job when they are eighteen. I took responsibility for their
lives. If I have responsibility for twenty children and their lives, and then if
they fail . . . it became too much for me. It occupied my whole mind even
during my leisure time.
Whenever an action is subjected to evaluative inquiry there are two main

narrative strategies – or ‘accounts’ – that a narrator can adopt: excuses
and justifications.15 Either or both are likely to be invoked when a person
is accused (by themselves or by others) of having done something that is
considered bad, wrong, inept, unwelcome, or, in another of numerous
possible ways, untoward.
Excuses are socially approved vocabularies for mitigating or relieving
responsibility when conduct is questioned, for example by appealing to
accidents, to defeasibility, to biological drives, or ‘scapegoating’.16 None
of our narrators use excuses to explain why they got exhausted. Instead,
they use justifications. Like excuses, justifications are socially approved
vocabularies that neutralise an act or its consequences when one or both
are called into question. Yet here is the crucial difference with excuses: to
justify an act is to assert its positive value in the face of a claim to the
contrary. Justifications restore harmony in an interaction and preserve
the image of a person in the others’ eyes. This is done by placing the
responsibility on the self, but simultaneously seeking absolution by the
counterpart. This is what Claudia is doing in the quotation above; more
specifically, she is ‘appealing to loyalties’.17
There are different forms of justifications (‘denial of injury’, ‘denial of
victim’, ‘condemnation of condemners’, and ‘appeal to loyalties’), but
15
Marvin Scott and Stanford Lyman, ‘Accounts’, American Sociological Review 33 (1968), 46–62.
16
Gresham Sykes and David Matza, ‘Techniques of Neutralization: A Theory of Delinquency’,
American Sociological Review 22 (1957), 664–70.
17
Scott and Lyman, ‘Accounts’, p. 51.
the latter category, appeal to loyalties, is the most common type used by
Alex, Belinda, and Claudia. In cases that fall into this category, they
assert that their actions were permissible or even right since they served
the interests of another to whom they owe an unbreakable allegiance or
affection. The most obvious form of appealing to loyalty is by directing
it towards concrete others such as clients. This is what Claudia does
when she declares that her main loyalty is to her patients, the elderly
people living in the care home where she works: ‘If the residents are
happy, I am happy. I do not work to make the staff or the boss satisfied.
I take care of my residents who live here. I am always there when they
need me.’ She adds:
Why can’t I just say “no, I’m done for the day and I’m going home”?
However, I work with humans, I can’t really think like that. I could go
home, but then . . . I can’t just not give a damn about someone who
haven’t yet received pain relief or haven’t got their food. And if I don’t
do it, I feel even worse.
In a similar fashion, Belinda talks about loyalty to her pupils, which

becomes especially evident when she mentions one case regarding a
pupil from Somalia who had recently come to Sweden and could hardly
talk any Swedish or English:
That caused me a lot of stress. Even though I had been placed in an

impossible situation of teaching him I felt an obligation, both as a human
and a professional, to help him. I could see he was suffering. He was
terrified because he didn’t understand what was going on and what he
should do. I felt completely alone in that situation, and I had a stomach
ache every evening when I got home from work.
However, when comparing the justifications presented by Alex,

Belinda, and Claudia with those often cited in other narrative studies
a difference can be detected. As an example of a justification, Scott
and Lyman refer to a soldier in combat who may admit that he has
killed other men, but denies that he did an immoral act since those
he killed were members of an enemy group and hence ‘deserved’
their fate.18 The combat soldier could admit the wrongfulness of killing but
claim that his acts were not entirely undertaken under his own volition; he
was ‘under orders’ and had to obey. Interestingly, all of our three narrators
admit ‘wrongdoing’ and take full responsibility for becoming exhausted,
but not based on any outer, objective, criteria (i.e. being under orders from
someone else). Rather, their loyalties are based on inner, subjective criteria.
Put differently, their perceived ‘orders’ are not defined by their organisa-
tion’s formal rules or policies or by their clients, but by themselves.
As indicated in the quotations above, Alex, Belinda, and Claudia take
responsibility for their exhaustion by referring to their own feelings of
responsibility for others. The narrators describe themselves as people
who take considerable personal responsibility for their work, as well as
for becoming ill. Their approach to work would then be an indication of
the ongoing ‘subjectivisation of work’, making it possible for the indi-
vidual to invest and articulate her or his ‘subjectivity’ at work, but also
compelling the individual in doing so to become a ‘labour entrepreneur’,
alone answerable for one’s successes or failures.19 To continue this line
of thought and further examine the narrators’ readiness to accept
responsibility for their own illnesses, we will now discuss the function
of the narratives within the societal system of meaning.
Failure to Accomplish Societal Expectations

of Self-Realisation
Alex, Belinda, and Claudia strongly emphasise their genuine engage-
ment with their work, and their feelings of personal responsibility for the
people with whom they work. It is obvious that they regard their work as
important for their senses of self. This is evident in the following
18
Ibid., p. 47.
19
Frank Kleemann, Ingo Matuschek, and G. Günter Voß, ‘Subjektivierung von Arbeit – Ein
Überblick zum Stand der Diskussion’, in Subjektivierung der Arbeit, ed. Manfred Moldaschl and
G. Günter Voß (Munich and Mering: Rainer Hampp Verlag, 2003), pp. 57–114; G. Günter Voß
and Hans J. Pongratz, ‘Der Arbeitskraftunternehmer. Eine neue Grundform der “Ware
Arbeitskraft”’, Kölner Zeitschrift für Soziologie und Sozialpsychologie 50 (1998), 131–58.
quotation by Claudia, in which she describes how her strong commit-

ment to her work makes her stand out from her colleagues:
I enjoy my job. I want to do the best. They [her colleagues] think I am

stupid – I notice it – for working so much: “You might as well live here”,
they say. But if you think that only money and time are important, you
should not be in this job. Some just want to finish the job or what is
written on the card and then “Bye!”. We are all different.
Alex, Belinda, and Claudia’s engagement with their work is also impor-
tant for their senses of self-esteem. For instance, Alex declares that
making a difference at work is vital in giving his life meaning:
Of course there are more things in life than work that are important, but it
is my opinion that work is central. [ . . . ] I think you can become stressed
by too much commitment, but I also believe that one can become stressed
by not feeling needed, that what you do has no significance.
This engaged and self-enterprising attitude towards work, observed in

the narratives, can be considered as a sign of the subjectivisation of work.
More specifically the narrators’ approach can be interpreted as personal
motivations to present their ‘true’ or ‘authentic’ selves, that is, their self-
perceived and ‘felt’ identities, through work.20
Over the last few decades, the concept of authenticity has been used to
study narratives on different topics, such as studies of consumer cultures,
professional ethics and emotional labour.21 In identity theory, the notion
of authenticity is understood as commitment to ‘self-values’, that is,
values applied to oneself as vital parts of feeling authentic or true to
oneself.22 By conceptualising authenticity in terms of a system of self-
values, the self is put forth as changeable and dynamic. An understanding
20
Rebecca Erickson, ‘The Importance of Authenticity for Self and Society’, Symbolic Interaction
18: 2 (1995), 125–7.
21
Arlie Hochschild, The Managed Heart; Birgitte Malm, ‘Authenticity in Teachers’ Lives and
Work: Some Philosophical and Empirical Considerations’, Scandinavian Journal of Educational
Research 52 (2008), 373–86.
22
Rebecca Erickson and Amy Wharton, ‘Inauthenticity and Depression: Assessing the
Consequences of Interactive Service Work’, Work and Occupations 24 (1997), 188–213.
is enabled not only of how emotions are fundamental to the experience of

oneself as authentic but also of how such feelings shape and motivate
behaviour at the same time as they are influenced by the surrounding social
and interactional settings. ‘Feelings of inauthenticity, which may follow the
violation of a commitment to self’, are seen ‘as a result of violating one’s
level of commitment to a particular self-value’, Rebecca Erickson con-
cludes.23 Authenticity can, in this regard, be defined as being in the state
of acting in accordance with one’s own underlying, but culturally bound,
moral values, or, in Scheff’s terms, social standards. As Phillip Vannini and
Patrick Williams write: ‘Authenticity is not so much a state of being as it is
the objectification of a process of representation, that is, it refers to a set of
qualities that people in a particular time and space have come to agree
represent an ideal or exemplar.’24
In today’s authenticity culture, ‘more and more the presentation of an
“authentic self” is one of the demands placed upon individuals, above all in
the sphere of skilled labour’.25 The result of this subjectivisation is the
exploitation rather than the enabling or empowerment of the employee,
who is liable to develop a social pathology as an answer to infinite self-
realisation demands, according to Axel Honneth.26 Honneth refers to Alain
Ehrenberg’s claim that the individual becomes exhausted by the diffuse but
constant demand to be yourself.27 Honneth’s – and Ehrenberg’s – stand-
point is that the societal development in the context of which self-realisation
has transformed into a compulsion can explain the substantial expansion of
psychic illnesses such as depression in the Western world.28
23
Erickson, ‘The Importance of Authenticity for Self and Society’, 131.
24
Phillip Vannini and Patrick Williams, Authenticity in Culture, Self, and Society (Farnham:
Ashgate, 2009), p. 3.
25
Axel Honneth. ‘Organized Self-Realization: Some Paradoxes of Individualization’, European
Journal of Social Theory 7 (2004), 467.
26
Ibid., 473–4.
27
Alain Ehrenberg, The Weariness of the Self. Diagnosing the History of Depression in the
Contemporary Age, trans. David Homel et al. (Montreal: McGill-Queen University Press, 2010),
pp. 183–8 and pp. 217–29.
28
Honneth, ‘Organized Self-Realization: Some Paradoxes of Individualization’, 463–78.
As indicated above, Alex, Belinda, and Claudia express certain standards

concerning the relationship to others in need of assistance – the unem-
ployed, pupils, or patients. With the help of the concept of self-values, the
analysis can now be deepened, and it can be concluded that their commit-
ment is motivated by what can be called ‘altruistic values’ – that is, values
that are associated with solidarity and conformity with the community –
dictating the care or consideration of others. Altruistic values can be
regarded as an attachment to the intrinsic elements of a job, which include
feelings of accomplishment and self-worth, as Belinda puts it:
So I begin each day by greeting the kids and looking them in the eyes and
trying to reassure them, and with that I feel that I do some good. That’s
why I have chosen to work as a teacher. To feel that you can influence and
add values and ideas that are important. It provides meaning for my work.
This dedication to altruistic values can be considered as particularly

desirable in our authenticity culture, since these values can give meaning
to work and generate feelings of pride in the lives of the workers.
The same dedication can, however, also give rise to feelings of shame
and inauthenticity if, as in the narrators’ cases, workers perceive that they
are not able to fulfil their values in their interpersonal relations at work.
Emotions of shame are then connected to feelings of not being the person
one wants to be (that is, inauthentic), and instead being a ‘bad’ or an
‘unworthy person’. Claudia describes this emotion in the following terms:
Sometimes I feel really bad, like today, because we have a client who will
not get up. She just wants to sleep, but I go to her several times and try to
give her something to eat, to drink, and to talk to her so that she’ll hear a
little voice, and feel my touch, and know that I’m there. If I’m not doing
this I’m not feeling good about myself.
Alex, Belinda, and Claudia tend to connect the evaluation that they
failed to fulfil their altruistic self-values with their experiences of exhaus-
tion. This is, for instance, evident in the following quotation by Alex:
What I personally believe was most draining was the feeling that there was
so much I could have done, but I always felt that I did not have the time. It
made me feel unsatisfied, because I . . . well, there were a lot of opportunities

to do things if I had had enough strength and there had been enough time.
And then I felt that I got deeply stuck in administration. There was a lot of
administrative work and work to arrange money, and very little service
directly related to employment. If I can take two hours and make eight calls,
I can actually find an internship in which this person can get a chance to see
what she is capable of and sort of get her confidence back, but I didn’t find
those hours. And they never came. I mean, there were quite a lot of cases I
had where I didn’t contribute to anything good.
To conclude and proceed to the final step of the narrative analysis, it is

understood that the functions of the narratives are individual expressions
of the internalised societal demand to be authentic in the work sphere.
With Erickson, we understand authenticity in terms of the fulfilment of
self-values. What is of particular interest in our analysis are the two dimen-
sions of shame visible in Alex, Belinda, and Claudia’s narratives. Besides
expressing feelings of shame for not being able to cope with organisational
demands and becoming exhausted, we have seen how they also express
feelings of shame for not being able to realise personal values, and therefore
for being inauthentic, unworthy, or bad people. This becomes particularly
evident in Alex’s quotation above, in which he states that the most draining
was the feeling that there was so much he could have done, but never had the
time to do, because he became stuck doing administrative duties and other
‘meaningless’ tasks that hindered him in fulfilling his self-values by helping
others. In our interpretation, what Alex talks about is not just being unable
to cope with organisational demands, it is the exhausting experience of not
being able to fulfil the social expectations to realise one’s true self through
work by fulfilling altruistic self-values.
Exhaustion as the Outcome

of Intertwined Demands
In this chapter, we have explored how Swedish public service workers
use language to explain their syndromes of exhaustion related to work.
We began our narrative analysis by discussing the narrators’ evaluations
of their experiences of exhaustion, and how the narrators accept respon-

sibility for becoming ill. It is suggested that the narrators’ justifications
reflect societal demands to be authentic and true to personal values, and
that the dominating values expressed are associated with altruism. In our
examination two forms of social values, or standards, are detectable in
the sphere of labour, whose unsuccessful fulfilment creates two dimen-
sions of shame.
The first dimension of shame is generated by feelings of failure in
coping with organisational demands concerning the good treatment of
others. Alex, Belinda, and Claudia’s stories have shown that when they
think that they fail to deliver what they believe is their job – helping
others to get a job, treating pupils with respect, or taking care of elderly,
they feel shame. In relation to this organisational dimension of shame, it
can be mentioned that studies of health-care workers reveal that their
work situations easily give rise to a ‘stress of conscience’, in situations
containing ethical dimensions where the worker experiences difficulties
in maintaining all suitable interests and values. These situations are often
followed by exhaustion syndromes, since accelerating demands for per-
sonal relationships and responsibilities undertaken at work are
obstructed by continuous reorganisations and cutbacks.29 Other studies
of health-care workers show that conflicting ideals and moral uncer-
tainty, together with external constraints, cause ethical conflicts and
‘moral distress’.30
As outlined by Scheff, research about a ‘stress of conscience’ and ‘moral
distress’ highlights the importance for the self of the maintenance of social
standards in interpersonal relations. Scheff regards shame as a key compo-
nent of our conscience or moral sense: ‘it signals moral transgression even
29
Gabriella Gustafsson, Astrid Norberg, and Gunilla Strandberg, ‘Meanings of Becoming
and Being Burnout – Phenomenological-Hermeneutic Interpretations of Female Healthcare
Personnels’ Narratives’, Scandinavian Journal of Caring Sciences 22 (2008), 520–8; Christina
Juthberg et al., ‘Perceptions of Conscience in Relation to Stress of Conscience’, Nurse Ethics 14:
3 (2007), 329–43.
30
Reidun Førde and Olaf Gjerløw Aasland, ‘Moral Distress among Norwegian Doctors’, Journal
of Medical Ethics 34: 7 (2008), 521–525; Sofia Kälvemark et al., ‘Living with Conflicts – Ethical
Dilemmas and Moral Distress in the Health Care System’, Social Science and Medicine 58 (2004),
1075–84.
without thoughts or words. Shame is our moral gyroscope.’31 If we bring

Scheff’s thought about shame as a sign of moral transgression together with
the idea of syndromes of exhaustion as effects of a stress of conscience, we
can conclude that the organisational dimension of shame is generated by
feelings of a moral failure. This kind of shame can be regarded as an
indicator that exhaustion syndromes can be understood in terms of diffi-
culties in realising conflicting organisational demands.
The second dimension of shame is generated by feelings of failure to fulfil
social expectations of authenticity. The expectation of self-realisation has
moral connotations as well, in being a moral imperative to the self.
However, unlike the first form, this demand concerns the relation to the
private self, not to others. We have indicated that the narrators’ altruism
should not only be understood as manifesting organisational standards.
Their altruism can be identified as a matter of self-valuation as well,
reflecting the demand to present an authentic self in the sphere of work.
Alex, Belinda, and Claudia portray themselves as people with great personal
interest in, even connecting their identity to, their realisation of altruistic
values at work. Survey and case study evidence from other research suggest
that employees in the public sector often own more altruistic motivations,
and greater attachment to ‘social values’, than those in the private sector.32
In the narratives, there are signs (such as the willingness to accept respon-
sibility and the feelings of shame connected to failure) of a new demand of
not only being loyal and devoted to social values but of transforming those
values into one’s own, as parts of one’s authentic self. Failure to realise
oneself in accordance with those social values is not just experienced as a
professional failure but also as a personal failure. Hence, not presenting an
authentic self in the authenticity culture generates feelings of shame. We
comprehend this sort of shame as an indicator that exhaustion syndromes
are not only caused by difficulties in realising organisational demands but
31
Scheff, ‘Shame in Self and Society’, 254.
32
Marc Buelens and Herman Van den Broeck. ‘An Analysis of Differences in Work Motivation
between Public and Private Sector Organisations’, Public Administration Review 67 (2007), 65–74;
Gail Hebson, Damian Grimshaw, and Michael Marchington, ‘PPPs and the Changing Sector Ethos:
Case-study Evidence from the Health and Local Authority Sectors’, Work Employment Society
17 (2003), 481–501.
also by problems in fulfilling societal expectations of self-realisation.

Besides the stress of consciousness, we may also talk about a ‘stress of
self-realisation’.
By studying narratives about exhaustion, we have demonstrated that the
current rise in work-related illnesses can not only be comprehended in
terms of workers’ difficulties in managing changed organisational demands
but also in terms of their problems in accomplishing society’s expectations
of self-realisation and authenticity. By doing this, we offer an understand-
ing of how, in an intertwined process, both organisational and societal
demands may give rise to an identity crisis with moral undertones, or the
breakdown of the coherent self, and ultimately the exhaustion of the self.
References
Marc Buelens and Herman Van den Broeck, ‘An Analysis of Differences in
Work Motivation Between Public and Private Sector Organisations’, Public
Administration Review 67 (2007), 65–74.
Alain Ehrenberg, The Weariness of the Self. Diagnosing the History of Depression in the
Contemporary Age (Montreal: McGill-Queen University Press, 2010).
Rebecca Erickson, ‘The Importance of Authenticity for Self and Society’,
Symbolic Interaction 18: 2 (1995), 121–44.
Rebecca Erickson and Amy Wharton, ‘Inauthenticity and Depression: Assessing
the Consequences of Interactive Service Work’, Work and Occupations
24 (1997), 188–213.
Ulla-Britt Eriksson, Bengt Starrin, and Staffan Jansson, Utbränd och emotionellt
utmärglad [Burnout and Emotional Emaciation] (Lund: Studentlitteratur,
2003).
Reidun Førde and Olaf Gjerløw Aasland, ‘Moral Distress among Norwegian
Doctors’, Journal of Medical Ethics 34: 7 (2008), 521–5.
Gabriella Gustafsson, Astrid Norberg, and Gunilla Strandberg, ‘Meanings
of Becoming and Being Burnout – Phenomenological-Hermeneutic
Interpretations of Female Healthcare Personnels’ Narratives’, Scandinavian
Journal of Caring Sciences 22 (2008), 520–28.
Gail Hebson, Damian Grimshaw, and Michael Marchington, ‘PPPs and the
Changing Sector Ethos: Case-Study Evidence from the Health and Local
Authority Sectors’, Work Employment Society 17 (2003), 481–501.
Max Henderson, Samuel Harvey, Simon Øverland, Arnsten Mykletun, and

Matthew Hotopf, ‘Work and Common Psychiatric Disorders’, Journal of the
Royal Society of Medicine 104: 5 (2011), 198–207.
Arlie Hochschild, The Managed Heart (Berkeley, CA: University of California
Press, 1983).
Axel Honneth, ‘Organized Self-Realization: Some Paradoxes of Individualization’,
European Journal of Social Theory 7 (2004), 463–78.
Christina Juthberg, Sture Eriksson, Astrid Norberg, and Karin Sundin,
‘Perceptions of Conscience in Relation to Stress of Conscience’, Nursing
Ethics, 14: 3 (2007), 329–43.
Sofia Kälvemark-Sporrong, Anna Höglund, Mats Hansson, Peter Westerholm,
and Bengt Arnetz, ‘Living with Conflicts – Ethical Dilemmas and Moral
Distress in the Health Care System’, Social Science and Medicine 58 (2004),
1075–84.
Frank Kleemann, Ingo Matuschek, and G. Günter Voß, ‘Subjektivierung von
Arbeit – Ein Überblick zum Stand der Diskussion’, in Subjektivierung der
Arbeit, ed. Manfred Moldaschl and G. Günter Voß (Munich and Mering:
Rainer Hampp Verlag, 2003), pp. 57–114.
Birgitte Malm, ‘Authenticity in Teachers’ Lives and Work: Some Philosophical
and Empirical Considerations’, Scandinavian Journal of Educational Research
52 (2008), 373–86.
Robert Merton, Marjorie Fiske, and Patricia Kendall, The Focused Interview.
A Manual of Problems and Procedures (New York: Free Press, 1990]).
Elliot Mishler, ‘Models of Narrative Analysis: A Typology’, Journal of Narrative &
Life History 5 (1995), 87–123.
OECD, Sick on the Job? Myths and Realities about Mental Health and Work
(Paris: OECD Publishing, 2012).
———, Mental Health and Work: Sweden (Paris: OECD Publishing, 2013).
Marvin Scott and Stanford Lyman, ‘Accounts’, American Sociological Review
33 (1968), 46–62.
Thomas Scheff, ‘Shame and Conformity: The Defence-Emotion System’,
American Sociological Review 53: 3 (1988), 395–406.
———, ‘Shame in Self and Society’, Symbolic Interaction 26: 2 (2003),
239–62.
Swedish Council on Health Technology Assessment and Assessment of Social
Services, Arbetsmiljöns betydelse för symtom på depression och utmattningssyn-
drom. En systematisk litteraturöversikt’ [‘The Significance of the Work
Environment for Symptoms of Depression and Chronic Fatigue Syndrome. A
Systematic Literature Review’] (Stockholm: Swedish Council on Health

Technology Assessment, 2014).
Swedish Code of Statutes (SFS), Enactment with Instruction for the Swedish
Public Employment Service (Stockholm: Fritzes, 2007).
Swedish Work Environment Authority, Work-related Disorders 2014
(Stockholm: Swedish Work Environment Authority, 2014).
Swedish Government Official Reports (SOU), A Dignified Life in the Elderly
Care. Petition of the Dignity Investigation (Stockholm: Fritzes, 2008).
The Swedish Insurance Office, ‘Sjukfrånvaro i psykiska diagnoser. En studie av
Sveriges befolkning 16–64 år’ [‘Sick-leave in Psychiatric Diagnoses. A Study
of the Swedish Population 16–64 Years’], Social Insurance Report 4 (2014).
The Swedish National Agency for Education, Curriculum for Compulsory
School, Preschool Class and the Leisure-Time Centres 2011 (Stockholm:
Fritzes, 2011).
Gresham Sykes and David Matza, ‘Techniques of Neutralization: A Theory of
Delinquency’, American Sociological Review 22 (1957), 664–70.
Phillip Vannini and Patrick Williams, Authenticity in Culture, Self, and Society
(Farnham: Ashgate, 2009).
G. Günter Voß and Hans J. Pongratz, ‘Der Arbeitskraftunternehmer. Eine
neue Grundform der “Ware Arbeitskraft”’, Kölner Zeitschrift für Soziologie
und Sozialpsychologie 50 (1998), 131–58.
Elin Thunman (Ph.D.) works as a researcher at the Department of Sociology,

Uppsala University, Sweden. Her main research interests are the consequences
of societal and organisational changes for the individual’s identity and health.
She has worked on several research projects about management-oriented
reforms in public organisations and professionals’ experiences of everyday
encounters, stressful dilemmas, self-realisation, and authenticity.
Marcus Persson (Ph.D.) works as a researcher at the Department of

Sociology, Uppsala University, Sweden. His main research interest is the
impact of information and communication technologies and robotics on social
behavior in education and health care. He has worked on several research
projects about the implementation of new technologies, socio-technical rela-
tionships, and professionals’ experiences of boundary work between home and
work domains.
9
Exhaustion and Euphoria:
Self-Medication with Amphetamines
Greta Wagner
Ever more people in contemporary societies are suffering from condi-

tions such as depression, tiredness, and exhaustion, which are increas-
ingly often considered to require medical treatment. According to the
WHO, 7% of the population suffer from severe depression each year.1
In addition, burnout is being diagnosed with increasing frequency in
many countries, such as Sweden, the Netherlands, and Germany. It is a
matter of dispute whether there has, in fact, been an increase in exhaus-
tion in recent years, or whether there has only been an increase in the
pathologisation and medicalisation of conditions of exhaustion. There is
considerable evidence that the rapid pace of social change since the
1990s, as manifested most clearly in the digitalisation of communication
and the neo-liberalisation of the social system, is placing a strain on
1
WHO, online at: http://www.euro.who.int/en/health-topics/noncommunicable-diseases/
mental-health/news/news/2012/10/depression-in-europe (accessed July 2016).
G. Wagner (*)
e-mail: greta.wagner@soz.uni-frankfurt.de

DOI 10.1007/978-3-319-52887-8_9
196 G. Wagner
people’s subjective resources. Apparently, the rapid rise in exhaustion-

related syndromes is not just a matter of the greater attention devoted to
this topic but of an increase in manifestly experienced suffering.2
Regardless of whether people do, in fact, feel more exhausted and
depressed than in other historical periods, however, exhaustion has
certainly become a more serious problem. The state of inactivity and
emotional indifference to which tired, depressed, and exhausted people
succumb is the exact opposite of the subjective condition which is so
highly valued today. It is at odds with the practical ideals of autonomy
and self-realisation. A state of exhaustion effectively prevents the pro-
ductivity and dedication to work which are held in such high regard in
contemporary society.
In recent years, a phenomenon which can be understood as a reaction
to the problem of exhaustion has captured the public imagination –
namely, neuroenhancement or self-medication with drugs that increase
alertness, concentration, and motivation. The practice of taking psycho-
tropic drugs that were originally developed and approved for the treat-
ment of attention-deficit disorders (ADD and ADHD) has become
increasingly more common, especially among students. Considering
the clinical studies on the effects of these drugs on healthy people, it is
at first sight astounding that drugs such as Ritalin are being taken as
neuroenhancers at all. They neither make those who take them more
intelligent, nor are they of any significant help when it comes to solving
tasks under laboratory conditions.3 However, they do have an effect
which apparently plays a minor role in a laboratory setting, but a central
role for students and in mental work in which people determine their
own working hours: Those who consume these substances use them to
postpone their exhaustion and tiredness, and to enable themselves to
devote themselves euphorically to their work. Nothing can distract them
or diminish their suddenly piqued interest.
2
See Neckel and Wagner in this volume.
3
See Dimitris Repantis et al., ‘Modafinil and Methylphenidate for Neuroenhancement in Healthy
Individuals: A Systematic Review’, Pharmacological Research 62: 3 (2010), 187–206.
9 Exhaustion and Euphoria: Self-Medication with Amphetamines 197
In the following sections, I present excerpts from a qualitative inter-

view study in which I have investigated the interpretations and motives
of those who consume such performance-enhancing drugs.4 I analyse
these interpretations and motives in the context of the importance of
self-realisation, autonomy, and activation in present-day society.
Self-Realisation, Autonomy, and Activation

Alain Ehrenberg explains the increase in depression as a result of the greater
importance attached to autonomy today, in comparison to the disciplinary
society of the past. The question which indicates whether one has behaved
correctly has undergone a change during this time. Whereas in a society
organised around discipline the question was ‘May I do that?’, today the
question is ‘Can I do that?’. According to Ehrenberg’s hypothesis, the history
of depression follows a course that runs parallel to the decline in the type of
the disciplined individual.5 The claim is that, since the Second World War,
the emancipated individual no longer suffers from the fear of violating social
prohibitions, but instead from the exhaustion that sets in as a result of the
perceived failure to satisfy requirements. ‘Depression [ . . . ] brings to light the
difficulties unavoidably faced by an individual who attempts to give himself a
structure in a society which attaches supreme importance to personal initia-
tive and self-realisation. But someone who lacks structure at the same time
lacks an essential precondition of practical capability.’6 Ehrenberg captures
this transition from the neuroses of the disciplinary society to the depression
of contemporary society in a much-quoted formula: ‘Becoming ourselves
made us nervous, being ourselves makes us depressed.’7
4
The findings of the study have also appeared as a monograph: Greta Wagner, Selbstoptimierung:
Praxis und Kritik von Neuroenhancement (Frankfurt: Campus, 2016).
5
Kreation und Depression. Freiheit im’gegenwärtigen Kapitalismus, ed. Christoph Menke and Juliane
Rebentisch (Berlin: Kadmos 2010), pp. 52–62, p. 54f.
6
’Ibid., p. 55.
7
Ehrenberg, The Weariness of the Self: Diagnosing the History of Depression in the Contemporary Age,
trans. Enrico Canouette et al. (Toronto: McGill-Queen’s University Press, 2010), p. 44.
198 G. Wagner
Taking the initiative and getting things done have become general
requirements. Today such major importance is attached to self-activa-
tion also because, under the conditions of flexible capitalism, subjects
have to continually search autonomously for opportunities to capitalise
on their capabilities. To the extent that temporary employment has
become the norm, work and life are increasingly unfolding in discrete
units of time. Luc Boltanski and Ève Chiapello speak in this context of
the ‘project-based Polis’ in which life is conceived as a succession of
projects. In the project-based Polis, a person’s value is measured by the
activity she performs.8 ‘The level of activity’, as Stephan Lessenich also
puts it, ‘tends to displace all other social distinctions – or rather, all other
social distinctions tend to be subsumed under the social meta-difference
of activity or inactivity, mobility versus immobility’.9 Passivity and
routines are the arch enemy of the entrepreneurial self and, according
to Ulrich Bröckling, are supposed to be overcome by an ‘ethos of
beginning’.10
But the exhausted and the depressed are incapable of achieving this.
They cannot motivate themselves to take the initiative; they suffer from
lethargy, passivity, and immobility. Especially in employment relation-
ships, in which motivation and initiative are crucial, in which employees
are required to take a passionate interest in their work and also to show
this interest, and in which employees largely determine their own work-
ing hours, those who have difficulty getting up in the morning have a
particularly hard time. Even many people who are not susceptible to
depression often feel overwhelmed and fail to measure up to the perma-
nent social dictate that urges them to use their freedom and to develop
their potential.
8
See Luc Boltanski and Ève Chiapello, The New Spirit of Capitalism, trans. Gregory Elliott (New
York: Verso, 2005).
9
Stephan Lessenich, ‘Mobilität und Kontrolle: Zur Dialektik der Aktivgesellschaft’, in Soziologie –
Kapitalismus – Kritik: Eine Debatte, ed. Klaus Dörre, Stephan Lessenich, and Hartmut Rosa
(Frankfurt: Suhrkamp, 2009), pp. 161–2.
10
Ulrich Bröckling, ‘Jeder könnte, aber nicht alle können: Konturen des unternehmerischen
Selbst’, Mittelweg 36 (2002), 6–26.
Neuroenhancement and the Problem

of Exhaustion
Therefore, it is not particularly surprising that much has been said in
recent years about a phenomenon which is intimately bound up with
this dictate. The consumption of alertness- and motivation-enhancing
psychotropic drugs is being discussed under the heading of ‘neuroen-
hancement’, also known as ‘cognitive enhancement’ or ‘brain doping’.
Those measures qualify as enhancements which are not medically
indicated, because the term ‘enhancement’ (in the sense of improve-
ment) is used in contrast to ‘treatment’, which refers to the medical
treatment of diseases. However, the distinction between treatment and
enhancement is often controversial when it comes to judging specific
cases because it rests on normatively charged and historically and cultu-
rally contingent concepts of physical and mental normality. Consider,
for example, the case of a very shy and introverted young man who is
prescribed Paxil by his doctor, a selective serotonin reuptake inhibitor,
which enables him to approach others openly and confidently. Is he
using the medication to treat his social anxiety disorder, a disease which
was ‘discovered’ a number of years ago, was incorporated into the ICD
9, and has been diagnosed ever more frequently since then? Or is the
patient changing his character in accordance with his own desires
because he is dissatisfied with his social inhibitions, so that what he is
doing must be described as a case of ‘cosmetic psychopharmacology’ and
thus of enhancement?11 Or is it the case that, as an employee in the
service sector, he cannot afford his pronounced shyness because custo-
mer contact in his job calls for an open nature, and hence he feels
compelled to adapt his personality to the requirements of his company
by pharmacological means? This example not only poses the question of
the distinction between treatment and enhancement but also of the
distinction between autonomous and heteronomous forms of enhance-
ment. Of course, there is also the question of how the two can be
distinguished in a society which calls for permanent self-optimisation.
11
Peter Kramer, Listening to Prozac (New York: Viking Press, 1993).
200 G. Wagner
Which conditions are declared to be pathological and in which cases

psychiatric medication is prescribed vary from one culture to another. In
1972, for example, the psychiatrist Gerald Klerman drew attention to
the problem that people in the United States were excessively sceptical
about medication that improved the sense of well-being, a phenomenon
for which he coined the phrase ‘pharmacological Calvinism’.12 By this
Klerman meant the widespread view that drugs which enhance well-
being are morally questionable.
Which measures are deemed to be treatments and which enhance-
ments depends on what states are considered to be expressions of health
and disease. The case in which brain performance is improved pharma-
cologically or, to be more precise, in which stimulants are taken which
contribute to activation and concentration, is also beset by this difficulty.
What degree of listlessness and lack of concentration still counts as
healthy? Beyond what point is medication justified and by which nor-
mative standards can this be measured?
Bioethics, in particular, deals with the normative problems raised by
attempts to improve the brain. Neuroenhancement, in contrast to other
forms of self-optimisation, is especially interesting for bioethics because
the brain is so intimately bound up with personal identity, and inter-
ference with its operation raises ethical questions concerning authenti-
city and autonomy.13 However, as a general rule the bioethical literature
on neuroenhancement discusses fictitious and anticipated techniques for
improving the brain that are not yet medically possible, and enquires
into the effects of applications that make people more intelligent. The
enhancement agents which are actually consumed, however – namely,
amphetamines and amphetamine-like substances – do not make those
12
Gerald L. Klerman, ‘Psychotropic Hedonism vs. Pharmacological Calvinism’, The Hastings
Center Report 2: 4 (1972), 1–3.
13
See Martha J. Farah et al., ‘Neurocognitive Enhancement: What Can We Do and What Should
We Do?’, Nature Reviews Neuroscience 5: 5 (2004), 421–25; Martha Farah and Paul Root Wolpe,
‘Monitoring and Manipulating Brain Function: New Neuroscience Technologies and Their Ethical
Implications’, Hastings Center Report 34 (2004), 35–45; Walter Glannon, ‘Psychopharmacological
Enhancement’, Neuroethics 1: 1 (2008), 45–54; Henry Greely et al., ‘Towards Responsible Use of
Cognitive Enhancing Drugs by the Healthy’, Nature 456 (2008), 702–5.
who consume them more intelligent. They are taken because they
temporarily eliminate fatigue and exhaustion and because exhaustion
and tiredness clearly represent a problem. The substances most com-
monly consumed in this context in the United States are amphetamine-
based drugs, whereas in Europe, where amphetamines are not approved,
the amphetamine-like stimulant methylphenidate, which is contained in
Ritalin, is more likely to be taken.
The History of Amphetamines

The history of psychiatric medication is closely intertwined with the
history of narcotics. Psychiatric medication cannot be clearly distin-
guished from narcotics solely based on the substances involved. Instead,
the purpose and the conditions under which these substances are taken
need to be taken into consideration. Thus, many substances that were
initially taken by consumers for recreational purposes were subsequently
used in the context of medical treatment, were then prohibited, and
finally were once again made available for recreational use through the
black market.
Amphetamine was first synthesised in 1887 by Lazăr Edeleanu, a
Romanian chemist who discovered the substance in the context of his
doctoral thesis. Yet, since he saw no use for it, his work disappeared into
the archives and was not taken up again until 1908, when the British
physiologist Henry Hallett Dale demonstrated the similarity between
the substance and the hormone adrenaline.14 In 1929, Gordon Alles, a
biochemist from Los Angeles, rediscovered the substance amine, which
had been synthesised 40 years earlier by Edeleanu as part of his efforts to
develop a medicine similar in structure to adrenaline for treating asthma.
He tried out the substance on himself and described experiencing strong
heart palpitations, a ‘feeling of well-being’, unusual talkativeness, and
finally ‘a rather sleepless night’ in which his ‘mind raced from one topic
14
Hans-Christian Dany, Speed: Eine Gesellschaft auf Droge (Hamburg: Edition Nautilus, 2008),
p. 14.
202 G. Wagner
to another’.15 From the initial letters of the substances which form

the chemical compound – Alpha Methyl PHenyl EThyl AMINE –
Gordon Alles formed the acronym amphetamine. He sent his sub-
stance to various pharmaceutical companies, and the company Smith,
Kline & French Laboratories (SKF) began to manufacture an inhaler
against respiratory ailments with the trade name Benzedrine, which
was even offered to air passengers to make take-off and landings more
comfortable.16
Benzedrine was brought onto the market in tablet form in 1937.
Subsequently, various tests were conducted into which ailments besides
asthma the substance could alleviate. The American neurologist Charles
Bradley discovered that it helped children suffering from nervousness and
lack of concentration to solve problems. With this he laid the foundation
for the treatment of children with ADHD with amphetamines.17
However, in 1937 SKF decided that the main field of application for
Benzedrine sulphate should be mood enhancement, and started the adver-
tising campaign which would make amphetamine, as the first ‘anti-depres-
sant’, into a blockbuster among prescription drugs in the early 1940s.18
In the late 1930s, the mass consumption of an amphetamine deriva-
tive began in Nazi Germany as a means of improving the performance
of front-line soldiers. In 1938, the Berlin pharmaceutical company
Temmler Werke began production of a medication with the active
substance methamphetamine under the brand name Pervitin. Before the
invasions of Poland and France, a large proportion of the Wehrmacht
soldiers had taken methamphetamine, which provided a short-term
boost to their physical performance, postponed their need for sleep,
and removed their fear. After the first soldiers became addicted to
Pervitin and developed psychoses, however, administration of the sub-
stance was made subject to the Reichsopiumgesetz and was restricted
from 1941 onwards. Methamphetamine, however, continued to be
15
Nicolas Rasmussen, On Speed: The Many Lives of Amphetamines (New York: NYU Press, 2008),
p. 16.
16
Dany, Speed, pp. 27–8.
17
Rasmussen, On Speed, p. 30.
18
Ibid., pp. 25ff.
administered to submarine crews. British, American, and Japanese

soldiers also took methamphetamine during the Second World War
to enhance their performance.19
When the prescription requirement for methamphetamine was made
more restrictive in the 1960s, the production and sale of the substance
shifted increasingly to the black market. In spite of their affinity with
drug use, the hippies of the counterculture movement in the 1970s kept
their distance from amphetamines. They regarded amphetamine as a
soldier drug which was not based on a natural active ingredient and was
therefore alien to the nature of the body. Hallucinogenic substances such
as LSD and marijuana were common among hippies, while they rejected
amphetamines as part of American capitalist culture. Timothy Leary
even decried them as part of the ‘cheap, neon, plastic, ugly America’:20
‘The good drugs collectively referred to as “dope” comprised marihuana
and hallucinogens. They were meant to give rise to authenticity, human
warmth, and the spiritual life.’21
In the 1980s, amphetamines experienced a boom in various subcul-
tures as so-called designer drugs. Analogously, the valorisation of the
natural went out of fashion: ‘What the New Wave had already done for
music or the postmodern novel for literature, problematising the authen-
tic, now extends to dealings with the body and as a result becomes
attractive for a broad public.’22 In the 1990s, an amphetamine derivative
was taken en masse in techno clubs in Europe which differs from
amphetamine in that it not only functions as a stimulant but also has
psychedelic effects: 3,4-methylenedioxymethamphetamine (MDMA),
the principal active ingredient in the party drug ecstasy. Demand for
another type of amphetamine also underwent a sudden rapid increase.
Methamphetamine in crystalline form, which as a result of new
19
Ibid., pp. 66ff. See also Norman Ohler, Blitzed: Drugs in Nazi Germany, trans. Shaun Whiteside
(London: Allen Lane, 2016).
20
Leary quoted in Nicolas Langlitz, ‘Political Neurotheology: Emergence and Revival of a
Psychedelic Alternative to Cosmetic Psychopharmacology’, in Neurocultures: Glimpses into an
Expanding Universe, ed. Francisco Ortega and Fernando Vidal (Frankfurt: Peter Lang, 2011),
p. 146.
21
Ibid., p. 146.
22
Dany, Speed, p. 152.
204 G. Wagner
production techniques is much stronger than in the 1960s, is now

known under the name ‘crystal meth’ – rendered infamous by the recent
American TV series Breaking Bad. Crystal meth leads to a rapid physical
decline and was primarily a drug of the poor white underclass. Yet, in
recent years, there has been an increase in consumption in middle-class
milieus as well. The medical use of amphetamine also increased during
the 1990s. In the United States, the rise in diagnoses of ADD and
ADHD resulted in ever higher numbers of prescriptions of dexamphe-
tamine to children.
Amphetamine, methamphetamine, dexamphetamine, methylpheni-
date, and modafinil affect the brain in the same way and have the same
set of effects. In particular, their activating, motivating, and alertness-
enhancing effects are found useful and attractive and are thus used for
‘enhancement’.23 The history of amphetamine use pervades the entire
twentieth century. Medical treatment, military conditioning, and youth
culture recreational use are all part of this story. Amphetamines were
used as an instrument of power as well as being appropriated by subjects
for purposes of their own – but always with the goal of eliminating fatigue
and exhaustion and instead allowing the user to remain awake, active,
and driven.
Amphetamines as Study Drugs

But how do present-day consumers of amphetamines interpret their prac-
tice themselves? How do they experience the effects of the substance and
what normative evaluation do they attach to their amphetamine use? When
they take amphetamines, are they medicalising their exhaustion and
tiredness?
In the United States, a significantly larger proportion of students take
so-called study drugs than in Germany. A representative nationwide
survey found that 6.9% of students in the United States had taken
23
Nicolas Rasmussen, ‘Psychostimulanzien steigern nicht die kognitive Leistung. Lehren aus der
Geschichte’, in WestEnd. Neue Zeitschrift für Sozialforschung 02 (Frankfurt: Campus, 2014),
pp. 69–80 (p. 69).
Ritalin or Adderall at least once in their lives without a recommendation

from a doctor. There were pronounced differences in the consumption
of these prescription drugs among the different colleges: most neuroen-
hancers were taken in the north-eastern states, at colleges with highly
selective admissions.24 By contrast, a study revealed that in Germany
only 0.78% of students had taken prescription drugs for cognitive
enhancement on at least one occasion.25
For my study, I interviewed individuals who take prescription drugs
without medical need in order to remain more alert, focused, and
motivated in their work. Half of my interviewees come from various
German cities, the other half from New York. Most of them are students
and take Ritalin or Adderall – some regularly, others only in intensive
work phases – to write their term papers. Once the effect of the
substance sets in, they experience an urge to work and feel enthusiasm
for the object of their activity.
For example, when Aleksandra, a New York undergraduate student,
first took Adderall together with her friend, she felt a sudden burst of
energy and a burning interest in her examination topics: ‘We studied so
much we made like colour coded flash cards. I was like “wow this
actually works, I’ve never been so interested.”’ In Alexandra’s case, the
effect of the drug ensures that she can devote her complete attention to
the subject matter and is enthusiastic about her work.
Tabitha, another interviewee, who studies biology in Berlin and
regularly takes Ritalin in order to cope with the study workload, reports
how strongly Ritalin directs one’s focus: ‘You have to imagine that, no
matter what you are doing, you are completely absorbed. [ . . . ] You can
completely block out everything from outside.’ Tabitha describes the
feeling that Ritalin generates when she is working as ‘euphoric’. The
drug produces a burning interest in her field of study: ‘When you’re
24
See Christian J. Teter et al., ‘Illicit Use of Specific Prescription Stimulants among College Students:
Prevalence, Motives, and Routes of Administration’, Pharmacotherapy 26 (2006), 1501–10; Sean
Esteban McCabe et al., ‘Non-Medical Use of Prescription Stimulants among US College Students:
Prevalence and Correlates from a National Survey’, Addiction 100: 1 (2005), 96–106.
25
Andreas Franke et al., ‘Non-Medical Use of Prescription Stimulants and Illicit Use of
Stimulants for Cognitive Enhancement in Pupils and Students in Germany’, Pharmacopsychiatry
44: 2 (2011), 60–6.
206 G. Wagner
really in, at the beginning, in the first ten minutes, you have a real
endorphin discharge; so you’re looking forward to what you’re doing,
you love your studies, your work.’ Alongside her studies Tabitha works
as a trade fair hostess, and also takes Ritalin in order to be able to cope
with the 12-hour workdays during which she must stand and smile for
hours on end. With Ritalin, this work also comes easily to her and she
feels no sense of fatigue.
Nils studies philosophy and American studies in Munich and takes
Ritalin when writing his term papers. He has examined the effect of the
drug carefully: ‘Of course, it’s advisable to eat something before taking
Ritalin, it almost completely suppresses feelings of hunger and tiredness, you
get into a so-called fight-or-flight situation, so at first your airways expand a
bit, you can easily get sweaty palms, you notice your heart is beating a little
faster, you notice you’ve become more focused.’ He takes the drug because
he thinks that it enables him to study more successfully. He reports that he is
also able to write good term papers without Ritalin, but that is much more
strenuous and with the substance he is more alert and focused.
Tyler is 19 years old, studies philosophy and hip-hop in New York, and
sometimes takes Adderall during finals. He relates how he came to take it
for the first time: ‘We went to the NYU library to do our finals and
everybody had like Adderall [ . . . ] there was this girl who had like a
whole bottle and was passing it to her friends. It was like a joint or
something, it was really odd.’ Among New York undergraduates, using
amphetamines is often a social practice. Consumption is part of the every-
day culture of the students. Thus, Tyler explains: ‘And it’s kind of a social
thing although it doesn’t seem like it is, but like when finals come around,
just like drinking at a party people are doing Adderall at the library.’
However, just as drinking at a party does not always have exactly the effect
desired, taking Adderall does not always lead to concentrated work. Tyler
reports the problem of aimless activation: ‘it doesn’t necessarily get me
focused on one thing, it just gets me active in some sense [ . . . ] it gets me
like “Oh okay, let’s do everything!”’
When young New York students, as the other interviews with this
group also show, study at the end of the semester in Bobst Library and
take Adderall, they do so together in a quasi-ritualistic way. It is a
collective practice that takes place in a liminal phase during the
transition to the holidays. Adderall, with its amphetamine-like effect, is

not per se a substance that fosters a sense of community. On the
contrary, it has an individualising effect, because it specifically enables
those who consume it not to be influenced by others, but instead to
remain highly motivated in what they are doing and with their own
thoughts. When they pass around their Adderall, therefore, the students
communalise their individual work on their term papers. They share –
each for him- or herself – their boundary-transgressing bodily experi-
ences and their intoxication with their work.
In Germany, by contrast, neuroenhancement is not only less widespread
but it also enjoys less social acceptance. Many of those who consume
Ritalin tend to keep the fact that they are taking a medication to them-
selves. Analogous to doping in sport, neuroenhancement is regarded by
Germans as an illegitimate competitive advantage. In addition, there is
greater scepticism concerning medication in general, and in particular
concerning psychotropic drugs, than in the United States. Someone who
takes psychotropic drugs without being ill is for many German students
either desperate, or unable to cope, or pathologically ambitious. In New
York neuroenhancement is much more likely to be regarded as a legitimate
strategy for success that is a matter of individual choice.26
Amphetamines in the Workplace

Still less open about their use of performance-enhancing drugs are as a
general rule professionals. They take their medication alone and often tell
their colleagues nothing about their consumption, out of fear of being
accused of enjoying an illegitimate advantage. Neuroenhancement is
especially likely to occur in the case of subjects with burnout symptoms.27
26
Aside from the interpretations of those who take neuroenhancers, I have also studied the normative
orientations of students in Frankfurt and New York who do not take medication to enhance
performance. See Greta Wagner, Selbstoptimierung: Praxis und Kritik von Neuroenhancement
(Frankfurt: Campus, 2016).
27
See Helmut Schröder et al., Einfluss psychischer Belastungen am Arbeitsplatz auf das
Neuroenhancement – empirische Untersuchungen an Erwerbstätigen (Dortmund: Bundesanstalt für
Arbeitsschutz und Arbeitsmedizin, 2015), p. 74.
208 G. Wagner
However, my interview partners also often cited hedonistic motives for

their substance use. They find work more fun when using amphetamines,
they are interested in what they are doing and do not need to motivate
themselves – the medication looks after that.
Andreas, for example, is a 34-year-old mathematician who works for
an insurance company and takes one tablet of modafinil every morning.
As a result, he is motivated and interested in his tasks throughout the
day, enjoys work that he would otherwise find boring, and in the course
of which he would otherwise also have to struggle with tiredness. He is
afraid of being unpopular with his colleagues because he does not take
coffee breaks but prefers to remain at his desk. No one at the company
knows that he takes medication in order to work. At the weekend
Andreas goes out to clubs and takes other types of amphetamines such
as MDMA, so that he can dance euphorically all night without symp-
toms of fatigue.
Anne is 36 years old, lives in Hamburg, and works as a freelance
author. A couple of days a week she takes Ritalin to enhance her
concentration. She claims that she finds it impossible to do things that
she does not want to do, because then she immediately falls asleep. She
has, in fact, been diagnosed with narcolepsy and gets her medication on
prescription. However, she does not attach any particular importance to
the narcolepsy diagnosis: ‘It’s always difficult to distinguish what is now
in fact technically illness and what is something like a fixed part of one’s
character and what is just plain laziness and unwillingness that you could
easily overcome if you wanted to. I don’t know.’ Moreover, Anne thinks
that taking Ritalin is legitimate even without a diagnosis of correspond-
ing syndromes. She takes the view that medications to increase concen-
tration should be freely available to everyone and not be regulated by
prescription.
Anne takes two doses of Ritalin per day that work for about three
hours each. She is self-employed and determines her own working hours.
In her view the biggest challenge that comes with this way of working is
‘pulling oneself together’, the need to motivate oneself to work on the
texts one would like to write, and not to ‘have a quick look at what
happened in the last three minutes on Facebook, Twitter, and 37 other
sites’. She says: ‘I have the feeling that my work consists of around 80%
pulling-myself-together work.’ For her, Ritalin looks after precisely this

‘pulling-oneself-together work’. Thus, thanks to two doses per day, she
puts in a workday that generally does not last longer than six hours.
Unlike many others, Anne does not take the medication in order to be
able to cope with excessively long working days, but in order to facilitate
her time management, which is completely up to her, and to divide her
days into working and leisure hours. She does not need self-discipline,
because she works spontaneously as long as Ritalin exerts its effects. Nor
does she think, therefore, that Ritalin is emblematic of the adaptation of
human beings to the performance society. On the contrary, she believes
that the drug liberates her from the many requirements of the present-
day performance-oriented society: ‘The accusation is always that people
take Ritalin or modafinil in order to fit in better into the rigid corset of
the performance society. But in fact it’s only a very temporary and
effortless way of fitting in. Swallow the tablet, become a useful cog in
society, after four hours the effect wears off and you can go out again and
hang out [laughs].’ Anne believes that using Ritalin leads to a less
extreme adjustment to the requirements of the performance society
than ‘readjusting your personality with great effort and self-discipline
so that it’s able to meet those demands automatically all day long. That
way I would feel more strongly deformed by society’. Thus, Anne resorts
to Ritalin specifically because she does not want to internalise any
performance imperatives. For her, this externalisation of self-discipline
is a kind of relief. Paradoxically, she thinks that she can protect her core
self against the encroachments of the performance society by using
Ritalin because it means that she does not have to change her ‘lazy’
personality.
Activation in the Contemporary World of Work

As soon as the effect kicks in, consumers of amphetamines and Ritalin
are activated. One interviewee describes the effect in the following
words: ‘It’s about getting shit done.’ In doing so, those who have
been activated have to be careful that self-activation does not lead to
misdirected activity, as in the case of procrastination. The drive that
210 G. Wagner
leads you to clean a window when you should be finishing a text,

something which many students and knowledge workers with no fixed
working hours complain about, can under certain conditions also be
induced by performance-enhancing drugs. One interviewee, for exam-
ple, describes the effect of the drugs in the following words: ‘You just
wanna do things. It can be the laundry or it can be the midterm paper.’
Therefore, many of those who take the substances have to adjust their
focus already when the effect kicks in, if their activity is to be directed
to the desired object.
Both students and professionals take amphetamines because these
substances help them to remain alert and motivated, and because
they arouse interest in any arbitrary subject. Amphetamines structure
the time of those who take them by dividing it into working and
leisure hours. Under flexibilised working conditions, among the self-
employed and, of course, students, this task devolves to each individual
and is often beset by problems. Many fail by postponing tasks for hours
before they start working, or they postpone the end of the working day
for hours before they actually stop working. Consumers of neuroen-
hancers externalise these requirements of the new world of work. They
start working when the effect kicks in and stop working when it wears
off. Motivation and enthusiasm for their work occur of their own
accord during these hours. That this effect is so highly valued among
users also has to do with changes in the demands placed on work. Since
the 1960s, the world of work has been increasingly criticised by social
movements as hierarchical and alienating. This critique contributed to
the flexibilisation and subjectivisation of work, but it also gave rise to
new pitfalls and impositions.28 Today, the call for self-realisation in
work has changed from a call into a demand.29 Nowadays, employees
are compelled to emphasise their work as an expression of intrinsic
interests, as something they do because they want to, and not solely in
order to earn money.
28
Boltanski and Chiapello, The New Spirit of Capitalism.
29
See Axel Honneth, ‘Organized Self-Realization: Some Paradoxes of Individualization’, European
Journal of Social Theory 7: 4 (2002), 463–78.
Therefore, the question ‘Can I do that?’, which according to Ehrenberg

replaced the question ‘May I do that?’, must be supplemented by a
question that young members of the middle class continually have to
ask themselves today when they work: ‘Does that interest me?’ Where
the call to realise oneself has become a demand, you not only have to
ask yourself whether you are good enough, but also whether you
are sufficiently motivated and enthusiastic about what is defined as your
self-realisation – work. Drugs such as Ritalin or Adderall are taken in
order to induce motivation and enthusiasm for any arbitrary subject. In
this respect, neuroenhancement is practised in the hope of solving one of
the key practical problems facing subjects under the conditions of con-
temporary capitalism.
References
Ulrich Bröckling, ‘Jeder könnte, aber nicht alle können: Konturen des unter-
nehmerischen Selbst’, Mittelweg 36 11: 4 (2002), 6–26.
Hans-Christian Dany, Speed: Eine Gesellschaft auf Droge (Hamburg: Edition
Nautilus, 2008).
Alain Ehrenberg, ‘Depression: Unbehagen in der Kultur oder neue Formen der
Sozialität’, in Kreation und Depression. Freiheit im gegenwärtigen Kapitalismus,
ed. Christoph Menke and Juliane Rebentisch (Berlin: Kadmos, 2010a),
pp. 52–62.
———, The Weariness of the Self: Diagnosing the History of Depression in the
Contemporary Age, trans. Enrico Canouette et al. (Toronto: McGill-Queen’s
University Press, 2010b).
Martha J. Farah et al., ‘Neurocognitive Enhancement: What Can We Do and
What Should We Do?’, Nature Reviews Neuroscience 5: 5 (2004), 421–5.
Martha J. Farah and Paul Root Wolpe, ‘Monitoring and Manipulating Brain
Function: New Neuroscience Technologies and Their Ethical Implications’,
Hastings Center Report 34: 3 (2004), 35–45.
Walter Glannon, ‘Psychopharmacological Enhancement’, Neuroethics 1: 1
(2008), 45–54.
212 G. Wagner
Henry Greely et al., ‘Towards Responsible Use of Cognitive Enhancing Drugs

by the Healthy’, Nature 456 (2008), 702–5.
European Journal of Social Theory 4 (2002), 463–78.
Gerald L. Klerman, ‘Psychotropic Hedonism vs. Pharmacological Calvinism’,
The Hastings Center Report 2: 4 (1972), 1–3.
Peter Kramer, Listening to Prozac (New York: Viking Press, 1993).
Nicolas Langlitz, ‘Political Neurotheology: Emergence and Revival of a
Psychedelic Alternative to Cosmetic Psychopharmacology’, in Neurocultures:
Glimpses into an Expanding Universe, ed. Francisco Ortega and Fernando
Vidal (Frankfurt am Main: Peter Lang, 2011), pp. 141–65.
Stephan Lessenich, ‘Mobilität und Kontrolle: Zur Dialektik der
Aktivgesellschaft’, in Soziologie – Kapitalismus – Kritik: Eine Debatte, ed.
Klaus Dörre, Stephan Lessenich and Hartmut Rosa (Frankfurt am Main:
Suhrkamp, 2009), pp. 126–80.
Sean Esteban McCabe et al. ‘Non-Medical Use of Prescription Stimulants
among US College Students: Prevalence and Correlates from a National
Survey’, Addiction 100: 1 (2005), 96–106.
Norman Ohler, Blitzed: Drugs in Nazi Germany, trans. Shaun Whiteside
(London: Allen Lane, 2016).
———, ‘Psychostimulanzien steigern nicht die kognitive Leistung. Lehren aus
der Geschichte’, in WestEnd. Neue Zeitschrift für Sozialforschung 02
(2014), 69–80.
Dimitris Repantis et al, ‘Modafinil and Methylphenidate for Neuroenhancement
in Healthy Individuals: A Systematic Review’, Pharmacological Research 62: 3
(2010), 187–206.
Helmut Schröder et al., Einfluss psychischer Belastungen am Arbeitsplatz auf
das Neuroenhancement – empirische Untersuchungen an Erwerbstätigen
(Dortmund: Bundesanstalt für Arbeitsschutz und Arbeitsmedizin, 2015).
Christian J. Teter et al., ‘Illicit Use of Specific Prescription Stimulants among
College Students: Prevalence, Motives, and Routes of Administration‘,
Pharmacotherapy, 26: 10 (2006), 1501–10.
Greta Wagner, Selbstoptimierung: Praxis und Kritik von Neuroenhancement
(Frankfurt: Campus, 2016).
WHO, online at: http://www.euro.who.int/en/health-topics/noncommunic
able-diseases/mental-health/news/news/2012/10/depression-in-europe
(accessed July 2016).

Part IV
Exhaustion Discourses
10
Rechargeable Man in a Hamster Wheel
World: Contours of a Trendsetting Illness
Ulrich Bröckling
If every era is marked not only by certain auspicious words that combine
promises and hopes but also by inauspicious words in which it recognises
its problematic sides, then there can be no doubt that ‘burnout’ deserves
a prominent place in the glossary of the present. The medical experts
may argue over whether it presents an independent clinical picture or is
just another word for fatigue-related depression, and over whether it can
serve as a professional diagnosis, merely refers to a subjective experience,
or is nothing more than a marketing gag by the therapy and wellness
industry. However, burnout is one thing for certain, namely a discourse
event of almost epidemic proportions. With burnout, the phenomenon
of trendsetting illness (Zeitkrankheit) has become self-referential.1 It is
not only constantly talked and written about but when it is talked and
1
Note that the German term for a trendsetting or fashionable illness, Zeitkrankheit, contains a
reference to time, Zeit, that unfortunately gets lost in translation.—Trans.
U. Bröckling (*)
University of Freiburg, Freiburg, Germany
e-mail: ulrich.broeckling@soziologie.uni-freiburg.de

DOI 10.1007/978-3-319-52887-8_10
218 U. Bröckling
written about, then always as a trendsetting illness. Burnout is never only

a matter of individual suffering but always also a social pathology; the
burnout patient is not just a case for treatment, but is in the first instance
a social phenomenon. Even clinical studies and the psychological test
inventory associated with the condition offer an analysis of the present,
which is even truer of cover stories, talk show discussions, self-help
books, and first-person reports by sufferers. To speak of burnout is to
employ the vocabulary of cultural criticism.
On top of this, it is an illness whose very symptoms and aetiology make
a direct reference to time [Zeit], specifically to accelerated and compressed
time. If we follow common sense, the skyrocketing number of burnout
victims is a reflection of the exorbitant performance expectations of a
ubiquitous regime of competition, of the relentless rhythm of project
deadlines and target agreements, of ‘milestones’ and deadlines, and
ultimately of the all too well-founded fear of not being able to keep up
with the accelerated pace of work and of being left behind. In response,
the booming prevention and therapeutic programmes propose strategies
of deceleration or so-called slow movement. No less critical of culture
than the complaints about the unreasonable demands of contemporary
work relations is the ever louder scepticism expressed – especially in the
features pages – about the modish burnout diagnosis. The oversaturation
of the media with constantly new case histories tends to foster ironic
detachment; some scornful voices even detect initial symptoms of ‘burn-
out burnout’.2 Even the medical profession is distancing itself. Physicians
deplore the differential diagnostic fuzziness of the syndrome, which even
lacks the consecration of a WHO ICD-10 number of its own, and oppose
a conception that ‘equates the notion of burnout with a disease of the
high achievers and the “strong”, but associates the notion of depression
with a disease of the (constitutionally) “weak”’.3
While not so long ago collapsing workaholics were still pinning
burnout on their chests like a veteran’s medal to set themselves apart
2
Hilmar Klute, Wir Ausgebrannten (Munich: Diederichs, 2012).
3
Wolfgang P. Kaschka, Dieter Korczak, and Karl Broich, ‘Modediagnose Burn-out’, Deutsches
Ärzteblatt 108: 46 (2011), 781–7.
10 Rechargeable Man in a Hamster Wheel World . . . 219
from the mere depressives, the diagnosis is now afflicted with an acute
loss of symbolic capital. Soon enough there will probably be no gains in
distinction to be derived from it. On the other hand, adult education
courses on burnout prevention are booming and self-help books are
cluttering the aisles of airport bookstores. We are witnessing the demo-
cratisation of a condition – from the first references to the excessive
demands that autistic idealists make on themselves in the medical
literature of the 1970s,4 through the fatigue syndrome of permanently
stressed managers into which these mutated at the turn of the millen-
nium at the latest, up to the recent presentations of burnout as a
universal ailment. Taking the pervasiveness of the topic in the media
as a yardstick, the burnout epidemic reached a provisional climax in
2011. Already in January of that year the weekly magazine Der Spiegel
pronounced its diagnosis: The Germans are an ‘exhausted people’. This
provided the opening salvo for a battery of lead stories by the major news
magazines, which was brought to a close in December by the weekly
newspaper Die Zeit with the rhetorical question ‘Anyone left without
burnout?’.5
What sets trendsetting illnesses apart is not just the frequency of
their occurrence but above all that their symptoms hold up a mirror to
contemporary society. They reflect people’s fears, ailments, and failures –
and thereby show ex negativo the vanishing points of present-day
lifestyles, that is, current conceptions of how people see themselves,
of how they work on and take care of themselves. Reading burnout
discourse in this way is to treat it as a symptom in its own right.
This approach is strictly sociological. It leaves it up to doctors and
psychotherapists to provide answers to the question of what actually
ails people and why, and especially to make proposals about how they
should be helped. Its role is not to raise the alarm about a collective
4
Herbert J. Freudenberger, ‘Staff Burn-out’, Journal of Social Issues 30: 1 (1974), 159–65; and
Freudenberger, ‘The Staff Burn-out Syndrome in Alternative Institutions’, Psychotherapy: Theory,
Research and Practice 12: 1 (1975), 73–82.
5
All quotations cited in what follows are drawn, unless otherwise stated, from articles from the
print and online editions of prominent German daily and weekly newspapers and magazines and
from the popular self-help literature. A list of sources can be found at the end of the chapter.
220 U. Bröckling
malady of the soul. Of far more interest for the sociological approach is
the implicit anthropology and social theory embedded in the ubiquitous
descriptions and explanations of the condition: If a society sees burnout
as its characteristic mark, what does that tell us about its image of itself?
What weaknesses does it attribute to those who are susceptible to
burnout and what strengths does it attribute to those it deems immune?
What forces does it think individuals are exposed to, and who among
them are supposed to be able to resist becoming burned out? As burnout
discourse is less a matter of thematising a specific psychophysical condi-
tion than of making a global diagnosis of the present, it gives rise to a
proliferation of metaphors. And it is in this verbal imagery that the
contradictory contours of the trendsetting illness and those afflicted by it
emerge most clearly.
Matchsticks Without a Firewall

Already the very label ‘burnout’ is a metaphor: Fire is among the most
elementary and powerful of all images.6 Fire stands not only for passion but
also for danger. When tamed it is useful for human purposes, but uncon-
trolled it is the epitome of sheer destruction. A fire gives off more heat than
is needed to ignite it. But once the fuel is spent, it goes out. A fire that has
burned out still shows traces of the embers; but where flames once blazed
only ashes remain. The burnout metaphor derives its intuitive obviousness
from this ambiguity. The metaphor evokes simultaneously the past expen-
diture and the present inability to continue to expend energy. Someone
who is no longer able to keep going can nevertheless look down on those
who do not even push themselves to their limits. The proudly defiant ring
of the assertion that ‘only those who caught fire can also burn out’, which is
supposed to mark the difference from depressive listlessness, reaffirms the
norm of performance without limit even while acknowledging that the
speaker has fallen short of this norm. Psychoanalysts call this ‘identifying
with the aggressor’. It is also supposed to be possible to derive therapeutic
6
Gaston Bachelard, The Psychoanalysis of Fire, trans. Alan C. M. Ross (Boston: Beacon Press, 1964
[1938]).
capital from this phenomenon. Thus, we read in a medical journal article

that the physician can point out already in the first session that it is the
dedicated employees who are at risk of becoming burned out.
The physician can employ a metaphor: the dedicated employee was

evidently ‘on fire’ for her work, but then became inflamed in a wasteful
way and in the end burned out. Now the patient must become aware of
the tinder that fuelled the fire if she wants to be able to simmer on a low
flame in future.7
The iconography of burnout guidebooks, however, prompts very differ-

ent associations. Numerous dust jacket images offer variations on the
motif of the spent matchstick. Anyone who recognises herself in this
image has little reason to brag about her past enthusiasm in an attempt
to justify her present breakdown. Spent matches are good for nothing
and end up in the dustbin – and recycling is out of the question. A more
cynical way of expressing the reduction of human beings to their labour
power is hard to imagine: she who has ceased to burn will be incinerated.
However, the associations evoked by the fire metaphor are far from
being exhausted by the image of the individual as a spent matchstick.
Burnout is itself becoming a conflagration: ‘Burnout has long since taken
root in the majority of companies and among top management. Germany
is burning – only nobody wanted to admit it for a long time’, as Manager
Magazin sounds the alarm bells and reinforces its message with a ranking
of burnout rates among the major German listed companies. There is an
explosion in the number of sick days, resulting in ‘catastrophic economic
losses’, and it is hardly possible to prevent the flames from spreading:
‘Focus: Is burnout something that everyone needs to fear if the current
trend continues? Marwitz: Yes. Some get it sooner, others later’. The fire
brigade – in the form of workplace health screenings, seminars on stress
management, or advice hotlines – always arrives ‘too late’.
The media fire alarm links social dynamics – ‘Burnout is the collateral
damage of globalisation’ – with personal life stories. Worrying statistics
7
Roland von Känel, ‘Das Burnout-Syndrom: Eine medizinische Perspektive’, Praxis 97 (2008),
477–87.
222 U. Bröckling
alternate with harrowing case histories. A permanent change in discur-

sive register means that one can switch at will between social aetiology
and individual disposition, so that individuals can either be let off the
hook as victims of circumstances or pathologised as overambitious, ultra-
hardworking, perfectionist, and at once dogged and thin-skinned indi-
viduals who are not able to say no, and hence made responsible for their
own affliction. The question ‘Is the world of work too hard, or are we
too weak?’ posed in this way must remain unanswered. What is clear,
though, is that ‘the world in which we have to survive is a tough place’.
Moreover, because there may be even tougher times ahead, the advice to
the individual is that she should begin with prevention at home by
building a personal ‘burnout firewall’. ‘Whereas companies should’, in
the words of a spokesman for the employers’ associations, ‘ensure that
processes are as stress-free as possible’, they should also assist employees
in strengthening their resistance – ‘for instance by asking: how can I
develop a thicker skin?’
Racing Cars with Energy Problems

Closely related to the image of an individual’s work or life as a burning
or extinguished flame is the topos of burnout as a ‘personal energy crisis’
rooted in an imbalance between energy supply and consumption. This
motif replaces dramatic images of blazing fires and cold ashes with the
technical association of a cybernetic system that depends on an even
balance of forces. De La Mettrie’s L’Homme Machine (1747) makes a
comeback in the image of the fatigue syndrome as a regulatory distur-
bance.8 As the author of a self-help book defines burnout with the
sobriety of an engineer: ‘Burnout describes a permanent excessive expen-
diture of energy under stress for too little effect coupled with an
insufficient energy supply. Technically this could be compared to an
oil lamp that no longer has enough fuel but is nevertheless supposed to
8
Julien O. de La Mettrie, Machine Man and Other Writings, trans. & ed. A. Thompson
(Cambridge: Cambridge University Press, 1996 [1747]).
shine brightly.’ Of course, analogies to contemporary technologies are

more popular than this comparison with an archaic device. Most often
the already proverbial empty battery pack must do duty as a symbol of
burnout: Someone who works ‘with the discipline of a machine’ but fails
to notice ‘that one warning lamp after another is lighting up’ should not
be surprised if the battery pack ends up not only empty but so empty
‘that for the moment it cannot be recharged’. The result: ‘The screen
goes blank – blackout, burnout’.
Not only is the loss of energy as such dangerous, but also the loss of
control that precedes it. The highly tuned engine uses up all its reserves
and can hardly be brought back under control: ‘The healthy person has
control mechanisms that curb him when he comes under excessive
pressure. A person who exhibits symptoms of burnout has lost a sense
of proportion. He chronically pushes himself too far, as it were.’
Clinically speaking, the collapse may mark the ‘final stage in a long
process of physical and mental erosion’. However, the victims them-
selves do not experience it as a gradual extinction of their forces, but as a
sudden system crash in turbo mode. One of various burnout patients
interviewed by Der Spiegel compares his job, or himself, to a sports car:
‘With each new rung in the career ladder a couple of more horsepower
are added, and you drive faster and faster.’ At some point he was going
so fast that the exits just raced past. He saw a big black wall looming, but
could neither change course nor slow down: ‘So you just keep going and
hope you don’t crash into it’ – but at some point you do anyway.
Perhaps it would have done the sports car-self good to have honed its
driving skills in time with the popular computer racing game ‘Burnout
Paradise’, whose advertising promise reads: ‘Slam, Shunt and Wreck
opponents in cross-town race events, where you decide the fastest route
to the finish line. Hit the jumps and find shortcuts, smash through
barriers and get to the places that other racers can’t reach to get that
competitive edge.’ Here we learn in addition that burnout not only
refers to the end of a business trip but also to deliberately spinning one’s
wheels at the start of a motor race. Someone who makes such a show of
power will soon lose tyre profile and end up driving on the wheel rim.
Like the fire metaphor, this image of man as machine is also contra-
dictory in the extreme. Burnout seems to be as much a malfunction of the
224 U. Bröckling
Human Motor as an effect of an ominous mechanisation of the self.9 Either

the human machine is simply malfunctioning and is using up all of its
reserves of energy until finally breaking down, or the specific problem is
that human beings ‘are becoming estranged from their nature’ and func-
tioning only as machines. According to her case history, Eva M. ‘was
robotic’. ‘In the morning she switched on the device that had until recently
been herself, had it get up, dressed it in a business suit, in remote control
mode, pinned its hair up in a bun, steered it onto the train to work, made it
smile.’ But in reality she had not been present for a long time. Because the
metaphor is invoked both as a paradigm of human existence and as a cipher
of dehumanisation, the proposed solutions vary between technical main-
tenance programmes and calls to reject the machine model. Either you take
a break to ‘downregulate your physiology’ and ‘recharge the battery pack’,
practice relaxation techniques, and perhaps even place your life ‘under the
microscope’ and install ‘detectors’ that will provide prompt warnings in the
future. Or you opt for introspection and the wisdom of the ancients like the
porn star Lara Love. During her burnout crisis she asked herself ‘many
questions’ – ‘What do I want to do? What will the coming years bring?
Where do I belong?’ – and found the answers in the literature: ‘The books
showed me that there is more out there. Things that I miss out on when I
just work.’ However, it is doubtful whether the insights gained through
introspection will be sufficient to prevent future collapses in the ‘brutally
tough’ pornography business: ‘We porn stars all suffer from the same
disease, the princess syndrome. We want to be the centre of attention.
We want confirmation. But at some point this confirmation becomes
worthless. Men reduce me to my appearance. They don’t care about my
character. Once you start asking yourself questions like this, it’s time to take
a break.’ It’s hard to imagine a more concise explanation of the concept of a
‘gratification crisis’ that burnout specialists regard as a key to understanding
the syndrome.10
9
Anson Rabinbach, The Human Motor: Energy, Fatigue, and the Origins of Modernity (Berkeley
and Los Angeles: University of California Press, 1990).
10
Johannes Siegrist, ‘Berufliche Gratifikationskrisen und körperliche Erkrankung – Zur
Soziologie menschlicher Emotionalität’, in Macht und Recht: Festschrift für Heinrich Popitz zum
65. Geburtstag, ed. Hans Oswald (Opladen: Westdeutscher Verlag, 1990), pp. 79–94.
The machine metaphor, whether used in a positive or a negative

sense, implies the notion of a subject that splits himself into a technical
apparatus, on the one hand, and an instance that observes this apparatus
and tries to optimise it or begins to dismantle it in order to recover a
sentient being, on the other. People are described in burnout discourse
as empty battery packs and soulless robots, but also as maintenance
engineers of their life motors and experts in restoring their own affective
biotope. Objectification and subjectification, self-discipline and self-
care, mimesis of technology and machine wrecking on behalf of a non-
alienated life run in parallel. Which of the two sides is accorded priority
is open. The decisive point is to be able to play both registers. This leaves
people at the same time with a permanent sense of insufficiency, because
progress in one register must be accompanied by corresponding efforts
in the other. Only those who keep moving find respite. The counterparts
of the fissured images in the flurry of metaphors are the double binds of
therapeutic practice. In the clinic you rush ‘from relaxation to relaxa-
tion’, put yourself under pressure ‘not to put yourself under pressure’,
and in an excess of holism end up not knowing where to begin.
Salmon in the Hamster Wheel

Metaphors condense things – sometimes down to a single word – for which
conceptual language requires whole treatises. Just as the motif of the empty
battery pack summarises an entire anthropology, so too another key
metaphor in burnout discourse contains a whole sociology of the contem-
porary world of work, if not a complete theory of society: ‘There are
hundreds of images that aptly describe modern office life. But scarcely
any of them is such an ideal fit as the hamster wheel: we run and run and
run and, if in doubt, even a little faster, but never really reach a destination.’
The sports equipment of the small rodents does not stand so much for
a fitness cult as for meaningless and unconscious running on the spot
behind bars – a kind of hospitalism syndrome of domesticated long-term
prisoners. Nobody forces the animals to keep the wheel spinning. They
could just as well spend their days in idleness, lazing around in the litter;
however, they cannot leave their prison, at least not on their own.
226 U. Bröckling
Because the cage is locked, the supposedly clever advice to pull the
pinwheel apart and turn it into a ladder to climb up and ‘contemplate
your situation from above’ – constructivist psycho-technicians call this
‘metaphor work’ – leads at best to a second-order fatigue syndrome.
Someone who speaks of hamster wheels should not fail to mention the
internment in the cage. But what is the connection between a hamster
cage – wheel and inmates included – and the modalities of human
socialisation? We do not need to fall back on Michel Foucault’s
(1979) gloomy description of modernity as a ‘prison system’ of general-
ised discipline. We need only open the humorous Invitation to Sociology
by the liberal humanist Peter L. Berger to find the comparison of society
to a prison:
Society . . . surrounds us, encompasses our life on all sides. . . . Society, as

external and objective fact, confronts us especially in the form of coercion.
Its institutions pattern our actions and shape our expectations. They
reward us to the extent that we remain within our assigned performances.
If we step out of these assignments, society has at its disposal an almost
infinite variety of controlling and coercing agencies. The sanctions of
society are able, at each moment of existence, to isolate us among our
fellow men, to subject us to ridicule, to deprive us of our sustenance and
our liberty, and in the last resort to deprive us of life itself. . . . In sum,
society is the walls of our imprisonment in history.11
‘The fact of society is vexatious’, concurs Ralf Dahrendorf, another

liberal sociologist, ‘because we cannot escape it’ – just as little as the
hamster running furiously in her wheel can escape her cage.12
Although the ineluctable heteronomy of the socialised subject lends
any recommendation to finally take your life in your own hands an
illusory ring, it still does not explain the prominence of the hamster
wheel metaphor. The ‘malady of the soul’, if the burnout experts are to
11
Peter L. Berger, Invitation to Sociology: A Humanist Perspective (New York: Anchor Books,
1963).
12
Ralf Dahrendorf, ‘Homo Sociologicus: On the History, Significance, and Limits of the
Category of Social Role’, in Essays in the Theory of Society (Stanford, CA: Stanford University
Press, 1968), pp. 19–87.
be believed, is not so much a result of the monotonous turning in a circle

as of the combination of speed and running on the spot. Accordingly,
the pathogenic aspect is not the tension as such, but the fact that it is
incessant and that there is no goal where one could find rest. Yet, if we
follow recent sociological analyses, this is precisely what sets contempor-
ary unrestricted working conditions apart.13 Their model, the entrepre-
neur of her own labour power, lives in the comparative: Not only must
she be creative, resourceful, willing to take risks, and decisive; she must
be more creative, more resourceful, more willing to take risks, and more
decisive than the competition; and she must not allow herself a moment
of respite in her efforts to increase her creativity, resourcefulness, will-
ingness to take risks, and decisiveness still further. This is an endless
process, because the competition does not sleep either and it also does its
utmost to outdo its competitors. This race is as inescapable as it is
endless. The experience that no ‘enough’ is ever enough generates
permanent pressure for ‘more’. Because the demands know no bounds,
the individual always lags behind them – and nevertheless constantly
rushes ahead. The treadmill becomes a vicious circle.
According to the explanatory model of stress research, this compul-
sion to permanently optimise oneself under the banner of competition
culminates in burnout because there is an absence of fit between human
nature and social reality. We are ultimately victims of our archaic
constitution:
Our biological stress system was designed primarily for situations in which
it is a matter of life and death. It is a legacy of the Stone Age, built to
respond instantaneously to the acute threat of an attack by a sabre-toothed
cat. It is less suited to coping with the challenges of the modern world.
And thus in permanent stress situations in which neither of the two
immediate primal reactions – fight or flight – is possible, the stress system
sooner or later rebels. Increased amounts of stress hormones such as
corticotropin-releasing hormone, cortisol, adrenaline, and noradrenaline
13
See Luc Boltanski and Éve Chiapello, Der neue Geist des Kapitalismus (Konstanz: UVK, 2006);
Hans J. Pongratz and G. Günter Voß, Arbeitskraftunternehmer. Erwerbsorientierungen in entgrenz-
ten Arbeitsformen (Berlin: Edition Sigma, 2003); and Ulrich Bröckling, The Entrepreneurial Self.
Fabricating a New Type of Subject (London, New York: Sage, 2016).
228 U. Bröckling
are released and the production of the sex hormones testosterone

and oestrogen is suppressed. The body is placed on permanent alert. The
continuous alarm leads to insomnia, tension, memory loss, weaker immune
response, and exhaustion.
Whereas stress research points to our problematic evolutionary legacy,

analyses of burnout in neurobiology focus on synapse connection in
early childhood. Here, too, the animal world provides lessons in anthro-
pology, but now salmon take centre stage in place of the hamster.
During the mating season salmon are ‘driven back to the place of their
birth, where it smells of childhood when their neural network was
formed’. After they have fought their way upriver under great strain,
reached their childhood waters and produced offspring, they suffer a
lethal crisis of meaning: ‘After mating they are completely disoriented.
The poor salmon look around them and see what stress had previously
blinded them to: water too shallow, nothing to eat, everywhere other
salmon. No salmon can withstand that’; ‘Three days later they’re dead’.
It is no different with human beings whose neural networks were
programmed already in the womb to the basic need ‘for connectedness
and a life in which one can develop autonomously as a person’. If they
are later ‘constantly threatened with exclusion when they do not measure
up to the performance criteria’, then the brain adapts and dulls the
perception of pain: ‘Sufferers become deadened to the message that the
body is sending them: “Hey, you can’t go on like this, take a break.”’
This is the point ‘where human beings “are running like salmon” –
unrestrained, without a brake, to the point of collapse.’
Regardless of whether our hormonal stress management system ‘is still
attuned to the Stone Age’ or whether our brain unerringly engages in a
lifelong struggle for recognition and autonomy – either way biology is
destiny. And if it so happens that current conditions do not correspond
to our disposition, then nature punishes us with burnout, or worse.
What is in need of explanation in this approach is not why the condition
is so prevalent, but why we have not all burned out long ago. In the light
of this, the reassurances of empowerment, the advice of positive
psychology, and the spiritual exercises of mindfulness sound like the
proverbial whistling in the dark.
Rhetorically speaking, the observation that humanity and modernity

are not a good match and that the burnout epidemic proves this point is
a paradoxical strategy. On one hand, one could hardly paint a more
gloomy picture of the present suffused with cultural pessimism. But, on
the other hand, because this would be hard to endure and lead to
fatalism, when it comes to preventive and therapeutic measures there
is a shift in register to pragmatic activism. This oscillates between
relational and behavioural notions and – to no surprise – ends up by
calling for an integrative approach that is supposed to reduce stress while
increasing resilience and re-establishing an equilibrium between social
requirements and personal resources. If this proves to be unsuccessful,
one can always play the cultural pessimism card. Apocalyptic doomsday
scenarios and everyday bustle stabilise each other not only on the health
and advice market.
Balancing Exercises with Pause Button

Whereas when it comes to therapy the metaphor clusters of fire and
machines place the primary emphasis on individuals, the image of the
hamster wheel is associated more with social constraints. Common to all
of these images is the reference to models of imbalance: Becoming
burned out is a function of the mismatch between energy consumption
and supply, the sports car self drives into the wall because of a discre-
pancy between acceleration and braking force, and the tales of hamsters
and salmon point to the asymmetry between stress and relaxation.
The definition of burnout as an equilibrium problem implies that
prevention and treatment must involve rebalancing. If ‘the scales tilt’
they must be rebalanced. It is not the weights as such that are so
important, but that they should be distributed evenly on the scales:
‘Of course, all human beings have physical limits of endurance. But as
long as they are not injured, they can withstand an amazing amount of
work and deadline pressure unscathed – provided that the right balance
is struck between give and take, between work and recognition.’ The
goal, therefore, is to restore the balance. Whereas with milder forms of
burnout ‘the recommended measures are those designed to change
230 U. Bröckling
habits of life and optimize the “work-life balance”’, severe fatigue syn-
drome calls in addition for ‘psychotherapeutic interventions as well as
antidepressants, ideally in combination with psychotherapy’.
Interrupting the incessant tension is recommendable as a first step
towards achieving a new equilibrium. The inventory of metaphors for
the courage to take a break is derived in turn from the world of
machines: ‘Someone afflicted with burnout must learn to shift down a
gear’ – or to follow the operating instructions of the ‘burnout impact
protection system’: ‘Depress the clutch of the everyday working engine
and treat yourself to a break and distance.’ As an alternative you can
press the ‘pause button’ of life and switch your brain into the ‘default
mode’. ‘Recent findings’ suggests that this condition ‘is very important
for clearing our heads and creating space for new ideas . . . Without an
Internet connection, you can only work with the internal data on the
computer’s hard drive. In the same way, our brain also switches to
internal operation without signals from outside. Then it sifts, sorts,
and deals only with the existing information. New information is
organized, ordered, and integrated meaningfully into the existing net-
work of thoughts’.
Not least, a genuine work-life balance is the key to effective preven-
tion: ‘Someone who derives his self-esteem entirely from his job is
thrown out of balance much more easily by a setback than someone
who is able to withdraw after work into the company of a pleasant
partner, loving children, and good friends.’ Only someone who succeeds
in ‘bringing work, family, love, friends, and hobbies into a healthy
balance’ will be able ‘to feel completely human’. Trying to improve
the balance between ‘work’ and ‘life’ is, of course, an admission that they
are opposites and that life only begins after work. This may be a realistic
assessment, but it will not be of much help when it comes to reigniting
the enthusiasm of burnout victims for their work.
Equilibrium exists when countervailing forces – in this case tension
and relaxation, motivation system and stress system, the demands of
work and resources, performance and appreciation – neutralise each
other. The tightrope walker will avoid falling only if he spreads his
weight evenly at every moment to each side. The metaphors of equili-
brium do not only evoke thoughts of scales and tightrope artists, but
equally the homeostasis of biological systems whose functions are cali-

brated to normal values and which enable the organism to readjust
automatically, provided that the regulatory mechanisms are not over-
strained (vide the Stone Age stress system). After all, the metaphors of
human beings as machines with energy problems rest on the cybernetic
principle of feedback control, which more than the image of scales
assumes a dynamic equilibrium.
Economic thinking is also ultimately founded on models of equili-
brium.14 The term ‘balance sheet’ is not fortuitous. From the perspective
of equilibrium, burnout appears as a mismatch between investment and
return. Accordingly, a healthy person will be someone whose ‘accounts’
show a balanced position. One of the most elaborate theories of burnout
argues along these lines – namely, the analysis developed by Christina
Maslach and others of a sixfold ‘mismatch’ between the person and her
work-related environment, which cites as stress factors disparities regarding
workload, control over the work process, incentives, social embeddedness,
fairness, and shared values.15 The researchers describe burnout, a condition
marked by exhaustion, a negative, cynical attitude towards work, and a
reduced capacity to perform, as the negative pole of a continuum; the
contrasting positive pole is a condition of ‘job engagement’ distinguished
by physical, mental, and emotional energy, involvement, and a sense of
personal effectiveness. The latter condition arises when there is a relation of
fit between requirements and desires – ‘matching’ instead of ‘mismatch’.
If we apply the economic models of equilibrium to the relation between
the individual and his environment, then he appears as a human capitalist
operating in his own interest who makes rationally calculated investments
in his life and corrects his decisions when they do not (or no longer)
correspond to his preferences. If one can believe the research, it is precisely
this sober rationality of Homo economicus that the often over-motivated
and over-identifying burnout candidates lack. The source of their suffering
14
Cf. Georg Vobruba, Kein Gleichgewicht: Die Ökonomie in der Krise (Weinheim and Basel:
Juventa, 2012).
15
Christina Maslach, Wilmar B. Schaufeli, and Michael P. Leiter, ‘Job Burnout’, Annual Reviews
of Psychology 52 (2001), 397–422; on this, see also the contribution of Elin Thunman in this
volume.
232 U. Bröckling
is not so much the economic rationalisation of the world of work as their

own irrationality; they squander their loyalty on the company that employs
them instead of imagining themselves as companies. As a result, the ‘six
commandments’ that are supposed to protect employees against internal
resignation and burnout also sound as if they came from a construction
manual for ‘Me-Corporations’:
1. Employees must identify with their performance, not with the com-
pany. 2. They must keep an eye out for new opportunities and monitor,
and if possible increase, their market value. 3. They must build up reserves
that make them more independent and if necessary forgo a home of their
own if that makes them dependent. 4. They must prepare for crises and
develop the attitude that every crisis is an opportunity for reorientation.
5. They must have an eye on the future, formulate goals, desires, and visions
for themselves, develop personal initiatives, and cultivate their creativity.
6. They must always remain the ones who act and must never allow
themselves to become the ones acted upon.
The consistent economisation of one’s relationship to self, no less, is

supposed to provide the antidote to the excessive demands of radically
marketised work relations. Or, to use a metaphor of our own: The spear
that caused (and continues to lacerate) the wound is also supposed to
heal it. In the end, it is not clear what is worse – the trendsetting illness
or the recommended cure.
Translated by Ciaran Cronin
References
Harro Albrecht and Ulrich Schnabel, ‘Extrem viel Adrenalin’, Die Zeit, 1
December 2011.
Anonymous, ‘Zwölf Stufen zum Burnout’, Stern Gesund leben 4 (2009).
———, ‘Porno-Burnout mit Anfang 20: Wieso Lara Love trotzdem wieder
Sex-Filme dreht’, Bild Online, 14 August 2012. Online at: http://www.bild.
de/unterhaltung/erotik/lara-love/porno-burnout-mit-anfang-20-25534480.
bild.html (accessed November 2015).
Gaston Bachelard, The Psychoanalysis of Fire, trans. Alan C. M. Ross (Boston:

Beacon Press, 1964 [1938]).
Peter L. Berger, Invitation to Sociology: A Humanist Perspective (New York:
Anchor Books, 1963).
Luc Boltanski and Éve Chiapello, Der neue Geist des Kapitalismus (Konstanz:
UVK, 2006).
Ulrich Bröckling, Das unternehmerische Selbst. Soziologie einer Subjektivierungsform
(Frankfurt am Main: Suhrkamp, 2007).
Eva Buchhorn, Michael O. R. Kröher, and Klaus Werle, ‘Stilles Drama’,
Manager Magazin 6 (2012).
Eva Buchhorn and Klaus Werle, ‘Feuerwehr mit Verspätung’, Spiegel Online,
14 June 2012. Online at: http://www.spiegel.de/karriere/berufsleben/burnout-
was-dax-unternehmen-dagegen-tun-a-838241.html (accessed November 2015).
Ralf Dahrendorf, ‘Homo Sociologicus: On the History, Significance, and
Limits of the Category of Social Role’, in Essays in the Theory of Society
(Stanford, CA: Stanford University Press, 1968), pp. 19–87.
Markus Dettmer, Samiha Shafy, and Janko Tietz, ‘Volk der Erschöpften’, Der
Spiegel 4 (2011).
Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde
(DGPPN), Positionspapier zum Thema Burnout, 2012. Online at: http://
www.dgppn.de/fileadmin/user_upload/_medien/download/pdf/stellungnah
men/2012/stn-2012-03-07-burnout.pdf (accessed November 2015).
Electronic Arts, ‘Burnout Paradise’, 2013. Online at: http://www.ea.com/uk/
burnout-paradise (accessed November 2015).
Focus, ‘Generation Burnout’, 37 (2011a).
——— ‘Was ist Burnout? Was sind Depressionen?’, 48 (2011b).
Michel Foucault, Discipline and Punish: The Birth of the Prison, trans. Alan
Sheridan (New York: Vintage, 1979).
Herbert J. Freudenberger, ‘Staff Burn-out’, Journal of Social Issues 30: 1 (1974),
159–65.
———, ‘The Staff Burn-out Syndrome in Alternative Institutions’,
Psychotherapy: Theory, Research and Practice 12: 1 (1975), 73–82.
Carina Frey, ‘Was den Menschen ins Hamsterrad treibt’, Spiegel Online,
24 September 2012. Online at: http://www.spiegel.de/gesundheit/psychologie/
burnout-was-den-menschen-ins-hamsterrad-treibt-a-857540.html (accessed
November 2015).
Steffen Fründt, ‘Arbeiten, bis der Arzt kommt: Wenn Menschen ans Ende ihrer
Kräfte gehen’, Welt am Sonntag, 2 September 2007.
234 U. Bröckling
Joachim Galuska, Thomas Loew, and Johannes Vogeler, ‘Burn-Out-Alarm’,

Focus 43 (2010).
Frank Gerbert, ‘Verniedlichende Pseudo-diagnose’, Focus 43 (2006).
———, ‘Wenn Arbeit krank macht’, Focus 43 (2010).
Thorsten Giersch, ‘So entkommen Sie dem Hamsterrad’, Handelsblatt, 14
February 2012.
Edda Gottschaldt, ‘Ausgebrannt und leer gelaufen: Das Burn-out-Syndrom:
Über Ursachen, Symptome und Behandlungsmöglichkeiten. [Interview mit
Guido Deußing]’, Süddeutsche Zeitung, 9 June 2004.
Erich Hotter and Andreas Schnider von Leykam, Sieben Schritte gegen Burnout:
Positive Strategien gegen die persönliche Energiekrise (Graz: Leykam, 2010).
Roland Von Känel, ‘Das Burnout-Syndrom: Eine medizinische Perspektive’,
Praxis 97 (2008), 477–87.
Wolfgang P. Kaschka, Dieter Korczak, and Karl Broich, ‘Modediagnose Burn-
out’, Deutsches Ärzteblatt 108: 46 (2011), 781–7.
Hilmar Klute, Wir Ausgebrannten (Munich: Diederichs, 2012).
Dialika Krahe, ‘Das Leben danach’, Der Spiegel Special 1 (2009).
Julien O. De La Mettrie, Machine Man and Other Writings, trans. and ed. A.
Thompson (Cambridge: Cambridge University Press, 1996 [1747]).
Christina Maslach, Wilmar B. Schaufeli, and Michael P. Leiter, ‘Job Burnout’,
Annual Reviews of Psychology 52 (2001), 397–422.
Hans J. Pongratz and G. Günter Voß, Arbeitskraftunternehmer.
Erwerbsorientierungen in entgrenzten Arbeitsformen (Berlin: Edition Sigma,
2003).
Anson Rabinbach, The Human Motor: Energy, Fatigue, and the Origins of
Modernity (Berkeley and Los Angeles: University of California Press, 1990).
Julitta Rössler, Raus aus Hamsterrad und Tretmühle (Freiburg: Kreuz Verlag,
2012).
Arnfrid Schenk, ‘Nichts geht mehr’, Die Zeit, 26 April 2001.
Corinna Schöps, ‘Der Erschöpfung auf der Spur’, Stern Gesund leben 3 (2011).
Jörg-Peter Schröder, Wege aus dem Burnout: Möglichkeiten der nachhaltigen
Veränderung (Mannheim: Brockhaus, 2011).
Johannes Siegrist, ‘Berufliche Gratifikationskrisen und körperliche Erkrankung –
Zur Soziologie menschlicher Emotionalität’, in Macht und Recht: Festschrift
für Heinrich Popitz zum 65. Geburtstag, ed. Hans Oswald (Opladen:
Westdeutscher Verlag, 1990), pp. 79–94.
Der Spiegel, ‘Ausgebrannt. Das überforderte Ich’, 4 (2011a).
———, ‘Neustart. Wege aus der Burnout-Falle’, 30 (2011b).
Stern, ‘Total erschöpft’, 20 (2011).

Stern Gesund leben, ‘Sehnsucht nach Ruhe: Was gegen Stress und Erschöpfung
wirklich hilft’, 3 (2011).
Georg Vobruba, Kein Gleichgewicht: Die Ökonomie in der Krise (Weinheim and
Basel: Juventa, 2012).
Verena Wolff, ‘Wege aus der Krise’, Süddeutsche Zeitung, 11 June 2012.
Die Zeit, ‘Noch jemand ohne Burn-Out?’, 31 March 2011.
Walter Zimmermann, Raus aus dem Hamsterrad. Mehr Zeit – Mehr Erfolg – No
Burnout (Kaltental i. Allg: Zimmermann, 2011).
Ulrich Bröckling is Professor of Cultural Sociology at the Albert-Ludwigs

University Freiburg. His principal research interests include studies of govern-
mentality, political sociology, sociology of social technologies and technologies
of the self, contemporary social theory, and critical management studies. His
publications include The Entrepreneurial Self (Sage, 2016) and Governmentality:
Current Issues and Future Challenges, edited with Susanne Krasmann and
Thomas Lemke (Routledge 2011).
11
Literary Exhaustion
Michael Greaney
What can literature tell us about exhaustion? Why listen to novelists and
poets on this matter when we could consult scientists or health profes-
sionals? Why concern ourselves with the energy levels of people who do
not exist when we could learn from inhabitants of the real world about
how they cope with the ordeals of tiredness, fatigue, and burnout? In the
light of these possible objections, perhaps it would be worth spelling out
what literature cannot offer debates about the nature of exhaustion.
Novels, poems, and plays cannot provide anything that would count
as hard information or clinical evidence on the subject of exhaustion;
they cannot be read as part of the factual record of levels or kinds of
exhaustion that have been experienced through history, still less as
guides on how best to manage or treat the condition. Works of fiction
have no concrete data for epidemiologists of exhaustion to go to work
on. This is not the same as saying that epidemiologists – or other
M. Greaney (*)
University of Lancaster, Lancashire, UK
e-mail: m.greaney@lancaster.ac.uk

DOI 10.1007/978-3-319-52887-8_11
238 M. Greaney
students of exhaustion – should ignore literary representations of

this condition. What such representations can do is provide us with
vicarious access to the first-person experience of what it feels like to be
exhausted, an experience that cannot be measured or quantified, but that
can be conjured up in words and transmitted and shared in literary
texts. Moreover, attention to literary images of exhaustion can enable
us to shift our focus from exhaustion as an impersonal object of scientific
scrutiny to exhaustion as a subjective experience, the affective content
of which has an internal history that is inaccessible to blood tests and
brain scans.
Literature may contain no ‘data’ about exhaustion, then, but it is a
rich archive of the ways in which states of extreme tiredness and
fatigue have been perceived, imagined, and interpreted over time.
Not only can literary history serve as an imaginative record of the
fears, desires, and fantasies that have attached themselves to the pro-
spect of exhaustion, but it can also pose questions about the signifi-
cance of exhaustion that are beyond the scope of medical science.
What is at stake – socially, culturally, politically – when exhaustion
is given artistic representation? What, if anything, does exhaustion
mean? Might there be – counter-intuitive as it may seem – something
of value in this state? This contribution, which focuses on just one
chapter in the rich literary history of exhaustion, shows how the work
of a generation of modernist writers obsessed with tiredness can help
us explore these questions.
Modernist Exhaustion
For the purposes of this chapter, my focus is on the question of exhaus-
tion as it is raised by the literature of the late nineteenth and early
twentieth centuries, a period of intellectual history that we may plausibly
characterise as a golden age of exhaustion. There was a busy swirl of
medical speculation at this time around the origins of physical and
psychological exhaustion, notable contributions to which came from
American physicians such as George M. Beard (1839–1883) and Silas
Weir Mitchell (1829–1914), who diagnosed nervous exhaustion or
neurasthenia as a characteristic malaise of industrial modernity.1 The

Italian physiologist Angelo Mosso (1846–1910), who developed meth-
ods for measuring and minimising muscular tiredness, published his
groundbreaking work Fatigue in 1891. In the following year, the
Austrian physician and social critic Max Nordau (1849–1923) published
his magnum opus entitled Degeneration, a sweeping denunciation of the
moral health of late nineteenth-century Europe in which Nordau iden-
tifies exhaustion as a root cause of everything bad in the modern world,
from erotomania and alcoholism to Impressionist art and premature
ageing.2 A cosmological backdrop to the medical and sociological diag-
noses of Beard, Weir Mitchell, and Nordau is provided by the formula-
tion in the mid-nineteenth-century, by Rudolf Clausius (1822–1888)
and Lord Kelvin (1824–1907), of the second law of thermodynamics,
according to which even the universe itself is on a one-way journey
towards absolute exhaustion.
While scientists and sociologists wrestled earnestly with the problem
of exhaustion, the imaginative literature of this period was, by contrast,
on the cusp of an extraordinarily vibrant phase of inventiveness and
aesthetic renewal. This was an era of breath-taking innovation that
witnessed the publication of pioneering experimental works in fiction
and poetry by James Joyce, Virginia Woolf, Franz Kafka, T.S. Eliot,
Marcel Proust, and many others. The era of modernism, as it is now
known, is frequently imagined as an interlude of ferociously energetic
literary creativity, in which a generation of writers created work that
more than lived up to Ezra Pound’s famous imperative Make It New.3
1
See George M. Beard, A Practical Treatise on Nervous Exhaustion (Neurasthenia): Its Symptoms,
Nature, Sequences, Treatment (New York: W. Wood, 1880); Silas Weir Mitchell, Rest in the
Treatment of Nervous Disease (New York: G.P. Putnam’s Sons, 1875).
2
Max Nordau, Degeneration (Lincoln: University of Nebraska Press, 1968). Anson Rabinbach, in
The Human Motor: Energy, Fatigue and the Origins of Modernity (Berkeley and Los Angeles:
University of California Press, 1992), provides a thoroughgoing examination of tensions between
the ‘powerful and protean world of work, production, and performance’ and the ‘decrescent order
of fatigue, exhaustion, and decline’ (p. 63) in the age of industrial modernity. See also Lee Scrivner
on the ‘physiologies of exhaustion’ in the same period in Becoming Insomniac: How Sleeplessness
Alarmed Modernity (London: Palgrave, 2014), pp. 81–98.
3
See Pound’s essay collection Make It New (London: Faber and Faber, 1934).
240 M. Greaney
Nowhere is this fetishisation of novelty articulated with more aggressive

flamboyance than in the work of F.T. Marinetti, the Italian poet, nove-
list, provocateur, and author of the Futurist Manifesto of February 1909,
a contemptuous repudiation of the retrograde nostalgia of a modern
world whose reverential fascination with the past has left it ‘fatally
exhausted, shrunken, beaten down’.4 For Marinetti, the antidote to
this epidemic of cultural exhaustion lies in the hands of a new generation
of proudly and confrontationally indefatigable artists: ‘We are still
untired!’ he boasts, ‘Our hearts know no weariness because they are
fed with fire, hatred, and speed!’5 What our exhausted and shrunken
culture needs, according to Marinetti, is a joyous celebration of the
headlong dynamism of modern technological innovation, and an ico-
noclastic rejection of the relics venerated in museums, galleries, and
other graveyards of traditional culture.
The Futurist Manifesto, with its gleefully aggressive challenge from
untired youth to exhausted cultural senescence, is the most scintillating
of a constellation of literary works of this period in which Western
civilisation is perceived as emptied, desiccated, superannuated, and
definitively past its best. However, whilst Marinetti was by no means
alone in his impression that the modern world is characterised by a
catastrophically widespread loss of vigour and vitality, remarkably few of
his literary contemporaries were inclined to adopt Futurist shock tactics
as a cure for cultural exhaustion. Indeed, there is an important vein of
modernist writing that languorously immerses itself in the very tiredness
that Marinetti so bracingly denounces. In the 1890s, a generation of
jaded aesthetes succumbed to what Arthur Symons famously calls the
‘new and beautiful and interesting disease’ of fin de siècle decadence.6
The early poetry of T.S. Eliot, from ‘The Love Song of J. Alfred
Prufrock’ (1915) to ‘The Waste Land’ (1922), dwells fretfully on the
4
F. T. Marinetti, ‘The Founding and Manifesto of Futurism’, in Marinetti: Selected Writings, ed.
R. W. Flint, trans. R. W. Flint and Arthur A. Coppotelli (London: Secker & Warburg, 1972),
pp. 39–44 (p. 43).
5
Ibid., p. 44.
6
Arthur Symons, ‘The Decadent Movement in Literature’, Harper’s New Monthly Magazine 20
(1893), 858–68 (859).
half-lived lives of spiritless flâneurs and zombie-like commuters. The

fiction of Samuel Beckett, with its variously immobilised and bedridden
anti-heroes, showcases some of the most conspicuously unenergetic
people in literary history.7
Beckett’s anti-heroes are not the only modernist protagonists
to have terrible trouble getting out of bed; indeed, the four walls of
the bedroom represent the cramped horizons of some of the most
celebrated literary narratives of this period. Gregor Samsa, in Kakfa’s
surreal short story ‘The Metamorphosis’ (1915), experiences a night-
marishly inexplicable human-to-insect transmogrification that has
generated all sorts of symbolic or allegorical readings, but at one level
his story is a painfully simple account of not being able to summon
up the wherewithal to get out of bed and go to work in the morning.
The predicament of Kafka’s hero is both horrendously unique and
oddly typical, resonating as it does with a cluster of modernist texts
in which the bedroom becomes the existential headquarters of the
twentieth-century self. Notable contributions to what I have elsewhere
called the ‘world from a bed genre’ include Charlotte Perkins Gilman’s
classic feminist short story ‘The Yellow Wallpaper’ (1892), whose
anonymous heroine seemingly loses her grip on sanity as she undergoes
a disastrously unsuccessful ‘rest cure’ prescribed for an unspecified
malaise, and Marcel Proust’s multi-volume epic In Search of Lost
Time (1913–1927), in which the protagonist, luxuriating for extended
periods somewhere between sleep and wakefulness, seems to turn the
rest cure into a way of life.8
If the ‘world from a bed’ school of literature has a manifesto, it would
be Virginia Woolf’s celebrated essay ‘On Being Ill’ (1923), which divides
the human race into the ‘army of the upright’ – healthy, vigorous people
who engage briskly with the business of everyday life – and the ‘recum-
bent’, those who are confined to their sickbeds and alienated from daily
routine – but who, for that very reason, obtain a vantage point on
7
See Gilles Deleuze, ‘The Exhausted’, SubStance 24:3 (1995), 3–28, for a detailed consideration
of the permutations of psychological and logical exhaustion in Beckett.
8
Michael Greaney, ‘Sleep in Modern Fiction’, Literature Compass 7:6 (2010), 467–76 (470).
242 M. Greaney
human experience that would not otherwise be available.9 ‘It is only the
recumbent’, says Woolf, ‘who know what, after all, nature is at no pains
to conceal – that she in the end will conquer; the heat will leave the
world [ . . . ] the sun will go out’.10 In the light of Woolf’s essay, it would
be possible to read modernist literature, from the languorous aesthetes of
Wilde to the horizontal selves of Proust and Beckett, as constituting a
mass desertion from the ranks of the ‘army of the upright’. What is
more, Woolf finds an intellectual rationale for this pose of exhausted
recumbency in the language of thermodynamics: The recumbent are
thus imagined by Woolf as modernity’s bedridden cognoscenti, painfully
conscious of everything that their busybody counterparts would prefer
not to think about, and supremely well versed in the theory and practice
of entropy.
Exhaustion, in the early twentieth century, thus seems to be a
literary worldview with physics on its side. We should, however, be
wary of assuming that there was a straightforward meeting of minds
between, on the one hand, scientists pondering the effects of entropy
and the heat death of the universe and, on the other, literary artists
pondering the endemic tiredness of modern life. Exhaustion, especially
once it begins to migrate across disciplinary and intellectual bound-
aries, is more slippery and protean than that. It is, as we are already
beginning to discover, a busy, resourceful, complex, multi-tasking
concept; paradoxically, even as it signifies debilitating fatigue, it per-
forms a considerable amount of cultural work for Woolf and her fellow
modernists, as a new model of being in the world. This strange
performative contradiction – the notion that exhaustion was, in the
hands of writers, an active and productive intellectual category – forms
the basis of my next section.
9
Virginia Woolf, ‘On Being Ill’, in Selected Essays, ed. David Bradshaw (Oxford: Oxford
University Press, 2009), pp. 101–10 (p. 102). Woolf’s championing of recumbent disengagement
from the trivia of everyday life is curiously prophetic of Emmanuel Levinas’ thoughts on the value
of fatigue as a state of ontological hesitation that opens up a gap between individual subjectivity
and impersonal Being. See Existence and Existents, trans. Alphonso Lingis (Pittsburgh, PA:
Duquesne University Press, 2001), pp. 11–25.
10
Woolf, ‘On Being Ill’, p. 104.
The Language of Tiredness

This discussion has, so far, focused on tired men and women in the
literature of the modernist period, but we can also argue that there is an
important sense in which literature itself became ‘tired’ in this period,
displaying all the symptoms of fatigue and enervation that afflicted its
heroes, as though language itself was being drained of energy by the
modern world. To put it another way, I will suggest that we can think of
certain modernist texts as not only written about exhaustion but also
performatively enacting exhaustion at the level of style and language. In
the formal strategies of many modernist texts, we can observe an
ambivalent sense of exhaustion as both a physical ordeal and an aesthetic
opportunity for the writer.
I want to explore this new aesthetic of exhaustion with reference to
two landmark texts of the period: T.S. Eliot’s cryptic classic of cultural
pessimism, The Waste Land (1922), and James Joyce’s monumental experi-
mental novel, Ulysses (1922). Eliot’s poem, in which vacant minds confront
one another in desolate and desiccated landscapes, is haunted by nothing-
ness. ‘I can connect |Nothing with nothing’ (ll. 301–2), says one character-
istically baffled and doleful speaker, just another nameless member of the
ragged chorus of voices by which The Waste Land talks to itself, mumbling
semi-coherently through half-remembered snatches of plays, songs, poetry,
philosophy – the fragmentary souvenirs of a disintegrating culture. Written
in a language of worn-outness and used-upness, the poem is patched
together from fragments of other texts, inter-cutting imagery of cultural
fatigue and desolation with fragmentary dialogues between anonymous
neurasthenics.
Behind the poem is the story of Eliot’s own exhaustion: The Waste
Land is, in part, a veiled autobiography, a coded meditation on his
nervous breakdown of 1921. However, it is also the story of cultural
exhaustion on a European scale, its broader origins lying in a set of
interlinked historical traumas: the shattering impact of the Great War on
modern Europe; the decline of the European aristocracy; the rise of mass
culture, from cinema and radio to mass circulation newspapers and
affordable paperbacks, and its eclipse of high culture; and the second
244 M. Greaney
industrial revolution with its array of new technologies – cars, busses,

cinema, radio, telephones, gramophones – that were reshaping the fabric
of human experience. When Eliot’s poem looks at the impact of these
convulsive historical changes on early twentieth-century Europe what it
sees is a topography of exhaustion, a wilderness of ‘stony rubbish’ (l. 20)
littered with dry bones, broken images, handfuls of dust, tumbled
graves, shattered fragments, ruined cityscapes, empty chapels. The ‘with-
ered stumps of time’ (l. 104) over which Eliot’s poem broods are the
relics of a once-flourishing culture where the monuments of civilisation
have been reduced to ‘empty cisterns and exhausted wells’ (l. 384). Yet
the cisterns and wells are not, of course, completely empty – they
contain voices, voices that are heard ‘singing’ (l. 384). A natural
resource, water, has dried up, but its absence opens a space for a cultural
resource, the language of poetry and song. When Eliot’s poem hears
voices in exhausted wells it thus seems to be obliquely reflecting on its
own conditions of possibility as a text that is articulated in the gaps,
absences, and silences left by the exhaustion of the old resources of high
culture; in this sense, exhaustion, The Waste Land’s official enemy, is also
its secret accomplice.
This recuperation of exhaustion as an aesthetic resource is evident also
in one of the great novels of the period, Joyce’s Ulysses, a text that
occupies roughly the same eminence in the canon of modernist fiction
that The Waste Land occupies in modernist verse. Re-imagining as it
does a day in the life of an unremarkable Dublin advertising canvasser in
neo-Homeric terms as a latter-day Odyssey, Joyce’s novel is tirelessly
experimental, reinventing its own style in every chapter in an extraor-
dinary display of seemingly irrepressible linguistic virtuosity. Yet in
Chapter 16, the ‘Eumaeus’ episode, Joyce’s inventiveness seems to
have deserted him. The entire chapter, in which Leopold Bloom and
Stephen Dedalus stumble home via a cabmen’s shelter in the early hours
of the morning, is written in wall-to-wall clichés. Long-winded, slightly
pompous, and padded with redundant verbiage, the chapter slumps
from the high standards the novel has set itself: ‘Not to put too fine a
point on it’; ‘when all was said and done’; ‘to all intents and purposes’;
‘in any shape or form’; ‘needless to say’; ‘let bygones be bygones’; ‘it goes
without saying’; ‘To cut a long story short’; ‘the coast was clear’ – these
are not the sort of locutions that you would expect to find a place in any
self-respecting piece of literary fiction, let alone in the work of a writer as
stylistically fastidious as Joyce.11 How can a text that, in the words of
Martin Amis, wages nothing less than a ‘war against cliché’ allow itself to
speak the language of the enemy quite so enthusiastically?12
Of course, none of this counts against Joyce’s novel because the
clichés, tired as they are, have a job to do. ‘Eumaeus’ is a brilliant
exercise in imitative form; the tiredness of its writing imitates the
flagging energies of Joyce’s two heroes as they enter the final leg of
their 24-hour odyssey; Stephen is ‘fagged out’, and the prose as if it were
in sympathy finds its own energies at a low ebb.13 As Beckett puts it,
praising Joyce’s genius for linguistic mimicry: ‘when the sense is sleep,
the words go to sleep’.14 Indeed, the chapter contains numerous choice
examples of linguistic sleepwalking. For example, when Bloom reflects
that ‘Intellectual stimulation as such was, he felt, from time to time a
firstrate tonic for the mind’, we are invited to chuckle at his lifelessly trite
homily on self-improvement; there is precious little ‘intellectual stimula-
tion’ in these words.15 We might even be moved to speculate that
‘Eumaeus’ is what Ulysses would read like if it had been written by
Bloom. Yet if we accept these invitations too readily then we are liable
to view Bloom with a snobbery that the novel is careful to undermine.
To be sure, Bloom’s musings all too often feel like an autodidact’s
clumsily executed idea of fine writing, but there is a curious linguistic
energy in the tiredness of ‘Eumaeus’. Consider, for example, the
moment when Bloom takes the initiative in guiding Stephen out of
the real and imagined dangers of nocturnal Dublin: ‘Accordingly he
11
James Joyce, Ulysses, ed. Jeri Johnson (Oxford University Press, 1993), pp. 571, 591, 593, 596,
602, 609, 610, 613, 613.
12
See ‘The War Against Cliché: Ulysses by James Joyce’, in Martin Amis, The War Against Cliché:
Essays and Reviews 1970–2000 (London: Vintage, 2002), pp. 441–6. See also Joe Sutcliffe, ‘James
Joyce: Not Making It New’, Cambridge Quarterly 27:1 (1998), for extended discussion of the
centrality of cliché to Joyce’s art.
13
Joyce, Ulysses, p. 613.
14
Samuel Beckett, ‘Dante . . . Bruno. Vico . . . Joyce’ (1929), in Modernism: An Anthology, ed.
Lawrence Rainey (Oxford: Blackwell, 2005), pp. 1061–71 (p. 1069).
15
Joyce, Ulysses, p. 601.
246 M. Greaney
passed his left arm in Stephen’s right and led him on accordingly.’16
This is a moment of symbolic and narrative climax (Joyce’s two very
different heroes are finally arm-in-arm) delivered in the form of a
linguistic anti-climax (the sentence totters around itself, and goes
nowhere). Like a drunk repeating himself as he tries not to slur his
words, the writing in ‘Eumaeus’ over-compensates for its own limita-
tions. Yet the repetition of ‘accordingly’ is not sheer redundancy; it at
least gives us a second chance to notice that the notion of an accord
between the advertising man and the poet, middlebrow and mandarin,
exhaustion and innovation, is one of the animating dreams of Ulysses. In
the conjunction of two kinds of exhaustion – Stephen’s physical torpor
and Bloom’s verbal fatigue – Joyce’s novel thus discovers a powerful
source of renewable linguistic energy.
Whose Exhaustion?
Exhaustion seems to be no match for the inventive energies of Eliot and
Joyce. Not only does their art renew itself in spite of the fact that
everything else fades but it also makes entropy the principle of its
counter-entropic aesthetic. It may therefore seem appropriate to greet
their literary achievements as a triumph of the inexhaustibility of art over
various manifestations of cultural and physical exhaustion. Indeed, who
wouldn’t want to escape exhaustion or attain inexhaustibility? However,
tempting though it might be to say that modernist writers specialised in
the aesthetic recuperation of physical and psychological exhaustion, one
of the interesting perceptions in the literature of this period is that whilst
there is something punishing about exhaustion there is something ever
so slightly inhuman about inexhaustibility. If we call to mind some of
the monstrous creatures of the literature of the 1890s, one eerie quality
they have in common is a certain relentlessness or unstoppability. The
vampiric count in Bram Stoker’s Dracula (1897) has been preying on his
victims from his Transylvanian stronghold for something in the region
16
Ibid., p. 614.
of five centuries. The Martian invaders in H.G. Wells’ The War of the
Worlds (1897) are physiologically incapable of sleep. The beautifully
corrupt hero of Oscar Wilde’s The Picture of Dorian Gray (1891) attains
eternal youth by becoming a living work of art, granting his own body
immunity from exhaustion. Monstrosity in these fin de siècle texts is
associated with absolute tirelessness; the monstrous is that which is
simply invulnerable to everything that exhausts and erodes ordinary
mortals. All of which is to say that one of the cultural functions of the
fin de siècle monster is to remind us that human beings are, definitively
and inescapably, exhaustible creatures. The relentless monster may loom
in the imagination as a source of horrific danger, but at the same time its
absolute otherness offers the human race proof of its own humanity in
the fact of its exhaustibility. Exhaustion returns us to our bodies, in all
their frail finitude; and these creaturely limits, however, much we might
chafe against them, are what differentiate the human from its others.
Have we brought ourselves to the brink of saying that the moral of
modernist literature is that exhaustion is in some sense good for you? If
exhaustion makes us human then maybe we should have more of it? This
would be a dubious line of argument. It would be like taking the conceit
of Woolf’s ‘On Being Ill’ absolutely literally and deciding to champion
illness on the assumption that what is medically or physiologically bad
for you must always be culturally good for you. There is an obvious
danger in assuming that if something is physically debilitating it must
therefore be culturally enriching. This is a masochistic logic if applied to
oneself, and a sadistic logic if applied to other people. Before we embrace
exhaustion as proof of our humanity, then, we first need to pose an
important supplementary question: whose exhaustion, exactly, are we
talking about?
A closer look at The Picture of Dorian Gray might help us unfold this
question.17 Wilde’s novel often seems to imagine meaningful weariness
as a curious privilege of the idle rich; an arch language of upmarket
tiredness pervades the text like a prolonged theatrical yawn. Dorian Gray
is both ‘tired of sitting’ and ‘tired of standing’; he is also ‘too tired to eat’
17
Oscar Wilde, The Picture of Dorian Gray (Harmondsworth: Penguin, 2000).
248 M. Greaney
and ‘tired of myself’.18 None of this should surprise us, given that he has
been schooled in ennui by Lord Henry Wotton, a charming but amoral
aesthete with a ‘tired look in his eyes’.19 Lord Henry’s tired eyes are
worth noticing because this is a novel about tiredness not only as a way
of life but also a way of looking. Wilde’s heroes greet life with a kind of
well-heeled Weltschmerz; for them it is like a slightly dull work of art, a
book not worth reading or a painting that does not really catch the eye;
permanently and studiedly underwhelmed by human experience, they
find some ironic enjoyment in stylizing the exhaustion of their appetite
for enjoyment. Exhaustion, in their hands, is not simply a resource but a
luxury good.
There is even a sort of unofficial competition among Wilde’s heroes to
see who can strike the most immaculately world-weary pose. Consider,
for example, the following exchange at a soirée hosted by the worldly
and pleasure-seeking widow Lady Narborough:
‘Fin de siècle,’ murmured Lord Henry.

‘Fin du globe,’ answered his hostess.
‘I wish it were fin du globe,’ said Dorian, with a sigh. ‘Life is a great
disappointment.’
‘Ah, my dear,’ cried Lady Narborough, putting on her gloves, ‘don’t tell
me that you have exhausted Life. When a man says that one knows that
Life has exhausted him’.20
A kind of stylized or even pampered exhaustion seems to envelop Lady

Narborough and her guests, insulating them even from rumours of the
apocalypse. The world ends, for these gilded aesthetes, not with a bang
or a whimper but with a raised eyebrow and a polished witticism as they
compete to see who can be the most exquisitely disenchanted with life.
In this way, Wilde’s novel dramatises and explores what we can call a
modernist aesthetic of pre-emptive exhaustion whereby the subject finds
18
Ibid., pp. 18, 22, 101, 143.
19
Ibid., p. 77.
20
Ibid., p. 171.
a certain refined pleasure in the performance of tiredness, fatigue, and

ennui as strategies of being in the world.
Beyond Tired
It is impossible to think about exhaustion in Wilde’s novel without
considering the conditions of extraordinary social privilege that would
need to be in place for the prospect of the end of the world being the
subject of elegant drawing-room repartee rather than generating existential
dread. It could perhaps be argued that Wilde’s bored aristocrats, idly
trading bons mots in the shadow of the apocalypse, are doing nothing
more than exercising their ‘right to be lazy’– a right that would, in a fairer
world, be one that we could all enjoy.21 Yet for now exhaustion – or the
pose of exhaustion – seems to be the preserve of a well-to-do minority.
Not everyone in modernist literature gets to be exhausted in such an
exquisitely stylized manner as Wilde’s heroes. Let us consider, in this
regard, a pair of short stories that provide a servant’s-eye view of the
phenomenology of exhaustion. The first is Anton Chekhov’s ‘Spat hochet-
sya’ (1888) or ‘Let Me Sleep’ (sometimes also translated as ‘Sleepy’); the
second is Katherine Mansfield’s ‘The Child-Who-Was-Tired’ (1910).
Both these texts tell the story of a day in the life of a cruelly overworked
young female servant who is battling through an ordeal of unbearable
tiredness as she tends to a crying baby. Both stories revolve around a
contrast between a baby that is being gently coaxed towards sleep and a
desperately tired girl who is obliged, through cruelly insistent demands on
the part of her employers, to stay awake for extended periods. Both end
with the morally and cognitively befuddled girl taking the baby’s life so
that she can finally lie down and get some sleep.
The heroine of ‘Let Me Sleep’, Varka, a 13-year-old servant girl in the
home of a Russian shoemaker, keeps nocturnal vigil at the cradle-side of
21
Paul Lafargue (1842–1911), Karl Marx’s son-in-law, published an essay of this name in 1883,
arguing that the ‘love of work’ has ‘pushed even to exhaustion the vital force of the individual’.
The Right to Be Lazy, trans. Charles H. Kerr (Chicago: Charles H. Kerr, 1989), p. 21.
250 M. Greaney
her master’s relentlessly crying baby, humming ineffectual lullabies as

she struggles to stay awake.22 In its prolonged and unalleviated distress,
the shoemaker’s baby is a counterpart or miniature doppelganger for
Varka. However, in its relentless demands on her, and in its denial of her
access to sleep, it also represents her heartlessly exploitative master and
indeed seems to conspire with him to deprive Varka of rest. In its
obstinate and inexplicable refusal to indulge in the sleep for which
Varka is so desperate, the baby ultimately becomes the tragic scapegoat
of all her resentment.
Exhaustion, in ‘Let Me Sleep’, is an inevitable consequence of being
permanently ‘on call’ – subject to an impatient and endless litany of
commands: ‘Varka, make up the stove!’; ‘Varka, put on the samovar!’;
‘Varka, clean the master’s galoshes!’; ‘Varka, wash down the outside steps’;
‘Varka, run and buy three bottles of beer!’; ‘Varka, run and fetch some
vodka!’; ‘Varka, clean some herrings!’; ‘Varka, rock the baby!’.23 This
barrage of commands, the antithesis of the soft words with which Varka
tries to lull the baby to sleep, comprises a staccato anti-lullaby for
Chekhov’s heroine, who is cruelly subjected to a relentlessly iterated
demand that she be present, continuously and indefinitely; one of the
punishing ironies of the tale is that her work gives her employers breathing
space to berate her for not working even harder. Through the night, the
voices of her employers are replaced by the voice of the baby, and all those
daytime requests crystallise horribly into one request, one unignorable
demand, which is simply for absolute attention.
‘Let Me Sleep’ is a naturalist story inasmuch as it has a clear grasp of
the social and economic determinants of the state of exhaustion, but its
naturalistic engagement with the domestic politics of exhaustion is
tinged with a mildly phantasmagorical flavour as the narrative slides
between the brute facts of economic exploitation into the vividly strange
perceptual world of the exhausted person. Sleep deprivation takes Varka
away from reality – from the incessant cycle of cooking, cleaning,
22
Anton Chekhov, ‘Let Me Sleep’, in Early Stories, trans. Patrick Miles and Harvey Pitcher
(Oxford: Worlds Classics, 2000), pp. 191–6.
23
Ibid., pp. 194–5.
washing, sewing, shopping, fetching, carrying, and caring – but not in a

way that could remotely be described as escapist. In the fog of her acute
tiredness, the immediacy of the here-and-now is muffled as Varka slips
into uncannily vivid memories that she, and we, struggle to differentiate
from current experience. She also becomes weirdly alienated from her
own body: ‘Her eyes are glued together, her head droops, her neck aches.
She cannot move her eyelids or her lips, and she feels as though her face
is dried and wooden, as though her head has become as small as the head
of a pin’.24 The exhausted body mutinies, one constituent part at a time,
against the commands that its owner is trying to issue. Perceptually,
the world around Varka wobbles between reality and hallucination,
as objects shrink and balloon and shimmer in her exhausted gaze.
Housework – all the invisible labour that goes into maintaining an
orderly domestic establishment – is envisioned as a mind-altering ordeal.
Cleaning her master’s galoshes, she fantasises about ‘how nice it would
be to put her head into a big deep galosh, and have a little nap in it [ . . . ]
And all at once the galosh grows, swells, fills up the whole room’; as she
peels potatoes they ‘dance before her eyes’.25 Elements of the inanimate
world acquire what we might, in other circumstances, regard as an antic
life of their own – the dancing potatoes and over-sized galoshes are the
stuff of charming children’s fantasy. But these are the traces of a child-
hood from which Varka has been permanently excluded. Varka is duped
by tiredness into imagining fantastical transformations of her working
conditions, when all life has in store for her is more of the same.
Everyday life in Mansfield’s story, as in Chekhov’s, is monotonously and
viciously cyclical. Days for her heroine, a servant in a provincial German
household, are an unending round of chores. Family life is dominated by
cycles of cruelty and abuse. Night-time is dominated by the cries of the
baby. The unnamed heroine is identified, throughout, as ‘The Child-Who-
Was-Tired’, yoked to her tiredness by those three hyphens as though
fatigue is all she has to define her. Half-remembered images of a child
who ‘had once played for a whole day’, ‘not a little bit of tiredness’ floating
24
Ibid., p. 191.
25
Ibid., pp. 194–5.
252 M. Greaney
through her mind, possibly as fragments from her past, possibly as glimpses
from storybook fantasies of idyllic childhoods; in any case, the future holds
only more exhaustion for her.26 When she learns that the Frau is pregnant
the only prospects she can visualise for herself are more tiredness, redoubled
fatigue. Forbidden to rest, the Child-Who-Was-Tired is subject to what
amounts to torture through systematic sleep deprivation. Like Varka, she
experiences exhaustion as the seemingly interminable ordeal of never not
being present to others and to herself.
Exhaustion, for Chekhov and Mansfield, enjoys a cruel relationship
with closure. Roland Barthes once described exhaustion as the ‘paradox-
ical infinity of weariness: the endless process of ending’, and we can
point to Chekhov and Mansfield’s stories as harrowing illustrations of
the intolerable perception that nothing is more tiring than an ending
that never arrives.27 The baby in Chekhov’s story is a tiny incarnation of
unending and inexhaustible exhaustion: ‘For a long time he has been
hoarse and exhausted with crying; but he still goes on screaming, and
there is no knowing when he will stop’.28 What is exhausting about
exhaustion is its non-finality; it seems to draw on perverse reserves of
energy, to prolong itself beyond its natural lifespan, producing an
excruciating state of sleepiness without sleep, tiredness without repose.
Exhaustion, as imagined by Chekhov and Mansfield, implies that some-
thing is ending but has not yet ended, and it will go on and on ending; it
will never finish being finished with us.
Politics of Exhaustion
Numerous readers have observed that ‘Let Me Sleep’ and ‘The Child-
Who-Was-Tired’ are versions of the same story, and there has been a
lively, if not very interesting, controversy about whether Mansfield’s
26
Katherine Mansfield, ‘The Child-Who-Was-Tired’, in In a German Pension (Harmondsworth:
Penguin, 1964), pp. 77–86 (p. 83).
27
Roland Barthes, The Neutral: Lecture Course at the College De France (1977–1978), trans.
Rosalind E. Krauss and Denis Hollier (New York: Columbia University Press, 2005), p. 48.
28
Chekhov, ‘Let Me Sleep’, p. 191.
borrowings from Chekhov amount to plagiarism.29 The plagiarism

controversy is uninteresting because it couches the question of literary
originality in narrowly legalistic terms, and thereby potentially blinds
us to the ways in which Mansfield’s story covertly thematises its own
unoriginality. The imagery of tiredness, exhaustion, and repetitive
drudgery in ‘The Child-Who-Was-Tired’ might be read as allegorising
its ‘tired’ intertextual repetition of Chekhov’s story of exhaustion.
Indeed, Mansfield’s Chekhovian story is a very literal example of
what John Barth calls the ‘literature of exhaustion’; it is a text of
extreme physical tiredness, but also a meditation on how the modern
writer can make something of the exhaustion and ‘used-upness’ that
bedevil any attempt to achieve originality in the shadow of their
mighty predecessors.30
Like the revitalised clichés in Joyce’s Ulysses, the Chekhovian echoes in
‘The Child-Who-Was-Tired’ are evidence of modernism’s busily pro-
ductive relationship with formal and linguistic tiredness. Mansfield’s
re-writing of Chekhov enacts, on a narrative level, the sense of endless
and interminable repetition that so exhaustingly defines her heroine’s
life. Faced with an exhaustion of resources, Joyce, Eliot, Mansfield,
and their contemporaries thus find different ways to make a resource
of exhaustion; their work finds a curious kind of inspiration in the
spectacle of weariness, fatigue, and spentness.
What is salutary about ‘Let Me Sleep’ and ‘The Child-Who-Was-
Tired’, in this context, is the way their images of exhaustion are rooted
in the socio-economic contexts in which flesh-and-blood men and
women become exhausted; or, to put it another way, the aesthetic of
exhaustion in these texts manifests itself as an effect of a certain politics
29
See Claire Tomalin, in Katherine Mansfield: A Secret Life (London: Penguin, 1988), pp. 208–11,
for a concise account of the controversy that flared up in the pages of the Times Literary
Supplement in 1951 about the relationship between the two stories.
30
John Barth, in ‘The Literature of Exhaustion’, in The Friday Book: Essays and Other Nonfiction
(Baltimore: Johns Hopkins University Press, 1984), pp. 62–76, influentially argues that the
cardinal challenge for the postmodern author is how to deal with the ‘used-upness of certain
forms’ (p. 64) – namely, classical realism and the modernism that came after it, particularly the
unsurpassable achievements of Joyce.
254 M. Greaney
of exhaustion.31 If the contrast between the pampered world-weariness

of Wilde’s heroes and the atrociously grim exhaustion of Chekhov and
Mansfield’s heroines shows us anything, it is that not everyone gets to be
exhausted in the same way, and not everyone gets to take ownership of
the meaning of their own exhaustion or to parlay tiredness into an
aesthetic strategy or lifestyle choice. A politics of exhaustion is one that
would be alert to the social circumstances in which exhaustion is
produced, the differences and inequalities within exhaustion, and the
terms under which the exhausted get to speak of their plight. Such a
politics has never been more topical, given that in the early twenty-first
century, we are experiencing what Jonathan Crary describes as the
‘generalized inscription of human life into duration without breaks,
defined by a principle of continuous functioning’.32 A century after
the heyday of modernism, it seems that there are still grounds for
thinking of the modern individual as the Person-Who-Was-Tired, and
the challenge for literature, in this context, is to harness the power of
exhaustion without dreaming that it can exercise sovereign power over
exhaustion; to write in and with exhaustion, as Chekhov and Mansfield
have done, without imagining that it can be effortlessly recuperated at
the stroke of a pen.
References
Martin Amis, ‘The War Against Cliché: Ulysses by James Joyce’, in The War
Against Cliché: Essays and Reviews 1970–2000 (London: Vintage, 2002),
pp. 441–6.
John Barth, ‘The Literature of Exhaustion’, in The Friday Book: Essays and
Other Nonfiction (Baltimore: The Johns Hopkins University Press, 1984),
pp. 62–76.
31
For a different perspective on the politics of exhaustion, see Steven Connor, ‘Chronic Fatigue’,
Performance Research 9:4 (2004), 54–8, which argues that nothing is more tiring than the
compulsion to politicise everything.
32
Jonathan Crary, 24/7: Late Capitalism and the Ends of Sleep (London: Verso, 2013), p. 8.
Roland Barthes, The Neutral: Lecture Course at the College De France

(1977–1978), trans. Rosalind E. Krauss and Denis Hollier (New York:
Columbia University Press, 2005).
Symptoms, Nature, Sequences, Treatment (New York: W. Wood, 1880).
Samuel Beckett, ‘Dante . . . Bruno. Vico . . . Joyce’ (1929)’, in Modernism: An
Anthology, ed. Lawrence Rainey (Oxford: Blackwell, 2005), pp. 1061–71.
Anton Chekhov, ‘Let Me Sleep’, in Early Stories, trans. Patrick Miles and
Harvey Pitcher (Oxford: Worlds Classics, 2000), pp. 191–6.
Steven Connor, ‘Chronic Fatigue’, Performance Research 9: 4 (2004), 54–8.
Jonathan Crary 24/7: Late Capitalism and the Ends of Sleep (London: Verso,
2013).
Gilles Deleuze, ‘The Exhausted’, SubStance 24: 3 (1995), 3–28.
Michael Greaney, ‘Sleep in Modern Fiction’, Literature Compass 7: 6 (2010),
467–76.
James Joyce, Ulysses, ed. Jeri Johnson (Oxford University Press, 1993).
Paul Lafargue, The Right to Be Lazy, trans. Charles H. Kerr (Chicago: Charles
H. Kerr, 1989).
Emmanuel Levinas, Existence and Existents, trans. Alphonso Lingis (Pittsburgh,
PA: Duquesne University Press, 2001).
Katherine Mansfield, ‘The Child-Who-Was-Tired’, in In a German Pension
(Harmondsworth: Penguin, 1964), pp. 77–86.
F. T. Marinetti, ‘The Founding and Manifesto of Futurism’, in Marinetti:
Selected Writings, ed. R. W. Flint, R. W. Flint and Arthur A. Coppotelli
(London: Secker & Warburg, 1972), pp. 39–44.
Max Nordau, Degeneration (Lincoln: University of Nebraska Press, 1968).
Ezra Pound, Make It New (London: Faber and Faber, 1934).
Anson Rabinbach, The Human Motor: Energy, Fatigue and the Origins of
Modernity (Berkeley and Los Angeles: University of California Press, 1992).
Lee Scrivner, Becoming Insomniac: How Sleeplessness Alarmed Modernity
(London: Palgrave, 2014).
Joe Sutcliffe, ‘James Joyce: Not Making It New’, Cambridge Quarterly 27:
1 (1998), 56–70.
Arthur Symons, ‘The Decadent Movement in Literature’, Harper’s New
Monthly Magazine 20 (1893), 858–68.
Claire Tomalin, Katherine Mansfield: A Secret Life (London: Penguin, 1988).
Silas Weir, Mitchell Rest in the Treatment of Nervous Disease (New York:
G.P. Putnam’s Sons, 1875).
256 M. Greaney
Oscar Wilde, The Picture of Dorian Gray (Harmondsworth: Penguin, 2000).

Virginia Woolf, ‘On Being Ill’, in Selected Essays, ed. David Bradshaw (Oxford:
Oxford University Press, 2009), pp. 101–10.
Michael Greaney is Senior Lecturer in the Department of English and Creative

Writing at Lancaster University. He is the author of Conrad, Language, and
Narrative (Cambridge University Press, 2001) and Contemporary Fiction and the
Uses of Theory (Palgrave, 2006). Sleep and the Novel, a study of representations
of the sleeping body in literary fiction from Jane Austen to the present, is
forthcoming.
Part V
Exhaustion and the Social
12
Social Agony and Agonising
Social Constructions
Iain Wilkinson
On some accounts we have never had it so good. The majority of people

living in the most industrially developed parts of the globe are better fed,
more prosperous, and healthier than at any other time in human history.
Over the last century, life has become safer and people’s social and
political freedoms have increased exponentially. Most are privileged
enough to have access to educational and technical resources to experi-
ence a range of material, cultural, and symbolic goods that were
unknown to previous generations. There are unprecedented opportu-
nities for self-expression, personal development, and the pursuit of
pleasure.
In most other times and places, people have lived under conditions
that, when compared to contemporary standards, would seem uncon-
scionably brutal, violent, diseased, poverty-stricken, and inhumane. The
inhabitants of advanced industrial societies have no experience of
the chronic malnutrition, vicious cycles of famine, and regular outbreaks
I. Wilkinson (*)
e-mail: i.m.wilkinson@kent.ac.uk

DOI 10.1007/978-3-319-52887-8_12
260 I. Wilkinson
of epidemic disease that throughout the Middle Ages and early modern
period kept life expectancy to an average of between 25 and 30 years.1
Moreover, most of us now know little if next to nothing of ‘the
despairs, the rages, the impulsive acts [and] sudden revulsions of feeling’
experienced by people convinced that their lives were under the con-
stant surveillance of an angry God of judgment who at any moment
could smite them with calamity.2 The common experience of life
that Thomas Hobbes famously depicted as one lived in ‘continual fear
and danger of violent death’ and as ‘solitary, poor, nasty, brutish, and
short’ is now unknown to those grown accustomed to the relative peace
and material comforts of our modernity; especially so in countries
with more developed states of liberal social democracy and welfare
provision.3
It has long been recognised, however, that modern improvements in
people’s material and health conditions do not leave them feeling more
content with their lives. Our technical and technological mastery of the
world is not sufficient to make us feel more at home within it. The
institutionalisation of many new political and social freedoms has not
left us increasingly satisfied with life as we find it. Indeed, for a long time
now it has been commonplace to conclude that along with the advance
of civilisation grows a great deal of discontent.4
In his celebrated attempt to document the social character of modern
societies, Emile Durkheim observed that ‘while there is a host of plea-
sures open to us today that more simple natures knew nothing about
[ . . . ] on the other hand, we are exposed to a host of sufferings spared
them, and it is not at all certain that the balance is to our advantage
1
J. C. Riley, Rising Life Expectancy: A Global History (Cambridge: Cambridge University Press,
2001), pp. 31–5.
2
M. Bloch, Feudal Society (London: Routledge Kegan and Paul, 1961), p. 73; A. Walsham,
Providence in Early Modern England (Oxford: Oxford University Press, 1999).
3
T. Hobbes, Leviathan (Cambridge: Cambridge University Press, 1996 [1651]), p. 89.
4
S. Freud, ‘Civilzation and its Discontents’, in Civilization, Society and Religions: Group Psychology
and the Analysis of the Ego, Future of an Illusion and Civilization and Its Discontents (London:
Penguin, 1991 [1929]); D. N. Levine, ‘Modernity and its Endless Discontents’, in After Parsons: A
Theory of Social Action for the Twenty-First Century, ed. R. C. Fox, V. M. Lidz, and H. J. Bershady
(London: Russell Sage Foundation Publications, 2005), pp.148–68.
[ . . . ] if we are open to more pleasures, we are also open to more pain’.5 Like
many others among his generation he understood modern people to be
susceptible to states of nervous exhaustion that were not only implicated in
experiences of mental anguish but also forms of emotional and bodily pain.6
Durkheim held that this was derived from social conditions in which
relentless forces of individualisation were liable to make us feel morally
disorientated and lacking in social support. He took collective experiences of
anxiety, weariness, depression, and sad feelings of despondency as evidence
of some manner of social derangement (dérèglement). Durkheim’s sociology
was built on the premise that people embody their social conditions; and
where large numbers are prone to experience debilitating states of exhaus-
tion and associated symptoms of anxiety and depression, then this is in large
part due to the extent to which they are made to live in circumstances where
they feel bereft of moral purpose and devoid of social value.
In what follows I contend that in the twenty-first century, there is
renewed recognition of the extent to which social factors comprise physio-
logical manifestations of exhaustion and distress. The social determination
of our bodily and emotional health is now more widely acknowledged and
more extensively documented than it ever was in Durkheim’s day. By no
means, however, has this generated a consensus on how we should practi-
cally manage and/or respond to the inner turmoil that derives from condi-
tions set in social experience. Arguably, moreover, it has the effect of
making the social component of human health ever more politically con-
tentious. Here the social part of us is being discovered anew not only as an
enactment of substantive human values but also as an inherently disruptive
set of forces constituted by many conflicts of value and interest. The agony
of ‘the social’ is not only encountered in the morbid effervescence that
emanates from the poor quality of peoples’ moral-social lives, it also
encompasses the social as a vexed matter for debate in connection with
the conditions that are most conducive to the promotion of human health.
The now widespread recognition that diagnostic categories are subject to
5
E. Durkheim, The Division of Labour in Society (New York: The Free Press, 1964), pp. 241–42.
6
S. G. Meštrović and H. Brown, ‘Durkheim’s Concept of Anomie as Dérèglement’, Social
Problems 33: 2 (1985), 81–99.
262 I. Wilkinson
social construction and that they operate as a surrogate means to promote

favoured social values and interests brings further volume to the discord
over how we make sense of our embodied social health. Here social
consciousness is encountered more as an epistemological burden than as
a means to corral expert opinion towards a shared point of view on how we
can act to make life better.
I begin by reviewing current debates relating to the apparent resurgence
of the condition of ‘neurasthenia’, now diagnosed as ‘chronic fatigue
syndrome (CFS)’. I note that by no means is there any consensus when it
comes to explaining this, and that while some are inclined to attribute
current states of exhaustion to a series of social changes related to transfor-
mations in the organisation and experience of work, others place an
emphasis on the extent to which this represents a movement within med-
icine, and psychiatry in particular, to reassign the body with symptomatic
significance. As far as the latter is concerned, rather than simply accept that
we are witness to a real increase in the prevalence of exhaustion, we should
be more concerned to explore how this is a matter of social construction
related to the nosology of psychiatry and its enduring struggles for legiti-
macy. My analysis draws in to focus on the extent to which, one way or
another, the social features as a concern that operates to designate chronic
fatigue as a matter of etiological controversy. I further argue that this results
in making the diagnosis and treatment of exhaustion ever more politically
and morally contentious; especially in relation to its social aspects. Ever
more pronounced conflicts of interpretation relating to how we should
make sense of our social condition, and the social condition of the knowl-
edge of ourselves as such, is set to politicise the diagnosis and treatment of
extreme and chronic states of exhaustion. Our social agony is more fully
exposed, and so it seems, with ever-diminishing prospects for respite.
Neurasthenia Rediscovered
It is now widely reported that the populations of modern industrial
societies are experiencing high levels of fatigue. It is only since the 1990s,
however, that the epidemiology of fatigue has been developed as an
important area of study. Before this time, the overall prevalence and
severity of this condition is a matter for conjecture.7 There is not survey

data to provide us with reliable information on the overall prevalence of
exhaustion and its related conditions through most of the twentieth
century. In this regard, the epidemiological evidence at hand does not
provide a means to chart long-term trends and variations in the numbers
of people suffering from fatigue; but it is certainly the case that from the
1990s to the present it has been addressed as a significant health problem
that disrupts the lives of many people. More recently, it has been discovered
that around 50% of the population report themselves to frequently suffer
from fatigue, and that this is also a significant component of the symptoms
reported by around 20% of those seeking medical care.8 It is further
reported that the most recent cross-national studies of this experience
indicate that around 3.5% of these are experiencing fatigue in extremely
debilitating forms that can be classified as CFS or myalgic encephalomye-
litis (ME); that is, fatigue that lasts for six months or more and is accom-
panied by other symptoms such as joint and muscle pain, sore throats,
tender lymph nodes, and various cognitive impairments.9
These incidences of ME or CFS have prompted some to take an
interest in the extent to which people are suffering from a condition
that is akin to ‘the fatigue problem’ of the late nineteenth and early
twentieth centuries that was addressed under the umbrella diagnosis of
‘neurasthenia’.10 It is now widely concluded that ME and neurasthenia
have some shared characteristics, and that there are many instances where
attempts to document symptoms and trace their aetiology have involved
health researchers in decanting ‘old wine in new bottles’.11 For example,
7
G. Lewis and S. Wessely, ‘The Epidemiology of Fatigue: More Questions Than Answers’,
Journal of Epidemiology and Community Health 46: 2 (1992), 92–7.
8
N. Afari and D. Buchwald, ‘Chronic Fatigue Syndrome: A Review’, American Journal of
Psychiatry 16: 2 (2003), 221–36.
9
S. Johnston et al., ‘The Prevalence of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis: A
Meta-Analysis’, Clinical Epidemiology 5 (2013), 105–10.
10
K. Johannisson, ‘Modern Fatigue: A Historical Perspective’, in Stress in Health and Disease, ed.
Arnetz and R. Ekman (Weinheim: Wiley, 2006), pp. 3–19.
11
S. E. Abbey and P. E. Garfinkel, ‘Neurasthenia and Chronic Fatigue Syndrome’, American Journal of
Psychiatry 148: 12 (1991), 1638–46.; T. E. Davenport et al., ‘Conceptual Model for Physical Therapist
Management of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis’, Physical Therapy 90: 4
(2010), 602–14; S. S. Leone et al., ‘Two Sides of the Same Coin? On the History and
264 I. Wilkinson
in an influential article Simon Wessely notes that the symptomatic

parallels between neurasthenia and more recent outbreaks of chronic
fatigue can be drawn along a number of lines.12 First, as was the case
with neurasthenia, it is increasingly recognised that chronic fatigue results
from exposure to prolonged experiences of stress in connection to work,
and more broadly, the relentless pace of life. Accordingly, a focus is
brought to the pressures exerted on individuals by their social environ-
ment. Second, the profile given to the organic experience of distress in
neurasthenia is repeated in the renewed attention that is brought to the
ways experiences of fatigue derive not only from the ways individuals are
cognitively disposed to relate to their life situations but also from their
bodily capacity to cope with stress. In this regard, moreover, there is a
tendency for contemporary health practitioners to follow their nine-
teenth-century predecessors in treating sufferers with the understanding
that, while forms of depressive illness may moderate some symptoms of
fatigue, they are also connected to people’s physical ability to withstand
the ‘overload’ of stressful social pressures that are placed upon them.
The reappearance of exhaustion as a widespread social and health
problem has been accompanied by a considerable amount of debate over
how it should be explained. Many are inclined to point to transformations
that have taken place in the organisation and experience of work as a prime
cause of the return of this malaise. Here the rise of ever more ‘flexible’ work
practices allied to neo-liberal reforms of capitalist societies is understood to
have created increasingly stressful work environments in which individuals
are more likely to experience some kind of ‘burnout’ or ‘corrosion of
character’.13 It is argued that from the 1970s onwards, due to their
Phenomenology of Chronic Fatigue and Burnout’, Psychology and Health 26: 4 (2011), 449–64;
M. Riccio et al., ‘Neuropsychological and Psychiatric Abnormalities in Myalgic Encephalomyelitis:
A Preliminary Report’, British Journal of Clinical Psychology 31: 1 (1992), 111–20; P. K. Thomas, ‘The
Chronic Fatigue Syndrome: What Do We Know?’, British Medical Journal 306: 6892 (1993), 1557.
12
S. Wessely, ‘Old Wine in New Bottles: Neurasthenia and “ME”’, Psychological Medicine 20: 1
(1990), 35–53.
13
H. J. Freudenberger, ‘Burnout: Past, Present, and Future Concerns’, Loss, Grief & Care 3: 1–2
(1989), 1–10; C. Maslach, S. E. Jackson, and M. P. Leiter, Maslach Burnout Inventory Manual
(Mountain View, CA: CPP. Inc. and Davies-Black, 1996); R. Sennett, The Corrosion of Character:
The Transformation of Work in Modern Capitalism (New York and London: Norton Company, 1998).
contractual conditions and/or the experience of volatile market forces, ever-

increasing numbers of people have been left feeling more insecure in
employment and powerless to remove themselves from the threat of job
loss.14 In addition to this, some note that it is not just the perceived threat
of job loss that matters here but also (and perhaps more so) the sheer
intensity at which people are required to work when in paid employment.15
It is the demands that others as well as individuals place upon themselves to
increase their workloads and productivity that is understood to be impli-
cated in stress-related health problems. Since the global recession of 2008,
moreover, studies of people’s working lives and conditions have overwhel-
mingly discovered that many are declaring themselves to be constantly
‘stressed out’ by the additional pressures that are being placed upon them to
deliver more in less time and/or with less resources, or depleted measures of
institutional support.16
On this account, a ‘golden age’ of welfare capitalism in which many
Western societies were organised around principles of ‘industrial citizen-
ship’ has come to an end. It is argued that, while for almost 30 years
following the Second World War people experienced improved working,
living, and health conditions, we are now witness to processes that are
eroding these achievements. Many are being forced to endure ever more
precarious life circumstances.17 Looking back to the mid-1970s, but espe-
cially from the 1990s onwards, social researchers have charted people’s
increasing vulnerability to intensified levels and experiences of risk.18
14
S. A. Burgard, J. E. Brand, and J. S. House, ‘Perceived Job Insecurity and Worker Health in the
United States’, Social Science & Medicine 69: 5 (2009), 777–85.
15
B. Burchell, D. Ladipo, and F. Wilkinson (eds), Job Insecurity and Work Intensification
(London: Routledge, 2002).
16
B. Carter et al., ‘“Stressed Out Of My Box”: Employee Experience of Lean Working and
Occupational Ill-health in Clerical Work in the UK Public Sector’, Work, Employment & Society
27: 5 (2013), 747–67; S. Modrek and M. R. Cullen, ‘Job Insecurity During Recessions: Effects on
Survivors’ Work Stress’, BMC Public Health 13: 1 (2013), 1–11.
17
J. Fudge, ‘Beyond Vulnerable Workers: Towards a New Standard Employment Relationship’,
Canadian Labour & Employment Law Journal 12 (2005), 151–76; G. Standing, The Precariat: The
New Dangerous Class (London: Bloomsbury, 2014).
18
U. Beck, Risk Society: Towards a New Modernity (London: Sage, 1992); U. Beck, The Brave New
World of Work (Cambridge: Polity Press, 2000); G. Mythen, ‘Employment, Individualization and
Insecurity: Rethinking the Risk Society Perspective’, The Sociological Review 53: 1 (2005), 129–49.
266 I. Wilkinson
Here there is also a tendency to associate heightened states of anxiety with

the ways in which neo-liberal nation states have sought to cajole and
persuade citizens into taking more personal responsibility for their health,
employability, welfare, and security.19
Powerful new forms of ‘governmentality’ are understood to be oper-
ating to promote social conditions in which people are more likely to be
heavily preoccupied with their relative abilities as autonomous indivi-
duals to navigate a course through life without being able to rely on state
safety nets to keep them from harm’s way.20 It is believed that, insofar as
populations are more prone to experience states of exhaustion, this is
connected to the political realisation of new forms of social subjectivity
in which many ‘bodies speak’ of conditions of distress.21
Problems of Attribution
By no means, however, do commentators agree that the return of ‘the
fatigue problem’ is a direct consequence of new social arrangements that
are making people feel more distressed. Rather than explaining debilitat-
ing states of exhaustion as a product of prevailing social conditions, it is
argued that we should be more concerned to understand this manner of
explanation as a matter subject to social construction.22 Here a focus is
19
H. Kemshall, Risk, Social Policy and Welfare (Buckingham: Open University Press, 2001); J. S.
Hacker, ‘Privatizing Risk without Privatizing the Welfare State: The Hidden Politics of Social
Policy Retrenchment in the United States’, American Political Science Review 98: 2 (2004), 243–60;
P. Taylor-Gooby, New Risks, New Welfare: The Transformation of the European Welfare State
(Oxford: Oxford University Press, 2004); B. Greve, The Times They Are Changing: Crisis and the
Welfare State (London: John Wiley & Sons, 2012).
20
M. Cooper, ‘Insecure Times, Tough Decisions: The Nomos of Neoliberalism’, Alternatives: Global,
Local, Political 29: 5 (2004), 515–33; P. Miller and N. Rose, Governing the Present: Administering
Economic, Social and Personal Life (Cambridge: Polity Press, 2008); N. Rose, Powers of Freedom:
Reframing Political Thought (Cambridge: Cambridge University Press, 1999); I. Wilkinson, Anxiety in
a Risk Society (London: Routledge, 2001); I. Wilkinson, Risk Vulnerability and Everyday Life (London:
Routledge, 2010).
21
J. G. Biehl, B. Good, and A. Kleinman, Subjectivity: Ethnographic Investigations (Berkeley:
University of California Press, 2007).
22
N. C. Ware, ‘Suffering and the Social Construction of Illness: The Delegitimation of Illness
Experience in Chronic Fatigue Syndrome’, Medical Anthropology Quarterly 6: 4 (1992), 347–61.
brought to the ways in which disease classifications reflect the values at

work in the institutional settings where diagnoses are handed out for
people’s illness experiences. We are invited to debate the professional
and political interests governing particular fields of medicine and how
these are inclined to influence practitioners’ causal judgments and
methods of treatment.23
Alongside the many publications that seek to explain the more recent
reappearance of ‘the fatigue problem’ with reference to new conditions
of work and employment, a considerable amount of debate has been
directed towards the ways this is related to modifications in the cultural
values incorporated into the diagnostic terms used by medical and health
experts. Here the disappearance of neurasthenia from public debate in
Western societies from the 1930s onwards is attributed to the rise of
psychiatry as a clinical profession and to the extent to which its practi-
tioners succeeded in re-classifying symptoms of fatigue as problems
linked to some manner of affective or psychiatric disorder. It is argued
that while through most of the twentieth-century neurasthenia seemed
to have disappeared, this was not due to any significant transformations
in people’s bodily experiences or in the pressures of life that aggravate
feelings of exhaustion. Many people continued to suffer from exhaus-
tion; it is just that their symptoms were labelled differently.24 Within
quarters of medical science and its official terms of diagnosis, it was now
portrayed more as a psychological condition than as a bodily ailment. It
is argued that, following the ascendancy of psychiatry, many debilitating
N. C. Ware, ‘Toward a Model of Social Course in Chronic Illness: The Example of Chronic
Fatigue Syndrome’, Culture, Medicine and Psychiatry 23: 3 (1999), 303–31; N. C. Ware and
M. G. Weiss, ‘Neurasthenia and the Social Construction of Psychiatric Knowledge’, Transcultural
Psychiatry 31: 2 (1994), 101–24.
23
P. Brown, ‘Naming and Framing: The Social Construction of Diagnosis and Illness’, Journal of
Health and Social Behavior 35 (1995), 34–52; L. J. Kirmayer, ‘Cultural Variations in the Response
to Psychiatric Disorders and Emotional Distress’, Social Science & Medicine 29: 3 (1989), 327–39;
P. Wright and A. Treacher (eds), The Problem of Medical Knowledge: Examining the Social
Construction of Medicine (Edinburgh: Edinburgh University Press, 1982).
24
E. Shorter, ‘Chronic Fatigue in Historical Perspective’, in Chronic Fatigue Syndrome, ed. G. R.
Bock and J. Whelan (New York: John Wiley New York, 1993), pp. 6–16; R. T. Zorzanelli,
‘Fatigue and its Disturbances: Conditions of Possibility and the Rise and Fall of Twentieth-
Century Neurasthenia’, História, Ciências, Saúde-Manguinhos 16: 3 (2009), 605–20.
268 I. Wilkinson
experiences of exhaustion were reclassified as components of depression

and anxiety. The organic experience of distress was relegated to the
status of an ‘associated symptom’ of some manner of affective, nervous
or mental disorder.25
While many bodies may now be ‘speaking’ of material and social
conditions that are causing people to feel burnt out and exhausted with
their lives, here it is claimed that expert accounts of the intensity and
scale of this problem are more a product of the ways they are inclined
to listen to what is being said and how they are motivated to relate its
significance. The more recent appearance of diagnostic terms such as
‘myalgic encephalomyelitis’, ‘chronic fatigue syndrome’, or ‘burnout’ as
a means to document the chronic and extreme states of exhaustion of
the late twentieth and early twenty-first centuries is understood to
herald a return to treating the body as a key concern. They are taken
to signal a renewed concern within psychiatry and related fields of
medicine to address the somatic components of fatigue and people’s
bodily capacity to cope with stress. Insofar as ‘the fatigue problem’ has
reappeared in the late twentieth and twenty-first century, it is under-
stood to be connected to a movement to re-assign the body with
symptomatic significance.
A considerable amount of debate surrounds what we should make of
this. There are contrasting points of view on how this development is
best explained. In some quarters, it is regarded as a further movement to
psychopathologise those suffering from bodily ailments for which there
is no effective cure. For example, in a recent review of medical literatures
relating to the aetiology of exhaustion that compares nineteenth-century
accounts of what causes neurasthenia to contemporary explanations of
ME, Olaug Lian and Hilde Bondevik argue that there is plenty of
evidence to document the extent to which the latter is inclined to
attribute the cause of exhaustion to ‘individual peoples’ personalities
25
G. E. Berrios, ‘Feelings of Fatigue and Psychopathology: A Conceptual History’,Comprehensive
Psychiatry 31: 2 (1990), 140–51; R. E. Taylor, ‘Death of Neurasthenia and its Psychological
Reincarnation’, The British Journal of Psychiatry 179: 6 (2001), 550–57; N. C. Ware and M. G.
Weiss, ‘Neurasthenia and the Social Construction of Psychiatric Knowledge’, Transcultural
Psychiatry 31: 2 (1994), 101–24.
and coping skills’.26 Accordingly, they claim that while current concerns
with the incidence of ME represent a renewed focus on the somatisation
of stress, there is still an overwhelming tendency within modern med-
icine to explain this as a condition rooted in the maladaptive capacities
of individuals who have something wrong with them. On this account,
it appears that within modern medicine renewed efforts are taking place
to explain illness experiences relating to bodily stress as a largely ‘self-
inflicted psychological condition’.27 It essentially concerns a further
consolidation of a movement to confine the explanation for somatic
experiences of social distress to factors within an individual’s mental
make-up and personality.
By contrast, however, others are inclined to interpret this as a sign of a
movement to wrest control of the official explanation of exhaustion away
from psychology; or at the least to widen the account of how it is caused
so that more recognition is brought to sufferers’ accounts of the ways in
which their experiences are products of stressful work environments. For
example, it is argued that insofar as there is a renewed focus on the
bodily experience of stress in medical accounts of exhaustion, then this is
due to increasingly successful campaigns mounted by doctors to de-
stigmatise their own health problems and to issue a protest against the
conditions under which they are made to work.28 Insofar as psychiatry
has ceded some ground to immunology and virology, it is claimed
that this signals a greater preparedness among health professionals to
acknowledge exhaustion as condition resulting from pressures of the
social environment; and not least those that they experience in their own
daily work routines and practices. Accordingly, while more sociologically
geared accounts of commentators such as Lian and Bondevik may still be
inclined to portray the official account of exhaustion within medicine as
26
O. S. Lian and H. Bondevik, ‘Medical Constructions of Long-term Exhaustion, Past and
Present’, Sociology of Health & Illness 37: 6 (2015), 920–35 (928).
27
Ibid., p. 932.
28
S. Kumar, S. Hatcher, and P. Huggard, ‘Burnout in Psychiatrists: An Etiological Model’, The
International Journal of Psychiatry in Medicine 35: 4 (2005), 405–16; A. Sochos, A. Bowers, and
G. Kinman, ‘Work Stressors, Social Support, and Burnout in Junior Doctors: Exploring Direct
and Indirect Pathways’, Journal of Employment Counseling 49: 2 (2012), 62–73.
270 I. Wilkinson
ideologically disposed to foreground psychological factors relating to

particular individuals, others detect a movement to prise open a space
for attention to be brought to the ways in which fatigue is a product of
the stress borne through embodied experiences of social life.29
In this regard, the medical historian Charles Rosenberg offers some of
the most carefully considered reflections on the cultural status of modern
psychiatry and the social conditions that influence its diagnostic cate-
gories.30 He argues that throughout the twentieth century, psychiatry
has been mired in debates over the ‘epistemological legitimacy’ of its
disease classifications, and that as a discipline it suffers from ‘recurrent
status anxiety’.31 Rosenberg further argues that if it is now the case that a
greater focus is being brought to the ‘somatic mechanisms’ of exhaus-
tion, then this is due to a more pronounced tendency within psychiatry
to resolve its legitimacy crises by recourse to applied pharmacology. He
claims that at the same time as psychiatrists frequently perceive their
credibility and authority to be undermined by the criticisms that are
levelled towards their ideological leanings and apparent reticence to
acknowledge the social cause of people’s miseries, they are also placed
under a great pressure to come up with immediately practicable solu-
tions for people’s mental health problems. Rosenberg contends that the
return of a focus to the body is representative of psychology acceding to
demands for it to provide magic bullet solutions to symptoms of
exhaustion, while at the same time taking steps to avoid the unpleasant
controversies surrounding the ways this may be attributed to matters of
personal pathology. He argues that psychiatrists are now caught in a
bind where, at the same time as they are prepared to acknowledge the
validity of the sociological and ideological critiques of their nosology,
29
A. Aziz, ‘Sources of Perceived Stress Among American Medical Doctors: A Cross-Cultural
Perspective’, Cross Cultural Management: An International Journal 11: 4 (2004), 28–39; N. Dhar,
U. Datta, and D. Nandan, ‘Stress Among Doctors: A Review’, Health and Population: Perspectives
and Issues 31: 4 (2008), 256–66; L. Jason et al., ‘Estimating the Prevalence of Chronic Fatigue
Syndrome Among Nurses’, The American Journal of Medicine 105: 3 (1998), 91–3.
30
C. E. Rosenberg, ‘Contested Boundaries: Psychiatry, Disease, and Diagnosis’, Perspectives in
Biology and Medicine 49: 3 (2006), 407–24.
31
Ibid., p. 411.
they are still cowed by cultural demands for reductionist explanations

and solutions.
For Rosenberg the tactic of dispensing drugs to ‘diseased’ bodies
essentially amounts to a way of resolving this dilemma. It is a means
by which psychiatrists seek to disassociate themselves from controversies
relating to the ‘penumbra of stigma’, but at the same time manage the
ongoing demands that are placed upon them to provide unambiguous
solutions for people’s emotional pains. He hereby encourages us to
take contemporary debates over the medical classification and treatment
of fatigue as an opportunity to better understand the social and cultural
pressures that are placed on psychiatry and, further, how its disease
categories and practices are shaped in response to these. Here, moreover,
the attention that is brought to the body represents all at once a move-
ment towards and a flight from social understanding. At the same
time as social forces are acknowledged within the aetiology of distress
and as pressures within the institutional make-up and cultural biases
of psychiatry, paradoxically, they are also recognised as disruptive
matters that cannot intrude upon its practice. Treating mental health
problems as diseases of the body is the means by which psychiatrists
resolve the tensions inherent in their ongoing social role as doctors of
the mentally ill, while at the same time turning a blind eye to the agony
of the social.
Social Sanctions
As far as Western medicine is concerned, the aetiology and overall scale
of exhaustion as a health problem is resolutely uncertain. While it is now
recognised as amounting to a significant health problem for large num-
bers of people, it is by no means clear that either the prevalence of
exhaustion or its intensity as an embodied experience is particularly
unusual in our times. There is no doubt that it is a distinctively modern
complaint, but by no means is this accompanied by a shared under-
standing of why this is the case. Indeed, it might be argued that the
better our acquaintance with the history of conditions such as neur-
asthenia or CFS, the more we stand to be alerted to the fact that the
272 I. Wilkinson
causes and condition of exhaustion are inextricably tied to many con-

flicts of interpretation.
If any progress has been made towards understanding this state of
affairs, then it might be argued that this has taken place in connection
with the extent to which, both as an experience and within the terms in
which it is rendered accountable, exhaustion is a matter subject to
processes of social and cultural determination. While this is explicitly
recognised and expressly incorporated into its diagnosis and treatment,
however, it by no means serves to clarify how it should be addressed as a
health problem. Arguably, moreover, it also suggests that there is much
taking place within the experience of exhaustion that cannot be relieved.
In recent years, Arthur Kleinman and associated medical anthropol-
ogists have gone further than most to embrace the understanding that
experiences of exhaustion are ‘sociosomatic’, so as to stress the extent
to which people’s social conditions, political contexts and culturally
constructed ways of seeing the world are incorporated within bodily
symptoms of fatigue.32 They take the view that fatigue is a universal
human experience, but also recognise that the ways it is accounted
for and experienced is always mediated through forms of culture that
relate to particular social conditions. In this regard, bodily symptoms
of fatigue are understood to hold up a mirror to society. Furthermore,
the contrasting ways in which this is explained in particular cultural
and historical contexts are also approached as a matter for social
investigation.
In his groundbreaking studies of neurasthenia and depression in China,
Kleinman contends that while such an approach serves to acknowledge
and validate subjective experiences and accounts of exhaustion, it is also
32
A. Kleinman and A. E. Becker, ‘“Sociosomatics”: The Contributions of Anthropology to
Psychosomatic Medicine’, Psychosomatic Medicine 60: 4 (1998), 389–93; G. Ranjith &
R. Mohan, ‘Dhat Syndrome as a Functional Somatic Syndrome: Developing a Sociosomatic
Model’, Psychiatry 69: 2 (2006), 142–50; N. C. Ware, ‘Suffering and the Social Construction of
Illness: The Delegitimation of Illness Experience in Chronic Fatigue Syndrome’, Medical
Anthropology Quarterly 6: 4 (1992), 347–61; N. C. Ware, ‘Toward a Model of Social Course in
Chronic Illness: The Example of Chronic Fatigue Syndrome’, Culture, Medicine and Psychiatry
23: 3 (1999), 303–31; N. C. Ware & A. Kleinman, ‘Culture and Somatic Experience: The Social
Course of Illness in Neurasthenia and Chronic Fatigue Syndrome’, Psychosomatic Medicine
54: 5 (1992), 546–60.
set to disrupt the credibility and authority of medical nosologies that work
with the assumption that these can be addressed as specific types of diseases
or disorders linked to some personal pathology.33 The more that social
forces are acknowledged as components of the embodied experience of
exhaustion, the more likely it is that Western medical practitioners will
appear to be operating in a state of social denial. In this regard, Kleinman
stands alongside Rosenberg in stressing the extent to which modern
medicine, and psychiatry in particular, are governed by forces of rationa-
lisation that aim to make health problems reducible to specific causes and
treatments. He argues that, in Western contexts, it is often the case that
translation work involved in classifying people’s illnesses as particular types
of ‘disease’ also incorporates a delegitimisation of their social experience. At
the same time as his ethnographic work serves to profile the cultural and
ideological biases inherent in Western medical practice, it also serves to
greatly problematise how we might henceforth conceptualise the bound-
aries and condition of human health.
Kleinman argues that insofar as we are prepared to acknowledge social
experience as a vital component of human health, then this is set to draw us
to the point where we recognise that many of our health problems are not
amenable to symptomatic relief. His studies suggest that much that takes
place in people’s states of depression, chronic pains, and unremitting
exhaustion is a result of protracted feelings of disappointment, bitterness,
and loss that are connected to their lived experience of general social
conditions, historical events, and political processes. This calls for an
understanding of health that resists biomedical reductionism in a bid to
make sense of the ways in which people’s social, political, and economic
conditions are incorporated within their bodily and mental afflictions. At
the same time, however, he warns that here we may be confronted with
complexities that cannot be accommodated within established conceptual
frameworks and narrative traditions. He suggests, moreover, that we may
33
A. Kleinman, ‘Neurasthenia and Depression: A Study of Somatization and Culture in China’,
Culture, Medicine and Psychiatry 6: 2 (1982), 117–90; A. Kleinman, Social Origins of Distress and
Disease: Depression, Neurasthenia, and Pain in Modern China (New Haven: Yale University Press,
1986).
274 I. Wilkinson
be dealing with a range of negative health experiences that cannot be readily

‘worked through’, soothed, or healed.34
At the same time that Kleinman calls for a contextualisation of human
health that gives privileged space to ethnographic accounts of how this is
met within and moderated by social experience, Kleinman also acknowl-
edges that this involves a confrontation with many complexities and
diverse personal circumstances for which there is no master narrative. It
appears that in acknowledging people as social beings with distinct social
subjectivities we are set to be drawn into interminable debate over how we
can make adequate sense of their moral and embodied experience of the
world. This is not only due to the fact that the experience of life is always
set to exceed what can be grasped by conceptual thinking but also a result
of the sociological/anthropological reflexivity that pays heed to the fact
that we are also inevitably limited in this regard by our own social
conditioning and value orientations.35 Social life is recognised as an
enactment of substantive human values that are also incorporated within
people’s embodied health. At the same time, venturing to understand how
this takes place is also liable to involve us in many conflicts of value and
interest; and not least in connection with the question of how we should
proceed to account for and evaluate our social health condition.
Conclusion
In this chapter, I have presented a narrative that sets in relief the extent to
which social forces and social experience are acknowledged as causal factors
in both the experience and account of exhaustion. The earliest portrayals of
modern exhaustion in terms of neurasthenia were explicitly concerned with
locating the causes of this experience within stressful pressures of social life
(especially in relation to conditions of work) along with intolerable burdens
34
A. Kleinman and J. Kleinman, ‘The Transformation of Everyday Social Experience: What a
Mental and Social Health Perspective Reveals about Chinese Communities under Global and
Local Change’, Culture, Medicine and Psychiatry 23: 1 (1999), 7–24.
35
A. Kleinman, ‘Experience and its Moral Modes: Culture, Human Conditions, and Disorder’,
The Tanner Lectures on Human Values 20 (1999), 355–420.
of social responsibility and social disappointment connected to people’s

social roles and obligations. At first, it was recognised that modern states of
exhaustion were something done to people by conditions of social life and
by the stress of normative social expectations. For approximately 60 years
(between c. 1930 and c. 1990), it seems that in Western medicine there was
a widespread reticence to account for exhaustion in these terms. In large
part this is attributed to the hegemonic power of psychiatry and the extent
to which its practitioners succeeded in confining the explanation for
exhaustion to factors relating to problems of personality, faulty modes of
cognition, and individual maladaptive behaviours. As is the case in all
instances of hegemony, however, these were contested matters. From the
1990s onwards, it is possible to chart an ever more pronounced crisis of
legitimacy in the authority of psychiatry, at least, that is, when it comes to
explaining debilitating states of weariness and fatigue. People’s social
experiences of the world, and in particular the social conditions in which
they are made to work, are once again being acknowledged as significant
causes of exhaustion. At the same time, this is coupled to a more pro-
nounced understanding that official accounts of people’s health problems
are matters subject to processes of social construction that are also con-
nected to the practice of power and the pursuit of sectional interests. ‘The
social’ has returned, but not without controversy; and in this regard, much
dispute surrounds how we should make sense of human exhaustion and the
extent to which it can be open to relief.
Of course, the above narrative fails to acknowledge that during the
middle decades of the twentieth century, some notable attempts were
made to both socialise and sociologise psychiatry. For example, in current
debates the contributions of Erich Fromm are largely forgotten. This may
well be due to the extent to which his insights were too heavily associated
with a Marxist humanism that not only fell out of fashion with much
leftist thinking but more generally came to be viewed as naively utopian
in its political aspirations.36 Although a sympathetic reading of his work
36
C. S. Hall and G. Lindzey, Theories of Personality (New York: John Wiley & Sons, 1978);
N. McLaughlin, ‘How to Become a Forgotten Intellectual: Intellectual Movements and the Rise
and Fall of Erich Fromm’, Sociological Forum 13: 2 (1998), 215–46.
276 I. Wilkinson
might lead to the conclusion that Fromm retained a gritty realism when it
came to the practical task of creating a ‘sane society’, nevertheless, his
championing of democratic socialism as the means to nurture our mental
and emotional health has, more often than not, been dismissed as an
instance of utopian preaching.37 Certainly, it appears that such prescrip-
tions are now only notable in terms of their absence in connection to
contemporary debates over how we might understand the prevalence of
exhaustion and instances of CFS.
We appear to have arrived at a point where, at the same time as it is
widely recognised that the conditions of social life are heavily implicated
in experiences of exhaustion, we cannot agree on what to do about this.
Arguably, efforts to highlight this fact are more concerned with issuing a
protest against prevailing conditions of society than with advancing a
means to solve them. Moreover, where ‘the social’ is recognised as force
conditioning our knowledge and beliefs about our state of health and
its problems, then it appears that this is set to aggravate the debate over
the potential for these to operate as surrogate terms for advancing
sectional interests. Certainly, it is the case that the perceived crisis of
legitimacy surrounding psychiatric accounts of exhaustion is related to
the extent to which these are seen to result from the social conditions
governing psychiatry and the social interests of those who profit from
its practice. It appears that while we recognise that we are being subject
to a considerable amount of social agony, we are also left with many
agonising questions about how to make sense of this and what to do
about it.
Emile Durkheim argued that insofar as we are preoccupied by the
attempt to explain the condition of neurasthenia, then we should also
concern ourselves with the attempt to understand the ways in which our
personal health, well-being, and happiness are incisively shaped by our
moral experience of society; and in particular the moral texture of the
social relationships by which we are bound to others. If we take him
seriously, then we should be particularly concerned to understand the
social conditions under which individuals are most likely to feel valued
37
D. Burston, The Legacy of Erich Fromm (Cambridge, MA: Harvard University Press, 1991).
and cared for by others. In the twenty-first century, there is an abundance

of data documenting the social conditions that are involved in the
creation of many widespread and devastating health problems. Yet, in
this context, ‘the social’ is more often than not featured as an issue of
moral/political protest or as a matter that issues a call for better ways of
‘thinking about’ and ‘acting in the world’.38 We appear to be still
struggling to accommodate this within adequate terms of human under-
standing; and it often seems to be beyond the reach of practicable care.39
References
S. E. Abbey and P. E. Garfinkel, ‘Neurasthenia and Chronic Fatigue
Syndrome’, American Journal of Psychiatry 148: 12 (1991), 1638–46.
N. Afari and D. Buchwald, ‘Chronic Fatigue Syndrome: A Review’, American
Journal of Psychiatry 16: 2 (2003), 221–36.
A. Aziz, ‘Sources of Perceived Stress Among American Medical Doctors:
A Cross-Cultural Perspective’, Cross Cultural Management: An International
Journal 11: 4 (2004), 28–9.
U. Beck, Risk Society: Towards a New Modernity (London: Sage, 1992).
———, The Brave New World of Work (Cambridge: Polity Press, 2000).
G. E. Berrios, ‘Feelings of Fatigue and Psychopathology: A Conceptual
History’, Comprehensive Psychiatry 31: 2 (1990), 140–51.
J. G. Biehl, B. Good and A. Kleinman, Subjectivity: Ethnographic Investigations
(Berkeley: University of California Press, 2007).
M. Bloch, Feudal Society (London: Routledge Kegan and Paul, 1961).
P. Brown, ‘Naming and Framing: The Social Construction of Diagnosis and
Illness’, Journal of Health and Social Behavior 35 (1995), 34–52.
B. Burchell, D. Ladipo and F. Wilkinson (eds), Job Insecurity and Work
Intensification (London: Routledge, 2002).
S. A. Burgard, J. E. Brand and J. S. House, ‘Perceived Job Insecurity and
Worker Health in the United States’, Social Science & Medicine 69: 5
(2009), 777–85.
38
G. Therborn, The Killing Fields of Inequality (Cambridge: Polity Press, 2013).
39
I. Wilkinson and A. Kleinman, A Passion for Society: How We Think About Human Suffering
(Berkeley: University of California Press, 2016), pp. 161–67.
278 I. Wilkinson
D. Burston, The Legacy of Erich Fromm (Cambridge, MA: Harvard University

Press, 1991).
B. Carter et al., ‘“Stressed Out of My Box”: Employee Experience of Lean
Working and Occupational Ill-health in Clerical Work in the UK Public
Sector’, Work, Employment & Society 27: 5 (2013), 747–67.
M. Cooper, ‘Insecure Times, Tough Decisions: The Nomos of Neoliberalism’,
Alternatives: Global, Local, Political 29: 5 (2004), 515–33.
T. E. Davenport et al., ‘Conceptual Model for Physical Therapist Management
of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis’, Physical Therapy
90: 4 (2010), 602–14.
N. Dhar, U. Datta and D. Nandan, ‘Stress Among Doctors: A Review’, Health
and Population: Perspectives and Issues 31: 4 (2008), 256–66.
E. Durkheim, The Division of Labour in Society (New York: The Free Press, 1964).
S. Freud, ‘Civilization and Its Discontents’, in Civilization, Society and
Religions: Group Psychology and the Analysis of the Ego, Future of an Illusion
and Civilization and Its Discontents, ed. Albert Dickson (London: Penguin,
1991 [1929]).
H. J. Freudenberger, ‘Burnout: Past, Present, and Future Concerns’, Loss, Grief
& Care 3: 1–2 (1989), 1–10.
J. Fudge, ‘Beyond Vulnerable Workers: Towards a New Standard Employment
Relationship’, Canadian Labour & Employment Law Journal 12 (2005), 151–76.
B. Greve, The Times They Are Changing: Crisis and the Welfare State (London:
John Wiley & Sons, 2012).
J. S. Hacker, ‘Privatizing Risk without Privatizing the Welfare State: The
Hidden Politics of Social Policy Retrenchment in the United States’,
American Political Science Review 98: 2 (2004), 243–60.
C. S. Hall and G. Lindzey, Theories of Personality (New York: John Wiley &
Sons, 1978).
T. Hobbes, Leviathan (Cambridge: Cambridge University Press, 1996
[1651]).
L. Jason et al., ‘Estimating the Prevalence of Chronic Fatigue Syndrome
Among Nurses’, The American Journal of Medicine 105: 3 (1998), 91–3.
K. Johannisson, ‘Modern Fatigue: A Historical Perspective’, in Stress in Health and
Disease, ed. B. B. Arnetz and R. Ekman (Weinheim: Wiley, 2006), pp. 3–19.
S. Johnston et al., ‘The Prevalence of Chronic Fatigue Syndrome/Myalgic
Encephalomyelitis: A Meta-Analysis’, Clinical Epidemiology 5 (2013), 105–10.
H. Kemshall, Risk, Social Policy and Welfare (Buckingham: Open University
Press, 2001).
L. J. Kirmayer, ‘Cultural Variations in the Response to Psychiatric Disorders

and Emotional Distress’, Social Science & Medicine 29: 3 (1989), 327–39.
A. Kleinman, ‘Neurasthenia and Depression: A Study of Somatization and
Culture in China’, Culture, Medicine and Psychiatry 6: 2 (1982), 117–90.
———, Social Origins of Distress and Disease: Depression, Neurasthenia, and
Pain in Modern China (New Haven: Yale University Press, 1986).
———, ‘Experience and its Moral Modes: Culture, Human Conditions, and
Disorder’, The Tanner Lectures on Human Values 20 (1999), 355–420.
A. Kleinman and A. E. Becker, ‘“Sociosomatics”: The Contributions of
Anthropology to Psychosomatic Medicine’, Psychosomatic Medicine 60: 4
(1998), 389–93.
A. Kleinman and J. Kleinman, ‘The Transformation of Everyday Social
Experience: What a Mental and Social Health Perspective Reveals about
Chinese Communities under Global and Local Change’, Culture, Medicine
and Psychiatry 23: 1 (1999), 7–24.
S. Kumar, S. Hatcher, and P. Huggard, ‘Burnout in Psychiatrists: An
Etiological Model’, The International Journal of Psychiatry in Medicine 35:
4 (2005), 405–16.
S. S. Leone et al., ‘Two Sides of the Same Coin? On the History and
Phenomenology of Chronic Fatigue and Burnout’, Psychology and Health
26: 4 (2011), 449–64.
D. N. Levine, ‘Modernity and its Endless Discontents’, in After Parsons: A
Theory of Social Action for the Twenty-First Century, ed. R. C. Fox, V. M.
Lidz and H. J. Bershady (London: Russell Sage Foundation Publications,
2005), pp. 148–68.
G. Lewis and S. Wessely, ‘The Epidemiology of Fatigue: More Questions
Than Answers’, Journal of Epidemiology and Community Health 46: 2
(1992), 92–7.
O. S. Lian and H. Bondevik, ‘Medical Constructions of Long-Term
Exhaustion, Past and Present’, Sociology of Health & Illness 37: 6 (2015),
920–35.
C. Maslach, S. E. Jackson, and M. P. Leiter, Maslach Burnout Inventory Manual
(Mountain View, CA: CPP. Inc. and Davies-Black, 1996).
N. McLaughlin, ‘How to Become a Forgotten Intellectual: Intellectual
Movements and the Rise and Fall of Erich Fromm’, Sociological Forum 13:
2 (1998), 215–46.
S. G. Meštrović and H. Brown, ‘Durkheim’s Concept of Anomie As
Dérèglement’, Social Problems 33: 2 (1985), 81–99.
280 I. Wilkinson
P. Miller and N. Rose, Governing the Present: Administering Economic, Social

and Personal Life (Cambridge: Polity Press, 2008).
S. Modrek and M. R. Cullen, ‘Job Insecurity During Recessions: Effects on
Survivors’ Work Stress’, BMC Public Health 13: 1 (2013), 1–11.
G. Mythen, ‘Employment, Individualization and Insecurity: Rethinking
the Risk Society Perspective’, The Sociological Review 53: 1 (2005),
129–49.
G. Ranjith and R. Mohan, ‘Dhat Syndrome as a Functional Somatic
Syndrome: Developing a Sociosomatic Model’, Psychiatry 69: 2 (2006),
142–50.
M. Riccio et al., ‘Neuropsychological and Psychiatric Abnormalities in Myalgic
Encephalomyelitis: A Preliminary Report’, British Journal of Clinical Psychology
31: 1 (1992), 111–20.
J. C. Riley, Rising Life Expectancy: A Global History (Cambridge: Cambridge
N. Rose, Powers of Freedom: Reframing Political Thought (Cambridge:
Cambridge University Press, 1999).
C. E. Rosenberg, ‘Contested Boundaries: Psychiatry, Disease, and Diagnosis’,
Perspectives in Biology and Medicine 49: 3 (2006), 407–24.
R. Sennett, The Corrosion of Character: The Transformation of Work in Modern
Capitalism (New York and London: Norton Company, 1998).
E. Shorter, ‘Chronic Fatigue in Historical Perspective’, in Chronic Fatigue
Syndrome, ed. G. R. Bock and J. Whelan (New York: John Wiley New
York, 1993), pp. 6–16.
A. Sochos, A. Bowers, and G. Kinman, ‘Work Stressors, Social Support, and
Burnout in Junior Doctors: Exploring Direct and Indirect Pathways’,
Journal of Employment Counseling 49: 2 (2012), 62–73.
G. Standing, The Precariat: The New Dangerous Class (London: Bloomsbury,
2014).
R. E. Taylor, ‘Death of Neurasthenia and its Psychological Reincarnation’, The
British Journal of Psychiatry 179: 6 (2001), 550–7.
P. Taylor-Gooby, New Risks, New Welfare: The Transformation of the European
Welfare State (Oxford: Oxford University Press, 2004).
G. Therborn, The Killing Fields of Inequality (Cambridge: Polity Press, 2013).
P. K. Thomas, ‘The Chronic Fatigue Syndrome: What Do We Know?’, British
Medical Journal 306: 6892 (1993), 1557.
A. Walsham, Providence in Early Modern England (Oxford: Oxford University
Press, 1999).
N. C. Ware, ‘Suffering and the Social Construction of Illness: The

Delegitimation of Illness Experience in Chronic Fatigue Syndrome’,
Medical Anthropology Quarterly 6: 4 (1992), 347–61.
———, ‘Toward a Model of Social Course in Chronic Illness: The Example of
Chronic Fatigue Syndrome’, Culture, Medicine and Psychiatry 23: 3 (1999),
303–31.
N. C. Ware and A. Kleinman, ‘Culture and Somatic Experience: The Social
Course of Illness in Neurasthenia and Chronic Fatigue Syndrome’,
Psychosomatic Medicine 54: 5 (1992), 546–60.
N. C. Ware and M. G. Weiss, ‘Neurasthenia and the Social Construction of
Psychiatric Knowledge’, Transcultural Psychiatry 31: 2 (1994), 101–24.
S. Wessely, ‘Old Wine in New Bottles: Neurasthenia and “ME”’, Psychological
Medicine 20: 1 (1990), 35–53.
I. Wilkinson, Anxiety in a Risk Society (London: Routledge, 2001).
———, Risk Vulnerability and Everyday Life (London: Routledge, 2010).
I. Wilkinson and A. Kleinman, A Passion for Society: How We Think About
Human Suffering (Berkeley: University of California Press, 2016).
P. Wright and A. Treacher (eds), The Problem of Medical Knowledge: Examining
the Social Construction of Medicine (Edinburgh: Edinburgh University Press,
1982).
R. T. Zorzanelli, ‘Fatigue and Its Disturbances: Conditions of Possibility and
the Rise and Fall of Twentieth-Century Neurasthenia’, História, Ciências,
Saúde-Manguinhos 16: 3 (2009), 605–20.
Iain Wilkinson is a Reader in Sociology at the University of Kent, UK. His

publications include Anxiety in a Risk Society (Routledge, 2001), Suffering: A
Sociological Introduction (Polity, 2005), Risk Vulnerability and Everyday Life
(Routledge, 2010) and (co-authored with Arthur Kleinman) A Passion for
Society: How We Think About Human Suffering (University of California
Press, 2016).
13
Exhaustion as a Sign of the Present
Sighard Neckel and Greta Wagner
There are times when a certain concept has currency. It appears on

feature pages and in book titles, it crops up at symposia, and it seems to
give expression to a collective experience. Exhaustion is such a concept.
This is not because exhaustion is an experience specific to the present
time, but because this concept represents the condensation of problems
currently besetting the modern conduct of life. There is no good reason
to assert that the present is afflicted with exhaustion to a greater extent
than any previous era. As several of the contributions in the present
volume demonstrate, other historical periods also involved highly articu-
late discourses about exhaustion-related suffering (see Schaffner’s and
Kury’s chapters). However, we do not consider this to be a good reason
S. Neckel (*)
e-mail: sighard.neckel@wiso.uni-hamburg.de
G. Wagner

DOI 10.1007/978-3-319-52887-8_13
284 S. Neckel and G. Wagner
for rejecting the importance of discourses about exhaustion for a diag-

nosis of the times. Rather, we should ask what is shared by all periods in
which exhaustion serves or served as a sign of the present.
Even though there have repeatedly been historical moments in which
exhaustion played a special role in how societies understood themselves,
the periods which did not perceive themselves in such terms have been
no less frequent. An example of such a period within the temporal
horizon of modern society would be the war euphoria prior to the
First World War, during which people were gripped en masse by
aggressive nationalist enthusiasm; this moment also marked the end of
an era of exhaustion whose characteristic expression was the then wide-
spread diagnosis of neurasthenia (see Kury in this volume). Even the
1960s were by no means marked by a prevailing sense of exhaustion, but
instead by the revolutionary mood of a new dawn of the student move-
ment, as well as by widespread fear of the global threat posed by the
Cold War.
Yet what do the eras of exhaustion have in common? If we follow
Patrick Kury’s analysis, periods during which fatigue syndromes are
frequently diagnosed usually follow after rapid social change. Thus,
neurasthenia as a trendsetting illness was diagnosed on a massive scale
in the wake of the profound social upheavals from the middle of the
nineteenth century onwards – that is, following urbanisation, industria-
lisation, and advances in communication and transportation. Another
example is the ‘manager disease’ rampant in Germany during the 1950s
which followed the end of the Second World War and the German
‘economic miracle’. The present era is also marked by rapid social
change. Since the 1990s, lifestyles have undergone extreme acceleration
as a result of digitalisation, and the financialisation of the economy has
driven the idea of competition into the very centre of social life, to name
just two among a multitude of changes that shape contemporary social
experience.
When we analyse exhaustion as a sign of the present and study the
social changes which have given rise to this exhaustion, we are therefore
not claiming that exhaustion is a specifically modern experience or that
we are living in an era that is marked to an unprecedented extent by
exhaustion. Nor is it our intention to romanticise premodern forms of
life. Our goal is not a critique of culture but social criticism; when we
argue that certain forms of social change pose problems for a successful
conduct of life, this does not imply any idealisation of past eras.
Which symptoms and experiences testify to the exhaustion crisis of
the present? The German Federal Ministry of Labour and Social Affairs
estimates that psychological stress and burnout alone accounted for the
loss of 54 million working days in 2012, an increase of 60% over 2001.1
Burnout is most prevalent among 40–50-year-old professionals who
enjoy a high socio-economic status. By contrast, depression is being
increasingly diagnosed among the lower and middle classes, among
younger people, and more often among women than among men.
According to recent studies conducted by the Robert Koch Institute,
approximately 8% of adults in Germany have been diagnosed with
depression.2 It can be safely assumed that behind these diagnoses are
often symptoms similar to those identified as burnout among patients
from higher socio-economic groups.
Nevertheless, burnout is not classified among the medically recog-
nised diseases. Even the most recent list of diseases and health problems
issued by the World Health Organization in 2013 (ICD-10) recognises
burnout only as a ‘problem related to life-management difficulty’. Indeed,
one always hears about an acute burnout when emotional exhaustion is
connected with physical exhaustion and leads to a massive collapse
that renders the individual incapable of continuing his or her previous
conduct of life, at least for the time being. Chronic stress over long
periods of time, a persistent feeling of being overwhelmed or of unbear-
able strain and career setbacks are identified as causes of burnout. This
makes itself apparent to those in the social environment of the individuals
affected, in their pronounced irritability and a ‘depersonalisation’ of
their social contacts, whom they meet with indifference, distance, and
cynicism.
1
Ellen Braun and Steffen Hillebrecht, ‘Betriebliche Wahrnehmung des Burnouts’, Der
Betriebswirt. Management in Wissenschaft und Praxis 54: 3 (2013), 16–22 (16).
2
See Hapke et al., ‘Stress, Schlafstörungen, Depressionen und Burnout: Wie belastet sind wir?’ in
Bundesgesundheitsblatt-Gesundheitsforschung-Gesundheitsschutz (Berlin: Springer, 2012), pp. 987–8.
In medicine, the question of whether burnout is a condition clearly

different from chronic fatigue syndrome or depression, and marked by
distinctive symptoms of physical exhaustion, may be of major impor-
tance. Social research, by contrast, which is interested in burnout as a
contemporary phenomenon typical of modern lifestyles and of contem-
porary work environments, does not have to decide between ‘sick’ or
‘health’, ‘normal’ or ‘pathological’. Just as emotions in general constitute
a link between the person and society, and hence function as a mediator
between the body and the social realm, so too emotional exhaustion
serves as a sociological indicator of the status of individuals in their social
environment and provides information about problems and conflicts
arising out of different ways of conducting one’s life.
From a sociological perspective, burnout represents a form of sub-
jective suffering for which the medical diagnosis of a ‘disease’ in need of
treatment is not the decisive factor, because burnout documents social
problems, in particular problems of modern working life, that go beyond
individual stresses and strains. Thus, experts in medicine, psychology,
and social science are largely in agreement that burnout is predo-
minantly a work-related exhaustion syndrome, whose causes should
be sought in the stressful effects of a form of social transformation
which demands of the individual a high level of professional commit-
ment, a strong identification with work, temporal flexibility, personal
responsibility, and increased self-management in coping with everyday
problems.
In what follows, we characterise burnout as a form of social suffering
generated by the current regime of economic growth. Starting from the
sociological interpretation of subjective suffering as social suffering, we
analyse contemporary competitive society as a social order that gives rise
to suffering by compelling individuals permanently to monitor and
optimise their own performance. What makes individuals particularly
susceptible to burnout is that they exert themselves more and more in
an attempt to achieve professional personal fulfilment, a process that
often leads to self-exploitation. At the same time, exhaustion is able to
capture the contemporary crisis of the growth regime so comprehen-
sively that burnout can also be understood as the start of a process of
social transformation. The critique of the abuse of subjectivity in
contemporary capitalism can trigger the emergence of a new order of

justification, which no longer only promises individual self-fulfilment
but also to use subjective resources more sparingly. According to Weber,
capitalism has always made use of external orders of justification, and we
ask in conclusion whether we are witnessing the emergence of a
Buddhist spirit of capitalism which provides not only a metaphysical
meaning for the social order but also highly individualised strategies for
preventing exhaustion.
Burnout, Social Suffering, and Social Change

Understanding mental suffering as social suffering is part of the basic
understanding of sociology. Thus in his study of suicide Emile
Durkheim demonstrated the impact of social change, economic crises,
and communal integration on suicide rates.3 The apparently purely
individual act of suicide, as Durkheim demonstrates, is influenced by
social factors: the number of suicides rises ‘when a society is disturbed,
either by a painful crisis or by fortunate, but all too sudden transforma-
tions’.4 The time when Durkheim was investigating suicide as a ‘social
fact’ was marked by a growing awareness of socially conditioned suffer-
ing in general. An important contributory factor to this development
was the rapid spread of neurasthenia in Europe and North America in
the final two decades of the nineteenth century. At the time, neurasthe-
nia was regarded as the illness of the age par excellence. Modern living
conditions and the associated acceleration in the pace of life and work
seemed to be subjecting the human nervous system to unbearable strain.
Even Max Weber, who described the process of change between the eras
in sociological terms, was treated for neurasthenia and suffered under the
nervous disorder for years.5 However, the allegation that neurasthenia
was an imaginary condition and a fashionable diagnosis was also
3
Émile Durkheim, On Suicide, trans. by Robin Buss (London: Penguin Books, 2006).
4
Ibid., p. 244.
5
Jürgen Kaube, Max Weber. Ein Leben zwischen den Epochen (Berlin: Rowohlt, 2014), p. 116ff.
common at the end of the nineteenth century. In 1888, the psychiatrist

Carl Pelman wrote: ‘Like its other fashions, every era also has its fashionable
diseases. Among the most modern of the latter, the one most frequently
encountered is neurasthenia.’6 Nevertheless, it triggered a new awareness of
the mental suffering caused by social conditions. Henceforth, the ‘concept
of the exogenous’ became fundamental to the modern understanding of
psychological suffering: ‘An external factor gives rise to internal effects
resulting in a pathological reaction of the person.’7
The question for sociology, therefore, is what role certain states of a
social order play in producing subjective suffering. Pierre Bourdieu’s
study The Weight of the World has probably given the clearest voice to
present-day social suffering.8 By enabling people to talk about their
living and working conditions, their concerns and the injuries they
had suffered, Bourdieu and his research team provided interpretive
access to human distress in times of economic transformations and social
change brought about by neo-liberalism. Taking its lead from this work,
an interdisciplinary research field has arisen in recent years under the
heading of ‘social suffering’ which analyses this phenomenon in a two-
fold way: ‘Social suffering results from what political, economic, and
institutional power does to people and, reciprocally, from how these
forms of power themselves influence responses to social problems.’9
As a form of social suffering mainly rooted in work, burnout therefore
provides information about the stresses that mark the contemporary
working world. Research on burnout can be traced back to a political
and cultural milieu that has exerted a striking influence on how work
6
Carl Pelman cited in Patrick Kury, ‘Von der Neurasthenie zum Burnout – eine kurze Geschichte
von Belastung und Anpassung’, in Leistung und Erschöpfung. Burnout in der
Wettbewerbsgesellschaft, ed. Sighard Neckel and Greta Wagner (Berlin: Suhrkamp 2013),
pp. 107–28 (p. 112).
7
Kreation und Depression: Freiheit im gegenwärtigen Kapitalismus, ed. Christoph Menke and Juliane
Rebentisch (Berlin: Kadmos, 2010), pp. 52–62 (p. 52).
8
Pierre Bourdieu et al., Das Elend der Welt. Zeugnisse und Diagnosen alltäglichen Leidens an der
Gesellschaft (Konstanz: UVK, 1997).
9
Arthur Kleinman, Margaret Lock, and Veena Das (eds), Social Suffering (Berkeley: University of
California Press, 1997), p. ix; see also Iain Wilkinson, Suffering: A Sociological Introduction
(Cambridge: Polity, 2005).
is conducted today. The burnout syndrome was first described in the

mid-1970s by the New York psychoanalyst Herbert Freudenberger.10 He
encountered the condition within the ‘alternative’ helper milieu of social
workers for whom work represented much more than simply a source of
income. As a psychoanalyst involved in the Free Clinic Movement in
Spanish Harlem, and in work with drug addicts, he observed increasing
emotional emptiness, physical and mental fatigue, and cynical attitudes
towards clients in himself and among his colleagues. He established that the
danger of ‘burnout’ was particularly acute in alternative institutions,
because the high levels of commitment of the employees led them to
identify even more with the goals of the organisation.11 According to
Freudenberger, when the work with clients ended in failure the social
workers were plagued by a sense of a general personal failure, because of
the interpenetration of their private and working lives and their high
emotional investment.12
The psychological literature on burnout over the past four decades
paints a largely consistent picture: burnout follows a phase of ever-increas-
ing exertion in an effort to meet the demands on individuals made by
themselves or by others.13 Those who suffer from burnout try to com-
pensate for failures through redoubled commitment and as a result are
drawn into a spiral in which personal resources are expended faster
than they can be replenished. Although burnout is generally understood
as a matter of suffering from sheer overwork, overexertion alone is not
what leads people to ‘burn out’, but rather overexertion in the context of
certain normative expectations. Those who suffer from burnout make
high demands on their work as well as on their own labour power. They
want their professional activity to be invested with meaning, even at the
cost of depleting themselves. If a conflict arises between the reality of work
10
Herbert Freudenberger, ‘Staff Burn-Out’, Journal of Social Issues 30: 1 (1974), 159–65.
11
Herbert Freudenberger, ‘The Staff Burn-Out Syndrome in Alternative Institutions’,
Psychotherapy. Theory, Research and Practice 12 (1975), 73–82.
12
Ayala Pines et al., Burnout: From Tedium to Personal Growth (New York: Free Press, 1981),
p. 63.
13
See Wilmar Schaufeli and Dirk Enzmann, The Burnout Companion to Study and Practice:
A Critical Analysis (London: Taylor & Francis, 1998).
and their intentions and desires, they respond by increasing their work-
loads still further. Then burnout occurs as a self-destructive attempt ‘to
expend all one’s strength to meet unrealistic expectations’.14
Personal Responsibility
in the Competitive Society
Today burnout is not just a problem in the social professions, among
teachers and social workers. Unrealistic expectations concerning the resi-
lience of employees no longer stem from the idealism of the alternative
milieus of the 1970s, but have become the general rule in an economic
culture geared to permanently increasing performance at any price. The
burnout syndrome is an expression of widespread unease about the condi-
tions of work and life in a competitive society, which in the case of certain
individuals and certain phases of life becomes heightened into an acute
exhaustion crisis. The underlying reason is not particular conditions of
overwork and competition, but the confluence of numerous stress factors.
In a work environment which is encroaching more and more on private life
and which demands the expenditure of all subjective energies and motives,
the increasing competitive pressure is reflected in a close-meshed monitor-
ing of performance and success which exposes the individual to the feeling
of being continually tested. Coupled with the compression and acceleration
of everyday time management and with the norm of permanent accessi-
bility, work pervades the private sphere via digital communication – ‘after
work’ was yesterday. High mobility requirements, together with a simulta-
neous increase in precarious and temporary employment relationships and
in the demands made on work by both employers and employees, lead
to an increase in the pressure on the already high organisational demands
of everyday private and family life. In work and many other areas of
contemporary life, individuals are expected to assume responsibility for
themselves in ways that lead them to feel personally responsible
14
Herbert Freudenberger and Geraldine Richelson, Mit dem Erfolg leben (Munich: Heyne 1983),
p. 38.
for everything from their career paths to their personal health status and the
success of their children in school. This often leads to the subjection of
everyday life to business imperatives, something which many people find
very challenging in the long run.
The most important social factor in this subjection of everyday life to
business imperatives is the spread of competitive contests, as reflected in
contemporary business and professional life, but also far beyond this in
social life and popular culture. Contests are a modern way of allocating
resources. They are employed to ensure that resources are used and dis-
tributed effectively, which is why they are implemented wherever the
organisational goal is to boost individual performance. Being in competi-
tion with others is supposed to spur motivation and commitment and to
stimulate the drive to succeed. The rise of neo-liberalism since the 1990s led
to an increase in the frequency and duration of contests and their spread to
ever more areas of social activity, with the result that contests are increas-
ingly shaping the social order as a whole. On the one hand, more and more
goods are being distributed through contests and formerly public institu-
tions are becoming subjected to market forces. On the other hand, compe-
titive procedures are also being introduced as a measure for improving
effectiveness in areas where previously a market did not exist, such as in
universities and public administrations. As a result, contests are becoming
increasingly pervasive, so that the intervals between periods when people
are exposed to competitive pressures are becoming considerably shorter.
The status achieved is being placed in question again at ever shorter
intervals and must be contended for again ‘performatively’.15 This is
especially evident in temporary jobs, which increase the performance
pressure on employees and force them to prove their worth for the organi-
sation over and over again.
Thus contests, which are supposed to multiply resources, contribute
instead to their destruction on a massive scale, because they compel indivi-
duals ultimately to invest in nothing except their own competitiveness.
15
Hartmut Rosa, ‘Von der stabilen Position zur dynamischen Performanz. Beschleunigung und
Anerkennung in der Spätmoderne’, Sozialphilosophie und Kritik, ed. Rainer Forst et al. (Frankfurt:
Suhrkamp, 2009), pp. 655–71 (p. 662).
Each contest produces winners and losers. ‘Winner-take-all’ markets, in

which winners receive much more than all of the runners-up together,
produce especially high numbers of losers. To the extent that systems
of distribution in times of deepened social inequality are increasingly
characterised by such ‘all-for-one’ structures, more and more competi-
tors squander their resources on a mode of competition which has
become destructive.16 An example of this is the competition for third-
party funding in colleges and universities, which leads to countless
elaborate proposals for research that is never conducted. In business
enterprises, the effort expended in performing one’s job, which can be
measured, for example, in hours of work, is often no longer rewarded,
but instead the financial success achieved by the performance of the job
in competition with others.17 How long one has to work in order to
achieve this success is left up to the employee. This means not only that
contests produce many losers whose efforts go unrecognised but also
that employees never know when they have done enough work or
whether the time invested is already sufficient to be better than the
competition. This is one of the underlying reasons why burnout often
arises from the interplay between excessive exertion and a gratification
crisis, that is, as a result of permanent stress that does not lead to any
reward. When contests become a dominant feature of present-day
society and competitive encounters become commonplace, then con-
tests erode the subjective forces that they purport to enhance.
Authenticity, Self-Fulfilment, and New Forms

of Vulnerability
However, it is not only the diffusion of contests into every domain of social
life that makes human beings susceptible to total exhaustion. A further
subjective factor is the widespread desire that work should be more than
16
See Sighard Neckel, ‘Oligarchische Ungleichheit. Winner-take-all-Mechanismen in der
(obersten) Oberschicht’, WestEnd. Neue Zeitschrift für Sozialforschung 11: 2 (2014), 51–63.
17
See Sighard Neckel, Flucht nach vorn. Die Erfolgskultur der Marktgesellschaft (Frankfurt &
New York: Campus, 2008).
merely a matter of subsistence. Just as the burnout-prone social workers in

the helper professions in the 1970s sought to contribute to a better world
through their dedication, and as a result became trapped in a spiral of ever
greater efforts and disappointments, nowadays the desire for professional
self-fulfilment leads people to invest too much of themselves in their work.
The burnout research of the 1970s and 1980s identified bloated
bureaucracies, rigid hierarchies, dull routines, and small-scale checks as
the causes of burnout. Burnout was fostered by ‘ingrained habits’,
‘suppressed imagination’, and ‘robotic responses to the environment’,
as a typical study on burnout put it at the time.18 Following Luc
Boltanski and Ève Chiapello, this kind of criticism can be identified as
an ‘artist critique’: It is aimed at bureaucratic and Taylorist forms of
work organisation and calls for autonomy and self-fulfilment.19 Its
primary target is not the injustice of capitalist economic organisation,
but the servitude and inauthenticity to which capitalism gives rise and its
lack of opportunities for personal self-development. Many contempor-
ary forms of work have incorporated the demands for greater flexibility,
less bureaucracy, and the subjectivisation of work, and depict this as a
gain in authenticity and autonomy. Insofar as the claims to self-fulfil-
ment of employees are regarded in companies today as a source of the
creation of value, the demand for professional self-fulfilment has become
a requirement for modern employees.20
Representing one’s work as a result of an intrinsic interest is one of the
unreasonable demands of the present. Activity, self-transformation, and
commitment are the new values in the workplace. The desire to secure
personal success through high levels of motivation and continuous exertion
leads employees to link self-fulfilment with self-exploitation in a dangerous
way. Thus, the prospect of self-fulfilment lures the individuals concerned
into a trap: the more inadequate the working conditions, the more the
18
See Barbro Bronsberg and Nina Vestlund, Ausgebrannt. Die egoistische Aufopferung (Munich:
Heyne, 1988).
19
Luc Boltanski and Ève Chiapello, The New Spirit of Capitalism, trans. Gregory Elliott
(New York: Verso, 2005).
20
See Axel Honneth, ‘Organized Self-Realization: Some Paradoxes of Individualization’, European
identification with work drives the subsequent burnout victim to ever-greater

commitment, which eventually leads to an exhaustion breakdown.21
Thus, today’s burnout victims have a lot in common with the social
workers and teachers of the 1970s and 1980s, even though they are
working in completely different fields. The important difference
between the helper professions of four decades ago and present-day
employees, however, is that the high levels of identification with work,
which at the time was still mocked as the ‘helper syndrome’, has become
a requirement. The fear of being replaced drives people to work over-
time. A question posed in the German Bundestag revealed that the
number of employees who work at night has risen by 46% within a
decade, and that the number of those with excessive working hours has
risen by 23%.22 Post-Taylorist management practices in particular, in
which employees are free to choose how to achieve agreed objectives,
lead to the extension and compression of working hours: ‘What the
workers are promised as “freedom” proves on closer inspection to be
highly ambivalent self-responsibility.’23
Finite Resources
In recent years, a form of suffering caused by work in the competitive
society has become familiar under the heading of burnout, which is to a
large extent free from the stigma of individual failure. After all, the concept
of ‘burning out’ involves the notion that those afflicted were previously
inflamed by passion for their work and attests to them a socially recognised
commitment in spite of their failure. The concept of burnout created a
media space in talk shows, scholarly books, and the cover stories of
21
Elin Thunman, ‘Burnout as a Social Pathology of Self-Realization’, Distinktion: Journal of Social
Theory 13: 1 (2012), 43–60.
22
See Jutta Krellmann, ‘Atypische Arbeitszeiten dehnen sich aus, psychische Belastungen nehmen
weiter zu’ (2013), online at: www.linksfraktion.de/nachrichten/atypische-arbeitszeiten-dehnen-
sich-aus-psychische-belastungen-nehmen-weiter (accessed March 2016).
23
Rolf Haubl and G. Günther Voß, ‘Psychosoziale Kosten turbulenter Veränderungen. Arbeit
und Leben in Organisationen 2008‘, Positionen. Beiträge zur Beratung in der Arbeitswelt 1 (2009),
2–8 (7).
countless magazines to make overexertion and excessive demands into a

public issue. Changes in the world of work and the resulting psychological
costs, which the sociology of work had already been documenting in part
for decades, found their way into social debates. In this way, burnout
became a condensed symbol which made it possible to articulate criticism
of increasing performance pressure and of the inordinate demands of the
modern world of work.
Nevertheless, the normative status of burnout is in a certain sense
precarious, because quite different messages can be associated with the
exhaustion syndrome. For many the impositions of the contemporary
world of work are unavoidable in a globalised world in which companies
have to struggle for competitiveness, which is why they demand a high
level of competitive orientation among their employees. Moreover, since
the financial crisis, even being allowed to work seems to have become a
reason to be grateful. Southern European countries are stricken by reces-
sion and the crisis is reflected in unemployment and a lack of prospects, in
poverty and inadequate health care. Yet the German economy is a
beneficiary of the crisis and is growing. Against this background, the
suffering originating in the world of work is under particular pressure to
demonstrate its legitimacy, which often turns into the charge that those
afflicted with burnout are complainers who are demanding recognition
for their affluence problems. In a society in which progress and well-being
are equated with economic growth, the suffering of those who are unable
to cope is often a target of malice and scorn.
However, the self-help books on burnout agree that the main thing
an individual can do to avoid burnout is to use his or her subjective
resources sparingly. Even a cursory glance at the dust jackets of the genre
reveals the omnipresence of exhaustion metaphors, with images of men
in business suits dissipating their forces in frenzied hamster wheels and
empty battery packs which were not recharged soon enough. Such
guides advise managers not to waste the resources of their employees
if they want to prevent ‘organisational burnout’.24 The employees
24
Gustav Greve, Organizational Burnout. Das versteckte Phänomen ausgebrannter Organisationen
(Wiesbaden: Springer, 2012).
affected, by contrast, are advised to develop an awareness of the sources

of their subjective abilities and how they can use their personal life to
counterbalance work. Sport, relaxation exercises, mutual appreciation,
and the ability to recuperate and distance oneself from work are
regarded as resources that reduce the probability of burnout and help
those affected to endure chronic stress longer.25 In addition, time
management and a work-life balance are touted as suitable self-help
techniques for avoiding ‘burning out’.26 However, contemporary com-
petitive society leaves scant room for a sparing use of one’s subjective
resources. As the intervals between the moments when positions in
contests are won and the moments when they have to be defended
again become shorter, the resulting dynamisation of the status struggle
leaves little room for long-term allocations of physical and mental
forces. When this dynamic ends in collapse, the initial result is stagna-
tion. Burnout victims are paralysed, passive, and emotionless; they no
longer have any resources to contribute, let alone to put to effective use,
because the competitive society forced them to use up their entire
potential.
Often the source of exhaustion is not the demand from supervisors
to work overtime, but instead the employees’ own desire to perform
their work in such a way that the results provide them with personal
satisfaction, and they can regard their professional activity as an
important component of their self-fulfilment. In flexibilised job struc-
tures, everyone seems in addition to be at liberty to decide for him or
herself about the effort that he or she wants to invest. The direct result
is a paradoxical inversion of the quest for self-fulfilment into self-
exploitation.
25
Caroline Lanz, Burnout aus ressourcenorientierter Sicht im Geschlechtervergleich. Eine
Untersuchung im Spitzenmanagement in Wirtschaft und Verwaltung (Wiesbaden: Springer, 2010),
p. 19.
26
Stefanie Weimer and Maureen Pöll, Burnout. Ein Behandlungsmanual. Baukastenmodul für
Einzeltherapie und Gruppen, Klinik und Praxis (Stuttgart: Klett-Cotta, 2012); Julia Scharnhorst,
Burnout. Präventionsstrategie und Handlungsoptionen für Unternehmen (Freiburg: Haufe, 2012);
and Thomas M. H. Bergner, Burnout-Prävention: Sich selbst helfen. Das 12-Stufen-Programm
(Stuttgart: Schattauer, 2010).
A Buddhist Spirit of Capitalism?

Phases of social change may be accompanied by new social suffering. At
the same time, however, social suffering can also set social transforma-
tion processes into motion, because it provides a starting point for social
criticism. Capitalism responds to the criticisms aimed at it by endogen-
ising them, as Boltanski and Chiapello have shown in The New Spirit of
Capitalism in connection with the reflections of Max Weber. In The
Protestant Ethic and the Spirit of Capitalism, Weber showed that six-
teenth- and seventeenth-century Protestantism was shaped by a mental-
ity and a way of life that contributed decisively to the emergence of
modern capitalism. According to Weber’s analysis, Protestantism and
capitalism were united by an internal affinity involving inner-worldly
asceticism and economic acquisitiveness. Professional obligation, which
Protestantism invested with religious significance, is marked by a duty to
conduct one’s life in a methodical way and forms the core idea of the
ethos of capitalist culture, which Weber called the ‘spirit of capitalism’.
The general standards of social action, which – detached from their
erstwhile religious roots – today constitute the ethos of capitalist culture
and find expression in the duty of acquisition for its own sake, form, in
Weber’s famous words, the ‘iron cage’ of capitalism.
Boltanski and Chiapello take up and develop Weber’s thesis that
capitalism makes use of external patterns of justification when they
write that the spirit of capitalism is ‘an ideology that justifies engagement
in capitalism’.27 A form of critique of capitalism arose in the 1960s
which these authors describe as the ‘artistic critique’. It calls for auton-
omy, self-fulfilment, and authenticity in work.28 Its target is not the
injustice caused by growing social inequality, but the lack of freedom
and the inauthenticity to which capitalism gives rise, its rigid structures
27
Boltanski and Chiapello, The New Spirit of Capitalism, p. 6.
28
This critique is called the artistic critique because the ‘lack of any distinction between time at
work and time outside work, between personal friendships and professional relationships, between
work and the person of those who perform it’ are all ‘features which, since the nineteenth century,
had constituted typical characteristics of the artistic condition, particularly markers of the artist’s
“authenticity”’ (ibid., p. 422).
and its lack of opportunities for self-development. Thus, Taylorism was

criticised as a form of organisation that reduces people to the level of
machines and deprives them of their individuality. Not least, this artistic
criticism of the alienating working conditions of classical industrial
capitalism – of which the first burnout studies were a part – gave rise
to today’s subjectivised conditions of work characteristic of the ‘new
spirit of capitalism’.
Yet what new spirit is being brought forth by the critique of capital-
ism which takes the suffering caused by subjectivised working conditions
as its starting point? Has not the social critique represented by the
diagnoses of exhaustion of recent years already contributed to a change
in the patterns of justification of capitalism of the present?29 If one
considers the genre of self-help literature, for example, then it is notice-
able that a virtually unmanageably large number of how-to-guides have
appeared in recent years containing exercises for achieving ‘mindfulness’.
‘Mindfulness’ could represent a central concept of a new justification
order of capitalism whose explicit concern is the avoidance of exhaustion
crises. Granted, the fate of capitalism will not be decided by new
coaching programmes. Nevertheless, the manifest change in a public
discourse which takes the exhaustion crisis of subjects as its starting
point is an important indicator that the framework of legitimation of
capitalism in the twenty-first century is changing.
‘Mindfulness’ is a response to the fact that it is impossible to antici-
pate the requirements to which subjects are exposed in the conduct of
their daily lives, and it proclaims: ‘The source of stability lies within
you.’ Above all ‘mindfulness’ promises to reduce stress, to make us
healthier and happier, to increase professional success – and all this in
a working environment in which more and more processes elude the
direct control of the individual.
29
See also Sighard Neckel and Greta Wagner, ‘Erschöpfung als “schöpferische Zerstörung”.
Burnout und sozialer Wandel’, in Leistung und Erschöpfung. Burnout in der
Wettbewerbsgesellschaft, ed. Sighard Neckel and Greta Wagner (Berlin: Suhrkamp, 2013),
pp. 107–28; and Sighard Neckel and Greta Wagner, ‘Burnout. Soziales Leiden an Wachstum
und Wettbewerb’, WSI-Mitteilungen 67 (2014), 536–42.
Boltanski and Chiapello described the new spirit of capitalism as one

which represents the promise of creativity, authenticity, and autonomy.
Yet the key factor in avoiding burnout and exhaustion is acknowledging
that individuals are not able to control the conditions of their work and
that the context in which personal fulfilment is supposed to occur is
highly contingent. In a company one cannot control the order situation,
or target agreements, or the moods of team members. However, the less
predictable market developments in transnational corporations and the
behaviour of others in large teams become, the more the notion of
optimisation becomes focused on one’s own mind.
How-to-guides for achieving ‘mindfulness’ urge their readers to wel-
come situational uncertainties and to use them as a motor for innovation
without succumbing to stress in the process. They describe everyday
working life as unpredictable and full of new challenges, for which
routines cannot be developed. ‘Mindfulness’ enables one to perceive
such obstacles in a value-free way and then to welcome them as an
engine for innovation.30 For example, striving for continual change in
which, although one pursues one’s own goals, these can nevertheless
always be adapted to current situations is the credo of Buddha@Work.
Mastering Everyday Working Life in a Relaxed and Mindful Way: ‘Expend
your energy and time for changes and solutions. Do not persist in
deadlocked patterns and habits. Do not dissipate energy with nagging,
ranting and comparing. Do not block your flow of life by grasping,
clinging and adhering. Do not complain about how things are. The
sooner you are able to really accept the actual situation, the sooner you
will be able to let go of it. Now you have access to your full potential.’31
The potential we all have within us is inexhaustible, it is claimed; finite
resources only exist outside the self.
At times when the talk is everywhere of scarcity and the finite nature
of resources, the individual should focus on her wealth of inner
resources. Exhaustion seems to have become the sign of the present; it
30
See Ellen J. Langer, Mindfulness: Das Prinzip Achtsamkeit. Die Anti-Burn-out-Strategie (Munich:
Verlag Franz Vahlen, 2015).
31
Sandy Taikyu Kuhn Shimu, Buddha@Work. Den Berufsalltag gelassen und achtsam meistern
(Darmstadt: Schirner Verlag, 2014).
is ascribed to subjects, national budgets, the middle classes, and the

planet. It is not a specific present-day experience, but an experience in
which problems of contemporary life are condensed. The latter is
marked by a process of social change over the past two decades which
has been so profound that patterns of evaluation, action routines, and
social practices have been transformed from the ground up. On the one
hand, the individual with her claims to personal self-fulfilment has
moved into the centre of everyday life; on the other hand, competitive
contests as a mode of interaction have spread so dramatically that we
constantly find ourselves in competition with others, and as a result are
forced continually to invest in our own competitiveness. This require-
ment forms a debilitating alliance with the imperative to adapt one’s
personality to competitive conditions, while nevertheless remaining all
the more authentic. As a result, the social order of the present wears out
subjective resources and leads many people to collapse from exhaustion.
However, the critique of the abuse of subjectivity aimed at valorising
it is not only part of the diagnosis of the present of social criticism; it is
also a component of the self-renewal of capitalism. Far from merely a
form of economic production, capitalism is also a normative order, and
this normative order always includes narratives – be they religious or
cultural – which lend it legitimacy and thereby help it to renew itself.
Buddhist practices such as ‘mindfulness’ are introduced with the goal of
maintaining the ability to work, because they provide a way of dealing
with accelerated change and contingency. At the same time, they alle-
viate people’s fears of working environments in societies pervaded by
market imperatives, and make them appear attractive and as places of
spiritual growth. In this way, the Buddhist promise of unlimited poten-
tial within the self provides a new legitimation basis for a social order
based on permanently increasing value. The unperturbed acceptance and
promotion of constant change, trust in large networks, adjusting one’s
goals and desires to ever new circumstances, and the belief that one’s
potential is inexhaustible are key competences in flexible network capit-
alism. Buddhist practices such as mindfulness exercises provide resources
and coping strategies, as well as a metaphysical meaning, for this social
order. Therefore, exhaustion as a symbolic condensation of contempor-
ary lifestyles that have become problematic might even contribute to a
Buddhist spirit of capitalism which provides a spiritual framework for a

hyper-individualisation of social problems.
References
Thomas M. H. Bergner, Burnout-Prävention: Sich selbst helfen. Das 12-Stufen-
Programm (Stuttgart: Schattauer, 2010).
Pierre Bourdieu et al., Das Elend der Welt. Zeugnisse und Diagnosen alltäglichen
Leidens an der Gesellschaft (Konstanz: UVK, 1997).
Ellen Braun and Steffen Hillebrecht, ‘Betriebliche Wahrnehmung des
Burnouts’, Der Betriebswirt. Management in Wissenschaft und Praxis 54:
3 (2013), 16–22.
Barbro Bronsberg and Nina Vestlund, Ausgebrannt. Die egoistische Aufopferung
(Munich: Heyne, 1988).
Émile Durkheim, On Suicide, trans. Robin Buss (London: Penguin Books, 2006).
Alain Ehrenberg, ‘Depression: Unbehagen in der Kultur oder neue Formen der
Sozialität’, in Kreation und Depression: Freiheit im gegenwärtigen Kapitalismus,
ed. Christoph Menke and Juliane Rebentisch (Berlin: Kadmos, 2010),
pp. 52–62.
Herbert Freudenberger, ‘Staff Burn-Out’, Journal of Social Issues 30: 1 (1974),
159–65.
———, ‘The Staff Burn-Out Syndrome in Alternative Institutions’,
Psychotherapy: Theory, Research and Practice 12 (1975), 73–82.
Herbert Freudenberger and Geraldine Richelson, Mit dem Erfolg leben
(Munich: Heyne, 1983).
Gustav Greve, Organizational Burnout. Das versteckte Phänomen ausgebrannter
Organisationen (Wiesbaden: Springer, 2012).
Ulfert Hapke et al., ‘Stress, Schlafstörungen, Depressionen und Burnout:
Wie belastet sind wir?’, in Bundesgesundheitsblatt-Gesundheitsforschung-
Gesundheitsschutz (Berlin: Springer, 2012), pp. 987–8.
Rolf Haubl and G. Günther Voß, ‘Psychosoziale Kosten turbulenter
Veränderungen. Arbeit und Leben in Organisationen 2008’, Positionen.
Beiträge zur Beratung in der Arbeitswelt 1 (2009), 2–8.
European Journal of Social Theory 7: 4 (2004), 463–78.
Jürgen Kaube, Max Weber. Ein Leben zwischen den Epochen (Berlin: Rowohlt,
2014).
Arthur Kleinman, Margaret Lock and Veena Das (eds), Social Suffering
(Berkeley: University of California Press, 1997).
Jutta Krellmann, ‘Atypische Arbeitszeiten dehnen sich aus, psychische
Belastungen nehmen weiter zu’, 2013, online at: www.linksfraktion.de/
nachrichten/atypische-arbeitszeiten-dehnen-sich-aus-psychische-belastun
gen-nehmen-weiter (accessed March 2016).
Carl Pelman cited in Patrick Kury, ‘Von der Neurasthenie zum Burnout – eine
kurze Geschichte von Belastung und Anpassung’, in Leistung und
Erschöpfung. Burnout in der Wettbewerbsgesellschaft, ed. Sighard Neckel and
Greta Wagner (Berlin: Suhrkamp, 2013), pp. 107–28.
Ellen J. Langer, Mindfulness: Das Prinzip Achtsamkeit. Die Anti-Burn-out-
Strategie (Munich: Verlag Franz Vahlen, 2015).
Caroline Lanz, Burnout aus ressourcenorientierter Sicht im Geschlechtervergleich.
Eine Untersuchung im Spitzenmanagement in Wirtschaft und Verwaltung
(Wiesbaden: Springer, 2010).
Sighard Neckel, Flucht nach vorn. Die Erfolgskultur der Marktgesellschaft
(Frankfurt & New York: Campus, 2008).
Sighard Neckel, ‘Oligarchische Ungleichheit. Winner-take-all-Mechanismen in
der (obersten) Oberschicht’, WestEnd. Neue Zeitschrift für Sozialforschung
11: 2 (2014), 51–63.
Sighard Neckel and Greta Wagner, ‘Erschöpfung als “schöpferische Zerstörung”.
Burnout und sozialer Wandel’, in Leistung und Erschöpfung. Burnout in der
Wettbewerbsgesellschaft, ed. Sighard Neckel and Greta Wagner (Berlin:
Suhrkamp, 2013), pp. 107–28.
———, ‘Burnout. Soziales Leiden an Wachstum und Wettbewerb’, WSI-
Mitteilungen 67 (2014), 536–42.
Ayala Pines et al., Burnout: From Tedium to Personal Growth (New York: Free
Press, 1981).
Hartmut Rosa, ‘Von der stabilen Position zur dynamischen Performanz.
Beschleunigung und Anerkennung in der Spätmoderne’, in Sozialphilosophie
und Kritik, ed. Rainer Forst et al. (Frankfurt: Suhrkamp, 2009), pp. 655–71.
Julia Scharnhorst, Burnout. Präventionsstrategie und Handlungsoptionen für
Unternehmen (Freiburg: Haufe, 2012).
Wilmar Schaufeli and Dirk Enzmann, The Burnout Companion to Study and
Practice: A Critical Analysis (London: Taylor & Francis, 1998).
Sandy Taikyu Kuhn Shimu, Buddha@Work. Den Berufsalltag gelassen und

achtsam meistern (Darmstadt: Schirner Verlag, 2014).
Elin Thunman, ‘Burnout as a Social Pathology of Self-Realization’, Distinktion:
Stefanie Weimer and Maureen Pöll, Burnout. Ein Behandlungsmanual.
Baukastenmodul für Einzeltherapie und Gruppen, Klinik und Praxis
(Stuttgart: Klett-Cotta, 2012).
Iain Wilkinson, Suffering: A Sociological Introduction (Cambridge: Polity,
2005).


14
Conclusion
Sighard Neckel, Anna Katharina Schaffner
and Greta Wagner
Although the history of exhaustion theories and the search for medical
cures for states of chronic exhaustion reaches back all the way to classical
antiquity, diagnoses of exhaustion-related syndromes have risen sharply
in recent years. The psycho-social, medical, and economic effects of
exhaustion are a problem that attracts widespread public attention.
The chapters collected in this volume address the growing concern
with exhaustion from different disciplinary perspectives, reflecting on
the causes of the epidemic of exhaustion we are currently witnessing, on
S. Neckel (*)
e-mail: Sighard.Neckel@wiso.uni-hamburg.de
A.K. Schaffner
G. Wagner

DOI 10.1007/978-3-319-52887-8_14
306 S. Neckel et al.
cultural and historical differences in the assessment, theorisation, and

frequency of exhaustion, and on the wider socio-political implications of
specific exhaustion syndromes. In all accounts, the mind, the body, and
the social feature as the central aetiological driving forces of exhaustion,
but the conception of the exact status and significance of these compo-
nents, and also of the ways in which they are thought to interact with
each other, differ in each chapter.
While the precise relationship between psychological and somatic
dynamics is already a highly controversial topic among exhaustion
theorists, and among medical practitioners more generally, the intro-
duction of the social as an illness-generating force complicates matters
further.1 It is possible to characterise exhaustion as a social problem in
Max Weber’s sense. In order to tackle social problems, one has to
identify the social developments, structures, institutions, and practices
that cause those phenomena. While most people would probably agree
that high rates of depression and burnout cause social problems, such as
high health-care costs, some would propose that exhaustion may in
itself constitute a social problem. If chronic exhaustion were simply a
bodily reaction that followed sustained physical or cognitive effort, it
would be an anthropological constant; it would exist independently
from social structures and social change. The conceptualisation of
exhaustion as a social problem, by contrast, is based on the idea that
certain social demands in contemporary society have led to a chronic
overuse of subjective resources and have therefore given rise to new
forms of social suffering. According to this view, today’s epidemic of
exhaustion syndromes is directly related to the flexibilisation of work
and the growing demands to practise self-control and constant (emo-
tional) self-optimisation.2
1
For an excellent discussion of recent mind-body research, see Jo Marchant, Cure: A Journey into
the Science of Mind over Body (New York: Crown, 2016).
2
According to this view, which understands exhaustion as intricately related to the ills of
globalised neo-liberal capitalism, attempts to tackle exhaustion epidemics by recruiting more
therapists specialising in CBT – a strategy proposed by a recent LSE report discussed in Alain
Ehrenberg’s chapter – would seem hopelessly inadequate. Enhancing individual resilience, and
problems of ‘focus, empathy, and self-control’, would appear a wrong-headed, even absurd
approach, as it is clearly damaging external structures that need changing.
14 Conclusion 307
Furthermore, it is possible to describe the epidemic of exhaustion as

the result of a violation of human nature. The biological would then
serve as a normative criterion to assess the social and one could ask: Is it
the case that our energy levels have remained more or less the same
throughout history, and that demands on our energies have significantly
increased in the past decades? In other words, is there a considerable gap
between human nature and our current social reality, a fundamental
mismatch between our psycho-social constitution and our new working-
environment? Or, in more biological terms, is our hormonal stress
management system attuned to the Stone Age and unfit for purpose in
the age of neo-liberal techno-capitalism? Have our working environ-
ments become so stressful that we find ourselves in a state of chronic
alert, in constant fight or flight mode, resulting in a perpetual emission
of stress hormones such as cortisol, adrenaline, and noradrenaline, which
can lead to a weakening of our immune system and chronic exhaustion?
Regardless of whether the causes of exhaustion-related syndromes are
primarily biological, psychological, or social, every form of distress has a
somatic representation. Without that representation, it could be experi-
enced neither by the self nor be visible to others. Yet the interplay
between the biological and the social is always twofold: Not only do
biological-somatic processes need interpretation and diagnosis – which
are always social constructs that endorse specific social values and inter-
ests. Conversely, all social processes – provided that they are experienced
by actors – are reflected in biological processes.3
It is also possible to characterise the current concern with exhaustion
as a discursive event and to focus on the functions the discourse on
exhaustion performs. Alain Ehrenberg, for example, argues that we are
witnessing a dramatic ‘change in the social status of psychic suffering, and
an extension of its uses, particularly in the political sphere’. The question
of mental health more generally has acquired a value that extends well
beyond the area of individual psycho-pathology. Psychological suffering
‘has been extended to social issues and must be approached as an
3
See, for example, Birgitt Röttger-Rössler and Hans J. Markowitsch (eds), Emotions as Bio-
Cultural Processes (New York: Springer, 2009).
expected expression of social malaises’. Some of the core tensions of neo-

liberalism, Ehrenberg argues, are negotiated in the way states of exhaus-
tion are being problematised.
The debate about the causes of chronic exhaustion is not just of
academic interest, since it shapes public policies and the admini-
stration of specific medical cures and thus impacts on the lived
experience of patients. Furthermore, it determines the public status
of sufferers in a given society: Whether they are considered to be
victims of social developments that have turned our working environ-
ments into hostile places that do irreparable damage to our physical
and emotional well-being, or whether they are thought to be suffering
from an as yet largely undetermined biological illness, or whether
they are thought to be lacking in will power and commitment, or
else reacting psychosomatically to childhood adversity and loss,
shapes both public and medical attitudes towards the chronically
exhausted.
It is no coincidence that mindfulness is currently experiencing a surge
in popularity: Mindfulness exercises allow practitioners to re-establish a
sense of equilibrium, to re-focus their attention and energies on the here
and now, and to develop resilience against many of the energy-draining
stressors of modern life. Based on Buddhist principles, mindfulness is
just one of many Eastern practices designed to enhance energy and to
allow practitioners to relax and to de-stress, which are becoming ever
more popular in the West, and which also include yoga, qi gong, and
acupuncture. These Eastern holistic approaches have a noticeable advan-
tage over Western biomedical ones: They are based on an explicit notion
of human energy.
But what is human energy? How can we define and quantify it?
Although there are numerous theories of the exhaustion of human
energy – many of which have been discussed in the chapters of this
collection – it is striking that human energy in modern Western medical
and psychological accounts is generally defined ex negativo, that is, via
analyses of pathological states of energy depletion. Apart from the
prosaic thermo-chemical calorie model deployed in nutritional science,
there are currently no scientifically accepted models of human energy
available in Western medicine.
14 Conclusion 309
Even in the psychoanalytical tradition, Freud’s and his successors’

theories of libido, and of drive energy more generally, remain strikingly
vague. Human energy is a concept that is often taken for granted and
very rarely defined. In spite of its importance and increasing fears about
the chronic depletion of our energies, the discourse on human energy
often remains in the domain of esoteric speculation and is frequently
dismissed as pseudoscience.
Many Eastern cultures, in contrast, have been characterised by
widely accepted models of human energy, such as the chakras and
prana in the Indian tradition, qi in Chinese Medicine, and auras and
energy fields in shamanic cultures. In the West, too, more explicit
concepts of human or life energy are to be found in the pre-modern
era: Galen, for example, refers to the ‘animal spirits’, the Stoic
philosophers develop the notion of ‘pneuma’, and, more recently,
thinkers from the vitalist tradition have theorised the ‘élan vital’.
However, the tradition of widely accepted models of human energy
arguably ends with Freud’s notion of libido. While we have seen
the rise of ‘energy psychology’ in recent years, a holistic, integrative
school of thought that seeks to combine conventional therapeutic
approaches with techniques from yoga, qi gong, acupressure, and
energy medicine, combining insights from neurobiology and cogni-
tive behavioural therapy with ancient wisdom, the models proposed
by these practitioners are far from being universally accepted.
Although references to human energy are ubiquitous both in popular
and in medical discourse, the concept remains vague. Why has the
analysis of human energy been relegated to the realms of the esoteric
and the pseudoscientific in modern Western culture? The fact that ours
is an age in which scientistic, positivistic, and purely evidence-based bio-
medical materialism dominates has certainly contributed to the neglect
of this concept, and to the tendency to leave it profoundly underdeter-
mined. Holistic medical conceptions of the mind–body nexus have
increasingly fallen from favour in modern medicine. However, given
that concerns about burnout, stress, and depression have risen sharply in
recent decades, and that an entire industry is now dedicated to boosting
human energy (be it psychological or physical), the silence of the
medical establishment on the matter is striking.
Human energy remains, then, a curiously under-researched phenom-

enon, in spite of the centrality of human energy to conceptions of mind
and body, work and leisure, well-being and illness. In the age of stress,
burnout, and depression, the need for a working definition of human
energy has become ever more pressing. Energy in the sciences can be
expressed in neat formulae, it can be quantified and measured, and its
behaviour can be described in terms of laws. No such thing is possible
when it comes to human energy. We can only ever observe the effects of
human energy, or else the effects of its absence – which is what exhaus-
tion theorists have been doing for more than 2,000 years.
References
Jo Marchant (2016) Cure: A Journey into the Science of Mind over Body
(New York: Crown).
Birgitt Röttger-Rössler and Hans J. Markowitsch (eds), Emotions as Bio-
Cultural Processes (New York: Springer, 2009).


Humanities at the University of Kent, UK. She has published on the histories
of exhaustion, sexology and psychoanalysis, Dada, the film director David
Lynch, and various modern writers. Her most recent monograph, Exhaustion:
A History, was published by Columbia University Press in 2016.

Index
A in French society, 155, 156

Acedia, 5, 15, 27–48 self-defeating solution to
Agency, 44, 46 burnout, 228, 299
Alienation, 11, 14, 113 self-realisation, 196, 197
as evolved category in the modern
analysis of capitalism, 297
as western concept, 120, 121 B
Amphetamines, see Drugs Bauer, Michael
Aquinas, St Thomas, Summa on managerial disease, 51–71
Theologiae, 15, 42–45 Beard, George M., 46, 238
Attention Deficit Hyperactive analysis of neurasthenia, 54–58,
Disorder (ADHD), see Drugs 79, 113–114
Authenticity Behavioural health, 165
through work, 186 Bourdieu, Pierre
via altruistic values, 188 on social suffering, 288
Autonomy, 12, 17, 155–157, Brainworkers
160–162, 165–168 susceptibility to neurasthenia, 55,
challenged by exhaustion, 196, 299 114

DOI 10.1007/978-3-319-52887-8
312 Index
Buddhism specific features of development in

as spirit of capitalism, 297–301 Germany, 130, 131, 136, 137,
Burnout, 105–124 138, 139, 142
academic reception, 121, 131 stand-alone definition, 93, 107
as an industry, 105 trendsetting illness
associated imagery, 11, 18, 71, (Zeitkrankheit), 217, 219
220, 295 and ‘work-life balance’, 230, 296
in the Bible, 111 See also Freudenberger, Herbert
‘cover-up diagnosis’, 129–147
criticism as a diagnostic
C
category, 94, 218
Cameron, David, 45
development by
Cassian, John, The Monastic
Freudenberger, 93, 105, 107,
Institutes, 36–40
112, 114, 117
Chekhov, Anton, Spat’ hochetsya (Let
development of and increases in
Me Sleep), 249–254
diagnosis in America, 106, 109,
China
132
neurasthenia diagnoses, 7
development by Maslach, 105,
See also Far East
107–108, 113
Chronic Fatigue Syndrome (CFS), 3,
difference from CFS and
16, 77, 79, 87, 88, 89, 91
ME, 90–92
difference from burnout, 96–97
difference from depression, 90,
difference from depression, 90
116–118
difference from neurasthenia, 91
European-specific features, 122
See also Myalgic
lack of research on intervention
Encephalomyelitis (ME)
strategies, 106, 135, 136, 230
Cognitive Behavioural Therapy
as loss of control, 223
(CBT)
media appearances, 10
as treatment for mental
movement out of human services
illness, 164, 166
specific diagnoses, 107, 108,
Critiques of modernity, 4, 5
109, 110, 115, 121, 131, 139,
of enlightenment project, 5
140, 145
positive connotations, 16, 140,
142, 146, 225, 228, 231, 237, D
285 Depression, 1, 3, 5, 29, 31
research in non-Western difference from burnout, 95, 116,
countries, 119 117, 144
Index 313
differences from CFS and ME, 96 F

WHO depression estimates, 195 Far East
Drugs diagnoses of exhaustion
arguably a treatment, 196 syndromes, 80–85
cultural fashions in use, 203 Fashion
division of time into work and in diagnoses, 2, 3
leisure, 209, 210 in drug use, 203, 204
forms of neuroenhancement, 196, Foucault, Michel
199, 200, 207, 211 self-control, 161
history of amphetamines, 200, system of discipline, 226
201, 207, 208 France
use in the workplace, 207, 208 malaise, 157
Durkheim social cohesion, 163
social reasons for suicide, 287 workplace mental
health, 155–159
Freudenberger, Herbert J., 12, 52,
93, 105, 107, 112, 114, 117,
E 131–132, 289
Erb, Wilhelm, 7, 46 work with drug addicts, 107, 289
neurasthenia symptoms See also Burnout
definition, 53–54 Freud, Sigmund, 45
Evagrius Ponticus, Antirrhetikos, 35 Futurism, 240
Exhaustion
as an ‘endless ending’ in
Barthes, 252 G
consequence of autonomy, 196 Galen, 30–33
modern forms, 29, 284 On the Affected Parts, 15, 30, 31
in modernist literature, 242, 247, Germany
249 comparison with the U.S.A., 53,
overcoming as inhuman, 246 65, 67
overview, 1 ‘economic miracle’, 65, 284
relation to physics, 242 increase in neurasthenia diagnoses
responsibility for one’s own, 187, in the 19th century, 15, 28, 53,
219 54
whether vice or sin, 36, 41 managerial disease, 15
workplace causes, 175, 239, 293 post WWI decrease in
See also Literature diagnoses, 54, 60
314 Index
Germany (cont.) Liberalism

post WWII increases, 61, 62, 66, Varieties of, 157–158
67, 110 Literature
See also Managerial disease itself being tired, 249–252
God, 42–44 overcoming exhaustion, 237–254
Greene, Graham, A Burnt-Out See also Exhaustion
Case, 112
M
H
Magic
Halhuber, Max J.
Forms of dealing with
on managerial disease, 62
passions, 155
Hippocrates, 29
rites of the Azandes, 154
Hofer, Hans-George
Managerial Disease, 15, 61–66, 284
reasons for rise in burnout
decline of the term’s use, 62
diagnoses, 54
development in America, 53,
Hugh of Saint Victor, On the
63–65
Sacraments of the Christian
reasons for popularity of diagnosis
Faith, 41–44
in Germany, 66–68
Humoural theory, 15, 29–30, 33
rise in Germany see (Germany)
role in the development of stress
J research, 53, 66, 70
Jores, Arthur, 66–68 Mann, Thomas, Buddenbrooks, 112
reasons for backwardness in Mansfield, Katherine, The-Child-
German medicine, 68 Who-Was-Tired, 251–250
Meckel, Miriam, 141–142
Melancholia, 29, 30, 31, 33, 34, 36
K Mental health
Kermode, Frank, 48 costs, 154
Kraepelin, Emil, 6, 60, 114 as global idiom, 164, 166
Krafft-Ebing, Richard von, 46 as social necessity, 163
Mind-body relation
in Galen, 32, 33
L Mindfulness, 298, 299, 300
Latour, Bruno, Nous n’avons jamais Miss Jones (proto-burnout case
été moderns, 51, 52 study), 112, 113
Index 315
Monks, 34, 35, 36, 38, 39, 40 Neuroenhancement, see Drugs

Myalgic Encephalomyelitis (ME), 8, Nietzsche, Friedrich, 5
79, 86, 87, 88 Nordau, Max, Degeneration, 239
difference from burnout, 95
difference from depression, 90
difference from neurasthenia, 91 P
See also Chronic Fatigue Paul, Helmut
Syndrome (CFS) development of stress research, 69,
70
Performance pressure, 63, 218, 291
N methods of avoidance, 209
Nature The “Personal Equation”, 161
as contradicted by modern work Pope Gregory the Great, 40
patterns, 220, 223, 299 Pride
separation from culture, 51 in the workplace, 180, 181
Neo-Liberalism, 28, 288, 291 Psychoanalysis, 42, 45
Neurasthenia, 5 in America, 71
collapse of diagnoses, 79, 115
cross-pollination between Western
and Eastern usages, 84 Q
default diagnosis for unexplained Quinlan, Mary Lou, 143
symptoms, 79, 80, 116
difference from CFS and ME, 89,
91
R
disease of civilization, 53, 58, 115
Radkau, Joachim
general causes of growth in
reasons for rise in burnout
diagnosis, 113
diagnoses, 59
for the history of the neurasthenia
Restlessness, 29, 30, 35, 36, 38
diagnoses in the Far East cf Far
Roelke Volker, 52, 57
East
for the history of the neurasthenia
diagnoses in Germany cf S
Germany Saint Paul, 39
nineteenth-century diagnoses, 28, Selye, Hans, 46, 53, 69
113, 115, 116, 284, 287, 288 Seven Deadly Sins, 34, 35, 40
U.S. to German diagnostic Shakespeare, William, 111
differences, 52, 53 Shame
316 Index
Shame (cont.) mental health problems

in the workplace, 181–182, 188, increase, 173, 174
190 sick leave, 173
Sloth, see Acedia
Social pathologies, 218 W
Sociology Weber, Max, 287, 297
role in burnout investigation, 158, exemplary burnout case, 59
159, 162, 225, 287, 288 ideal types, 4
Soul Wenzel, Siegfried, 34, 40
in Galen, 32 White, Peter
Spiro, Herbert J. causes of misdiagnoses, 89
On managerial disease, 63, 64 Women
Sweden gender differences in burnout or
education system, 177 neurasthenia diagnoses, 57,
elderly care, 178 135, 140

Burnout, Fatigue, Exhaustion

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Burnout, Fatigue, Exhaustion

Uploaded by

Copyright:

Available Formats

Burnout, Fatigue, Exhaustion

Sighard Neckel • Anna Katharina Schaffner • Greta Wagner

ISBN 978-3-319-52886-1 ISBN 978-3-319-52887-8 (eBook)

© The Editor(s) (if applicable) and The Author(s) 2017

Cover design by Tom Howey

Printed on acid-free paper

This Palgrave Macmillan imprint is published by Springer Nature

Part I Cultural-Historical Perspectives

2 Pre-Modern Exhaustion: On Melancholia and Acedia 27

3 Neurasthenia and Managerial Disease in Germany and

Part II Exhaustion Syndromes

4 Exhaustion Syndromes: Concepts and Deﬁnitions 77

5 Burnout: A Short Socio-Cultural History 105

6 Burnout: From Work-Related Stress to a Cover-Up

Part III Exhaustion and Self-Realisation

7 What We Talk About When We Talk About Mental

8 Self-Realisation Through Work and Its Failure 173

9 Exhaustion and Euphoria: Self-Medication with

Part IV Exhaustion Discourses

10 Rechargeable Man in a Hamster Wheel World:

11 Literary Exhaustion 237

Part V Exhaustion and the Social

12 Social Agony and Agonising Social Constructions 259

13 Exhaustion as a Sign of the Present 283

Table 4.1 Fatigue Syndromes 81

Our age, it seems, is the age of exhaustion. The prevalence of exhaustion –

© The Author(s) 2017 1

As the precise organic causes of chronic exhaustion are still being

This concept is thus able to connect individual psychological crises with

of the increase in diagnoses of mental illnesses oﬀered by social sciences

Exhaustion as a Sign of the Times?

contradictory symptoms into a diagnosis of a disease. They are also often

variously been explained as a product of biochemical imbalance, as a

transformed in a short time by technical innovations and were thought to

behavioural, and psychological factors may subsequently contribute to

with the increasing pace of work and communication, with excessive

and excessive commitment, and the battery must be recharged through

Exhaustion and Self-Fulﬁlment

also accorded a central role, in addition to sheer overload, to the feeling

observed in the past as well, and is it a typically Western phenomenon?

common characteristics, initially all working in environments presenting

personal fulﬁlment, a process which often results into self-exploitation.

Wilhelm Erb, Über die wachsende Nervosität unserer Zeit (Heidelberg:

Sighard Neckel is Professor of Sociology at the University of Hamburg. He

Anna Katharina Schaﬀner is Reader in Comparative Literature and Medical

Greta Wagner is Research Associate at the Institute of Sociology at the

A.K. Schaﬀner (*)

© The Author(s) 2017 27

intensiﬁed competition in the context of globalised neo-liberal capital-

psychologists since classical antiquity. The speciﬁc ways in which

BC, and further developed by the Greek physician Galen of Pergamum

some of the behavioural signs of depression today.7 Galen proposes that,

As some kind of sooty and smoke-like evaporation or some sort of heavy

Ostensibly ﬁgurative expressions still in use today, such as ‘clouded

exclusive attention to and memory of negative information, which can

proceeds to impact adversely on the mind and the spirit by slowing or

Evagrius’s deﬁnition of acedia thus includes not only the exhaustion

is akin to dejection, and is especially trying to solitaries, and a dangerous

Here, Cassian describes the physical symptoms of acedia in terms of

extended walking, and which results in a craving for sustenance. Like

is disturbed, until, worn out by the spirit of accidie, as by some strong

All the inconveniences of this disease are admirably expressed by David in

Rather than conceiving of the various symptoms of exhaustion as having

failing caused by a lack of willpower or a moral defect. The behavioural