Short version of the book:

What Nobody Tells You About Burnout

Author: Marcos Mendanha (Brazil)

About the author: Physician, director and professor at the CENBRAP College
(www.cenbrap.edu.br), where he has conducted and coordinated studies, courses and events on
psychiatry and workers' mental health for over 10 years. He specializes in Occupational Medicine,
and Forensic Medicine and Medical Expertise. He is a lawyer specializing in Labor Law;
postgraduate degree in Philosophy; and visiting professor of the postgraduate course in
Occupational Medicine at the Faculty of Medicine of the University of São Paulo (FM-USP). He
is the author of the books "What nobody told about Burnout - Practical and controversial aspects"
(Editora Mizuno), "Occupational Medicine and Medical Expertise - Practical and controversial
aspects" (Editora LTr), and co-author of several works. He is coordinator of the Brazilian Congress
of Occupational Psychiatry (CBPO: www.congressopsiquiatria.com.br).

Author contacts:
Site: www.professormendanha.com.br
Instagram: @professormendanha

To quote from this book:

Mendanha, M. O que ninguém te contou sobre Burnout. Leme-SP: Mizuno, 2022.

To purchase this complete book in print and original format:

https://www.amazon.com.br/que-Ningu%C3%A9m-Contou-Sobre-Burnout/dp/655526540X
DEDICATION

To Paula (my wife), Clarice and Mateus (our children).

Whenever I think of living a life of love and meaning, you are the one I think of first.
ACKNOWLEDGEMENTS

To God, thank you very much!

Also, to my whole family, for the richness of the moments we have spent together.

To my wonderful co-workers at CENBRAP, to all my students, former students, and people who
assisted me at some institution and/or event, in addition to the many walking partners on social
networks (part of our good discussions and ideas was materialized in this work).

To the participants of the Brazilian Congress of Occupational Psychiatry (Congresso Brasileiro de

Psiquiatria Ocupacional – CBPO: www.congressopsiquiatria.com.br), which I have the honor of
coordinating.

To all who somehow encouraged me and contributed to this challenging and uplifting work.
 CONTENTS

PRESENTATION

CHAPTER 1: “BURNOUT: WHAT SONG IS THAT?” (Note: Required reading to

understand this book)
1. What Burnout are we talking about: “Freudenberger’s Burnout”, “Maslach/MBI Burnout”,
“ICD-11 Burnout” or “Common Sense Burnout”?

CHAPTER 2: MENTAL SUFFERING IS A SERIOUS THING

2. Does mental suffering exist?
3. Can work cause mental illness?
4. Should institutions invest in the mental health of their workers, or is this a human and financial
waste?

CHAPTER 3: STRESS AND ITS CONSEQUENCES (GOOD AND BAD)

5. Does every stress fall ill?
6. What is the difference between adaptive stress and non-adaptive stress?
7. May chronic stress be adaptive to some people and non-adaptive to others?
8. Will all workers who are exposed to chronic stress fall ill?
9. Why, in the same work environment with intense and perpetual moral harassment (chronic
stress), do some workers fall ill, and others do not?
10. Is work a risk factor for suicide?

CHAPTER 4: SYNDROME, DISEASE, AND DISORDER CONCEPTS

11. What is the difference between syndrome and disease?
12. Why does Burnout Syndrome not meet the technical criteria of a syndrome?
13. Why are mental illnesses also called mental disorders?
CHAPTER 5: BURNOUT, FROM BIBLICAL REFERENCES TO THE EARLY 1970'S

14. How did the expression “Burnout” arise?

15. How did the term “Burnout” become popular even before it was classified as syndrome?

CHAPTER 6: ‘FREUDENBERGER’S BURNOUT’ (FB)

16. When was Burnout first described as a syndrome, and who created this description?
17. Who was Herbert Freudenberger and, what made him think of Burnout Syndrome?
18. H ow did Freudenberger find the term Burnout to name his proposed syndrome?
19. What were the clinical characteristics (signs and symptoms) of the Burnout Syndrome
described by Freudenberger?
20. According to Freudenberger, what were the causes and risk factors for Burnout Syndrome?
21. According to Freudenberger, what are the possible types of Burnout?
22. According to Freudenberger, who is more likely to develop Burnout Syndrome?
23. For Freudenberger, is Burnout Syndrome a disease?
24. For Freudenberger, is Burnout Syndrome curable? What are the ways to combat it?

CHAPTER 7: ‘MASLACH/MBI BURNOUT’ (MMBIB)

25. How did Burnout become more emphatically and specifically work-related?
26. Who is Christina Maslach, and why is this researcher so essential to understand Burnout
Syndrome nowadays?
27. For Maslach, what is Burnout Syndrome?
28. What are the main differences between ‘Freudenberger’s Burnout’ (FB) and ‘Maslach/MBI
Burnout’ (MMBIB)?
29. Is there any relationship between the Burnout Syndrome proposed by Maslach and the so-
called Impostor Syndrome?
30. What is the recommended instrument for individual and/or population assessment of Burnout
Syndrome proposed by Christina Maslach?
31. Besides MBI (Maslach Burnout Inventory), are other instruments proposing to “measure
Burnout”?
32. What is MBI, how was it made, and why is it important?
33. What are the MBI versions?
34. How is MBI structured? How is it used?
35. How should the MBI score be interpreted, and what is the cutoff point to assure that someone
has (or has not) the Burnout Syndrome proposed by Maslach?
36. Is MBI used to identify if someone has (or not) the Burnout Syndrome proposed by Maslach?
37. In MBI, are there exclusion criteria for the Burnout Syndrome proposed by Maslach? Is there
any way of avoiding ‘Maslach Burnout’?
38. What is the most significant risk to public health when using MBI as a reference for the
diagnosis of Burnout Syndrome proposed by Maslach?
39. Is MBI used to measure “Freudenberger’s Burnout”?
40.What is the concept of depersonalization for psychopathology (fundamental subject for
psychiatry and clinical psychology)? What about MBI and Burnout Syndrome proposed by
Maslach?
41.If someone with “serious and constant problems in the marriage” undergoes MBI: can the
results suggest higher degrees of the Burnout Syndrome proposed by Maslach?
42.If someone with a depressive disorder (non-work related) undergoes MBI, can the results
suggest higher degrees of the Burnout Syndrome proposed by Maslach?
43. What other mental disorders can “contaminate” (confuse) the results measured by MBI?
44. According to MBI, how many symptoms does the Burnout Syndrome proposed by Maslach
have?
45. Can MBI consider other psychiatric diagnoses as being the Burnout Syndrome proposed by
Maslach?
46. Is it possible to establish any correlation between the Burnout Syndrome proposed by Maslach
and RSI/WRMDs?
47. It is not the purpose of MBI to certify whether someone has (or not) the Burnout Syndrome
proposed by Maslach. Why does most of the research using this instrument not respect this?
48. What are the impacts of this divergence between Christina Maslach (who states that it is not
the purpose of MBI to certify whether someone “has” or “does not have” the Burnout Syndrome
proposed by her) and the researchers who also base their studies on MBI, but do not follow the
recommendation of the author of the instrument?
49. If MBI qualifies 100% of respondents with the Burnout Syndrome proposed by Maslach, why
are there studies that use MBI but show different percentages of Burnout in the evaluated
population? Should it not be 100% Burnout for every analyzed sample and study?
50. Is it true that MBI and its manuals are copyrighted? If so, what are the impacts of that?
51. For Maslach, is Burnout Syndrome a disease?
52. For Maslach, is there a ‘cure’ for the Burnout Syndrome proposed by her and her collaborators?
If so, how is this “cure” established?
53. According to Christina Maslach, what are the six most essential areas an institution must
observe so its employees become increasingly engaged (and without the Burnout Syndrome
proposed by her)?
54. According to Maslach, how should institutions measure workers' perception of the six possible
areas of disagreement between a person and work?

CHAPTER 8: “ICD-11 BURNOUT” (ICD11B)

55. Why should ICD-11 (the tenth version of the International Classification of Diseases proposed
by WHO) be considered the primary resource about Burnout nowadays?
56. Is Burnout in ICD-10? If so, which part?
57. Is Burnout in ICD-11? If so, which part?
58. Considering only causal factors, ‘Freudenberger’s Burnout” is to ICD-10 what ‘Maslach
Burnout/MBI’ is to ICD-11. What is the meaning of this correlation?
59. How is Burnout Syndrome defined in ICD-11?
60. According to ICD-11, is Burnout a syndrome?
61. What was the theoretical basis used to conceptualize the Burnout Syndrome proposed by ICD-
11?
62. According to ICD-11, is Burnout a disease? What about DSM-5?
63. If it were a disease, in which chapter of DSM-5 (and also of ICD-11) would the Burnout
Syndrome proposed by ICD-11 be described?
64. According to ICD-11, which mental disorders must be excluded before certifying someone has
Burnout Syndrome?
65. What are the differences between the Burnout Syndrome (BS) proposed by Maslach and her
collaborators and the one proposed by ICD-11?
66. Is the Burnout Syndrome proposed by ICD-11 a severe condition?
67. What is the difference between the Burnout Syndrome proposed by ICD-11 and depression?
68. Between having Burnout or having depression, what do people prefer?
69. What is the difference between the Burnout Syndrome proposed by ICD-11 and generalized
anxiety disorder (GAD)?
70. What is the difference between the Burnout Syndrome proposed by ICD-11 and panic disorder?
71. What is the difference between the Burnout Syndrome proposed by ICD-11 and adaptive (or
adjustment) disorder?
72. According to ICD-11, can Burnout Syndrome be related to extra-work issues (e.g., a case of
illness in the family, a conflicted marriage, financial problems, etc.)?
73. According to CID-11, which classification is the closest to Burnout, but can be caused by
chronic stress of any origin and not just occupational origin, as is the case of Burnout?
74. According to CID-11, does Burnout have a ‘cure’?
75. According to ICD-11, is there a causal link between Burnout Syndrome and work?
76. According to ICD-11, what is Schilling’s classification suggested for Burnout Syndrome?
77. According to current literature, who is most likely to develop the Burnout Syndrome proposed
by ICD-11?
78. What can workers do (individually) to avoid Burnout and the unwanted effects of chronic stress
resulting from work?
79. How can institutions act and support themselves (including legally) regarding the confrontation
of Burnout Syndrome and mental disorders among their workers?
80. After all, for the author of this book, in practice, does the Burnout Syndrome proposed by ICD-
11 exist, or does it not exist?

CHAPTER 9: THE FUTURE OF BURNOUT

81. What does the future hold for Burnout? (A reflection based on a brief history of neurasthenia.)
 PRESENTATION

In 2018, with my dear friends and competent psychiatrists, Dr Pablo Bernardes and Dr
Pedro Shiozawa, I had the honor and joy of writing the book Unraveling burn-out: an
interdisciplinary analysis of the professional burnout syndrome (LTr, 2018).
Among the three of us, at that moment, I was perhaps the most critical of the current idea
of Burnout, both in academia and in common sense. Nowadays (2022), with a greater baggage of
studies on the subject, I confess that this level of criticism is much, much more accentuated.
In this change process of so many readings, some impacted me more than others. Despite
any disagreements we have, I cannot fail to mention, as an example, the precious, rich, and
inspiring writings of Dr Estevam Vaz de Lima, Dr Flávio Fernandes Fontes, and Dr Renzo Bianchi,
all of whom are heavily referenced in this work.
Yes, my conviction about Burnout is different when compared to 2018. And now? Then,
two paths are evident: leave everything as it is, not assume that I have changed and do not
compromise my alleged biography; or “look into the eyes” of the same audience that bought and/or
read the 2018 book and make the words of Brazilian singer and composer Raul Seixas (1945-1989)
exactly my words:

“I prefer to be that ambulant metamorphosis,

than having that old opinion formed about everything.”

I opted for the latter path. It did not work anymore. Teaching about Burnout started becoming
distressing and, every time, in front of eyes that showed me more questions than anything else,
ending with the phrase “This subject is really complicated, do not worry”.
As someone who embraced teaching as a major career, I began to feel incompetent and, at the
same time, challenged to make this topic more understandable for people. I revisited it in every
way I could find, front to back and vice versa. I turned it “inside out, inside out, inside out”.
With some degree of predictability, I ended up in Plato, in the work Politician narrating a
hypothetical dialogue between the Foreigner of Elea and the young Socrates:
“Foreigner: Suppose we are asked the following question: In classes where we learn to read,
when we ask someone what letters this or that word is made up of, do we do it to get them to solve
that particular problem or in order to make you more able to solve all possible grammar
problems?
Young Socrates: All possible problems, of course.”

In Phaedrus, Socrates reinforces that the method of division is the best way to learn to speak
and think. The way was given. I had to divide the complex Burnout issue into four parts, explained
in the first of the 100 questions in this book.
Yes, this book was written with questions and answers for the sake of didactics. There are
81 discursive questions carefully ordered, answered, and substantiated.
This work can be used as a “guide”. In other words, reading the previous question is
unnecessary to understand the next one. In order to fulfil this purpose, in some questions, I was
forced to return to ideas previously addressed so the reader “does not waste time” in case he needs
the answer to just a single question.
Anyway, everything became more straightforward and more understandable. This was the
great bonus of this hard work of dividing and analyzing the 4 “types” of Burnout. Once again,
Greek philosophers were right.
However, there is also a burden. Those who have so far walked in the conceptual
superficiality of Burnout, having as references, for example, the many journalistic articles that deal
with this complex topic, they may be taken by some degree of astonishment and perplexity. At
some point, it was like that with me too. “It is so different from what I imagined”, indeed some
will say after reading this work. If you do not want to take that risk, it is better not to read it.
Nevertheless, to those who read it, I now emphasize that I understand and respect those
who think differently regarding what I have explained about Burnout throughout this book. It really
is a highly controversial topic. Either because of disagreement with the arguments I present,
because of the difficulty of changing one's opinion, or because of personal, technical, corporate,
political and/or ideological convictions: if the divergence is followed by the intellectual honesty
of those who disagree, I consider it legitimate and worthy of all my consideration.
 With all the possible burdens and bonuses, the fact is that I needed to write this work and
materialize the walking metamorphosis that I attest to be. I do not think as I did in 2018 anymore.
What I think now is in this book. It was the same Raul who instigated me to make this new attempt
to approach Burnout and mental health when he sang:

“Don't think the song is lost.

Have faith in God, have faith in life.
Try again.”

Ladies and gentlemen, welcome to my new attempt. I wish you a great read.

Anyway, take care. The song is not lost. Faith in God. Faith in life.
CHAPTER 1: “BURNOUT: WHAT SONG IS THAT?” (Note: Required reading to
understand this book)

1. What Burnout are we talking about: “Freudenberger’s Burnout”, “Maslach/MBI

Burnout”, “ICD-11 Burnout” or “Common Sense Burnout”? (Note: Required reading to
understand this book)
In 2022, I completed exactly 25 years as a professor. Whether for high school students and
pre-college courses (when I started), or for students with higher education in the most diverse areas
of knowledge (public with which I currently work); my biggest teaching challenge has always
been to try to be as didactic and simple as possible in all the information I transmit, making it easy
to assimilate. Some subjects, however, make my goal difficult, due to their complex nature.
Burnout is one of those subjects.
I advance that throughout this work, I will use the terms Burnout and Burnout Syndrome
with capital initials, only for the appreciation of the theme of this book. As the World Health
Organization (WHO) did, in the news published on its official website, I will occasionally refer to
Burnout as an occupational or simply a phenomenon. Furthermore: when referring to Burnout, I
will occasionally use the word diagnosis without quotation marks, considering the broadest
possible meaning of the verb to diagnose: identify, indicate, determine, detect, describe, among
other possible synonyms.
Continuing, why is it so challenging to explain Burnout and leave no one in doubt? I am
going to make an analogy to answer this question. Imagine an instrumental music band. It is formed
by four musicians: a drummer, a bassist, a guitarist, and a keyboardist.
Now, imagine that when this band performs, all the components play different songs: the
drummer plays a song called FB, the bassist, another song called MMBIB, the guitarist, another
one called ICD11B, and the keyboardist, another one called CSB. There are four different songs
played at the same time. Did you imagine the musical chaos that would ensue? Even if each
member perfectly sang all the band's songs, the audience would only hear a noisy, ugly, and
confused sound.
 The question arises: “But what does Burnout have to do with it?”. In this analogy, keeping
due proportions, the four songs played by the instrumentalists represent the main existing ideas
and concepts about Burnout worldwide. The sound produced by the whole band, constituted by
the anachronistic and simultaneous joining of these four songs, is Burnout in the broadest and most
general sense possible: a tangle of musical notes that are confusingly intertwined in unequal
measures, a sound impossible to understand and admire. However, if we know separately each of
the four songs played by the members of this band, everything will make more sense. In this regard,
I present, from now on, an unpretentious caption about these four songs that, I repeat, represent
the four main ideas and concepts about Burnout today:

• FB: “Freudenberger's Burnout”. Burnout was characterized as a clinical syndrome, for the
first time, in 1974, by Herbert Freudenberger.

• MMBIB: “Maslach/MBI Burnout”. It refers to the Burnout Syndrome characterized by

Christina Maslach and her collaborators, and it is measured by MBI (Maslach Burnout Inventory).
MMBIB is different from FB.

• ICD11B: “ICD-11 Burnout”. The Burnout Syndrome was described in the eleventh and last
review of the International Classification of Diseases (ICD-11) by the World Health Organization
(WHO). ICD11B differs from MMBIB (albeit with some similarity), which, in turn, differs from
FB.

• CSB: “Common Sense Burnout”. It refers to the Burnout that is not FB, MMBIB, or ICD11B,
and that is usually printed in popular language, in family lunches, in bar conversations, in many
literary works, in some academic papers and, often, in mainstream media, as a synonym for
extreme states, whether exhaustion (something often expressed as “I'm at my wits’ end, I can't
stand it anymore”) or a lack of patience and a high degree of intolerance (in the latter case,
expressed as “I am fed up with everything").

I return to the question: Why is it so challenging to explain Burnout and leave no one in
doubt? Because, in the face of all its possible uses, Burnout has become a too broad and generic
term. Several types of Burnout are floating around, whether in informal conversations or in
academic environments. Therefore, to better understand the subject, it is essential to know each of
its main types: FB, MMBIB, ICD11B, and CSB. This is what we will also do throughout this book.
I advance that, as a personal option, I chose ICD-11 (WHO, 2018) as the principal, less
iatrogenic, and more reliable source of Burnout today. Although ICD-11 is also a target of
countless and constant criticisms for having the WHO signature, for its collegiate and
representative academic preparation, for the importance and worldwide recognition of this
document, in addition to other reasons I describe in question n. 55 of this book, I am convinced
that I made the best choice and from now on, I suggest everyone else do the same.
To finish this question, here is a practical and precious tip for you, the reader of this book:
When you hear about Burnout, be sure to ask: “which Burnout are you talking about? FB, MMBIB,
ICD11B, or CSB?” The answer to this simple question is amazingly enlightening for
understanding the complex topic of Burnout.

CHAPTER 2: MENTAL SUFFERING IS A SERIOUS THING

2. Does mental suffering exist?

Yes, it does.
I assume that I am critical of the idea of Burnout (here encompassing FB, MMBIB,
ICD11B, and CSB) as a clinical entity equivalent to mental disorders already known and duly
catalogued. Throughout this work, there will be several substantiated arguments in this regard.
However, such a position cannot be confused, under any excuse, with insensitivity on my part
regarding the mental suffering of others, particularly of workers affected by this type of pain.

Yes, regardless of the causes, mental suffering exists. Psychiatrists and psychologists'
offices are increasingly full, and that is not for nothing. This tear is real. This suffering is genuine.
It is not "whining", it is not "fashionable". It hurts. In some cases, it hurts a lot. It can be terrifying,
heartbreaking, disabling, and annihilating hope for better days. It can take the color out of life and,
in extreme cases, end it.
 Yes, mental health and, consequently, mental suffering are serious matters. Very serious.
Anyone who lives or has lived with someone who suffers or has suffered mentally knows this
topic's real, immense, and unequivocal importance. I know.

3. Can work cause mental illness?

For Dejours (1998), work is never neutral regarding health and favors either illness or
health. Therefore, yes, work can cause or be related to a worker's mental illness.
Work can. The illness of a loved one can. A troubled marriage can. As we will see later,
any source of chronic stress (including work) can make someone mentally (as well as physically)
ill.

4. Should institutions invest in the mental health of their workers, or is this a human and
financial waste?
Yes, they should. Institutions (public and private) should spare no effort to promote the
mental health of their workers. And the reasons are many, including financial ones.
Governments, employers, and workers recognize that introducing management systems
and promoting safety and health at work (OSH) in an institution has a positive impact, both in
reducing accidents, diseases, and other occupational hazards and in increasing productivity. (ILO-
OSH, 2001).
In addition to theoretical and bureaucratic programs that are much more aimed at
certifications and/or documentary evidence to whom it may be of interest, institutions must act
effectively (based on evidence and best practices), continuously, planned (metered, measured, and
with assigned responsibilities) and revised periodically, in favor of the mental health of its
employees.

CHAPTER 3: STRESS AND ITS CONSEQUENCES (GOOD AND BAD)

5. Does every stress fall ill?

No, it does not. Not every stress falls ill. Indeed, a fair recognition of the so-called adaptive
stress is necessary, which can be defined as a series of autonomous biological reactions that occur
in our organism in response to environmental stressors (threats). Since humankind exists, these
stressors awaken fear in us, a state of alarm that, ultimately, is responsible for our self-preservation
and have been extensively studied over the last decades (RODRIGUES; LEDOUX; SAPOLSKY,
2009).
Therefore, in short, at work, in sports, in studies, and in everyday social life, adaptive stress has
undoubtedly been (is and will be) related not only to our toughest challenges but also to most (if
not all) of our greatest successes. Even for the most devout of an earthly life free of any shocks, I
warn that, from a physiological perspective, the total and permanent absence of stress is
incompatible with existence itself. In other words, it is equivalent to death. So, here's to life, here's
to adaptive stress!

6. What is the difference between adaptive stress and non-adaptive stress?

Accurately differentiating adaptive stress from non-adaptive stress, also called
pathological or pathogenic stress, may be a complex task.
Adaptive stress, as a rule, is acute stress with a non-lasting effect (SAPOLSKY, 2003).
However, it does not mean acute stress must always be understood as adaptive. Depending on the
individual vulnerability, acute stress of great intensity may cause the so-called acute stress
disorder (ASD), as described in the Diagnostic and Statistical Manual of Mental Disorders - 5th
Edition - DSM-5 (APA, 2014).
On the other hand, the neuroscientific thesis that states that chronic, long-lasting stress,
regardless of its cause (whether work, stormy marriage, socioeconomic problems, etc.), is a
potential cause of the disease is increasingly consolidated. Therefore, chronic stress, also as a rule,
is considered non-adaptive (SAPOLSKY, 2003).
Besides its significant negative impact on the central nervous system, countless studies
have demonstrated that chronic stress may harm the immune, cardiovascular, and neuroendocrine
systems (Anderson, 1998). Among its consequences, which have already been well reported, we
mention the weakening of the immune system; arterial hypertension; diffuse muscle pain; heart
diseases; obesity; and mental disorders or illnesses, such as depressive and anxiety disorder
(BAUM; POLSUSNZY, 1999).

7. May chronic stress be adaptive to some people and non-adaptive to others?

 Yes, it may. The magnitude and consequences of chronic stress are more related to the
valuation and individual meanings attributed to it than to the frequency, intensity, and length of
the stressor agent/fact itself.
Due to different reasons, which often intertwine (e.g., genetics, personality, psychological
structure, affective sensitivity, among others), it has already been shown that some people are more
resilient to chronic stress, while others are more vulnerable (ELBAU; CRUCEANU; BINDER,
2019).
Once the brain's adaptive mechanisms in the face of a given stressor are exhausted and the
stressor agent is maintained, the sine qua non-mechanisms to the development of possible
disorders, including mental ones, are consolidated with individual vulnerability.
Hence, we can hypothesize that stressor agents are more capable of triggering mental
disorders when our adaptive resources are less resilient, and our genetic predisposition for the
disease in question is significant (BORSBOOM, 2017).
In other words, attention should be paid to the notion that psychopathological symptoms
are connected through many biological, psychological, and social mechanisms. These mechanisms
act together in the etiopathogenesis of mental disorders, in a continuous process that goes from
adaptive to dysfunctional processes: an immeasurable and indivisible line between health and
pathology (MENDANHA; BERNARDES; SHIOZAWA, 2018).
The fact is that resilient people adapt more easily to a specific type of chronic stress (for
them, therefore, this stress could be classified as adaptive). On the other hand, a more vulnerable
person, faced with this chronic stress, may become ill (for them, this stress would be non-adaptive).
Thus, I point out that accurately differentiating adaptive stress from non-adaptive stress
(also called pathological or pathogenic stress) may not be a simple task and often demands
individualised and retrospective analyses (from the past to the present). Based only on this
analysis, which considers the complex “digestion” that each of us makes of the chronic stress that
affects us, we can classify it with greater confidence as adaptive or non-adaptive stress.

8. Will all workers who are exposed to chronic stress fall ill?
Not all workers exposed to chronic stress fall ill. In this analysis, individual vulnerability
matters.
 Do all parents who have bedridden children for long years fall ill? Does everyone who
suffers from financial hardship for “endless” periods fall ill? Do all husbands and wives in long
and contentious marriages fall ill? Do all workers in the same sector affected by intense moral
harassment by their managers fall ill? To all these questions, the answer is no. Even in the face of
chronically stressful situations, each person will elaborate, within their repertoire, their own
response and their own reaction in an individualized and unique way.
As I have already mentioned, the magnitude and consequences of chronic stress are more
related to the valuation and individual meanings attributed to it than to the frequency, intensity,
and length of the stressor agent/fact itself. Due to different causes often intertwined (e.g., genetics,
personality, psychological structure, affective sensitivity, among others), it has already been shown
that some people are more resilient to chronic stress and the illness it is liable to provoke. Others
are more vulnerable to chronic stress and fall ill (ELBAU; CRUCEANU; BINDER, 2019).
Throughout this book, we will study Burnout in-depth, conceptualized by the ICD-11
(WHO, 2018) as “resulting from chronic stress in the workplace that has not been successfully
managed”. This concept explains the importance of studying chronic stress before delving into
Burnout itself.

9. Why, in the same work environment with intense and perpetual moral harassment
(chronic stress), do some workers fall ill, and others do not?

For the same reasons and arguments set out in the previous question.

10. Is work a risk factor for suicide?

As a rule, and generally speaking, no. As an exception, a specific job can be a risk factor
for someone's suicide.
In Japan, in 2017, 208 suicides were officially considered karojisatsus, that is, when a
worker takes his own life due to psychological problems that might be linked to experiences in the
professional environment. In a famous case, Matsuri Takahashi, a 24-year-old advertising office
worker, killed herself after working over 100 hours of overtime in the months before her death in
2015. Japanese authorities concluded that excessive workload led to the young woman’s death
(UCHOA, 2020).
According to Dejours (1992), work is never neutral to health and favors either disease or
health.
Yes, there are indeed jobs that are unhealthy and sickening in every way. However, it is
undeniable that, for many people, work continues to be a source of sustenance and joy, new
friendships and support networks, and even of meaning in life.
Thus, generically stating that work is related to suicide does not reflect the truth. The more
significant proof is that unemployment (and not work) is considered an important risk factor for
suicide (BJORKLUND, 1985).
This finding seems to reinforce Emile Durkheim’s thesis (2019), for whom suicide is rather
a social fact. According to Durkheim, suicide is inversely proportional to an individual's healthy,
affective, and social relationships. From this perspective, it is worth emphasizing that the
relationships established among workers from the same institution are often healthy. When this
happens, work, in addition to not being a risk factor, is a protective factor against suicide.

CHAPTER 4: SYNDROME, DISEASE, AND DISORDER CONCEPTS

11. What is the difference between syndrome and disease?

Technically, a syndrome can be defined as a recognizable (differentiable), constant, and stable
set of signs and symptoms that indicate a specific condition and for which a direct cause (etiology)
has not been fully elucidated or remains unknown (DALGALARRONDO, 2019). Once science
identifies a causative agent or process (etiology) with a high degree of certainty, it is possible to
refer to the condition as a disease and no longer as a syndrome (CALVO et al., 2003).
For instance, the infamous viral syndrome is so called due to the uncertainty regarding
the specific viral agent(s) that is(are) causing the respective clinical presentation. Once the
causative virus(s) has(have) been identified with a high degree of certainty (e.g., through
respiratory viral panel testing), clinicians can then refer to the condition as a disease rather than
a syndrome.
The case of Acquired Immunodeficiency Syndrome (AIDS) is also quite illustrative.
AIDS was recognized as a syndrome in mid-1981, in the United States, after the identification of
a large number of male adult patients, homosexuals, who lived in San Francisco or New York
and presented Kaposi's sarcoma (a malignant neoplasia characterized by vascular proliferation,
which usually manifests itself in the skin), pneumonia by Pneumocystis carinii (a fungus), and
weakened immune system. None of these cases presented an elucidated causal factor at that time.
Therefore, because of its clinical presentation, AIDS was properly named a syndrome.
In 1986, after the publication of several studies that managed to isolate the viruses
responsible for AIDS (HIV-1 and HIV-2), an international committee recommended the
term HIV (Human Immunodeficiency Virus) to name them and recognized these viruses as capable
of infecting humans. Along with identifying its causative agent, AIDS ceases to be a syndrome
and officially becomes a disease. In ICD-11, for example, it is correctly called Human
Immunodeficiency Virus Disease and not a syndrome, although using the term AIDS is still
allowed by force of custom.
The Law n. 12,842/2013 (the so-called medical act law) requires that, for a condition to
be called a disease, in addition to presenting itself as such in the most up-to-date version of the
International Classification of Diseases (ICD), a document prepared by the World Health
Organization (WHO), its characterization must meet at least two of the following criteria:
I - recognized etiological agent;
II - an identifiable group of signs or symptoms;
III - anatomical or psychopathological alterations.
Moreover, it is worth noting that, unlike organic diseases, most mental disorders do not
have their etiology sufficiently elucidated. However, as we will see later, this does not prevent
them from being called mental illnesses.

12. Why does Burnout Syndrome not meet the technical criteria of a syndrome?
As we have already seen, from a technical point of view, a syndrome is a recognizable
(differentiable), constant, and stable set of signs and symptoms that indicates a specific condition
for which a direct cause (etiology) has not been fully elucidated or remains unknown
(DALGALARRONDO, 2019).
Burnout Syndrome (BS) does not meet the technical criteria of a syndrome [although it is
qualified as a syndrome in ICD-11 (WHO, 2018), for example] for several reasons. I cite the first
reason that the term syndrome requires stability of signs and symptoms, which is not found in
Burnout. We will see throughout this book that the most renowned authors in this field, especially
Herbert Freudenberger and Christina Maslach, differ in characterization and in the way of
describing the clinical presentation of the Burnout phenomenon.
The second reason I understand that BS does not meet the syndromic criterion involves the
excessive number of symptoms predicted for Burnout, which is beyond the conceptual
reasonableness of a syndrome. In ICD-11, Burnout’s clinical presentation is described as part of
the phenomenon’s concept, in a very nonspecific way and with the following text:

“It is characterized by three dimensions: 1) feelings of mental breakdown or

energy exhaustion; 2) increased mental distance from work, or feelings of
negativism or cynicism about work; and 3) a sense of ineffectiveness and lack
of accomplishment.” (WHO, 2018).

As we will see throughout this book, this concept was inspired by the studies of Maslach
and his collaborators, including Schaufeli and Enzmann (1998), who listed 132 possible symptoms
for Burnout, an extravagant number to have in the label of a single syndrome. In fact, all nine
possible symptoms of major depressive disorder listed in the DSM-5 (APA, 2014) fit among the
132 possible symptoms for Burnout described by Schaufeli and Enzmann. Broadly, it is as if the
clinical presentation of Burnout encompassed all the symptoms of depression and other mental
(and organic) disorders.
According to Lima (2021), the third reason BS does not meet the technical criteria of a
syndrome is that different syndromes require differential diagnoses among them. A father is
recognizable to a son, as the son can differentiate him from others. Likewise, a syndrome will only
be recognizable by a health professional if it is possible to differentiate it from other syndromes,
even with some overlapping signs and symptoms. For the author, due to the immense number of
signs and symptoms described in the literature, Burnout “is confused with more than 20 psychiatric
diagnostic categories”. In other words, it is not recognizable and differentiable, as the very concept
of syndrome requires.
We can refer to at least part of depression clinical presentation, such as 'depressive syndrome'
or 'schizophrenic syndrome', as schizophrenia. However, one cannot be confused with the other,
just as 'inflammatory syndromes' cannot be confused with 'infectious syndromes'. 'Syndrome' is
not synonymous with 'any set' (LIMA, 2021).
The fourth reason we can point out is that the term syndrome tends to individualize and
standardize the therapeutic approach (whether through psychotherapy, drug administration, etc.),
which has also never been observed in the case of Burnout (FONTES, 2016).
The academic community recognizes no treatment protocol for the Burnout phenomenon.
The wide range of signs and symptoms does not allow directing the clinical-diagnostic reasoning
towards any assertive direction, which prevents any standardized and effective therapeutic
proposal.
The fragility of the term syndrome regarding Burnout is also evidenced by the apparent
insecurity of the most renowned authors in using it emphatically and constantly. Sometimes, these
experts need clarification. Let us see.
For Freudenberger, Burnout is sometimes referred to as a concept, sometimes as a feeling,
sometimes as an occupational risk, sometimes as a syndrome (LIMA, 2021), and sometimes as a
disease (FREUDENBERGER, 1981).
In the work “The Truth about Burnout: how organizations cause personal stress and What
to do about it (1997)”, Maslach and Leiter state that Burnout “is not a personality flaw or a clinical
syndrome. It is an occupational problem.” Oddly, in the same work, while acknowledging that
Burnout is not a clinical syndrome, the authors elevate this phenomenon to the status of a disease
when they categorically state: “It is a disease that spreads gradually and continuously over time,
putting people in a downward spiral from which it is difficult to recover.”
In the MBI Manual (Maslach Burnout Inventory), the concept of Burnout as a disease is
rejected, and the idea of the phenomenon as a psychological syndrome is reinforced (MASLACH;
JACKSON; LEITER, 2018).
The fact is, Freudenberger, Maslach, and many other authors and researchers have never
discarded the idea of Burnout being a syndrome (whether clinical or psychological), instigating
the perpetuation of this qualification, both in everyday and academic use. ICD-11 itself
appropriates it and describes Burnout as a syndrome.
Once again, I emphasize that, as a personal choice, I chose ICD-11 as the principal, less
iatrogenic, and more reliable source of Burnout today. Although ICD-11 is also the target of
numerous and consistent criticisms for having the signature of the World Health Organization
(WHO), for its collegiate and representative academic preparation, and for the importance and
worldwide recognition of this document, in addition to other reasons that I describe in the question
n. 55 of this book, I am convinced that I made the best choice and from now on, I suggest that
everyone else do the same.
As a tribute and reference to ICD-11, I will use the term Burnout Syndrome throughout this
book, routinely and without further questioning.

13. Why are mental illnesses also called mental disorders?

For DSM-5:
“(...) a mental disorder is a syndrome characterized by a clinically
significant disturbance in an individual's cognition, emotion regulation, or
behavior that reflect dysfunction in the psychological, biological, or
developmental processes underlying mental functioning. Mental disorders are
often associated with significant distress or disability that affect social,
professional, or other important activities.” (APA, 2014).
For ICD-11:
“(...) mental, behavioral, and neurodevelopmental disorders are syndromes
characterized by clinically significant disturbances in an individual's cognition,
emotion regulation, or behavior that reflect dysfunction in the psychological,
biological, or developmental processes underlying mental and behavioral
functioning. These disorders are usually associated with distress or impairment
in personal, family, social, educational, occupational, or other important areas of
functioning.” (WHO, 2018).
According to the concepts presented, we understand that every mental disorder is a
syndrome. However, we will see in due course, and more detail throughout this work, that not
every syndrome is a mental disorder.
The term disorder is a hierarchically superior equivalent to the expression syndrome since
it has more specificity and detail than the latter (WANG; ANDRADE, 2012). It is as
if syndrome were a genus of which disorder was a species. Due to this greater specificity, whether
in DSM-5, ICD-11 or the vast psychiatric literature, the term mental disorder is often used as a
synonym for mental illness.
 In Brazil, considering mental disorder as a synonym for mental illness is also supported by
Law n. 12,842/2013 (the so-called medical act law). The legal text requires that, for a condition to
be called a disease, in addition to being presented as such in the most up-to-date version of the
International Classification of Diseases (ICD) proposed by the World Health Organization
(WHO), its characterization must meet at least two of the following criteria:
I - recognized etiological agent;
II - an identifiable group of signs or symptoms;
III - anatomical or psychopathological alterations.
Observe that mental disorders are also named as mental illnesses throughout the ICD-11
(the most up-to-date version of the International Classification of Diseases), present identifiable
clusters of signs or symptoms, and are characterized by psychopathological changes. Thus, in
Brazil, mental disorders meet all the legal criteria to be considered synonyms of mental illnesses.
If so, why do DSM-5 and ICD-11 prefer the term mental disorder to the term mental illness?
As we have previously studied, classically, the term disease refers to a medical condition in which
the causative agent or process (etiology) is identifiable with a high degree of certainty. We also
saw that, unlike organic diseases, most psychiatric conditions do not have the privilege of
sufficiently elucidating the etiology. This results in one of the reasons for these classifications'
resistance to the use of the term mental illness.
Furthermore, for historical reasons, the term mental illness is more stigmatizing
than mental disorder. This is another crucial reason why DSM-5 and ICD-11, as well as most
current scientific literature, predominantly prefer the term mental disorder.

CHAPTER 5: BURNOUT, FROM BIBLICAL REFERENCES TO THE EARLY 1970'S

14. How did the expression “Burnout” arise?

The term's first citation is mistakenly attributed to the English poet, playwright, and actor
William Shakespeare (1564-1616) (GREENBLATT, 2011).
In The Passionate Pilgrime, published in 1599 by William Jaggard, there are 20 texts,
including poems and sonnets, all initially attributed to Shakespeare. However, experts agree that
only 5 of the 20 texts are authentically Shakespearean. The seventh text, for example, is a poem
described in the literature as of uncertain authorship.
 In the seventh text, the term burnt out appears (one of the spelling variations of the term
Burnout that we use today). In summary, this poem refers to a seductive and unfaithful character,
and it is narrated by a man who fell in love with this woman.
Upon discovering the falsehoods of his beloved, this man projects, with an air of contempt, a
sad end for his muse. The narrative is created as if the woman had already experienced the
projection made by the betrayed. In the only passage where the term burnt out appears in the work,
the narrator states: “She burnt with love as straw with fire flameth, She burnt out love as soon as
straw out-burneth (...)”
It is worth noting the artistic, literary, and passionate tone given to the term burnt out in The
Passionate Pilgrime. I do not see in this work any intention of the author to associate the term burnt
out with anything that comes close to the phenomenon we know today. Therefore, in my
classification, the burnt out described in The Passionate Pilgrime is one of the members of the CSB
(“Common Sense Burnout”). To understand what I call CSB and better understand the rest of this
work, see question n. 1 of this book.
However, it is necessary to recognize that there are essential authors who suggest the
opposite. Among them is Wilmar Schaufeli, the most important theorist on Burnout (LIMA, 2021).
For Schaufeli (2017), the term burnt out was used in The Passionate Pilgrime in a “psychological
sense, in other words, to describe a process of energy exhaustion regarding love”.
I observe that by associating the term burnt out mentioned in The Passionate Pilgrime with
a psychological process of exhaustion, Schaufeli tries to force a flirtation between the term burnt
out of 1599 with the most accepted technical concept in recent decades for the Burnout Syndrome.
This concept has precisely one of its main pillars in the process of exhaustion. I insist that I
consider such association forced and mistaken.
Schaufeli is not alone. Throughout this work, we will observe that, in order to give Burnout
a concept of a universal and timeless character, a critical researcher named Christina Maslach also
uses the prestige of past literature in an attempt to legitimize and make it seem that there is unity
for the Burnout phenomenon as if every existing collection had always been dealing with the same
reality (FONTES, 2016).
For Shaufeli and Maslach, the burnt out described in The Passionate Pilgrime crosses time and
jointly integrates all the types of Burnout that I described in my classification: FB, MMBIB,
ICD11B, and CSB (to understand this classification and thus better understand the rest of this
work, see question n. 1 of this book). This concept of a single “timeless Burnout” does not hold,
as we will see in detail below. The assumed and mistaken “timeless Burnout” is confusing and
difficult to explain and understand, as it is so broad, abstract, and generic.
To finish this question, I repeat a valuable and precious tip for you, this book’s reader: When
you hear about Burnout, be sure to ask: “which Burnout are you talking about? FB, MMBIB,
ICD11B, or CSB?” The answer to this simple question is amazingly enlightening for
understanding the complex topic of Burnout.

15. How did the term “Burnout” become popular even before it was classified as syndrome?
As we have already seen, the first citation of a spelling variation of the term Burnout (more
precisely: “burnt out”) was mistakenly attributed to William Shakespeare in The Passionate
Pilgrime, published in 1599. A long time had passed until the 20th century, especially until the
1970s, when Burnout Syndrome was classified for the first time. It is important for us to understand
what happened in this time lag.
As I said before, in order to value the theme and give Burnout a concept of a universal and
timeless character, some experts (e.g. Christina Maslach and Wilmar Schaufeli) used the prestige
of past literature in an attempt to legitimize and make it seem that there is unity for the Burnout
phenomenon as if all existing collections had always been dealing with the same reality (FONTES,
2016), which is not valid, as we will extensively observe throughout this work.
In this sense, some of these experts, mainly in publications from the last 50 years,
misappropriate many stories that, even though they did not use the expression Burnout (or any of
its spelling variants, e.g. burn-out), denoted, in these authors’ interpretation, something associated
with a process of psychological exhaustion and, consequently, with the Burnout Syndrome, which
was only named from the 1970s onwards. I cite as examples biblical stories such as Elijah (narrated
primarily in the book of 1 Kings, chapter 19), Jonah (narrated in the book of 1 Jonah, chapter 4),
and Moses (narrated in the book of Numbers, chapter 11), who, in extreme moments, even asked
God for the end of their own lives.
In addition to the bible, non-scientific literature was also used to legitimize Burnout as
something unique that has always been among us. For Zrazhevskaya and collaborators (2020),
there is a relationship between the newly known Burnout Syndrome and the plot of the book Ward
No. 6 (1892) by Anton Chekhov. As they conclude, in the book, Chekhov shows quite precisely
the process of formation and the development of the professional deformation of a doctor with
signs of emotional exhaustion.
In the novel Buddenbrooks (1901), Thomas Mann shows the transformation of Senator Thomas
Buddenbrook, with the loss of energy and idealism that had strongly impacted him in his youth
being replaced by exhaustion and boredom, which, incidentally, Thomas seeks to cover up,
guarding appearances. For Schaufeli (2017), the way Senator Buddenbrook is portrayed by Mann
is strongly reminiscent of a current case description of Burnout Syndrome, as it includes mental
exhaustion, disappointment, and loss of interest and drive (i.e., the impoverishment and desolation
of his inner life).
In the academic field, in 1953, Schwartz and Will studied the relationship between the “low
morale” (lowered mood and disposition) of professionals in a psychiatric clinic and its
repercussion on patient care. They describe the case of a young psychiatric nurse (better known as
Miss Jones) who became disillusioned with her work, sharing feelings and attitudes with other
staff members and working in the same ineffective way. “Emotional withdrawal” (affective
distancing from work) was described by Schwartz and Will as a way of coping with “low morale”
and later characterized by some authors as depersonalization (or cynicism), one of the pillars of
Christina Maslach’s current job construct for Burnout Syndrome.
Returning to non-scientific literature, in 1960, Graham Greene, an award-winning author,
published the novel A burnt-out case, which tells the story of a famous architect (Querry) who,
after abandoning his work, takes refuge in a forest after experiencing a state of indifference and
disillusionment that affected him. The protagonist complained about the inability to feel anything,
including pain and suffering.
In all of Greene's novels, the term burnt-out only appears about ten times, but it can be seen as
a running thread of the story, an interpretation that seems to be confirmed by its presence in the
title (FONTES, 2016). The work is a complex literary creation that allows different interpretations
but has often been claimed by some experts (e.g., Christina Maslach and Wilmar Schaufeli) as an
evident and mistaken example, in my opinion, of the Burnout Syndrome as a single concept and
capable of traversing history.
It is possible that the success of A burnt-out case was one of the main popularizers of the term
Burnout from 1960 onwards. In that same decade, the term began to be used commonly used, first
among the most contumacious American drug users, especially heroin users. This is because the
acidulants used as heroin diluents (especially citric acid) are related to venous irritation (intense
pain when inserting the syringe and a “burning sensation”) and damage, such as sclerosis of
peripheral veins (HARRIS et al., 2019). According to drug addicts, after repeated punctures, some
veins became “useless” for new drug applications; in other words, they were “burned out”
(MALESIC, 2022).
Over time, Burnout has become a popular slang associated with extreme states, whether from
overuse of narcotics, exhaustion (something often expressed as “I’m at my wits’ end, I can’t stand
it anymore”), or lack of patience, and a high degree of intolerance (in the latter case, expressed as
"I’m fed up with everything”).
From 1967, the term Burnout was also embraced by volunteers from free clinics (clinics with
massive participation of volunteers, which appeared in the United States in 1967, to provide free
services to chemical dependents, indigent, marginalized, people with sexually transmitted
infections, etc.). The expression was often used when these volunteers succumbed to the working
conditions and demands of the clientele (LIMA, 2021).
Back in the academic environment, in 1969, Bradley used the expression Staff Burn Out in one
of his articles. In it, he addressed the need for resting periods for agents of a correctional unit for
young offenders as a way to avoid the “burn out” phenomenon with the team. It is not part of
Bradley's goal to provide a definition for the term, which appears in the study in quotation marks
(“burn out”), apparently as an acknowledgement that it is a metaphorical use of popular slang
(FONTES, 2016).
In 1973, in a text published by “American Psychologist” entitled “The burnt-out chairman”,
Sommer describes the suffering of a university professor who becomes head of the department and
gets frustrated with the position. The author clarifies that this is suffering linked to work, but the
term burnt-out is not defined and not even used in the body of the text, only in the title (FONTES,
2016).
Observe the different spelling variations used for the term Burnout so far: burnt out (1599),
burnt-out (1960 and 1973), and burn out (1969). This also confirms the non-existence of a unique
and timeless Burnout phenomenon.
In my classification, the situations experienced by the cited biblical characters; those narrated
in the books Ward No. 6 (1892), Buddenbrooks (1901), A Burnt Out Case (1960); and those
presented in the academic works of Schwartz and Will (1953), Bradley (1969), Sommer (1973)
are part of what I called, in question n. 1, of CSB (“Burnout for common sense”), along with the
use of the term Burnout in a widespread and recognized way in common American parlance.
As for experts who seek to give Burnout a unitary and permanent character (e.g., Christina
Maslach and Wilmar Schaufeli), all these cases are not limited in time and jointly integrate the
four types of Burnout that I described in my classification: FB, MMBIB , ICD11B, and CSB (to
understand this classification and thus better understand the rest of this work, see question n. 1 of
this book).
I insist that this idea of a single “timeless Burnout” does not hold itself, as we will see in detail
later. This supposed and mistaken “timeless Burnout” is confusing and difficult to explain and
understand, as it is so broad, abstract, and generic.
I have not yet mentioned 1974, when Burnout was first characterized as a syndrome. However,
it is necessary to point out again that, in the early 1970s, Burnout was already widespread in
popular parlance.

CHAPTER 6: ‘FREUDENBERGER’S BURNOUT’ (FB)

16. When was Burnout first described as a syndrome, and who created this description?
The term burnout was first used in a clinical sense in the first half of the 1970s. In 1974, Herbert
J. Freudenberger (1926-1999) wrote the article Staff Burnout, in which he described the signs and
symptoms of those affected by the phenomenon. Therefore, Freudenberger is considered Burnout
Syndrome's concept's “founding father” (SCHAUFELI; BUUNK, 2003).
Interestingly, the word syndrome does not appear in Staff Burnout (1974), although it was
present in an article by the same author dated from the previous year (1973). Regardless, the
clinical presentation's richness shows that Freudenberger's reasoning followed the conceptual logic
of a syndrome (FONTES, 2016).

17. Who was Herbert Freudenberger and, what made him think of Burnout Syndrome?
Herbert J. Freudenberger (1926-1999) was a psychologist who was active as a psychoanalyst.
He was a Jew of German origin. He reported having lived, in his childhood, a “tragic experience”
in Nazi Germany and “having survived almost by a miracle” (FREUDENBERGER, 1981). He
managed to emigrate to the United States and graduated in Psychology from New York University,
where he also received his doctorate.
Freudenberger played a vital role in the free clinic movement (LIMA, 2021). From 1967
onwards, this movement encouraged the opening of several clinics in the United States, with the
massive participation of volunteers. They provided free services to drug addicts, indigent,
marginalized, people with sexually transmitted infections and general medical problems
(FONTES, 2016).
Freudenberger helped to organize and intensively worked on the first free clinic in New York
(St. Mark Free Clinic), which opened in January 1970 (MALESIC, 2022).
At that time, he attributed part of his motivation to care for the neediest to an identification he
made between his patients and the suffering he had experienced in Nazi Germany
(FREUDENBERGER, 1981). He would work 10 to 12 hours daily as a clinical psychoanalyst in
his private office and then stay up until midnight or later, work at St. Mark Free Clinic
(FREUDENBERGER, 1975). He remained at this crazy pace for almost a year (MALESIC, 2022).
In a state of recognized fatigue, irritability, intolerance, and impatience resulting from his
chronic overload, Freudenberger narrates what would have been the trigger that made him think
about (his own) Burnout Syndrome:
“It was Christmas, and my wife insisted we all go on vacation. Not wanting to
take time off work at the clinic, I agreed because I realized I should make up for
my time away from my family. My wife arranged everything, hotel reservations
and plane tickets. I had to pack my suitcase on the eve of the trip. However, that
day I did not get home until two in the morning, and I was so exhausted that I
only wanted to lie down and sleep. I told my wife I would pack my things the
next day. But I could not wake up the next morning. I spent two days sleeping,
no one travelled, and that is how I ruined everyone's vacation. By the third day,
even though I could not get out of bed, I was able to reflect on my behavior.”
(FREUDENBERGER, 1981).
In this book, I call “Freudenberger's Burnout” (FB) the syndrome proposed and characterized
by this psychologist. In addition to FB, I name other “types” of Burnout: MMBIB, ICD11B, and
CSB (to understand this classification and thus better understand the rest of this work, see question
n. 1 of this book).
18. How did Freudenberger find the term Burnout to name his proposed syndrome?
As we have already seen, Freudenberger helped to organize, and he intensively worked on the
first free clinic in New York (St. Mark Free Clinic), which opened in January 1970 (MALESIC,
2022). At that time, the term Burnout was already widespread among chemical dependents (who
were the main patients of free clinics) and, over time, it became a popular mass slang and
associated with extreme states, whether excessive use of narcotics, either from exhaustion
(something often expressed as “I'm at my wits’ end, I can't stand it anymore”), or from a lack of
patience and a high degree of intolerance (in the latter case, expressed as “I'm fed up with
everything”).
As expected, the term Burnout was also embraced by voluntary workers at free clinics. They
often used the expression when they succumbed to working conditions and clientele demands
(LIMA, 2021). This context undoubtedly influenced Freudenberger, who recognized that he did
not create the term Burnout. He merely incorporated it from its everyday use in the free clinic that
he ran. Freudenberger wrote:
“A few years ago, some of us who were working intensively in the free clinic
movement started talking about a concept we referred to as 'burnout'. After
experiencing this feeling of exhaustion, I began to ask myself a series of
questions about it.” (FREUDENBERGER, 1974).
Thus, Freudenberger was inspired by the popular use of Burnout to name the syndrome he
proposed.

19. What were the clinical characteristics (signs and symptoms) of the Burnout Syndrome
described by Freudenberger?
Freudenberger is considered the “founding father” of the Burnout Syndrome concept
(SCHAUFELI; BUUNK, 2003). In 1974, he wrote the article Staff Burnout, in which he describes
the clinical presentation of those affected by the Burnout Syndrome proposed by him, which I call
in this work “Freudenberger’s Burnout” (FB).
In addition to FB, I name other “types” of Burnout: MMBIB, ICD11B, and CSB (to understand
this classification and thus better understand the rest of this work, see question n. 1 of this book).
 For Freudenberger (1974), Burnout “manifests itself through many symptomatic forms that
vary in symptom and severity from person to person.” These are the clinical characteristics (set of
signs and symptoms) of “Freudenberger’s Burnout” (FB):
• feelings of exhaustion and fatigue;
• “inability to get rid of a persistent cold” (low immunity);
• frequent headaches;
• gastrointestinal disorders (e.g., stomach pain and diarrhea);
• insomnia;
• “shortness of breath” (denoting an anxious state of shortness of breath);
• “quickness to get angry”;
• instant, thoughtless responses and reactions when angry or frustrated;
• “struggle containing feelings”;
• emotional lability (easy crying);
• low resilience to pressures, even if small;
• attitude of suspicion and paranoia, in which the victim may feel that everyone wants to harm
him (including members of his work team);
• feeling of omnipotence, arrogance, self-confidence based on great experience in what he does,
and lack of patience for any kind of change or new learning. Such condition makes the person
routinely act imprudently and criticize everything he disagrees with (“everything that is
suggested is bad”);
• excessive use of tranquillizers, barbiturates, and hashish (cannabis derivatives) for relaxation;
• rigidity, stubbornness, and inflexibility;
• introspection and depressed mood;
• work presenteeism: more time at work, with less production.
In Burnout: How to Beat The High Cost of Success, Freudenberger (1981) compares FB to a
burned-out building: the façade might even be intact, but terrible void is inside. In this work, he
adds “guilt” as a component emotion of the syndrome.

20. According to Freudenberger, what were the causes and risk factors for Burnout
Syndrome?
 In the form of a vent Freudenberger (1981) summarizes that the Burnout Syndrome he
proposed, which I call in this work “Freudenberger Burnout” (FB), “is a demon caused by society
and the times in which we live, and our ongoing struggle to give meaning to our lives.” Another
time, he states that the leading cause of FB is “the dichotomy between desire and reality”.
In a more gradual, detailed, and didactic way, the psychologist lists many possible causes for
FB, among them the “loss of leader's charisma”. Everything suggests that this was an
autobiographical reference since, for Freudenberger (1974), the FB he reports having experienced
as leader of St. Mark Free Clinic negatively affected the other institution's workers, making them
vulnerable to the same FB.
The psychologist also advocates that the leader's indifference can cause FB in subordinates. To
sustain this thesis, he narrates the story of 7 young people who dedicated themselves with all their
intensity to the projects of a governor and were not recognized for their work, being affected by
the so-called “Group Burnout” (FREUDENBERGER, 1981).
For Freudenberger, denial is also a cause of FB, including denial of failure, age, fear, death, and
feelings (FREUDENBERGER, 1981 apud LIMA, 2021). The psychologist states: “If you feel that
you are exhausting yourself, you can be sure that you have assumed a posture of denial in critical
areas of your life” (FREUDENBERGER, 1985).
Denial, thought by Freudenberger in a Freudian way, has the power to become our main “energy
drain”. This is because denial is a defense mechanism, as it is used to maintain a false image,
demanding a very high energy cost (FONTES, 2016). This energy deficit is closely related to the
genesis of FB.
Even “distractions” such as sports, movies, food, drink, sex, etc., if they take up too much time
and control an individual's mind, can cause FB (FREUDENBERGER, 1981).

21. According to Freudenberger, what are the possible types of Burnout?

As we will see in detail in this work, due to CID-11’s literalness (WHO, 2018), the Burnout
Syndrome defined therein [what I call in this work “CID-11 Burnout” (ICD11B)] is precisely (and
only) related to the occupational context (work). According to CID-11, there is no need to talk, for
example, about “matrimonial (or marriage) burnout”.
The Burnout Syndrome proposed by Freudenberger [what I call “Freudenberger’s Burnout”
(FB)] is different. In the psychologist's view, in addition to work, FB may be related to chronically
troubled marriages and relationships, which is in line with the current neuroscientific thesis that
defends the innumerable harms arising from chronic stress (whether it comes from work,
marriages, relationships etc.). Note: To learn more about the aforementioned neuroscientific thesis,
see question n. 6 of this book.
Freudenberger goes beyond the individual limits of Burnout and suggests the phenomenon’s
collective dissemination. For him, American society is on the path of FB: “Why, as a nation, both
collectively and individually, do we seem to be on the trail of a rapidly spreading phenomenon -
Burnout?” (FREUDENBERGER, 1981).
In another text, and as already mentioned in this work, the psychologist narrates the story of 7
young people who dedicated themselves with all their intensity to projects of a governor and were
not recognized for the work they did, being affected by the so-called “Group Burnout”
(FREUDENBERGER, 1981).
For Lima (2021), the psychologist also extends the concept of Burnout to the planet in an
ecological bias (“a Burnout of energy and resources on the planet”), in addition to citing the
“Burnout of political leadership, ethics in public life and of morality” (FREUDENBERGER, 1981
apud LIMA, 2021).
For didactic purposes, I remind you that, besides FB and ICD11B, I name other “types” of
Burnout: MMBIB and CSB (to understand this classification and thus better understand the rest of
this work, see question n. 1 of this book).

22. According to Freudenberger, who is more likely to develop Burnout Syndrome?

The Burnout Syndrome proposed by Freudenberger, which I call in this work “Freudenberger’s
Burnout” (FB), is definitely not for everyone. It is only for those who can, not those who want to.
In Lima’s words (2021), according to Freudenberger, FB only affects “absolutely
extraordinary” people. In Burnout: How to Beat the High Cost of Success (1981), Freudenberger
states:
Not every personality is subject to Burnout. A mediocre worker and the so-called
‘crowd follower’ could never reach that state. Burnout is limited to those
dynamic, charismatic, determined men and women or idealists who dream of
perfect unions [referring to affective unions - my emphasis], with perfection at
 work, with child prodigies [referring to children - emphasis mine], and who want
their community to be the best (FREUDENBERGER, 1981).
Let us remember that Freudenberger (1974) reports having been a victim of BF. Incidentally,
Schaufeli (2017) states that Freudenberger “was a victim of Burnout twice”. Hence, the superlative
and perfectionist description he makes of those who are subject to FB is, to say the least, suspicious
of an autobiographical description.
It is essential to recognize that experts, such as Stoeber (2016), attest that when a worker is a
perfectionist, considering the sum of all possible forms of perfectionism (adaptive and
maladaptive), in other words, the so-called global perfectionism, the resulting is the increased risk
for Burnout. This thesis seems to corroborate, at least in part, to Freudenberger's ideas.
It is also true that, in the last pages of Burnout: How to Beat The High Cost of Success (1981)
- already writing as someone who experienced FB, learned from it, and overcame it -
Freudenberger warns about the harm of perfectionism when he emphasizes: “Fritz Perls said:
'Friend, don't be a perfectionist. Perfectionism is a curse and a weakness.
In the final part of the same work, as someone who became humbler in the face of what he
suffered for FB, the psychologist also defends resignation and realism. He attests that resignation
is a strengthening that “comes from the moment we learn to recognize that the world is the way it
is, and we accept it as one of the conditions that we will have to live with”. This would be a way
of combating and minimizing what, for Freudenberger, is the leading cause of FB: the dichotomy
between desire and reality.
However, even if it was not his intention, it is inevitable to infer that Freudenberger, when
considering at some point that FB affects only particularly virtuous people, seems to have
contributed to mitigating personal vulnerability as one of the justifications for the phenomenon.
At the same time, he reinforced other possible main causes and culprits for FB, such as: bad job,
troubled marriage, or any other cause of chronic stress.
As already mentioned in this book, current knowledge allows us to state that the magnitude and
consequences of chronic stress (whatever it may be) are more related to the valuation and
individual meanings attributed to it than to the frequency, intensity, and length of the stressor
agent/fact itself.
 However, at some stage of his work, Freudenberger goes in the opposite direction and values
the stressor much more than the possible individual vulnerability in FB’s genesis, which continues
to be “music to the ears” of many.
Let us face it: the great contemporary mass loves to have “someone to blame”. In Silva’s words
(2018), “the contemporary victim is not the cause of his own suffering. There is an external agent
that affects him and makes him suffer, a person, an illness, financial crisis, among others”. Before,
the argument would be “It’s my fault I’m suffering”, related to the Catholic faith in which their
own sins would lead to penance. The current discourse is “I suffer because of the other”, in which
one is free from the blame for one's own suffering, placing the blame on a person, group of people,
or institution that promotes suffering (VAZ, 2014). Some experts call this phenomenon guilt vector
inversion.
Not coincidentally, Bianchi et al. (2016) observe that Burnout’s label seems less stigmatizing
than the depressive disorder label. For Schaufeli (2017), the diagnosis of Burnout is sometimes
used with pride, almost like a badge of honour: “I had Burnout for getting at my wits’ end”.
According to Maslach and Schaufeli (1993), one of the reasons for Burnout’s popularity is that
it is a socially accepted label that transmits a minimum of stigmatization. Depressive disorder (as
well as most mental illnesses) has multifactorial causes and individual vulnerability as one of its
important and correct explanations.
In other words, depression carries the notable mark of a vulnerability that is part of the patient,
which cannot be delegated to anyone. Thus, the patient becomes one of those responsible for his
mental disorder, as he assumes he is vulnerable, as every human being is, to a greater or lesser
extent.
In Burnout, which affects only the best individuals, as defended by Freudenberger at some
point, the victim tends to reduce and even reject his vulnerability to chronic stress, choosing the
supposed source of stress as the greatest villain, the one who ends up absorbing, if not all, most of
the blame for the phenomenon.
To be fair, it should be noted that, after overcoming FB and becoming more humane and
supportive due to the suffering experienced, Freudenberger (1981) emphatically advises: “Get rid
of the habit of blaming others. See first how much you can be to blame.” The impression is that
many people did not and still do not want to read this part of the psychologist's work. It might be
just an impression. Let us reflect.
23. For Freudenberger, is Burnout Syndrome a disease?
The Burnout Syndrome proposed by Freudenberger, which I call in this work “Freudenberger’s
Burnout” (FB), is vast, confusing, and imprecise. Sometimes psychologists refer to Burnout as a
concept, sometimes as a feeling, sometimes as an occupational risk, sometimes as a syndrome
(Lima, 2021), and sometimes as a disease (FREUDENBERGER, 1981). Then, for him, FB is also
a disease, but not only that.
In one of his texts, Freudenberger (1981) tries to give FB the status of a disease when he states:
“One of the main reasons why I started researching more deeply about Burnout was my own
experience with the disease, many years ago”. This attempt is conceptually unsustainable, as we
will see below.
Remember that a syndrome is technically defined as a recognizable, constant, and stable set of
signs and symptoms that indicate a specific condition for which a direct cause (etiology) has not
been fully understood or is unknown (DALGALARRONDO, 2019). Once science identifies a
causative agent or process (etiology) with a high degree of certainty, it is possible to refer to the
process as a disease and no longer as a syndrome (CALVO et al., 2003).
Freudenberger (1974) describes a significant and non-specific set of signs and symptoms for
FB (see question n. 19). Therefore, Freudenberger (1973) named Burnout as a syndrome.
However, as Lima (2021) well expressed, “syndrome is not synonymous with any set”. This set
must be recognizable, in other words, differentiable. In this wake, a syndrome will only be
recognizable by a health professional if it can be differentiated from other syndromes, even with
some overlapping signs and symptoms.
Lima (2021) states that different syndromes require differential diagnoses among them. I
confirm that the clinical presentation presented by Freudenberger (1974) is relatively unspecific
and does not direct the clinical-diagnostic reasoning towards any assertive direction. In other
words, it is not recognizable as the syndrome concept requires.
Due to the significant set of signs and symptoms, it has (see question n. 19), we observe that
FB embraces, at once, parts of several other syndromes already catalogued and duly recognized,
such as pain syndrome, depressive syndrome, anxiety syndrome, and manic syndrome, not to
mention other possible ones. This fact also prevents the effective individualization and
standardization of any type of treatment (whether through psychotherapy, drug administration,
etc.), which once again refutes the technical classification of FB as a syndrome.
In short, conceptually, BF does not fit even as a specific syndrome.
Going further, Freudenberger lists multiple and imprecise causes for FB, such as the “society
and times we live in” (1981); “dichotomy between desire and reality” (1981); “loss of leader
charisma” (1974); “leader's indifference” (1974); denial of failure, age, fear, death, and feelings
(1981); besides “distractions” like sports, movies, food, drink, sex, etc. (1981). Thus, even if we
conceptually considered FB a syndrome, “Freudenberger’s Burnout” etiology is vague, confirming
it has not been properly understood. From a conceptual point of view, it also disqualifies FB as a
disease.
This reasoning is corroborated by the title of the book published by Freundeberger in 1981,
Burnout: How to Beat The High Cost of Success. The translation of Burnout is overworked, defined
in the same work as “a state of fatigue or frustration caused by devotion to a certain cause, way of
life, or a relationship that did not correspond to expectations” (a dichotomy between desire and
reality, the main cause of FB, according to the psychologist). None of the described terms (whether
exhaustion, fatigue, or frustration) is characterized as a disease in the CID-11 or the DSM-5 (APA,
2014), just as Burnout is not.
In summary, although Freudenberger (1981) literally gave FB the status of a disease,
conceptually and in the most referenced literature on mental disorders or illnesses diagnoses (CID-
11 and DSM-5), Burnout is currently not considered a disease.
For teaching purposes, I remind you that, besides FB, I name other “types” of Burnout:
MMBIB, ICD11B, and CSB (to understand this classification and thus better understand the rest
of this work, see question n. 1 of this book).

24. For Freudenberger, is Burnout Syndrome curable? What are the ways to combat it?
Yes, for Freudenberger, the Burnout Syndrome proposed by him, which I call in this work
“Freudenberger's Burnout” (FB), is curable. In Burnout: How to Beat The High Cost of Success
(1981), the psychologist states: “Burnout is reversible, no matter what stage it is in”. Freudenberger
wrote this work from the perspective of someone who went through FB and overcame it.
Therefore, he feels free to propose a series of therapeutic recommendations to the reader, here
summarized in 10 propositions.
 I. Be resigned and realistic. Resignation is a strengthening that “occurs from the moment
we learn to recognize that the world is the way it is, and we accept it as one of the
conditions we will have to live with”. According to the psychologist, this would be a way
of combating and minimizing the main cause of FB: the dichotomy between desire and
reality.
II. Do not be enslaved by the will of others. At a given moment, Freudenberger (1981) asks:
“Do you think you are the owner of your own life, or are you being dominated by it?” The
psychologist encourages his reader to establish differences between their own and real
goals and those that were imposed by the expectations of others.
III. Be aware of yourself. Freudenberger (1981) states: “If you want to overcome Burnout,
you will have to continue observing yourself”. Referring to the high demands imposed by
everyday life, Freudenberger (1981) warns: “You are the one who will determine whether
or not to stop. Only you know how long you can take it. You are the best judge of this
difference between your desire and the energy available to fulfil it. Only you will be able
to maintain your own control.”
IV. Revisit childhood and rediscover its own values. Using psychoanalysis strategies,
Freudenberger suggests we revisit old photo albums to reconnect with the child we once
were. For the psychologist, it is in our childhood that we build our greatest code of values,
which, in turn, influences the potential that each one has to be affected by FB.
V. Have self-acceptance and self-kindness. Freudenberger (1981) argues that “self-
acceptance is kindness, and kindness is a benign force.” Moreover, he adds: “By kindness,
we multiply our strengths, we develop and blossom, and our weaknesses disappear”.
VI. Do not be a perfectionist. Directly, the psychologist warns the reader: “Fritz Perls said:
‘Friend, don’t be a perfectionist. Perfectionism is a curse and a weakness’”
(FREUDENBERGER, 1981).
VII. Take responsibility, and do not blame others. Freudenberger (1981) teases: “If things
are not going well, try to find out what your contribution has been.” Emphatically, he
advises: “Get rid of the habit of blaming others. See first how much you can be to blame.”
VIII. Do not be a compulsive worker (a workaholic). The psychologist asks: “Are you
working yourself to death? (...) Would you have the courage to take a day off to do what
you want?” Then he leads his reader to reflect on the reasons for a hypothetical
 “workaholism”: “Be honest with yourself about your motivations for working so hard. Are
you trying to escape some other area of your life?” Here, Freudenberger (1981) refers to
what he attributed as a possible cause of FB: denial (of failure, age, fear, death, feelings,
etc.).
IX. Cultivate social ties. Frendeberger (1981) asks: “Are you letting your social life
deteriorate?”. Then, in line with Emile Durkheim’s ideas, Freudenberger (1981) argues that
“people surround the more an individual, the more protected he will be from Burnout”.
X. Cultivate pleasures, and have fun. The psychologist suggests pleasant activities: “Take
long walks, ski, swim, play tennis, play volleyball, or go dancing. The important thing is
to do something. It will add more joy to your life. It will make you forget the routine and
eliminate your tension.” At another moment, he determines: “Let go. Have a good time. I
repeat: Have fun. You deserve it”, but he makes a caveat: “Stay away from false cures”,
from distractions. For the psychologist, “distractions” such as sports, movies, food, drink,
sex, etc., if they take too much time and control an individual's mind, they can cause FB
(FRENDEBERGER, 1981).

CHAPTER 7: ‘MASLACH/MBI BURNOUT’ (MMBIB)

25. How did Burnout become more emphatically and specifically work-related?
In a more emphatic and specific way, Burnout began to be related to working with Christina
Maslach’s research, PhD in Social Psychology, professor and researcher at the University of
California, Berkeley (USA).
As we have already seen, the Burnout Syndrome proposed by Freudenberger, which I call in
this work “Freudenberger’s Burnout” (FB), may be related to work, but not only to it. For the
psychologist, there may be several types of Burnout, depending on its probable etiology: Burnout
of energy and resources of the planet, Burnout of political leadership, Burnout of marriage, and
Burnout of ethics in public life and morality, among others. (FREUDENBERGER, 1981 apud
LIMA, 2021).
Still in the first half of the 1970s, when Burnout became Maslach’s main object of study, the
researcher prioritized in her work professionals who worked directly with the public in the
provision of care and services (e.g., nurses, doctors, health assistants, social workers, among
others). Among them, she conducts interviews and obtains the following observation:
As a result of these interviews, she learned that these workers often felt emotionally drained,
developed negative perceptions and feelings about their clients or patients, and experienced crises
of professional competence as a result of this emotional turmoil. Following the workers' self-
descriptions of symptoms, professionals referred to this psychological condition as 'Burnout'.
(SCHAUFELI, 2017).
We observe that Maslach's inspiration for using of the term Burnout comes from popular
sources and, according to the researcher, at the same time and in a similar way to the inspiration
taken by Freudenberger (LIMA, 2021).
However, unlike the psychologist, Maslach chooses to focus her object of study on labor
relations, not expanding the concept of Burnout to other areas of life as Freudenberger did.
Maslach’s option fundamentally contributes to the history of Burnout Syndrome as an
occupational syndrome, which is still widespread. If Maslach had limited her studies to any other
field, for example, marital relations, maybe, the history of the Burnout phenomenon would have
been entirely different.
Despite all sorts of criticism, Maslach's research on Burnout advances, becoming much more
celebrated by academia and the media than Freudenberger's studies. Thus, Maslach's publications
become fundamental to spreading the concept she created about Burnout, a concept that, although
considering the existence of individual factors (e.g., personality), from a practical point of view,
defends work as the only and sufficient factor to cause the phenomenon.
In 1981, Maslach and her collaborators published the famous MBI (Maslach Burnout
Inventory), an instrument similar to a questionnaire, still used as the main “Burnout measurer”.
Reflecting Maslach's thesis on the phenomenon, MBI also explicitly places work as the only and
sufficient factor to cause the syndrome (MASLACH; JACKSON; LEITER, 2018).
Maslach's thesis and complete characterization of Burnout are what I call “Maslach/MBI
Burnout” (MMBIB) in this work. I remember that, in addition to FB and MMBIB, I name other
“types” of Burnout: ICD11B and CSB (to understand this classification and thus better understand
the rest of this work, see question n. 1 of this book).
26. Who is Christina Maslach, and why is this researcher so essential to understand Burnout
Syndrome nowadays?
According to the curriculum available on her personal website, Christina Maslach holds a
bachelor's degree magna cum laude (translation: "with great honors") in Social Relations from
Harvard-Radcliffe College (1967) and a PhD in Social Psychology from Stanford University
(1971).
Soon after completing her doctorate, she began her teaching career at the University of
California, Berkeley (USA). Currently (2022), she still is a professor (emeritus) of Psychology and
the main researcher of the Healthy Workplaces Center in the same institution.
According to Fontes (2016), at the beginning of her research, Maslach devoted herself to
different subjects, such as: investigating the possibility that individuals might come to believe in
false confessions made by themselves (Maslach, 1971), use of hypnosis as a way to modify the
notion of time (ZIMBARDO; MARSHALL; MASLACH, 1971); individuation and
deindividuation - opposite processes in which a person seeks to differentiate himself from a group
or become indistinguishable in it (MASLACH, 1974); and influence that different levels of wealth
of a donor and obligation linked to the benefit have on the attraction that the beneficiary feels for
the donor (GERGEN et al., 1975). Data’s statistical treatment is observed in all this research, which
has always been very important for Maslach. Despite these studies' importance, research on
Burnout (which began in the first half of the 1970s) projects Christina Maslach’s name worldwide.
Based on psychometric psychology and statistical tools (MASLACH; SCHAUFELI; LEITER,
2001), Maslach establishes new concepts for Burnout throughout her years of study, which I call
in this work “Maslach/MBI Burnout” (MMBIB).
As already mentioned, Maslach praises situational factors (especially those related to work)
much more than individual factors (e.g., personality) as the Burnout phenomenon causes. From a
practical point of view, Maslach defends work as the only and sufficient factor to cause MMBIB,
which does not happen with the studied “Freudenberger’s Burnout” (FB), which has several
causes.
The difference between MMBIB and FB is not only the delimitation of work as a cause of the
Burnout phenomenon. Maslach's study is based on psychometric and statistical tools (something
familiar to her). Psychometrics is a branch of psychology that seeks to build and apply instruments
(e.g., MBI - Maslach Burnout Inventory and psychological tests) for quantitative measurement of
mental processes (PASQUALI, 2009).
On the other hand, Freudenberger’s studies are based on clinical psychology, especially
psychoanalysis and his autobiography. Schaufeli (2017) states that Freudenberger “was a victim
of Burnout twice”. As we will see in detail later, this different approach gives a huge conceptual
difference between FB and MMBIB.
In 1981, Maslach and his collaborators published the MBI (Maslach Burnout Inventory), a test
used today as the main instrument for measuring MMBIB (MASLACH; JACKSON; LEITER,
2018). Reflecting the construct of Burnout proposed by Maslach, MBI explicitly places work as
the only and sufficient factor to cause the syndrome.
Even with all possible criticism, the fact is that the 11th Revision of the International
Classification of Diseases [ICD-11 (WHO, 2018)], which came into force in January 2022,
considers Burnout Syndrome as an occupational phenomenon. Although there are some substantial
differences, the concept was inspired by Maslach and her collaborators’ research, including MBI.
We will see these differences in detail later in this work.
In short, for these reasons, Christina Maslach is so important for us to understand Burnout
Syndrome today.

27. For Maslach, what is Burnout Syndrome?

Based on psychometric psychology and statistical tools (MASLACH; SCHAUFELI; LEITER,
2001), Maslach created her own characterization of Burnout Syndrome throughout her years of
study, which I call in this work “Maslach/MBI Burnout” (MMBIB).
Although with similarities, Maslach's concepts about MMBIB undergo some variations over
time and as the researcher does new work.
In 1977, Masclach and Pinnes (1977) defined MMBIB as a syndrome characterized by physical
and emotional exhaustion that causes the development of negative attitudes towards work, low
self-concept, and loss of interest in clients/patients, and that appears, above all, in professionals
who work directly with the public, providing care and services.
In 1979, Maslach and Jackson conceptualized MMBIB as a syndrome characterized by
emotional exhaustion and consequent depersonalization (defined as an attitude of affective
distancing, a kind of indifference regarding clients/patients), which affects primarily individuals
whose work is aimed at people and who spend much time with them in relationships of a
confidential nature and chronic conditions of stress and tension.
In 1981, Maslach and collaborators published the MBI (Maslach Burnout Inventory), a test used
to this day as the main instrument for measuring MMBIB (MASLACH; JACKSON; LEITER,
2018).
Reflecting the construct of Burnout proposed by Maslach and Pines (1977), the original MBI
contemplates the three dimensions of the syndrome proposed by the researcher, at that time named
as follows: emotional exhaustion, depersonalization, and low professional achievement.
I emphasize that both the original concept of Burnout Syndrome proposed by Maslach and her
collaborators and the initial format of MBI undergo adjustments over time. Even so, didactically
and intentionally, in this work, I name all versions of the concept and the MBI (from the first to
the last) as MMBIB.
In 2001, in a proposal that is still in force, Maslach and collaborators defined MMBIB as a
syndrome caused by a crisis in the relationship between the worker and work, which can affect all
professionals (regardless of profession and activity) and has three dimensions, now called:
emotional exhaustion (or simply exhaustion), the most crucial dimension of the syndrome and
from which the others derive; depersonalization or cynicism; and low effectiveness or professional
achievement (MASLACH; JACKSON; LEITER, 2018). These dimensions are groups that
supposedly explain and settle the diversity of MMBIB signs and symptoms.
Emotional exhaustion is understood as an absence or low level of energy and enthusiasm and a
feeling of depletion of resources. Depersonalization or cynicism is understood as a behavior of
affective distancing, a kind of indifference, whether to clients/patients (depersonalization) or to
work as a whole (cynicism) (FIGUEIREDO-FERRAZ; GRAU-ALBEROLA; GIL-MONTE ,
2019).
The low efficacy or professional achievement dimension is characterized by the fact that the
person feels inefficient, incapable, with reduced self-esteem, and sure that their work makes no
difference (MASLACH; SHAUFELI; LEITER, 2001). This third dimension encompasses the
domain of the Self (MASLACH, 1993), self-image, self-assessment, and negative experiences of
the individual regarding the work he performs.
 Once again, I remind you that, besides MMBIB, I name other “types” of Burnout: FB, ICD11B,
and CSB (to understand this classification and thus better understand this work, see question n. 1
of this book).

28. What are the main differences between ‘Freudenberger’s Burnout’ (FB) and
‘Maslach/MBI Burnout’ (MMBIB)?
As we have already seen, MMBIB focuses its object of study on labor relations, not expanding
the concept of Burnout to other areas of life, as FB did. Let us remember that Freudenberger cites
several types of Burnout, for instance: Burnout of energy and resources of the planet, Burnout of
political leadership, Burnout of marriage, and Burnout of ethics in public life and morality, among
others. (FREUDENBERGER, 1981 apud LIMA, 2021). In turn, although Maslach considers the
existence of individual factors (e.g., personality), from a practical point of view, the researcher
defends work as a single and sufficient factor to cause the phenomenon.
It is not just because of the delimitation of work as a cause that MMBIB differs from FB. The
basis of Maslach's study always focused on academic research and relied on psychometric and
statistical tools.
Freudenberger, whose primary commitment was to the improvement and well-being of his
patients, bases his studies on clinical psychology, especially psychoanalysis and his
autobiography. Schaufeli (2017) states that Freudenberger “was a victim of Burnout twice”. This
difference in focus makes a significant distinction between Maslach and Freudenberger's proposals
for Burnout Syndrome.
As we have already seen, Freudenberger (1974) describes a significant set of signs and
symptoms for FB (see question n. 19). Therefore, Freudenberger (1973) named Burnout as a
syndrome for the first time.
To Fontes (2016), “Maslach will define Burnout as a syndrome in a more systematic and
continuous way while significantly modifying the characteristics described by Freudenberger”.
While this one had described in detail the signs and symptoms of the syndrome, Maslach's
construct on Burnout groups all the immense possible symptomatology that she and her
collaborators describe in just three groups, three dimensions: emotional exhaustion (or simply
exhaustion); depersonalization or cynicism; and low effectiveness or professional achievement
(MASLACH; JACKSON; LEITER, 2018). As we will see, this three-dimensional grouping
proposed by MMBIB does not find technical support in any internal medicine treatise.
For all the above, there is no doubt that FB and MMBIB are pretty different.
As well to Schaufeli (2017), in order to give Burnout a concept of a universal and timeless
nature, Maslach uses the prestige of past literature [e.g., Buddenbrooks (1901) by Thomas Mann,
A burnt-out Case (1960) by Graham Greene; in addition to a case study published by Schwartz
and Will, in 1953, on what became known as Miss Jones, a nurse who became disillusioned with
her work] in an attempt to legitimize and make it seem that there is a unity to Burnout’s
phenomenon as if every existing collection had always been dealing with the same reality
(FONTES, 2016), which is not valid.
In the same wake, at different times of her extensive work, Maslach cites Freudenberger as an
author who contributes to the knowledge of Burnout, suggesting that FB is the same or very similar
to MMBIB, which, as we have seen, is also untenable.
In a timely manner, it should be remembered that, technically, a syndrome is a recognizable
(differentiable), constant, and stable set of signs and symptoms that indicate a specific condition
and for which a direct cause (etiology) has not been fully understood or is unknown
(DALGALARRONDO, 2019).
As we have seen, one of the reasons why Burnout Syndrome does not meet the technical
criterion of a syndrome [although it is qualified as a syndrome in the ICD-11 (WHO, 2018), for
example] is that the term syndrome requires stability of signs and symptoms that is not found in
Burnout. Again: FB and MMBIB are pretty different, even in describing and characterizing the
phenomenon signs and symptoms, as we have already observed.
Maslach and her collaborators ultimately recognize the conceptual differences between FB and
MMBIB. At the same time, oddly and without presenting new justifications, they place these
differences as outdated and belonging to the past (MASLACH; GOLDBERG, 1998), especially
after the publication of MBI (Maslach Burnout Inventory) in 1981, a test used until the present
day. as the main “Burnout measurer” instrument (MASLACH; JACKSON; LEITER, 2018), and
which will still be the object of study in this work.

29. Is there any relationship between the Burnout Syndrome proposed by Maslach and the
so-called Impostor Syndrome?
 Yes, there is. First, it is worth remembering what Impostor Syndrome is.
Initially described as an impostor phenomenon by the psychologists Clance and Imes (1978),
the term that gained popularity was Impostor Syndrome (initials in capital letters just to draw
attention to the subject), which is characterized by the individual's belief that all success achieved
by them is attributed as luck, trickery, charm, or chance and not due to merit, effort, talent, or
competence.
[Note: Impostor Syndrome is not classified as a mental illness or disorder, neither by DSM-5
(APA, 2014) nor ICD-11 (WHO, 2018)].
As we have already seen, the Burnout Syndrome proposed by Christina Maslach and her
collaborators, which I call in this work “Maslach/MBI Burnout” (MMBIB), has three dimensions:
emotional exhaustion (or simply exhaustion); depersonalization or cynicism; and low effectiveness
or professional achievement (MASLACH; JACKSON; LEITER, 2018).
The low efficacy or professional achievement dimension is characterized by the fact that the
person feels inefficient, incapable, with reduced self-esteem, and sure that their work makes no
difference (MASLACH; SHAUFELI; LEITER, 2001). This third dimension encompasses the
domain of the Self (MASLACH, 1993), self-image, self-assessment, and negative experience that
the individual has of himself regarding the work he performs, which, in theory, might be related
to the so-called Impostor Syndrome.
Broadly, suppose workers diagnosed with MMBIB are successful and have impairment in the
dimension of low effectiveness or professional achievement (yes, it is possible to receive the
diagnosis of MMBIB without this dimension impacted, as we will see in this work). In that case,
they can experience feelings related to Impostor Syndrome, as they feel incompetent.
In another way, workers diagnosed with Impostor Syndrome, in 100% of the cases, also fit the
diagnosis of MMBIB. One of the reasons: Impostor Syndrome negatively impacts an individual's
feeling of professional efficiency, in other words, the dimension of low efficacy or professional
achievement that is part of MMBIB. As we will see, for Maslach, Jackson and Leiter (2018), the
impact on only one of the three dimensions [emotional exhaustion (or simply exhaustion);
depersonalization or cynicism; and low efficacy or professional accomplishment] is already
sufficient for the diagnosis of MMBIB.
The other (intriguing) reason, which will be further discussed in this work, is that any population
of workers, regardless of size (whether one or thousands), who undergo MBI (Maslach Burnout
Inventory), a test considered the “main measurer” of MMBIB worldwide (MASLACH;
JACKSON; LEITER, 2018), will be diagnosed with MMBIB, in 100% of cases, even in a low
degree. Therefore, all workers diagnosed with Impostor Syndrome also have the diagnosis of
MMBIB. All of them.

30. What is the recommended instrument for individual and/or population assessment of
Burnout Syndrome proposed by Christina Maslach?
The recommended instrument for individual and/or population assessment of Burnout
Syndrome proposed by Christina Maslach and her collaborators, which I call in this work “Maslach
Burnout/MBI” (MMBIB), is the test that bears the name of the researcher herself: MBI (Maslach
Burnout Inventory).
It is important to emphasize: MBI evaluates MMBIB exclusively. I remind you that, in addition
to MMBIB, I name other “types” of Burnout: the FB, ICD11B, and CSB (to understand this
classification and thus better understand this work, see question n. 1 of this book).

31. Besides MBI (Maslach Burnout Inventory), are other instruments proposing to “measure
Burnout”?
Yes, in addition to MBI, several other instruments (tests) propose to “measure Burnout”, each
with its own characteristics. As with MBI (as we will see in this work), most follow the logic of
questions or statements to be scored by the interviewees.
Lima (2021) cites as examples: CBI - Copenhagen Burnout Inventory (KRISTENSEN et al.,
2005), BM - Burnout Measure (PINES; ARONSON, 1988), BMS - Burnout Measure Short
(MALACH-PINES, 2005), SMBQ - Shirom-Melamed Burnout Questionnaire (SHIROM, 1989),
BBI - Bergen Burnout Inventory (FELDT et al., 2014), OLBI - Oldenburg Burnout Inventory
(HALBESLEBEN; DEMEROUTI, 2005), GBQ - Granada Burnout Questionnaire (DE LA
FUENTE et al., 2015), UBOS - Utrecht Burnout Scale (SHAUFELI; VAN DIERENDONCK,
2000), SIBM - Single Item Burnout Measure (DOLAN et al., 2015), BAT - Burnout Assessment
Tool (SHAUFELI et al., 2015). al., 2020), and IBP - Burnout Inventory for Psychologists
(BENEVIDES-PEREIRA; MORENO-JIMÉNEZ, 2000).
Let us remember that MBI is considered the main “Burnout measurer” used worldwide, being
used ten times more than other measures in articles and dissertations on the subject (SCHAUFELI;
ENZMANN, 1998). Therefore, in this work, I chose not to evaluate any other “Burnout
measurement scale” other than MBI.

32. What is MBI, how was it made, and why is it important?

MBI (Maslach Burnout Inventory) is a test designed by Christina Maslach, which aims to assess
(measure) quantitatively Burnout Syndrome, also proposed by this researcher and her
collaborators, which I call in this work “Maslach Burnout/ MBI” (MMBIB).
This is important to emphasize once again: MBI exclusively evaluates MMBIB. I remind you
that, in addition to MMBIB, I name other “types” of Burnout: FB, ICD11B, and CSB (to
understand this classification and thus better understand this work, see question n. 1 of this book).
In practice, the MBI concept coincides with the MMBIB concept and vice versa (SHAUFELI;
LEITER; MASLACH, 2009). Directly and objectively, MBI measures what MMBIB is, and
MMBIB is what MBI measures (KRISTENSEN et al., 2005). Let us go into the details.
Explaining how MBI was conceived, Schaufeli (2008) says that after Freudenberger and
Maslach began publishing about Burnout in the first half of the 1970s, the theme obtained
visibility. Other authors proposed, at that time, many different concepts for the phenomenon.
However, Schaufeli attests that it was already possible to identify, in many of these concepts, one
or more of the central aspects or dimensions that Maslach would later use in her own definition of
Burnout [read: exhaustion, depersonalization, and low achievement or professional effectiveness],
exhaustion being the most common dimension among the evaluated studies.
Schaufeli (2008) proceeds and states that, to advance in the establishment of a single definition
for Burnout, Maslach then began to conduct more extensive qualitative studies, initially
prioritizing her work professionals who worked directly in public service in the provision of care
and services (e.g., nurses, doctors, health assistants, social workers, among others). Among them,
she conducts interviews and obtains the following finding:
As a result of these interviews, she learned that these workers often felt
emotionally drained, developed negative perceptions and feelings about their
clients or patients, and experienced crises of professional competence due to this
emotional turmoil. (SCHAUFELI, 2017)
 Thus, Maslach observes, now in her own research, that the impacts of Burnout were similar to
those found by other authors and could be accommodated in three dimensions: exhaustion,
depersonalization, and low achievement or professional effectiveness (SCHAUFELI, 2008).
Armed with this knowledge, using psychometrics as a basis [a branch of psychology that seeks
to build and apply instruments - for example, MBI itself - for the quantitative measurement of
mental processes (PASQUALI, 2009)], Maslach performs a factor analysis of different
questionnaires made previously by herself and her working group, conceives and publishes, in
1981, the MBI.
It is an instrument similar to a questionnaire, developed inductively from items that are
supposed to capture the perception of respondents about the three dimensions of Burnout
Syndrome proposed by Maslach and her collaborators (SCHAUFELI; ENZMANN, 1998), in other
words, from MMBIB. From that moment on, it is no longer possible to distinguish between
MMBIB and MBI itself.
See how interesting. When she first submitted MBI for publication, Maslach received the
material back from the editor of a scientific journal with the observation: “(...) we do not publish
'pop psychology' (MASLACH; JACKSON, 1984).
Nevertheless, Cindy and Donald McGeary (2012) document an exponential increase in Burnout
publications from when MBI was introduced. In the 1980s, publications increased by 64%; in the
1990s, the increase was 150% (SCHAUFELI, 2017).
Therefore, MBI became well known, and by the end of the 1990s, it was the main “measurer”
of Burnout Syndrome used worldwide, being used ten times more than other measures, in articles
and dissertations on the subject, in other words, 93% of papers published in journals used MBI
(SCHAUFELI; ENZMANN, 1998).
For all these reasons, it is no exaggeration to say that, in practice, the MBI concept coincides
with the MMBIB concept and vice versa (SHAUFELI; LEITER; MASLACH, 2009). Directly and
objectively, MBI measures what MMBIB is, and MMBIB is what MBI measures (KRISTENSEN
et al., 2005).
According to Lima (2021), using MBI is very simple and allows the self-diagnosis of MMBIB
in a few minutes. We will address several issues involving MBI and its practical use later on.

33. What are the MBI versions?

 According to Maslach, Jackson and Leiter (2018), currently, there are five versions of MBI
(Maslach Burnout Inventory): MBI-HSS; MBI-HSS (MP); MBI-ES; MBI-GS and MBI-GS (S).
Let us go into the details of each one of them.
I) MBI-HSS (MBI - Human Services Survey). It is the original and most widely used version
of MBI. Therefore, this version is used as a synonym for MBI in other questions of this book.
It is a test with 22 statements. As in all other versions of MBI, in MBI-HSS, the respondent
assigns scores ranging from zero to 6 to each statement, varying according to the frequency
experienced by them. Such statements are always declarations of feelings that, in some way, are
related to work, which also happens in the other versions.
MBI-HSS was published in 1981 and has remained unchanged ever since. It is intended to use
by healthcare and human services professionals, for instance: nurses, physicians, health aides,
social workers, health counsellors, therapists, police, correctional officer, and others.
II) MBI-HSS (MP) (MBI - Human Services Survey for Medical Personnel). It is also a 22-
statement test, and it resulted from MBI-HSS. It is a more specific version for health professionals
who work directly with patients (e.g., doctors and nurses). It has slightly modified wording
compared to MBI-HSS: instead of referring to “recipients”, MBI-HSS (MP) uses the term
“patients”.
III) MBI-ES (MBI - Educators Survey). It was initially called MBI-Form Ed. It also has 22
statements. It was published in 1986 and has remained unchanged ever since. It is specific to
educators, including teachers, administrators, other staff members and volunteers working in any
educational setting [Note: does not apply to students for whom MBI-GS(S) is indicated].
IV) MBI-GS (MBI - General Survey). It is a test with 16 (and not 22) statements. It was
published in 1996 and has remained unchanged ever since. It is the broadest audience version,
designed for all professionals except those in human services, health and education, and students.
There are corresponding specific versions for them: MBI-HSS; MBI-HSS (MP), MBI-ES and
MBI-GS (S).
V) MBI-GS (S) (MBI - General Survey for Students). It is also a test with 16 statements. It
resulted from MBI-GS. It is aimed at students, especially university students.
I emphasize that MBI-HSS is the most used version of MBI. Therefore, this version is used as
a synonym for MBI in other questions of this book.
34. How is MBI structured? How is it used?
I will use MBI-HSS (MBI - Human Services Survey), the most used version of MBI (Maslach
Burnout Inventory), according to Maslach, Jackson and Leiter (2018), as a reference to answer
these questions. Therefore, in this book's next paragraph and other questions, the MBI-HSS version
will be used as a synonym for MBI itself.
MBI has 22 statements divided into three blocks, each representing a dimension of the Burnout
Syndrome proposed by Christina Maslach and her collaborators, which I call in this work
“Maslach/MBI Burnout” (MMBIB). There are nine statements related to the emotional exhaustion
dimension, five to the depersonalization dimension, and eight to the professional achievement
dimension (MASLACH; JACKSON; LEITER, 2018). (Figure 1)
Once again, it is worth emphasizing that MBI is a test aimed exclusively at MMBIB. I remind
you that, in addition to MMBIB, I name other “types” of Burnout: FB, ICD11B and CSB (to
understand this classification and thus better understand this work, see question n. 1 of this book).

(Figure 1: The three blocks of MBI)

The 22 statements represent possible perceptions experienced by the interviewee and that, in
most cases, make direct mention of work.
For each statement, a 7-point Likert scale is used, in which the respondent assigns a score
ranging from zero to 6, depending on the frequency they experienced on each of the 22 items.
These scores indicate that the situation mentioned in each statement:
0 - never happens;
 1 - happens once a year;
2 - happens once a month;
3 - happens a few times a month;
4 - happens once a week;
5 - happens a few times a week;
6 - happens every day.
As suggested by Lima (2019), using MBI is simple, fast, and allows self-diagnosis of MMBIB
in a few minutes.
Unfortunately, the use of MBI is protected by copyright, a subject that will be further addressed
in this work. Therefore, and in appreciation of didactics, I made a non-committal and respectful
model test that “resembles MBI” in its 22 statements, showing us how MBI can be easily used in
practice.
I emphasize that this test is only illustrative. It is not MBI. It does not intend to replace MBI. It
does not follow the sequence proposed by MBI. Its statements are not the same as those of MBI.
Therefore, this test should not be equivalent to MBI under any circumstances. Having made this
incisive caveat, let us go to the model test:
0 1 2 3 4 5 6
E1 “I feel quite tired from work and am on edge.”
E2 “I feel exhausted after 8 hours of work.”
E3 “I feel tired from the moment I wake up to go to
work.”
E4 “Living with people from my work tires me a lot.”
E5 “My work sucks all my energy.”
E6 “I feel disappointed by things I do at work.”
E7 “I think I should work less and prioritize other things.”
E8 “I get tense with my work team and my
clients/patients.”
E9 "I cannot deliver more than I am already delivering for
my work."
D1 “I treat some people from work as if they were
animals.”
 D2 “People say I am cold.”
D3 "I am not moved by anyone's suffering in my work,
but I do not think that is a good thing."
D4 “I would rather be further away from my
clients/patients.”
D5 “I get the impression that some people want me to
solve their problems.”
P1 “I have the gift of understanding what people feel.”
P2 “I feel encouraged to live with people with problems.”
P3 “I feel like I radiate good energy to my co-workers.”
P4 “I am very excited about my work and my life.”
P5 “I transmit peace to those who live with me.”
P6 “I love working with people and can capture the good
vibes they transmit to me.”
P7 “In recent times, my professional progress has been
admirable.”
P8 “I have great emotional self-control in matters
involving my work.”
(Merely illustrative test: It is not equivalent to MBI)

In this illustrative test, making a non-committal and respectful parallel with MBI, the
first nine statements (E1 to E9) would be related to the emotional exhaustion dimension.
The five intermediate statements (D1 to D5) would be related to the depersonalization
dimension and the last eight statements (P1 to P8) would be related to the professional
achievement dimension.
As well as with MBI, in a few minutes, the worker completes the test (just marking an
“x” in the score determined for each of the 22 statements), according to the caption:
0 - never happens;
1 - happens once a year;
2 - happens once a month;
3 - happens a few times a month;
 4 - happens once a week;
5 - happens a few times a week;
6 - happens every day.
All are very simple, easy, and fast to use.
In short, I reiterate that the 22 MBI statements portray possible perceptions experienced by
the interviewee and that they usually make direct mention of work. Despite this, as we saw in the
model test, among these statements, there is no possibility of objective assessment of the critical
issues that could be considered by the MBI and that make any work environment a potentially and
truly sickening place, for instance: the different possibilities of harassment (moral, sexual, etc.). I
believe that, in this regard, MBI missed a great opportunity.

35. How should the MBI score be interpreted, and what is the cutoff point to assure that
someone has (or has not) the Burnout Syndrome proposed by Maslach?
It is worth emphasizing again: MBI is a test aimed exclusively at measuring the Burnout
Syndrome proposed by Christina Maslach and her collaborators, which I call in this work
“Maslach/MBI” Burnout (MMBIB). I remind you that, in addition to MMBIB, I name other
“types” of Burnout: FB, ICD11B and CSB (to understand this classification and thus better
understand this work, see question n. 1 of this book).
As it could not be different, the answer to this question is based on Maslach Burnout Inventory
Manual, 4th Edition (MASLACH; JACKSON; LEITER, 2018), a document that is equivalent to
a “user guide” for using MBI (Maslach Burnout Inventory), in any of its versions. All explanations
about the correct handling of the instrument, its applications, and interpretations are in this
document.
Unfortunately, as well as MBI, Maslach Burnout Inventory Manual, 4th Edition, is also
copyrighted, a subject that will be further addressed in this work. Let us go ahead.
MMBIB is defined as a syndrome caused by a crisis in the relationship between the worker and
work, which can affect all professionals (regardless of profession and activity) and which has three
dimensions, so-called: emotional exhaustion (or simply exhaustion), the most important dimension
of the syndrome and from which the others derive; depersonalization or cynicism; and low
effectiveness or professional achievement (MASLACH; JACKSON; LEITER, 2018). These
dimensions are groups that supposedly explain and accommodate the diversity of MMBIB signs
and symptoms.
As it could not be different, the answer to this question is based on the Maslach Burnout
Inventory Manual, 4th Edition (MASLACH; JACKSON; LEITER, 2018), a document that is
equivalent to a “user guide” for using MBI (Maslach Burnout Inventory), in any of its versions.
This document explains the correct handling of the instrument, its applications, and interpretations.
Unfortunately, as well as MBI, Maslach Burnout Inventory Manual, 4th Edition, is also
copyrighted, a subject that will be further addressed in this work. Let us go ahead.
MMBIB is defined as a syndrome caused by a crisis in the relationship between the worker and
work, which can affect all professionals (regardless of profession and activity) and which has three
dimensions, so-called: emotional exhaustion (or simply exhaustion), the most critical dimension
of the syndrome and from which the others derive; depersonalization or cynicism; and low
effectiveness or professional achievement (MASLACH; JACKSON; LEITER, 2018). These
dimensions are groups that supposedly explain and accommodate the diversity of MMBIB signs
and symptoms.

(Figure 1: The three blocks of MBI)

Emotional exhaustion dimension block:

Minimum score: 0 (zero);
Maximum score: 54 (the equivalent of 9 times 6);
Interpretation (as per MASLACH; JACKSON; LEITER, 2018): Higher scores indicate a higher
MMBIB degree. Lower scores indicate a lower degree. No cut-off point defines what it means
“not having MMBIB”. All respondents in this block receive the diagnosis of MMBIB, albeit to a
low degree (regardless of the scores assigned to this and the other blocks).
Depersonalization dimension block:
Minimum score: 0 (zero);
Maximum score: 30 (the equivalent of 5 times 6);
Interpretation (as per MASLACH; JACKSON; LEITER, 2018): Higher scores indicate a higher
MMBIB degree. Lower scores indicate a lower degree. No cut-off point defines what it means
“not having MMBIB”. All respondents in this block receive the diagnosis of MMBIB, albeit to a
low degree (regardless of the scores assigned to this and the other blocks).
Professional achievement dimension block:
Minimum score: 0 (zero);
Maximum score: 48 (the equivalent of 8 times 6);
Interpretation (as per MASLACH; JACKSON; LEITER, 2018): In this block, the analysis is
inverse. In other words, higher scores indicate a lower MMBIB degree. Lower scores indicate a
higher degree. Once again, no cut-off point defines what it means “not having MMBIB”. All
respondents in this block receive the diagnosis of MMBIB, albeit to a low degree (regardless of
the scores assigned to this and the other blocks).
I repeat that, according to Maslach Burnout Inventory Manual, 4th Edition (MASLACH;
JACKSON; LEITER, 2018), each of the three blocks of MBI must be evaluated and interpreted
individually. In other words, it is unnecessary to add or average the scores of the three blocks to
reach any conclusion.
Thus, if we analyze only the emotional exhaustion dimension block, scoring only 4 points (in
a score ranging from zero to 54), we can already infer (without even going through the other
blocks) that we are dealing with a low degree of MMBIB. If, in the same block, the score is 50,
just for that reason, we can also affirm (without observing the other blocks) that we are dealing
with a high degree of MMBIB. This same analysis also applies to the other block: the
 depersonalization professional achievement dimension. (Figure 2)

(Figure 2: For MBI, the individual assessment of any of the three dimensions can lead to
the same result, in other words, MMBIB)

Observe that MMBIB is measured on MBI within a continuum ranging from low to high
degree. No cut-off point defines “not having MMBIB” (MASLACH; JACKSON; LEITER, 2018).
Therefore, whatever the scores attributed by the respondent, the MMBIB will always be present,
even if to a low degree. There is no exclusion.
Any population of workers, regardless of size (whether one or thousands), who undergo
MBI will be diagnosed with MMBIB, even if at a low degree, in 100% of cases. From the happiest
to the saddest individual, the strongest to the weakest, the richest to the poorest, and the most
accomplished to the most dissatisfied, MBI assigns MMBIB to all interviewed workers. All. None
escape.

36. Is MBI used to identify if someone has (or not) the Burnout Syndrome proposed by
Maslach?
No, it is not.
 As it could not be different, the answer to this question is based on Maslach Burnout Inventory
Manual, 4th Edition (MASLACH; JACKSON; LEITER, 2018), a document that is equivalent to
a “user guide” for using MBI (Maslach Burnout Inventory), in any of its versions.
According to Maslach, Jackson and Leiter (2018), MBI does not attempt to make a dichotomous
diagnosis of the Burnout Syndrome proposed by Christina Maslach and her collaborators, what I
call in this work “Maslach/MBI Burnout” (MMBIB), in other words, it is not the purpose of MBI
to certify whether someone “has” or “does not have” MMBIB.
For these authors, the purpose of MBI is to evaluate MMBIB, individually or collectively, for
comparisons and/or subsequent interventions, but always within a continuum, which goes from
low to high degree of MMBIB.
I insist: that no cutoff point in MBI can separate who has or does not have MMBIB
(MASLACH; JACKSON; LEITER, 2018). There is no way to undergo MBI and not receive the
diagnosis of MMBIB. Any population of workers, regardless of size (whether one or thousands),
who undergo MBI will be diagnosed with MMBIB, even if at a low degree, in 100% of cases.

37. In MBI, are there exclusion criteria for the Burnout Syndrome proposed by Maslach? Is
there any way of avoiding ‘Maslach Burnout’?
Let us not forget: MBI is a test aimed exclusively at measuring the Burnout Syndrome proposed
by Christina Maslach and her collaborators, which I call in this work “Maslach/MBI Burnout”
(MMBIB). I remind you that, in addition to MMBIB, I name other “types” of Burnout: FB,
ICD11B and CSB (to understand this classification and thus better understand this work, see
question n. 1 of this book).
Atypically, there is no way of not having MMBIB. If you are a worker and underwent MBI,
you have MMBIB, even at a low degree.
As it could not be different, the answer to this question is based on Maslach Burnout Inventory
Manual, 4th Edition (MASLACH; JACKSON; LEITER, 2018), a document that is equivalent to
a “user guide” for using MBI (Maslach Burnout Inventory).
As we have already observed and I confirm now, for this document, no cutoff point in MBI can
separate who has or does not have MMBIB (MASLACH; JACKSON; LEITER, 2018). There is
no way to undergo MBI and not receive the diagnosis of MMBIB. From the happiest to the saddest,
the strongest to the weakest, the richest to the poorest, and the most accomplished to the most
dissatisfied, MBI assigns MMBIB to 100% of the interviewed workers. No one is left out.
In her research, Maslach sometimes states that MMBIB is a disease, but sometimes she says
the opposite (LIMA, 2021). However, we will yet see in this work that the Burnout phenomenon
has never been and is not recognized as a disorder or mental illness, either by ICD-11 (WHO,
2018) or DSM-5 (APA, 2014). Nevertheless, if it were a disease, as pneumonia is, for instance,
MMBIB would be as absurd as stating that “100% of people have pneumonia, regardless of any
symptoms”. I do not know how it is for you, but MMBIB bewilders me.
To conclude with art, I remember that when she presented MBI for publication for the first time,
Maslach received the material back from the editor of a scientific journal with the observation:
“(...) we do not publish 'pop psychology' (MASLACH; JACKSON, 1984). Humberto Gessinger
would certainly agree with this editor. For this renowned singer and songwriter from Rio Grande
do Sul and MBI, “pop spares no one”.

38. What is the most significant risk to public health when using MBI as a reference for the
diagnosis of Burnout Syndrome proposed by Maslach?
In my opinion, the most significant risk to public health when using MBI as a reference for
diagnosing the Burnout Syndrome proposed by Maslach, which I call “Maslach Burnout/MBI”
(MMBIB) in this work, is disseminated iatrogenic. I will explain.
Iatrogenic (from the Greek: iatros = healer + genesis = origin) is usually understood as the
negative effect on the patient, resulting from any action performed by a health professional,
whether it be the prescription or administration of drugs, whether the performance or indication of
any allegedly beneficial procedures.
Some iatrogenic effects are easily observed, such as, for example, a hematoma after a
venipuncture for blood collection. Others are less obvious, such as some drug interactions.
Although it is not associated with the usual concept of the term, it should be noted that an
iatrogenic effect can be pretty predictable and not harmful, such as a scar resulting from a surgical
procedure.
In this context, the most appropriate denomination could be iatropathogenesis, a term that
emphasizes the harmful notion of the health professional’s act, in other words, an act that causes
harm to the patient (TAVARES, 2005).
 Therefore, in the most usual sense of the term, iatrogenesis encompasses material damage (side
effects from the use of drugs, undesirable surgical consequences, etc.) and psychological damage
(psychoiatrogeny - behavior, attitudes, words directed at the sick person) caused to the patient, not
only by the doctor but also by their team (nurses, psychologists, social workers, physical therapists,
nutritionists, and other professionals) (PADILHA, 2001).
As we have already seen, there is no way a worker who undergoes MBI (Maslach Burnout
Inventory) does not receive the diagnosis of MMBIB. From the individual with no complaints to
the individual with severe depressive disorder, MBI assigns MMBIB to 100% of the interviewed
workers.
It is impossible not to recall the words Freudenberger spoke in 1989: “We need to be careful
not to attribute so many concepts to Burnout that it becomes meaningless” (FREUDENBERGER,
1989 apud LIMA, 2021).
Regarding MMBIB, this prophecy has not been fulfilled. Let us face it: a syndrome that affects
100% of those investigated, as proposed by MMBIB, is not a syndrome. Wanting so much to be
everything should not mean anything.
Due to misinformation, MMBIB still means a lot to many people. It camouflages itself with
other “types” of Burnout [e.g. “Freudenberger’s Burnout” (FB), “ICD-11 Burnout” (ICD11B) and
“Common Sense Burnout” (CSB)]. It perpetuates itself as one of the agents that foster confusion
on the subject (ps.: to understand the differences between the cited “types” of Burnout and thus
better understand this work, see question n. 1 of this book).
A severe and colossal problem arises: when you diagnose badly, you treat badly. Let us see.
Unlike the Burnout phenomenon (here referring to any Burnout), the most prevalent mental
disorders and illnesses (for example, anxiety disorders, depressive disorders, etc.) have treatment
protocols, medication, and psychotherapy, well-established and recognized by the academic
community.
When a severely depressive patient is given, for example, the diagnosis of MMBIB, the latter
diagnosis tends to mask the former. Thus, it is very likely that this individual will not be correctly
and adequately treated for the severe depression that affects him.
This immense suffering is extended. The risk of voluntary abbreviation of life is increased. The
opportunity to use the best therapeutic practices anchored in recognized guidelines is lost.
According to Lima (2021), it can be considered iatrogenic conduct to treat the patient described
above only with psychotherapy and not use the drug arsenal available and necessary for the case.
Some say: “Whether it is Burnout or not, it does not matter; what matters is the workers'
suffering”. I dare to disagree emphatically. The correct diagnosis always matters, and it matters a
lot. Again: when a wrong diagnosis is made, it is poorly treated, and suffering is extended.
It is important to emphasize that no specific treatment protocol is recognized worldwide for the
Burnout phenomenon. In this scenario, off-label treatments (outside standardized indications) for
Burnout increase in a practical and usually erratic way. The iatrogenic potential here is immense.
For all the above, I believe the most significant risk to public health when using MBI as a
reference for diagnosing MMBIB (the “type” of Burnout for which MBI was designed) is
disseminated iatrogenesis. Along the same lines, due to the highly confusing power that the
instrument has, Bianchi, Schonfeld and Laurent (2016) strongly contraindicate the use of MBI to
support any type of action in favor of public health.
In short, I remind you that I made the personal choice of choosing the ICD-11 (WHO, 2018) as
the principal, less iatrogenic, and more reliable source on Burnout nowadays. Although ICD-11 is
also a target of numerous and consistent criticisms, for having the signature of the World Health
Organization (WHO), for its collegiate and representative academic preparation, for the
importance and worldwide recognition of this document, in addition to other reasons that I describe
in the question n. 55 of this book, I am convinced that I made the best choice and from now on, I
suggest that everyone else do the same. Throughout this work, we will discuss in detail what I call
“ICD-11 Burnout” (ICD11B).

39. Is MBI used to measure “Freudenberger’s Burnout”?

As its name suggests, MBI (Maslach Burnout Inventory) evaluates only the Burnout Syndrome
proposed by Christina Maslach and her collaborators [what I call in this work “Maslach
Burnout/MBI” (MMBIB)].
Moreover, it could not be different. MMBIB is quite different from what I named
“Freudenberger’s Burnout” (BF), as we observed in detail in question n. 28 of this book.
40. What is the concept of depersonalization for psychopathology (a fundamental subject for
psychiatry and clinical psychology)? What about MBI and Burnout Syndrome proposed by
Maslach?
For psychopathology, depersonalization is a term used since the end of the 19th century
(BERRIOS, 1996). It is part of a presentation named Alteration of the Consciousness of the
Self by Karl Jaspers (DALGALARRONDO, 2019).
Depersonalization pertains to identity disorders (LIMA, 2021). In short, it is a subjective feeling
of being unreal, odd, or unknown to oneself (KAPLAN; SADOCK, 2007).
For Correia, Guerreiro and Barbosa (2014), depersonalization is a disturbing, frightening, and
unsetting feeling of strangeness and lack of familiarity with oneself; a feeling of unreality ("I am
not me"; "I am just a machine"; "I feel like nothing, dead").
For Dalgalarrondo (2019), depersonalization is the true strangeness of oneself, which creates
much anguish and deep perplexity in the individual. They begin to have the horrible feeling that
they will go crazy and lose self-control. The patient feels strange about himself and experiences a
significant transformation in his familiar and everyday psychic and bodily self is experienced as
something strange, different, and bizarre. In depersonalization, there is a total or partial loss of the
basic empathic relationship, of the unmistakable familiarity of the self with oneself. There is a
profound strangeness from what is most familiar to us: our own self.
In the same wake, for DSM-5 (APA, 2014), depersonalization is the “feeling of being distanced,
as if you were an external observer, from your own mental processes, body or actions (e.g., feeling
like you are in a dream; a feeling of unreality of oneself, perceptive changes; emotional and/or
physical anesthesia; temporal distortions; and feeling of unreality)”.
Depersonalization, as mentioned earlier, can happen, for example, in cases of intense anxiety
and panic attacks, psychotic conditions (including toxic psychoses) and severe depression, in
addition to dissociative conditions.
As for Christina Maslach and her collaborators, consequently, for MBI (Maslach Burnout
Inventory) [in the versions in which the term is used, which includes the most used version, MBI-
HSS (MBI - Human Services Survey)], depersonalization refers to a feeling of insensitivity,
indifference, detachment, and impersonality regarding the other, with whom one lives in the work
environment (MASLACH; JACKSON; LEITER, 2018).
 Observe the striking difference between the concepts. In psychopathology (an indispensable
discipline for psychiatry and clinical psychology), the term depersonalization (described since the
19th century) is used to designate an alteration in the consciousness of the self, in other words, an
entirely subjective perception, which concerns only the individual himself.
On the other hand, for Maslach/MBI, the concept of depersonalization (proposed by Christina
Maslach herself in the 1970s) refers to insensitivity, indifference, and emotional detaching
regarding the other, a third party.
In psychopathology, emotional detaching and depersonalization are distinct phenomena in
mental processes. While the first one is evaluated mainly within the key to mood and affectivity,
the second one concerns the alteration of the consciousness of the Self.
As Lima (2021) rightly pointed out, “Maslach/MBI Burnout”, which I call MMBIB in this
work, is spoken, “in a foreign language to psychopathology, a kind of mini psychopathology of its
own, improvised and, above all, artificial”. There is no conceptual interlocution between the
psychopathological language standard used worldwide and in a secular way and the recently
announced MMBIB.
Perhaps this explains the lack of approach to the Burnout theme in the main residencies and
specializations in psychiatry since this science has as its main tool the performance of a good and
detailed psychological examination of each patient.
Psychological examination, in turn, is deeply supported by the knowledge of classic
psychopathology, the same in which mental disorders are described, and differentiates these from
one another, which is also a reference for the main guides and classifications on mental illness
[e.g., ICD-11 (WHO, 2018) and DSM-5 (APA, 2014); which was totally neglected in the
formulation of the concept of the Burnout Syndrome proposed by Christina Maslach and her
collaborators, and also in MBI.
The most extreme attestation is that “either psychiatry or clinical psychology exist, or MMBIB
exists. The coexistence of MMBIB and these sciences is impossible”. It is worth reflecting on.
Note 1: In MBI-GS (MBI - General Survey) and MBI-GS (S) (MBI - General Survey for
Students) versions, the term depersonalization was replaced by cynicism, a word that, by itself,
does not direct the psychological examination towards any diagnosis. According to Lima (2021),
from a psychopathology perspective, the term cynicism can be used to describe, for example, a
“mere personality trait”.
 Note 2: Probably out of respect and appreciation for classic psychopathology, in ICD-11, as we
will see later, the term depersonalization does not appear in the description of Burnout, it gives
rise to the expression “increased mental distance from work or feelings of negativism or cynicism
about work".

41. If someone with “serious and constant problems in the marriage” undergoes MBI: can
the results suggest higher degrees of the Burnout Syndrome proposed by Maslach?
Yes, they can. In that case, there would probably be a higher score for the Burnout Syndrome
proposed by Christina Maslach and her collaborators (what I call in this work “Maslach/MBI”
Burnout (MMBIB) which, in turn, is measured by MBI (Maslach Burnout Inventory).
A continuously troubled marriage relationship is an unquestionable source of chronic stress.
This factor can result in fatigue and exhaustion in affected individuals (KOCALEVENT et al.,
2011), in addition to favoring the onset of diseases, such as arterial hypertension; heart diseases;
and mental disorders, such as depressive disorder and anxiety disorder (BAUM; POLSUSNZY,
1999).
For any minimally healthy individual, a chronically unhealthy marital relationship will result
in, at least being optimistic, occasional peaks of exhaustion, lack of patience, and a high degree of
intolerance. This would certainly “contaminate” (confuse) the result of an eventual test with MBI.
To support this thesis, I do not need to evoke any dimension of MMBIB other than emotional
exhaustion. Let us see.
Unfortunately, the use of MBI is protected by copyright, a subject that will be further addressed
in this work. For this reason, and in appreciation of the didactics, I made a non-committal and
respectful model test, which “resembles MBI” only in its nine statements related to the emotional
exhaustion dimension.
I emphasize that this test is only illustrative. It is not MBI. It does not intend to replace MBI.
Its statements are not the same as those of MBI. Therefore, this test should not be equivalent to
MBI under any circumstances. Having made this incisive caveat, let us go to the model test:
0 1 2 3 4 5 6
E1 “I feel quite tired from my work and I am on edge.”
E2 “I feel exhausted after 8 hours of work.”
 E3 “I feel tired from the moment I wake up to go to
work.”
E4 “Living with people from my work tires me a lot.”
E5 “My work sucks all my energy.”
E6 “I feel disappointed by things I do at work.”
E7 “I think I should work less and prioritize other things.”
E8 “I get tense with my work team and my
clients/patients.”
E9 "I cannot deliver more than I am already delivering for
my work."
(Merely illustrative test: It is not equivalent to MBI)

I remind you that, to answer the test, the respondent must use the following caption:
0 - never happens;
1 - happens once a year;
2 - happens once a month;
3 - happens a few times a month;
4 - happens once a week;
5 - happens a few times a week;
6 - happens every day.
Now consider that this respondent is a worker (since MBI only makes sense if applied to
workers, as MMBIB is limited to the occupational environment) with severe and constant
problems in the marriage and who, for this reason, is in a moment of peak exhaustion (something
often expressed as “I'm at my wits’ end, I can't stand it anymore”), lack of patience, and a high
degree of intolerance (something expressed as “I'm fed up with everything”).
It is reasonable to assume that, under these conditions, this individual would attribute higher
scores to the statements measured by MBI regarding the emotional exhaustion dimension. That
would be enough to qualify this respondent as having a high MMBIB degree, even if not because
of work but because of the peak of exhaustion due to the marital context that he is experiencing.
42. If someone with a depressive disorder (non-work related) undergoes MBI, can the results
suggest higher degrees of the Burnout Syndrome proposed by Maslach?
Yes, they can. In that case, there would probably also be a higher score for the Burnout
Syndrome proposed by Christina Maslach and her collaborators [what I call in this work
“Maslach/MBI Burnout” (MMBIB) which, in turn, is measured by MBI (Maslach Burnout
Inventory)].
According to DSM-5 (APA, 2014), in depressive disorder, the individual presents, constantly
and frequently, the following possible symptoms: depressed mood for most of the day; markedly
reduced interest or pleasure in all or nearly all activities for most of the day; significant weight
loss or gain when not on diet, or reduced or increased appetite; insomnia or hypersomnia (“too
sleepy”); psychomotor agitation or retardation (feeling of “being much slower”); fatigue or loss of
energy nearly every day; feelings of worthlessness or excessive or inappropriate guilt; diminished
ability to think or concentrate, or indecisiveness; and recurrent thoughts of death and frequent
suicidal ideation.
In depressive disorder, the possibility of the individual presenting depressed mood and
fatigue (physical and mental exhaustion), in addition to other symptoms, is significant. This would
certainly “contaminate” (confuse) the result of an eventual test with MBI. Once again: to support
this thesis, I do not need to evoke any dimension of MMBIB other than “emotional exhaustion”.
Let us see.
In appreciation of the didactics, I recall this non-committal and respectful model test, which
“resembles MBI” only in its nine statements related to the emotional exhaustion dimension.
I emphasize that this test is only illustrative and should not be used as an equivalent to MBI
under any circumstances. Having made this incisive caveat again, let us go to the model test:
0 1 2 3 4 5 6
E1 “I feel quite tired from my work, and I am on edge.”
E2 “I feel exhausted after 8 hours of work.”
E3 “I feel tired from the moment I wake up to go to
work.”
E4 “Living with people from my work tires me a lot.”
E5 “My work sucks all my energy.”
E6 “I feel disappointed by things I do at work.”
 E7 “I think I should work less and prioritize other things.”
E8 “I get tense with my work team and my
clients/patients.”
E9 "I cannot deliver more than I am already delivering for
my work."
(Merely illustrative test: It is not equivalent to MBI)

I remind you that, to answer the test, the respondent must use the following caption:
0 - never happens;
1 - happens once a year;
2 - happens once a month;
3 - happens a few times a month;
4 - happens once a week;
5 - happens a few times a week;
6 - happens every day.
As an exercise, consider that this respondent is a worker (since MBI only makes sense if
applied to workers, as MMBIB is limited to the occupational environment) with a depressive
disorder, which, in turn, is expressed markedly with depressed mood, fatigue (physical and
psychic), in addition to other symptoms.
It is feasible to assume that, under these conditions, this individual would attribute higher
scores to the statements measured by MBI regarding the emotional exhaustion dimension. That
would qualify this respondent as having a high MMBIB degree, even if not because of work but
because of the depressive disorder that affects him.

43. What other mental disorders can “contaminate” (confuse) the results measured by MBI?
Many. In summary, using nomenclatures proposed by DSM-5 (APA, 2014), I mention some
mental disorders that could contaminate the results measured by MBI (Maslach Burnout
Inventory), even though these disorders might not be related to work.
For didactic purposes, I will categorize them according to the three blocks used in MBI,
referring to the three dimensions proposed in the concept of Burnout Syndrome proposed by
Christina Maslach and her collaborators, which I call in this work “Maslach/MBI Burnout”
(MMBIB).
Some mental disorders that can “contaminate” the emotional exhaustion dimension:
• Major depressive disorder;
• Persistent depressive disorder (dysthymia);
• Premenstrual dysphoric disorder;
• Substance/medication-induced depressive disorder;
• Depressive disorder due to another medical condition;
• Panic disorder;
• Agoraphobia;
• Generalized anxiety disorder;
• Post-traumatic stress disorder;
• Acute stress disorder;
• Adjustment disorders;
• Schizoaffective disorder;
• Bipolar disorder (types I and II), with the current or most recent depressive episode;
• Among other possibilities.
Some mental disorders that can “contaminate” the depersonalization dimension [also called
cynicism in MBI-GS and MBI-GS(S) versions]:
• Personality disorders (may be from groups A, B, or C);
• Post-traumatic stress disorder;
• Among other possibilities.
Some mental disorders that can “contaminate” the professional achievement dimension:
• Type I bipolar disorder, with the current or most recent manic episode;
• Type II bipolar disorder, with the current or most recent hypomanic episode;
• Cyclothymic disorder;
• Major depressive disorder;
• Persistent depressive disorder (dysthymia);
• Premenstrual dysphoric disorder;
• Substance/medication-induced depressive disorder;
• Depressive disorder due to another medical condition;
• Panic disorder;
• Agoraphobia;
• Generalized anxiety disorder;
• Among other possibilities.
Let us remember that all 22 MBI statements portray possible perceptions experienced by the
interviewee and that they usually make direct mention of work.
In all the mentioned mental disorders, even if unrelated to the work context, there could be a
“contamination” (confusion) in the results of an eventual test with MBI. This is because such
entities have clinical repercussions, to a greater or lesser extent, on the self-perception of feelings
experienced by affected individuals in all contexts, including occupational ones.

44. According to MBI, how many symptoms does the Burnout Syndrome proposed by
Maslach have?
Schaufeli and Enzmann (1998) list 132 possible symptoms for the Burnout Syndrome proposed
by Christina Maslach and her collaborators, which I call in this work “Maslach/MBI Burnout”
(MMBIB). Lima (2021) warns that this list could be even longer, as other authors suggest
additional symptoms to those described by Schaufeli and Enzmann.
It is an extravagant number to have on the label of a single syndrome. To give you an idea,
all nine possible symptoms of major depressive disorder, listed in DSM-5 (APA, 2014), fit among
the 132 possible symptoms of MMBIB described by Schaufeli and Enzmann. Broadly, it is as if
MMBIB had captured all symptoms of depression and other mental (and also organic) disorders.
Let us not forget that MBI assigns MMBIB to 100% of the interviewed workers.
It is important to emphasize that Wilmar Schaufeli is not just “another” researcher on
Burnout. According to Lima (2021), Schaufeli is a clinical and organizational psychology
professor at the University of Utrecht (The Netherlands). He is considered the most important
theorist on Burnout in the world.
Schaufeli is a co-author of several publications with Christina Maslach, he is a contributor
to Maslach Burnout Inventory Manual, 4th Edition (2018), MBI “user guide”, and he is one of the
copyright holders of two versions of MBI [MBI-GS (MBI - General Survey) and MBI-GS (S)
(MBI - General Survey for Students)].
45. Can MBI consider other psychiatric diagnoses as being the Burnout Syndrome proposed
by Maslach?
Not only can, but considers, in 100% of cases.
MBI (Maslach Burnout Inventory) assigns the Burnout Syndrome proposed by Christina
Maslach and her collaborators, what I call in this work “Maslach/MBI Burnout” (MMBIB), for all
workers who undergo the test. I repeat: all, 100% of cases.
Remember that MMBIB is measured in MBI within a continuous spectrum from low to
high degrees. Thus, whatever the MBI scores attributed by the interviewed workers, MMBIB will
always be present. There is no exclusion. Any population of workers, regardless of size (whether
one or thousands), who undergo MBI will be diagnosed with MMBIB, even if to a low degree, in
all cases.
Then, it is evident that MBI assigns MMBIB to all workers, with or without any illness,
whether psychiatric (mental) or organic, whether light or severe. I repeat: from the healthiest to
the sickest, from the happiest to the saddest, from the strongest to the weakest, from the richest to
the poorest, and from the most accomplished to the most dissatisfied, MBI assigns MMBIB to all
respondent workers.

46. Is it possible to establish any correlation between the Burnout Syndrome proposed by
Maslach and RSI/WRMDs?
Yes, it is. Let us see the similarities between the Burnout Syndrome proposed by Christina
Maslach and her collaborators, what I call in this work “Maslach/MBI Burnout” (MMBIB) and
RSI/WRMDs.
I remember that RSI stands for Repetitive Strain Injury, and WRMD stands for Work-
Related Musculoskeletal Disease.
The term RSI/WRMD became famous in Brazil in the 1990s, when there was intense
digitization of work processes, and it came to be interpreted by common sense as a synonym for
disease. It was common to hear from workers: “I have RSI” or “My disease is called WRMD”.
However, there has never been a disease named RSI or WRMD. On the contrary, we
know that the term RSI/WRMD represents a set of diseases that can be caused by work (or not),
such as Carpal Tunnel Syndrome (CTS), different types of tendinitis, epicondylitis, among many
other diseases.
 I will try to be even more didactic. It is as if RSI/WRMD were a huge box. Inside that box,
there were several different diseases, each with its own peculiarity: its diagnosis, its treatment, its
prognosis, all in a particular way. Thus, the specialized technical literature does not establish a
generic treatment protocol for RSI/WRMDs, but an individualized treatment for the many diseases
that comprise the so-called “RSI/WRMD group”.
What is the similarity of “RSI/WRMDs, the group” with MMBIB? As well as
RSI/WRMDs have never been recognized as a unique disease, the Burnout phenomenon has also
never been recognized as a disorder or mental illness, either by ICD-11 (WHO, 2018) or DSM-5
(APA, 2014). Consequently, the medical literature has never established a treatment protocol for
RSI/WRMDs. The same happens with MMBIB.
There is one more similarity. My analogy of RSI/WRMD as a huge box full of several
diseases also applies to MMBIB, but in a much more elastic way. This is because MBI assigns
MMBIB to all workers, with or without any illness, whether psychiatric (mental) or organic,
whether light or severe. I repeat: MBI assigns MMBIB, albeit slowly, to 100% of the workers
interviewed. Thus, without limits, MMBIB encompasses diseases and situations that do not qualify
as diseases. P.S.: According to Jaspers (1979), mental processes that are not classified as disorders
or mental illnesses are called normal experiential reactions.
As I mentioned in question 38, I believe the tremendous implicit risk of MMBIB is
iatrogenesis. Many workers might suffer from mental distress due to a severe psychiatric disorder.
However, they are being treated wrongly due to a generic and non-specific diagnosis of Burnout
that they received. It is worth emphasizing that when the diagnosis is incorrect, the treatment is
usually wrong, and the excellent effect rarely happens.
It is important to stress once again that there is no specific treatment protocol recognized
worldwide for the Burnout phenomenon. In this scenario, off-label treatments (outside
standardized indications) for Burnout increase in a practical and usually erratic way. The iatrogenic
potential here is enormous.
It never hurts to remember that mental suffering is no joke in this somber context.
Anyone who has had or still has, or lives with someone who suffers or has suffered, knows how it
is. Treatment must be assertive and effective, which is only possible with a correct and case-
specific diagnosis.
 Finally, I remind you that I made the personal choice of choosing ICD-11 as the principal,
less iatrogenic, and more reliable source of Burnout nowadays. Although ICD-11 is also a target
of numerous and constant criticisms for having the signature of the World Health Organization
(WHO), for its collegiate and representative academic preparation, for the importance and
worldwide recognition of this document, in addition to other reasons that I describe in the question
n. 55 of this book, I am convinced that I made the best choice and from now on, I suggest that
everyone else do the same. Throughout this work, we will also discuss what I call “ICD-11
Burnout” (ICD11B).

47. It is not the purpose of MBI to certify whether someone has (or not) the Burnout
Syndrome proposed by Maslach. Why does most of the research using this instrument not
respect this?
The simple fact is that most studies that use MBI seek to state who “has” or “does
not have” Burnout in the assessed population, which is contraindicated by the instrument's “user
guide”.
As we have already seen, for Maslach, Jackson and Leiter (2018), MBI does not
propose to make a dichotomous diagnosis of the Burnout Syndrome proposed by Christina
Maslach and her collaborators, which I call in this work “Maslach/MBI Burnout” (MMBIB), in
other words, it is not MBI’s aim to certify whether someone “has” or “does not have” MMBIB.
Even so, Cindy and Donald McGeary (2012) report an exponential increase in Burnout
publications from when MBI was introduced. In the 1980s, publications increased by 64%; in the
1990s, the increase was 150% (SCHAUFELI, 2017).
This way, MBI became well known, and in the late 1990s, it was the main Burnout
Syndrome “measurer” used worldwide, being used ten times more than other measures in papers
and dissertations on the subject, in other words, 93% of papers published in journals used MBI
(SCHAUFELI; ENZMANN, 1998).
As the original MBI does not assign a “cutoff point” to separate those who “have” from
those who “do not have” MMBIB, contrary to the instrument's idealizer (Christina Maslach), it
was up to the thousands of experts who use (and used) the test in their research to do so, but always
randomly and without any uniformity.
 In other words, it is as if each researcher who uses MBI were to innovate and assign a
particular and arbitrary cut-off score to attest whether someone “has” or “does not have” Burnout
Syndrome within their own research. Thus, they end up misrepresenting the purpose of the original
MBI that is described in the Maslach Burnout Inventory Manual, 4th Edition (2018), the
instrument’s “user guide”, consequently creating many new concepts for Burnout (different
MMBIB concept), but it resulted from the same MBI.
To be fair, it is worth noting that this practice (of creating arbitrary cut-off scores in MBI)
continues to be strongly contraindicated by Maslach, Jackson and Leiter (2018), even though this
contraindication does not seem to have a practical effect.
As expected, the thousands of research that are based on the distorted use of MBI, assigning
individual and arbitrary cut-off scores to attest whether someone “has” or “does not have” Burnout
Syndrome, differ substantially from each other, both in results and in the concepts given to the
phenomenon. This made Schaufeli and Enzmann (1998) assume that “in fact, several definitions
and theoretical approaches suggest that the concept of Burnout is much broader and more
comprehensive than MBI proposes”.
According to Lima (2021), this research's different and inconsistent results multiply even
more the studies based on the distorted use of MBI, but without any critical questioning about the
instrument's own construct. Thus, more and more studies arise daily supported by MBI, but with
their own criteria for qualifying Burnout Syndrome. This erroneous circularity perpetuates and
glamorizes Burnout, both in academia and beyond.

48. What are the impacts of this divergence between Christina Maslach (who states that it is
not the purpose of MBI to certify whether someone “has” or “does not have” the Burnout
Syndrome proposed by her) and the researchers who also base their studies on MBI, but do
not follow the recommendation of the author of the instrument?
Directly and objectively, the most significant impact is the evidence that, despite being the
most used test in worldwide research, MBI (Maslach Burnout Inventory) is not reliable in assessing
Burnout’s phenomenon prevalence.
As we have already seen, the thousands of studies based on the distorted use of MBI differ
substantially from each other in terms of results and concepts given for the Burnout phenomenon.
This distortion can be explained by the attribution of particular and random cutoff scores to attest
whether someone “has” or “does not have” Burnout Syndrome, which is routinely done by the
authors of such research, despite the guidance given by MBI’s idealizer, Christina Maslach, who
contraindicates this practice.
Rotenstein et al. (2018), in the paper Prevalence of Burnout Among Physicians: A
Systematic Review, published in the Journal of the American Medical Association (JAMA), gives
us an idea of the problem’s staggering extent.
This is a systematic review of 182 studies published between 1991 and 2018, in other
words, carried out over 27 years. The population involved was robust and significant: 109,628
physicians from 45 countries.
According to the research, 85.7% (156/182) of the surveys evaluated used some version of
the MBI to assess Burnout, in which MBI-HSS (MBI - Human Services Survey) was the most
used version, used 57.8% of the analyzed studies (108/182).
These data align with Schaufeli and Enzmann (1998), who state that, at the end of the
1990s, MBI was already used ten times more than other measures in papers and dissertations on
the subject (a number relatively close to the found 85.7%). There is also an agreement between
Maslach, Jackson and Leiter (2018), who attest that MBI-HSS is the most used version of MBI.
Now, a piece of data that causes perplexity: the overall prevalence of Burnout, in this study
published in JAMA, ranged from 0% to 80.5%. Yes, the prevalence of Burnout found in the 182
surveys among physicians (the same professional category in all surveys) ranged from 0% to
80.5%. As we have already seen, this divergence can be explained by assigning arbitrary cut-off
scores to attest whether someone “has” or “does not have” Burnout Syndrome, which was done in
all the evaluated studies (albeit with some coincidences in the assigned cut-off scores).
This way, the authors of the evaluated research changed the purpose of the original MBI -
which is described in the Maslach Burnout Inventory Manual, 4th Edition (2018), the instrument's
"user guide" - consequently, they created new and several concepts for Burnout (different from the
concept of Burnout Syndrome proposed by Maslach and her collaborators, which I call in this
work “Maslach/MBI Burnout” - MMBIB), but resulted from the same MBI.
According to the systematic review published in JAMA, the evaluated studies used at least
142 unique definitions for the phenomenon, "indicating substantial disagreement in the literature
on what constitutes Burnout." It sounds unbelievable, but among the 182 surveys evaluated, there
were 142 concepts for Burnout.
 For the sake of justice, it is worth mentioning again that this practice (of creating arbitrary cut-
off scores in MBI) continues to be contraindicated by Maslach, Jackson and Leiter (2018), even
though this contraindication does not seem to have a practical effect.
What is even more startling is to consider that if at least one of the studies evaluated in the
paper Prevalence of Burnout Among Physicians: A Systematic Review (2018) strictly followed
Maslach’s guidance, not assigning such arbitrary cutoff scores and considering that MBI makes
the diagnosis of MMBIB for all test respondents, although, at a low degree, the prevalence of
Burnout phenomenon would vary between 0% and 100% among the studies evaluated in the paper
published in JAMA.
Let us face it: a test that, for different populations but of the same professional category,
can vary its results between 0% and 100% is unreliable. For Bianchi (2016), relying on such criteria
to estimate Burnout's prevalence is unjustifiable.
Thus, despite being the most used test in worldwide research, MBI is unreliable in
assessing Burnout Syndrome's prevalence.

49. If MBI qualifies 100% of respondents with the Burnout Syndrome proposed by Maslach,
why are there studies that use MBI but show different percentages of Burnout in the
evaluated population? Should it not be 100% Burnout for every analyzed sample and study?
The following results are from studies that used MBI (Maslach Burnout Inventory) to
“measure” Burnout in the respective evaluated medical populations:
• In the USA, the numbers from a study with 1,840 physicians presented different results. The
highest Burnout rates were observed in physicians from the private service (55%), followed by
physicians from the public sector (39%), and from the academic sector (37%) (Deckard, Hicks &
Hamory, 1992).
• More than half of North American physicians have burnout (Shanafelt et al., 2015).
• In China, a study involving 1,537 physicians presented that 76.9% of respondents reported some
symptom or severe symptoms of Burnout (Wen et al., 2016).
If, as already mentioned in this work, MBI qualifies 100% of respondents with the Burnout
Syndrome proposed by Maslach and her collaborators, which I call in this book “Maslach/MBI
Burnout” (MMBIB), why does this research present different percentages of MMBIB in the
evaluated populations? Should it not be 100% MMBIB for all analyzed samples and all studies?
The answers to these questions and their respective justifications are in the two previous questions.

50. Is it true that MBI and its manuals are copyrighted? If so, what are the impacts of that?
Yes, it is. According to Maslach, Jackson and Leiter (2018), both MBI (Maslach Burnout
Inventory), in all its versions [MBI-HSS; MBI-HSS (MP); MBI-ES; MBI-GS and MBI-GS (S)],
as well as their user guide [Maslach Burnout Inventory Manual, 4th Edition (2018)], have their
copy, in whole or in part, prohibited by the holder of the respective copyright: the Publisher
MindGarden, Inc. For this reason, I have not published excerpts from these documents, literally
and rigorously transcribed, throughout this book.
For Lima (2021), this protective attitude restricts the debate and free discussion of ideas about
the Burnout Syndrome proposed by Maslach and her collaborators, which, in turn, is measured
through MBI. This places the Burnout Maslach Inventory and its user guide as “untouchable
objects”, available only to those interested in the financial beneficiaries of the respective
copyrights. From an academic point of view, while this practice is not prohibited, it is still
regrettable.

51. For Maslach, is Burnout Syndrome a disease?

In her works, Maslach sometimes states that Burnout is a disease, but sometimes she says
the opposite (LIMA, 2021).
According to Maslach, Jackson and Leiter (2018), the Burnout Syndrome proposed by
Christina Maslach and her collaborators, which I call in this work “Maslach/MBI Burnout”
(MMBIB), should not be evaluated in a dichotomous way. Therefore, MBI (Maslach Burnout
Inventory) is not intended to attest whether someone “has” or “does not have” MMBIB. For the
researcher, this dichotomous view (of “having” or “not having” a specific condition) is typical of
medical illnesses in which MMBIB does not fit.
In the work “The Truth about Burnout: how organizations cause personal stress and What to do
about it” (1997), Maslach and Leiter state that Burnout “is not a personality flaw or a clinical
syndrome. It is an occupational problem”. Oddly, in the same work, while acknowledging that
MMBIB is not a clinical syndrome, the authors elevate the phenomenon to the status of a disease
by stating that “it is a disease that spreads gradually and continuously over time, placing people in
a downward spiral from which it is difficult to recover”.
I remind you that neither ICD-11 (WHO, 2018) nor DSM-5 (APA, 2014) place Burnout
Syndrome in the respective chapters of mental disorders or illnesses, including depressive disorder,
schizophrenia, etc. Thus, for these documents, the Burnout phenomenon is not a disease. We will
discuss it in detail throughout this work.
Allow me to take “a step back” and speak of the technical concept of syndrome, defined as
a recognizable (differentiable), constant, and stable set of signs and symptoms that indicate a
specific condition and for which a direct cause (etiology) has not been fully understood or is
unknown (DALGALARRONDO, 2019). Once science identifies a causative agent or process
(etiology) with a high degree of certainty, then it is possible to refer to the process as a disease and
no longer as a syndrome (CALVO et al., 2003).
Schaufeli and Enzmann (1998) list 132 possible symptoms of MMBIB. Due to this large
set of symptoms, the phenomenon is usually called a syndrome by Maslach herself.
However, as Lima (2021) well expressed, “syndrome is not synonymous with any set”.
This set must be recognizable, in other words, differentiable. A father is recognizable to a son, as
he can differentiate him from others. Likewise, a syndrome will only be recognizable by a health
professional if it is possible to differentiate it from other syndromes, even with some overlapping
of signs and symptoms.
The more than 130 symptoms assigned to MMBIB (quite an extravagant number to have
under the label of a single syndrome) are nonspecific and, therefore, do not direct clinical-
diagnostic reasoning towards any assertive direction. Thus, this set of symptoms is not
recognizable (differentiable) from other syndromes, as the concept of syndrome requires.
Among the symptoms cited by Schaufeli and Enzmann (1998) as possible for
MMBIB are: headaches and muscle pain (which can compose a pain syndrome), hyperactivity,
restlessness, and fear of going crazy (which can, for example, compose a psychotic syndrome);
anxiety, nervous twitches, sexual problems, sleeping disorder, shortness of breath, increased
consumption of caffeine, tobacco, alcohol, and other drugs (which can compose an anxiety
syndrome, for example); and depressive mood, emotional exhaustion, chronic fatigue,
abandonment of recreational activities, feeling of helplessness, loss of meaning and hope, a feeling
of impotence, feeling of failure, a feeling of inadequacy, low self-esteem, feeling of guilt, inability
to concentrate, insomnia or hypersomnia (“too sleepy”), hyperactivity, weight loss or gain, and
suicidal ideation, in other words, all (all!) of the symptoms that, according to DSM-5 (APA, 2014),
are part of the depressive syndrome.
Broadly, it is as if MMBIB abducted all the symptoms of depressive disorder and other
mental and organic disorders, pretending to be countless other syndromes.
In short, conceptually, MMBIB does not even fit as a specific syndrome. Even so, in
appreciation and reference to ICD-11, I am referring to Burnout as a syndrome throughout this
work, routinely and without further questioning, since this classification considers it that way.

52. For Maslach, is there a ‘cure’ for the Burnout Syndrome proposed by her and her
collaborators? If so, how is this “cure” established?
From the justifications that I present below, I deduce that, for Christina Maslach, the
Burnout Syndrome proposed by her and her collaborators, which I call in this work “Maslach/MBI
Burnout” (MMBIB), has a “cure”. More than that: there is no need for any medication and/or
psychotherapy for someone to be “cured” of MMBIB.
Before going further, I will explain why the words “healing” and “healed” are in quotes.
According to the dictionary of the Portuguese language, Priberam, one of the meanings of the
verb to cure is “to put an end to a disease”.
Remember, neither ICD-11 (WHO, 2018) nor DSM-5 (APA, 2014) place Burnout
Syndrome in the respective chapters of mental disorders or illnesses, including bipolar disorder,
panic disorder, etc. Based on these documents, the term “cure” for Burnout is inappropriate
because it is not a disease. Therefore, the quotes mentioned above.
As we have already seen, for Maslach, Jackson and Leiter (2018), MMBIB should not
be evaluated dichotomously. In other words, MBI (Maslach Burnout Inventory) is not intended to
attest whether someone “has” or “does not have” MMBIB.
The inevitable question arises: if MMBIB is not to be evaluated and classified
dichotomously, how should it be? For these authors, MBI aims to evaluate MMBIB, individually
or collectively, for purposes of comparisons and/or subsequent interventions, but always from low
to high MMBIB degree (there is no “having” or “not having” MMBIB: all workers have it, even
if at a low degree).
 In 1998, Maslach and Goldberg proposed a “Burnout-engagement” continuum. Just as
there are the antitheses “8 and 80”, “black and white”, and “silence and sound”, for these
researchers, there are also the opposite poles “, Burnout and engagement”.
While MMBIB has three dimensions [emotional exhaustion (or just exhaustion);
depersonalization or cynicism; and low effectiveness or professional achievement (MASLACH;
JACKSON; LEITER, 2018)], engagement is defined as its symmetrical opposite: high energy
(instead of exhaustion), engagement (instead of depersonalization or cynicism) and effectiveness
(instead of low efficacy or professional achievement) (MASLACH; GOLDBERG, 1998).
Here is the famous “one-million-dollar question”: How could an institution “cure” its
employees by taking them from the burnout pole and placing them in the engagement pole? As I
deduce from Maslach and Leiter (2004), the path is to resolve the six possible areas of
disagreement between person and work: work overload, lack of control, insufficient reward, loss
of community, lack of equity (or lack of justice) and conflict of values. (Figure 3)

[Figure 3: According to Maslach and Leiter (2004), solving the 6 areas of disagreement
between worker and work, an occupational environment ceases to be a “Burnout causative”
and becomes a source of engagement)]

Taking a step forward, I also understand that, by solving these six areas, in addition to
ceasing to be a “Burnout causative” and becoming a source of engagement for workers, this
organizational environment should consequently be considered as a protector of any mental
disorder or disease that might be related to chronic stress in the work environment. I explain it
better in question 98.
According to the authors, these six areas were identified from the analysis of many studies
previously done on Burnout and stress at work.
Although there is no unanimity in the literature that Burnout and engagement are
symmetrically opposed phenomena (TARIS; YBEMA; BEEK, 2017), many studies indicate a
certain consensus in the sense that, if there is an improvement in the occupational environment in
terms of one or more than one of these six areas, this work environment will improve, which,
inevitably, will positively impact the workers’ lives.
In the following question, we will deeply address each of these six possible areas of
disagreement between the individual and their work.

53. According to Christina Maslach, what are the six most essential areas an institution must
observe so its employees become increasingly engaged (and without the Burnout Syndrome
proposed by her)?
These six areas of disagreement between a person and work are work overload, lack of
control, insufficient reward, loss of community, lack of equity (or lack of justice), and conflict of
values (MASLACH; LEITER, 2004). Let us take a look at each one of them:
I) Work overload. It is the most prominent and most discussed area in one's professional life. It
refers to demands beyond the possibilities of the resolution, whether due to a lack of time or
resources. For the same authors, the critical point happens when people cannot recover from
work demand, which can lead to exhaustion and the Burnout Syndrome proposed by Christina
Maslach and her collaborators, which I call in this work “Maslach/ MBI Burnout” (MMBIB).
Under these conditions, it is also expected that there will be a worsening in the quality of work
and a rupture of relationships within the organization.
On the other hand, a sustainable workload breaks the exhaustion cycle, MMBIB’s key
dimension, and increases the engagement between workers and work. All this, in addition to
offering opportunities for workers to use and refine their professional skills and become efficient
in new activity areas (LANDSBERGIS, 1988).
 II) Lack of control. It concerns the worker's perception of their ability (or inability) to
influence decisions that affect their work, to exercise autonomy and to have access to the
necessary resources to do an adequate job.
Lack of work control happens when people need more authority over their own work or
are unable to shape the work environment to be consistent with their values (MASLACH; LEITER,
2004).
Including lack of control in the list of the six areas of disagreement between a person and
work was inspired by the demand-control of stress at work theory (KARASEK; THEORELL,
1990), which has already shown the positive effects of work management by the worker who
performs it.
For instance, the so-called role conflict is part of the lack of control. It is the lack (or
absence) of clarity of a hierarchical-institutional organization chart, which ends up allowing two
or more superiors to make conflicting requests to the same subordinate worker, causing for the
latter the perception of lack of control over their work, besides predisposing him to exhaustion
(SIEFERT et al., 1991; STARNAMAN; MILLER, 1992).
On the other hand, when people have more control over their work, their actions are more
freely chosen, leading to greater satisfaction and engagement with their professional activities and
the institution (MASLAC; LEITER, 2004).
III) Insufficient reward. This area of disagreement between worker and work assesses the extent
to which the rewards (monetary and social, internal and external to the institution) are aligned with
the worker's expectations.
The lack of recognition of the performed professional activities, either by the service/product
customer, colleagues, managers, directors, or by other interested parties, devalues both the work
and workers and is closely associated with feelings of professional inefficiency (CORDES;
DOUGHERTY, 1993; MASLACH et al., 1996), in addition to increasing the worker's
vulnerability to exhaustion and fatigue (CHAPPELL; NOVAK, 1992; GLICKEN, 1983;
MASLANKA, 1996; SIEFERT et al., 1991).
On the other hand, when rewards align with the worker's expectations, it tends to bring
satisfaction and engagement with the job and institution. The financial reward is crucial, but
studies suggest that what keeps work engaging for most people is the pleasure and satisfaction they
experience from the daily grind of a job that is doing well, which includes being properly
recognized at all levels (LEITER, 1992).
IV) Loss of community. The sense of community refers to the quality of all interpersonal
relationships at work, including existing conflicts and mutual support, proximity to coworkers and
the ability to work as a team. For Maslach and Leiter (2004), people thrive in community and work
better when they treat each other with cordiality and share praise and good mood with others they
like and respect.
In addition to effective exchange and technical support related to the work done, this type
of good environment reinforces a person's participation in a group with a shared sense of values,
giving them a definite sense of belonging, which increases engagement with professional their
activities and the institution they are part of (LEITER; MASLACH, 1988; SCHNORPFEIL et
al., 2002). Buunk and Schaufeli (1993) further suggest that a lively, attentive, and receptive
occupational community is incompatible with MMBIB.
On the other hand, it is observed that conflict, especially chronic (long-lasting), between
people on the same team, produces negative and constant feelings of frustration and hostility,
negatively impacting the sense of community and predisposing these people to exhaustion and
fatigue (MASLACH; LEITER, 2004).
In the most severe cases involving moral harassment, the process of repetitive and
prolonged exposure of the worker to humiliating and degrading conditions, and to aggressive
treatment in the work environment, in addition to ruining the feeling of community, causes fear,
anxiety, sadness, and it has a genuinely sickening potential, both from a physical and psychic
point of view (BORSBOOM, 2017; FERREIRA, 2010).
V) Absence of equity (or absence of justice). Equity (or fairness) refers to workers' perceptions
of how fair, equitable, and respectful decisions at work are (MASCLAH; LEITER, 2004).
In an institution, a decision is considered fair (“clean”, “fair play”) when it follows criteria
previously established and known by all, when there is no undue respect for people, and when it
treats particular cases with care and zeal. What they deserve is a decision in which workers have
the opportunity to present their arguments and, regardless of what they are, they feel treated with
respect and consideration.
Some research on legal cases shows that people are more concerned with the fairness of the
process than “winning the case” (LAWLER, 1968; TYLER, 1990). It is pretty likely that, in the
work environment, this is also the desire of most workers. Along these wakes, it was observed that
employees who perceive their supervisors as fair and attainable are less susceptible to exhaustion
and fatigue, in addition to better accepting organizational changes (LEITER; HARVIE, 1997,
1998).
On the other hand, the absence of equity (or injustice) is perceived when there is inequality in
workload or remuneration for the same or similar roles; when there is some cheating within the
team; when people are treated in a prejudiced way for different reasons; or when evaluations and
promotions are done inappropriately, privileging some over others, but without a consistent reason
to support this differentiation. Schaufeli et al. (1996) suggest that a lack of equity (or justice)
predisposes workers to MMBIB.
VI) Conflict of values. When we refer to the values of a worker, we must know the ideals and
motivations that initially attracted them to that job. When an employee's values are aligned with
institutional values, it tends to provide greater job satisfaction in that individual, consequently,
greater engagement with the organization (MASLACH; LEITER, 2004).
On the other hand, the greater the distance between the individual's values and those of the
institution, the greater the probability that this individual will be affected by MMBIB (LEITER;
HARVIE, 1997).

From an organizational point of view, an efficient policy to avoid conflict of values

between the individual and the institution consists of structuring, when possible, a rigorous
selection process for each person to be admitted, which includes interviews and questionnaires
applied by specialized professionals. The purpose of the procedure is to identify and not proceed
with the admission of candidates with personal values that differ from institutional values.

Remember that, according to Art. 7, item XXII, of the Federal Constitution of 1988, the
last resort falls on the employer the obligation to extinguish or reduce to the maximum all risks
arising from work, even if the risk is based on subjective issues inherent to the worker himself, as
is the case of a possible conflict of values between worker and work. I also emphasize the
importance of structuring a rigorous selection process for each person to be admitted by the
institution.
The purpose of this classification procedure is to prevent possible harm to the individual's
physical and mental health (MASLACH; LEITER, 2004; LEITER; HARVIE, 1997), with the
protective criterion prevailing to the detriment of any discriminatory claim. This needs to be
emphasized in a referenced way whenever necessary and for all purposes.
Examples of situations that might show the conflict of values between workers and institutions
are:
• when a worker is coerced into lying or besmirching the truth to obtain a commercial gain (e.g.,
making a sale), having their own values of appreciation for honesty and transparency disrespected;
• when institutional theory is not equivalent to its practice. In other words, the values said to belong
to the organization and are publicized to society do not correspond with the institution’s
actual modus operandi.

In the examples mentioned above, aligning the organizational approach with the best and most
ethical practices is a great challenge, which essentially depends on decisions and actions that come
from the highest hierarchical levels of the institution itself.

However, there are cases in which the core of the values conflict between worker and work lies
with the individual and not the institution. For example:

• when the individual enters an organization with mistaken personal expectations about the
dynamics of their professional activities, even if the institution has been transparent, honest, and
sincere in every detail of the offered job position;

• imagine the case of an employee of a large financial institution in which obtaining the highest
possible profit is the organization's central, explicit, and lawful mission. Also, imagine that this
worker is a persistent critic of capitalism and that they preach an equitable division of goods and
wealth for the entire population. This will likely cause an important conflict of values between this
employee and the financial institution they work for.

From the worker's point of view, the healthy, effective, and complete resolution of conflicts of
values with the organization will possibly fall on one of the following alternatives:

• the worker tries to change the organizational situation (for example, talking to managers) in
order to align institutional values with their own values (VILAS, 2021);
 • without compromising their values, the worker changes their own expectations and aligns them
with those of the institution (STEVENS; O'NEILL, 1983);

• the worker leaves the organization and searches for more rewarding career opportunities
(PICK; LEITER, 1991).
I draw your attention to the last of the alternatives, usually the last resort for resolving the
conflict of values between the contracting party and the worker: the worker already hired leaves
(of their own will, resigning) the institution.
We have already seen that, although Maslach considers the existence of individual
factors (e.g., personality), from a practical point of view, the researcher defends work as the only
and sufficient factor to cause MMBIB. However, she realizes that, although the phenomenon is
limited to the occupational environment, it is impossible to completely discard each worker's
individual component within MMBIB (MASLACH; LEITER, 2004). On the contrary, in cases
involving conflict of values and/or purposes, the last decision-making instance and, therefore,
resolving the problem is the worker's competence.
Without going into the merits of the countless and complex variables to be considered,
it is the worker who decides whether or not they want to continue in the work they do not identify
(obviously, starting from the principle that we are not dealing with a situation that, nowadays, is
called working in conditions analogous to slavery).

54. According to Maslach, how should institutions measure workers' perception of the six
possible areas of disagreement between a person and work?

Remember that, just as there are the antitheses “8 and 80”, “black and white”, and “silence
and sound”, for Christina Maslach and Michael Leiter (2004), there are also the opposite poles
“engagement and Burnout”, the latter referring to the Burnout Syndrome proposed by Maslach
and her collaborators, which I call in this work “Maslach/MBI Burnout” (MMBIB).

For these authors, the workers' perception of the six possible areas of disagreement between
person and work [read: work overload, lack of control, insufficient reward, loss of community,
lack of equity (or lack of justice) and conflict of values] can be measured by institutions through a
psychometric test, which is not MBI (Maslach Burnout Inventory), but AWS (Areas of Worklife
Scale).
AWS is composed of 29 statements that evaluate the six areas mentioned before. Six
statements assess work overload; 3 evaluate the lack of control; 4 evaluate insufficient reward; 5
assess the loss of community; six assess the lack of equity (or lack of justice); and five assess the
existing values conflicts between worker and organization.
As promised on its sales website, AWS is a complementary test to MBI, which allows users
to identify the main areas of strength or weakness in their institutions, enabling the process of
intervention and continuous improvement.
Unfortunately, as well as with MBI, AWS is copyrighted, and the copyright holder is the
same as MBI: Mind Garden Publishers, Inc. For this reason, and in appreciation of the didactics, I
did a non-committal and respectful model test that “resembles AWS” but in only 6 of its 29
statements. It already gives us an idea of how easily the test can be used in practice.
I emphasize that this test is only illustrative. It is not AWS. It does not intend to
impersonate AWS. It has a different number of items than AWS. Its statements are not the same
as those of AWS. Therefore, this test should be different from AWS under any circumstances.
Having made this incisive caveat, let us go to the model test:

1 2 3 4 5
1 “I wish I could sleep less to work more and complete all my
tasks.”
2 “In my work, I do things ‘my way’.”
3 “When I do well at my job, my coworkers come and talk to
me about it.”
4 “In my work, ‘everyone talks to everyone’.
5 “The financial and personal resources of the company where
I work are distributed correctly.”
6 “I have the same purpose as the company I work for.”
(Merely illustrative test: It is not equivalent to AWS)
 In this illustrative test, making a non-committal and respectful parallel with AWS, each of
the six statements would be related to the following areas of disagreement in professional life,
respectively: work overload, lack of control, insufficient reward, loss of community, lack of equity
(or lack of justice), and conflict of values.
As well as MBI, the workers evaluate each one of these items through a Likert range, with
5 points, in which the respondent assigns a score ranging from 1 to 5, depending on the frequency
experienced by him/her on each of the six statements. These scores indicate the worker-
respondent's impression of each statement, and They should be used according to the following
caption:
1 - strongly disagree;
2 - disagree;
3 - difficult to decide;
4 - agree;
5 - I strongly agree.
All are very simple, easy, and fast to be used.

CHAPTER 8: “ICD-11 BURNOUT” (ICD11B)

55. Why should ICD-11 (the tenth version of the International Classification of Diseases
proposed by WHO) be considered the primary resource about Burnout nowadays?
As I explained in question 1 of this book, the most didactic way I found to explain the
complex Burnout phenomenon was by dividing it into 4 “types”:
• FB: “Freudenberger's Burnout”. As we have already seen, it refers to the Burnout
that Herbert Freudenberger characterized as a clinical syndrome for the first time in 1974.
• MMBIB: “Maslach/MBI Burnout”. As we have already studied, it refers to the
Burnout Syndrome characterized by Christina Maslach and her collaborators, and it is measured
by MBI (Maslach Burnout Inventory). MMBIB and FB are different.
• ICD11B: “ICD-11 Burnout”. It refers to the Burnout Syndrome described in the
eleventh and last review of the International Classification of Diseases (ICD-11) by the World
Health Organization (WHO). ICD11B differs from MMBIB (albeit with some similarity), which
differs from FB.
 • CSB: “Common Sense Burnout”. It refers to the Burnout that is not the FB, MMBIB
or ICD11B, and that is usually printed in popular language, in family lunches, in bar conversations,
in numerous literary works, in some academic papers and, often in the mainstream media as a
synonym for extreme states, whether exhaustion (something often expressed as “I am at my wits’
end, I cannot stand it anymore”) or a lack of patience and a high degree of intolerance (in the latter
case, expressed as “I am fed up with everything”).
In practice, to solve the many daily problems and understand the subject, I had to (I had
to!) choose between one of these 4 “types” of Burnout. Then, I pragmatically chose ICD-11 (WHO,
2018) as the leading and most reliable source on Burnout nowadays. There are several reasons:
I) Among the 4 “types” of Burnout, I am sure that ICD11B is the least iatrogenic
option, in other words, it has the slightest possibility of causing adverse effects
on the patient, resulting from any action taken by a health professional;
II) Although ICD-11 is a target of countless and consistent criticisms, the document
is in force. It was prepared and signed by WHO (World Health Organization);
III) ICD-11 was developed over more than ten years of collegiate work;
IV) ICD-11 was made in a very representative way, with the participation of
researchers and scientists worldwide. “There was an unprecedented involvement
of health professionals, who joined in collaborative meetings and submitted
proposals. ICD’s team at WHO headquarters received more than 10 thousand
review proposals”;
V) ICD-11 is recognized worldwide and used by several countries;
VI) “ICD-11 provides significant improvements over previous versions”. As ICD-11
represents progress, it is up to me, as a physician that I also am, to enforce the
fifth fundamental principle of the current Code of Medical Ethics (CFM
Resolution n. 2.217/2018), which determines: “It is up to the physician to
continuously improve their knowledge and use the best of scientific progress for
the benefit of the patient and society.”
VII) In legal and medical expertise, ICD-11 complies with the determination imposed
by art. 473, item III, of the Code of Civil Procedure (CCP) (Law n. 13.105/2015):
“Art. 473. The expert report must contain: (...) III - the indication of the method
 used, clarifying it, and demonstrating it is predominantly accepted by experts in
the area of knowledge from which it originated.”
I am convinced I made the best choice when I chose ICD-11 as the leading and most reliable
source on Burnout nowadays. For all the reasons mentioned, in addition to other possible ones, I
suggest everyone does the same.
As a consequence of this option, I evaluate all problems that come to me involving Burnout
(whether as a professor, physician, forensic doctor, or legal practitioner) in the predominant light
of ICD-11. It is not that the other “types” of Burnout have ceased to exist. They exist as theory,
but as far as possible, I leave them to history alone.
Let us see a practical example. Maslach, Jackson and Leiter (2018) state that MBI is the
main “Burnout measurer” instrument worldwide. It is used about ten times more than other
measures in papers and dissertations on the subject (SCHAUFELI; ENZMANN, 1998).
Considering CCP, is MBI the predominantly accepted method by experts for diagnosing
Burnout? Answer: Not anymore. It would be if I were addressing MMBIB. However, I am not
anymore.
It is worth emphasizing again: MBI is a test aimed exclusively at MMBIB, which, on
January 1st 2022, with ICD-11 coming into force, ceased to be the dominant concept of the
Burnout phenomenon. It is impossible to compare the conceptual and referential strength of a
restricted group of researchers (in this case, Maslach and her collaborators) with the much greater
power of a formal document used worldwide and signed by WHO. I repeat: Although with some
similarities, ICD11B and MMBIB differ.
Now, my reference is ICD-11. In turn, ICD11B diagnosis is not based on and does not
depend on MBI but on characterising the phenomenon expressed in ICD-11 itself. Even more
directly: which method is predominantly accepted by experts for diagnosing Burnout? Answer:
Since January 1st, 2022, for all the reasons I have presented in this question, it is ICD-11, not MBI.
In Chapter 8, we will discuss ICD11B and its essential repercussions on the daily demands
we face.

56. Is Burnout in ICD-10? If so, which part?

 Yes, it is. Burnout is in ICD-10 (International Classification of Diseases, 10th Review)
(WHO, 2016) with code Z73.0. The term arises as a synonym for “exhaustion” and is defined only
as “a state of vital exhaustion”.
Note: Both ICD-10 and ICD-11, documents mentioned in this work, are classifications
prepared by World Health Organization (WHO).
A curiosity: Google Translate offers the word exhaustion as one of the first translations
into Portuguese (when it is not the first) of the terms Burnout or burn-out. It demonstrates, as we
have already seen in this work, the immense popularity of the term Burnout as synonymous
with fatigue or exhaustion in some countries, such as the United States, especially after the early
1960s (see the history of the use of the term Burnout in question n. 15).
This popularity was incorporated by ICD-10, which insisted on giving Burnout the same
meaning as in everyday language, in other words, “exhaustion”.
In ICD-10, the phenomenon is outside the group of disorders or mental illnesses (group of
the so-called “ICDs Fs”). It is worth emphasizing that, despite the International Classification of
Diseases name, this document does not just codify diseases. In ICD-10, for example, there are also
codes for a multitude of situations that, even though they are not illnesses, can lead a person to
seek a health service, for example: “collision between two people”; “travel and movement”; “poor
school results”; “lack of rest or leisure”; “Burnout” itself (as a synonym for “exhaustion”), among
many others. For all these situations, there is a specific code in ICD-10.
Also, in ICD-10, Burnout is within the subgroup of “problems related to the organization
of your way of life”. This classification does not limit Burnout to the occupational context, as ICD-
11 does (WHO, 2018). However, it relates it to something within the individual's competence: the
organization of their own way of life. It is as if ICD-10 said: “Work can cause exhaustion (Burnout)
in someone, but it is up to the individual to organize their way of life, so it does not lead to that”.
It is interesting to emphasize that ICD-10 does not include Burnout within the subgroup of
“problems related to employment or unemployment” but does, for example, with “other physical
and mental difficulties related to work” (code Z56.6). I will explain later the reason for this
emphasis that I now make.

57. Is Burnout in ICD-11? If so, which part?

 Yes, it is. Burnout is in ICD-11 (International Classification of Diseases, 11th Review)
(WHO, 2018), under the code QD85, and it remains synonymous with “exhaustion”. However, as
we will see, the classification that came into force in January 2022 brought a more complex
definition to Burnout.
As well in ICD-10 (WHO, 2016), in ICD-11, the phenomenon remains outside the group
of mental disorders or illnesses. Once again, it is worth emphasizing that despite the
name International Classification of Diseases, this document does not just codify diseases. In
ICD-11, for example, there are also codes for a multitude of situations that, even though they are
not illnesses, can lead a person to seek a health service, for example: “burping”, “falling from their
own height”, “poverty”, “inadequate food”, “exhaustion”, “fatigue”, among many others. There is
a specific code in the new classification for all these situations.
Unlike ICD-10, the subgroup “problems related to the organization of their way of life”
is not included in ICD-11, which seems to be replaced by “problems associated with the social or
cultural environment” in the new classification. However, Burnout is not part of this new subgroup,
and it is shifted to “problems related to employment or unemployment”, which already existed in
ICD-10. (Table 1)
in ICD-10. (Table 1)

ICD-10 Burnout ICD-11 Burnout

It is not in the group of mental disorders It is not in the group of mental disorders
or illnesses (code F-). or illnesses (code 6-).
It is placed within the large group of It is placed within the large group of
factors influencing health status or contact factors influencing health status or contact
with health services. with health services.
Burnout is placed in the “problems ICD-11 does not include the “problems
related to the organization of your way of related to the organization of their way of
life” subgroup under the code Z73.0. life” subgroup, which seems to be
replaced by “problems related to social or
cultural environment”, which does not
include Burnout.
 Burnout is not in the “employment- The “Problems related to employment or
related problems or unemployment” unemployment” subgroup excludes “other
subgroup, which, in turn, includes “other physical and mental difficulties related to
work-related physical and mental work” and includes Burnout (code QD85).
difficulties” (code Z56.6).
(Table 1: Comparison between ICD-10 and ICD-11 regarding Burnout
classification placement)

It is interesting to observe that “other physical and mental difficulties related to work”
were in ICD-10, in the “problems related to employment or unemployment” subgroup. However,
in ICD-11, “other physical and mental difficulties related to work” disappears from the mentioned
subgroup, which now has Burnout as one of its components. I did not find any mention that one
description replaced the other, but I understand that this observation is relevant.
In ICD-11, the situations (and their codes) considered as “employment or unemployment-
related problems” are:
• QD80: Problem associated with unemployment [only this situation is related to
unemployment – my emphasis].
• QD81: Problem associated with changing jobs.
• QD82: Problem associated with the threat of job loss.
• QD83: Problem with working conditions.
• QD83.0: Problem associated with an incompatible job.
• QD83.1: Problem associated with stressful working hours.
• QD83.Y: Another specified problem in terms of employment.
• QD84: Occupational exposure to risk factors.
• QD84.0: Occupational exposure to dust.
• QD84.1: Occupational exposure to toxic agents in agriculture.
• QD84.2: Occupational exposure to toxic agents in industries other than agriculture.
• QD84.3: Occupational exposure to vibration;
• QD84.4: Occupational exposure to ergonomic risk;
• QD84.Y: Another specified occupational exposure to risk factors;
• QD84.Z: Another occupational exposure to risk factors, unspecified.
 • QD85: Burnout (exhaustion).
• QE50.2: Problem associated with relationships with people at work.
• QD8Y: Other specific problems associated with employment or unemployment.
• QD8Z: Unspecified problems associated with employment or unemployment.
As exposed in ICD-11, Burnout is within the “problems related to employment or
unemployment” subgroup. Therefore, this classification circumscribes Burnout to the occupational
context, which did not happen with ICD-10.

58. Considering only causal factors, ‘Freudenberger’s Burnout” is to ICD-10 what ‘Maslach
Burnout/MBI’ is to ICD-11. What is the meaning of this correlation?
Remember that Freudenberger lists a vast range of possible causes for the Burnout
Syndrome he proposes, which I call in this work “Freudenberger’s Burnout” (FB), among them:
leader’s loss of charisma; denial of failure, age, fear, death, and feelings; and even “distractions”
like sports, movies, food, drink, sex, etc. Observe that Freudenberger does not limit FB to the
occupational context, as ICD-10 does (WHO, 2016).
As well ICD-10, it is as Freudenberger said: “Work can cause exhaustion (Burnout) in
someone, but it is up to the individual himself to organize their way of life so it does not happen”.
In question no. In question n. 24 of this book, I present Freudenberger’s propositions for combating
FB.
As for the Burnout Syndrome proposed by Christina Maslach and her collaborators, which
I call in this work “Maslach/MBI Burnout” (MMBIB), although considering the existence of
individual factors (e.g., personality), from a practical point of view, she considers work as the only
and sufficient reason to cause MMBIB, as well as ICD-11 (WHO, 2018) does. We will see it in
detail later.
From the above, it is possible to state that, considering only the causal factors, FB is for
ICD-10, and MMBIB is for ICD-11.
Remember, in addition to FB and MMBIB, I name other “types” of Burnout: ICD11B and
CSB. To understand this classification and thus better understand this work, see question n. 1 of
this book.

59. How is Burnout Syndrome defined in ICD-11?

 “Burnout is a syndrome conceptualized as a result of chronic stress in the
workplace that has not been successfully managed. Three dimensions
characterize it:
1. Feelings of exhaustion or energy exhaustion
2. Increased mental distance from work, or feelings of negativism or cynicism
about work
3. A sense of ineffectiveness and lack of accomplishment
Burnout refers explicitly to phenomena in the occupational context and should
not be applied to describe experiences in other areas of life.
Exceptions:
• Adaptive disorder;
• Disorders specifically associated with stress;
• Disorders related to anxiety or fear;
• Mood disorders.” (ICD-11)

This is the concept of the Burnout Syndrome proposed by ICD-11, which I call in this work “ICD-
11 Burnout” (ICD11B).
I confirm that, although with some similarity, ICD11B is different from “Maslach/MBI
Burnout” (MMBIB), which, in turn, is different from “Freudenberger’s Burnout” (FB).

60. According to ICD-11, is Burnout a syndrome?

Yes, it is. The Burnout conceptualized in ICD-11 (International Classification of Diseases,
11th Review) (WHO, 2018), which I call in this work “ICD-11 Burnout” (ICD11B), is a syndrome
by the very definition that was given to it in the document.
Recalling that ICD-11 states that ICD11B “is a syndrome conceptualized as a result of
chronic stress in the workplace that has not been successfully managed”.
Allow me to take “a step back” and speak of the technical concept of a syndrome, defined
as a recognizable (differentiable), constant, and stable set of signs and symptoms that indicate a
specific condition and for which a direct cause (etiology) has not been fully understood or is
unknown (DALGALARRONDO, 2019).
 I confirm that ICD11B, although with some similarity, is different from “Maslach/MBI
Burnout” (MMBIB), which, in turn, is different from “Freudenberger’s Burnout” (FB). Therefore,
historically, it is impossible to observe any stability or consistency in the definitions and
characterizations assigned to Burnout. From a technical-conceptual point of view, this reason alone
delegitimizes the qualification of the phenomenon described in ICD-11 as a syndrome.
I go further in this statement: if ICD-11B were technically and conceptually classified as a
syndrome (which is not), ICD-11 should have classified the Burnout phenomenon as a disorder or
mental illness. Let me explain.
Once science identifies a causative agent or process (etiology) of a syndrome with a high
degree of certainty, it is possible to refer to the process as a disease (Calvo et al., 2003). Remember
that according to ICD-11:
“Burnout is a syndrome conceptualized as a result of chronic stress in the
workplace that has not been successfully managed. (...) Burnout refers
specifically to phenomena in the occupational context and should not be applied
to describe experiences in other areas of life.”
According to the ICD-11 concept, the etiology of ICD11B is very well established: chronic
stress arising exclusively from the workplace. Thus, if ICD11B were indeed a syndrome, it would
be fair to elevate it to a disorder or mental illness by conceptual obedience. Let us think about it.
Finally, despite everything that was exposed, as a personal option, among all the ideas
about Burnout, I chose ICD-11 as the principal, less iatrogenic, and more reliable source on the
subject nowadays, for the reasons I describe in question n. 55 of this book. Thus, in appreciation
and reference to ICD-11, I consider ICD11B a syndrome throughout this work, routinely and
without further questioning.

61. What was the theoretical basis used to conceptualize the Burnout Syndrome proposed by
ICD-11?
It is undeniable that the theoretical basis used to conceptualize the Burnout Syndrome
proposed by ICD-11 (WHO, 2018), which I call in this work “ICD-11 Burnout” (ICD11B), rescues
the one previously made by Christina Maslach and her collaborators when proposing the
“Maslach/MBI Burnout” (MMBIB), but with differences. Let us see what ICD-11 establishes:
 “Burnout is a syndrome conceptualized as a result of chronic stress in the
workplace that has not been successfully managed. It is characterized by three
dimensions: 1) feelings of exhaustion or energy exhaustion; 2) increased mental
distance from work, or feelings of negativism or cynicism about work; and 3) a
sense of ineffectiveness and lack of accomplishment.”
This concept suggests that the symptomatology of the individual with ICD11B
simultaneously encompasses all three dimensions. ICD-11 does not provide any guidance to the
contrary. Therefore, I rely on the basic interpretation of this concept and consider that, in the
diagnosis of ICD11B, the three dimensions described must be considered simultaneously.
Remember, Maslach and her collaborators define Burnout as a syndrome caused by a
crisis in the relationship between worker and work (described by ICD-11 as a syndrome “resulting
from chronic stress in the workplace that has not been successfully managed”), which can affect
all professionals (regardless of profession and activity) and has three dimensions, so-
called: emotional exhaustion (or simply exhaustion), depersonalization or cynicism; and low
effectiveness or professional achievement (MASLACH; JACKSON; LEITER, 2018).
I emphasize that, from the point of view of medical semiology, these three dimensions are
pretty nonspecific and, therefore, do not guide medical reasoning towards an assertive nosological
diagnosis (of a disease), in addition, to preventing carrying out differential diagnoses.
Emotional exhaustion (characterized by ICD-11 as “feelings of exhaustion or depletion of
energy”) means an absence or low level of energy and enthusiasm and a feeling of depletion of
resources.
Depersonalization or cynicism (denominated by ICD-11 as “increased mental distance
from work, or feelings of negativism or cynicism regarding of work”) is understood as an attitude
of affective distancing, a kind of indifference, either regarding clients /patients, what Maslach
called depersonalization, or regarding of work as a whole, what the researcher called cynicism
(FIGUEIREDO-FERRAZ; GRAU-ALBEROLA; GIL-MONTE, 2019).
The low effectiveness or professional achievement dimension (called by ICD-11 “a feeling
of inefficiency and lack of accomplishment”) is characterized by the fact that the person
experiences himself as inefficient, incapable, with reduced self-esteem and confident that their
work does not make any difference (MASLACH; SHAUFELI; LEITER, 2001).
 On the other hand, for Maslach and MBI (Maslach Burnout Inventory), the concept of
depersonalization (proposed by Christina Maslach in the 1970s) refers to insensitivity,
indifference, and affective distancing regarding the other, a third party.
In the 1990s, some versions of MBI [MBI-GS and MBI-GS (S)] replaced the
term depersonalization with cynicism, a word that does not direct the psychic examination towards
any diagnosis. According to Lima (2021), from a psychopathology perspective, the
term cynicism can be used to describe, for example, a “mere personality trait”.
In ICD-11, the expression “increased mental distance from work, or feelings of negativism
or cynicism regarding of work”, clearly rescued from the ideas of Maslach and her collaborators,
definitively replaces the term depersonalization. Thus, perhaps out of respect for the classic
concepts used in psychopathology, the term depersonalization is not in ICD-11 in the “ICD-11
Burnout” (BCID11) conception.
Finally, I again emphasize that although ICD-11 used the theoretical basis that Maslach
and her collaborators previously proposed in defining Burnout, ICD11B is quite different from
MMBIB for reasons that we will see in this work.

62. According to ICD-11, is Burnout a disease? What about DSM-5?

Neither ICD-11 (WHO, 2018) nor DSM-5 (APA, 2014) places Burnout in the respective
chapters of mental disorders or illnesses, including depressive disorder and schizophrenia.
Regarding specifically of ICD (International Classification of Diseases), as well as in ICD-
10 (WHO, 2016), in ICD-11, Burnout remains outside the group of disorders or mental illnesses.
Once again, it is appropriate to emphasize that, despite the name International Classification of
Diseases, this document does not only codify diseases (see question n. 57).

Unlike the ICD, which addresses infectious, orthopedic, neurological diseases, etc., the
DSM (Diagnostic and Statistical Manual of Mental Disorders), proposed by the American
Psychiatric Association (APA), is a classification focused on mental disorders and their differential
diagnoses. The document includes criteria to facilitate the establishment of more reliable diagnoses
for psychiatric illnesses.
With consecutive editions over the last few decades, DSM has become a reference for
clinical practice in mental health. The most updated version of the document is DSM-5 (5th edition
of the classification), which includes over 300 diagnostic categories. Regardless of the version
(current or past), Burnout was never listed in DSM as a disorder or mental illness. Never.
For DSM-5:
“(...) a mental disorder is a syndrome characterized by a clinically
significant disturbance in an individual’s cognition, emotion regulation, or
behavior that reflects a dysfunction in psychological, biological, or
developmental processes underlying mental functioning. Mental disorders are
often associated with significant distress or disability that affect social,
professional, or other important activities.”
I emphasize that, for DSM-5, Burnout does not meet this concept since it is not listed as a
disorder or mental illness. On the contrary, the term Burnout is mentioned only once in the original
document (in English), as a mere example of a symptom, and as follows: “’Burnout (‘Exhaustion’),
the feeling of heaviness or the complaints of ‘gases’; excess body heat; or burning in the head are
examples of symptoms that are common in some cultures or ethnic groups but rare in others”
(APA, 2014).
Finally, I emphasize that according to ICD, DSM has been successfully used by
clinicians and researchers who seek a stable, global and common language to communicate the
essential characteristics of their patients' disorders or mental illnesses (APA, 2014). Dalgalarrondo
(2019) praises the contribution of these classifications, which are established by researchers and
experienced professionals from several countries. These documents are essential in the rapid and
fruitful progression of knowledge about mental disorders or illnesses.

63. If it were a disease, in which chapter of DSM-5 (and also of ICD-11) would the Burnout
Syndrome proposed by ICD-11 be described?
As mentioned, neither DSM-5 (APA, 2014) nor ICD-11 (WHO, 2018) places Burnout in
the mental disorders or illnesses chapters.
The reflection I now propose is: If it were considered as a disease in DSM-5 and ICD-
11, in which respective chapters would Burnout be? In the chapter on anxiety disorders? In the
chapter on depressive disorders? In some other chapter? Let us go deeper.
First, I inform you that although ICD-11 was published after DSM-5, the “type” of
Burnout that I consider in this question is the one proposed by ICD-11, which I call ICD11B in
this work, but without the exceptions of mental disorders that ICD11B concept requires. I will
name it “ICD11B (W/E)” in this question. In other words, ICD11B is without the mental illness
exceptions required by ICD-11.
If I considered these exceptions, making the proposed observation would not be possible
since it would not be possible to hypothesize ICD11B within any chapter of a mental disorder or
illness, whether in DSM-5 or ICD-11 itself.
By the way, it should be observed that ICD11B (W/E) is close to the Burnout defined by
Christina Maslach and her collaborators since it also does not exclude diseases and is based on the
three dimensions that were included in the theoretical basis from ICD11B: “feelings of exhaustion
or energy depletion; increased mental distance from work, or feelings of negativism or cynicism
about work; and a sense of ineffectiveness and lack of achievement” (WHO, 2018).
I emphasize that, from a medical semiology point of view, these three dimensions are pretty
nonspecific and, therefore, do not guide medical reasoning towards an assertive nosological
diagnosis (of a disease), in addition to preventing the realization of differential diagnoses. The
answers to this question confirm it. Let us go.
Remember part of the ICD11B concept: “Burnout is a syndrome conceptualized as a
result of chronic stress in the workplace that has not been successfully managed.”
In summary, this concept states that ICD11B results from stress. Thus, I depart from the
logical premise that if ICD11B (W/E) were considered as a mental illness, both in DSM-5 and in
ICD-11, it would probably be described in the respective chapters: “disorders related to traumas
and stressors” (DSM-5) or “disorders specifically associated with stress” (ICD-11). Thus, I answer
this question from the previous chapters in advance that ICD11B (W/E) symptoms can overlap
with mental disorders described in other chapters of the referenced classifications, given the
tremendous clinical nonspecificity of the three dimensions that comprise it.
I remind you that, in DSM-5, the following is part of the chapter on “trauma-related disorders and
stressors”:
I) reactive attachment disorder;
II) disinhibited social interaction disorder;
III) post-traumatic stress disorder;
IV) acute stress disorder;
V) adaptive disorder.
 Thus, the first question to be answered is: if ICD11B (W/E) were part of this DSM-5
chapter, would it be considered a specific disorder or “would it be within” an already existing and
described disorder? In order to get this answer, it is essential to carry out a brief study on each
disorder in this chapter of DSM-5. In this study, I take the opportunity also to address the ICD-11.
Let us go.
I) Reactive attachment disorder:
Question to be answered: If it were considered a disease by DSM-5, could ICD11B (W/E)
be “inside” reactive attachment disorder? Answer: No, it could not.
Justification: According to DSM-5, reactive attachment disorder is a disease that is
exclusively prevalent in children. The disorder is usually related to neglect or social deprivation in
the form of persistent failure to meet children’s basic emotional needs of comfort, stimulation, and
affection by adult caregivers. Observe that there is not, and could not be, any relationship to
occupational context, as ICD11B requires.
P.S.: For ICD-11, the reasoning is the same since reactive attachment disorder is
described in the group as “disorders specifically associated with stress”. Therefore, if ICD11B
(W/E) were considered a disease by ICD-11, it could not be “within” reactive attachment disorder.
II) Disinhibited social interaction disorder:
Question to be answered: If it were considered a disease by DSM-5, could ICD11B (W/E)
be an “inside” disinhibited social interaction disorder? Answer: No, it could not.
Justification: According to DSM-5, disinhibited social interaction disorder is a disease that
is exclusively prevalent in children. The disorder is related to a behavior pattern that involves (the
child’s) excessively familiar and culturally inappropriate conduct with strangers. Observe that
there is not, and could not be, any relationship to occupational context, as ICD11B requires.
Observe: For ICD-11, the reasoning is the same since disinhibited social interaction
disorder is described as “disorders specifically associated with stress”. Therefore, if ICD11B
(W/E) were considered a disease by ICD-11, it could not be “within” disinhibited social interaction
disorder.
III) Post-traumatic stress disorder (PTSD):
 Question to be answered: If it were considered a disease by DSM-5, could ICD11B (W/E) be
“inside” PTSD? Answer: In specific cases, yes.
Justification: Remember that, according to ICD-11, ICD11B results from chronic stress in the
workplace. According to DSM-5, PTSD results, as a rule, from the individual’s exposure to acute
stressors to one or more specific episodes or threats of death, serious injury, or sexual violence.
This exposure will create the so-called intrusive symptoms (such as, for example, recurrent and
distressing memories and dreams of the traumatic event), intense psychological suffering at any
sign that recalls the traumatic event, avoidance of stimuli associated with the traumatic event, and
mood swings, among others. Signs and symptoms may, to some degree, impact the three
conceptual dimensions of ICD11B.
It is necessary to recognize that this type of exposure to specific episodes or threats of death,
serious injury or sexual violence, save for exceptional cases, is not typical of a work environment.
However, there are specific work situations that can cause PTSD as an occupational disease.
Examples: bus driver who suffers the action of a kidnapper; bank guard victim of violent robbery;
police in a situation of armed confrontation; a worker who is raped by the threat of death in the
place where she works, among many others.
I highlight an essential difference between stress-causing PTSD versus the one-causing
ICD11B. While the first is usually acute, the second is necessarily and conceptually chronic.
Finally: why was the answer to this item “in specific cases, yes” instead of “yes”? Because I am
answering it based on the hypothesis “if ICD11B (W/E) were considered a disease by DSM-5”. If
it were, in situations where PTSD is occupational, and only in those cases, could there be an
overlap between PTSD and ICD11B (W/E) symptoms?
P.S.: For ICD-11, the reasoning is the same since PTSD is described in the group as “disorders
specifically associated with stress”. Therefore, if ICD11B (W/E) were considered a disease by
ICD-11, in specific cases, it “would be within” PTSD.
IV) Acute stress disorder (ASD):
Question to be answered: If it were considered a disease by DSM-5, could ICD11B (W/E) be
“inside” ASD? Answer: In specific cases, yes.
Justification: According to DSM-5, ASD also results, as a rule, from the individual’s exposure
to acute stressors to one or more concrete episodes or threats of death, severe injury, or sexual
violence. Again, such severe exposures are generally not typical of a work environment.
 However, specific work situations can cause ASD as an occupational disease. Examples: bus
driver who suffers the action of a kidnapper; bank guard victim of violent robbery; police in a
situation of armed confrontation; a worker who is raped by the threat of death in the place where
she works, among many others.
Observe that these are the same examples I mentioned when I discussed PTSD. This is because
the genesis of ASD stems from the same acute stressors that are liable to cause PTSD. The
symptomatology of ASD is also equivalent to that of PTSD. What changes, then? While in ASD,
the clinical presentation lasts 3 to 30 days after the trauma and does not exceed 30 days, in PTSD,
the clinical presentation must last more than 30 days. According to DSM-5, precisely in this
temporal marker lies the main diagnostic difference between ASD and PTSD.
Finally: why was the answer to this item “in specific cases, yes” instead of just “yes”? Because
I am answering it based on the hypothesis “if ICD11B (W/E) were considered a disease by DSM-
5”. If it were, in situations where ASD is occupational and only in these cases, there could be an
overlap between the symptoms of ASD and those of ICD11B (W/E).
P.S.: In ICD-11, ASD is called acute stress reaction (ASR). In the same classification, ASR is
not included in the “disorders specifically associated with stress” group and is not considered a
disease or mental disorder. However, depending on the specific case, it is possible to have
overlapping symptoms of ICD11B and occupational ASR, two entities not considered diseases by
ICD-11.
V) Adaptive disorder:
Question to be answered: If it were considered a disease by DSM-5, could ICD11B (W/E) be
“inside” the adaptive disorder? Answer: Often, yes.
Justification: According to DSM-5, the diagnostic criteria for the adaptive disorder (called
adjustment disorder in ICD-11) are as follows:
a) Development of emotional or behavioral symptoms in response to an identifiable stressor
or stressors (such as work) occurring within three months of the stressor or stressors
onset.

[Note 1: ICD-11 differs from DSM-5 in describing adaptive disorder concerning the time of
symptom onset. While in DSM-5, this time is three months after the stressor’s onset, in ICD-11
this time is only one month.]
b) These symptoms or behaviors are clinically significant, as evidenced by one or more of the
following:
- intense suffering disproportionate to the severity or intensity of the stressor, considering the
cultural context and cultural factors that could influence the severity and presentation of
symptoms;
- Significant impairment in functioning socially, professionally, or in other vital areas of the
individual’s life.

[Note 2: Remember that according to ICD-11, ICD11B is characterized by three dimensions:

exhaustion or energy depletion; increased mental distance from work or feelings of work-related
negativism or cynicism; and reduced professional effectiveness. These three dimensions may
overlap with the symptomatology described for adaptive disorder in DSM-5.]

c) The stress-related disorder does not meet the criteria for another mental disorder and is not
merely an exacerbation of a pre-existing mental disorder.
d) The symptoms do not represent normal grief.
e) Once the stressor or its consequences have ceased, the symptoms do not persist for more than
six months.

[Note 3: Regarding the time limit for the end of the symptomatology after the stressor ceases,
ICD-11 is equivalent to DSM-5, establishing that this period is six months.]

Also, according to DSM-5, the presence of emotional or behavioral symptoms in response

to an identifiable stressor is the essential feature of adaptive disorders (criterion “a”). The stressor
may be a single event (e.g., the end of a romantic relationship) or multiple stressors (e.g.,
significant professional difficulties and marital problems).
Stressors can be recurrent (e.g., associated with cyclical career crises or unsatisfactory
sexual relationships) or ongoing (e.g., a persistent painful illness with increasing disability, living
in a high-crime area). They can affect a single individual or an entire family, a larger group, or a
community (for example, a natural disaster).
 Some stressors may follow specific development events (e.g., going to school, leaving
parents’ home, returning to parents’ home, getting married, becoming a parent, failing at career
goals, retirement).
Thus, if the identifiable stressor is work and aspects related to it, it might cause emotional
or behavioral symptoms, such as a feeling of exhaustion or energy depletion, increased mental
distance from work or work-related feelings of negativism or cynicism, and reduced professional
effectiveness. This situation can lead to a significant loss in the individual’s professional life.
In the previous paragraph, I intentionally mixed up the symptoms of the adaptive disorder
(DSM-5) with those of ICD11B. The evident agreement between them, when the identifiable
stressor belongs to the world of work, allows me to conclude that there would be a substantial
conceptual overlap between work-related adaptive disorder and ICD11B (W/E) if the latter were
considered a disease by DSM- 5.
It is not by chance that, among mental disorders or illnesses, adaptive (or adjustment)
disorder, if related to work, is perhaps one of the easiest to be confused with ICD11B.
Finally: why was the response to this item “often yes” instead of “yes”? Because I am
answering it based on the hypothesis “if ICD11B (W/E) were considered a disease by DSM-5”. If
it were, as we saw in criterion “c”, before making the diagnosis of an adaptive disorder, it would
be necessary to exclude other mental illnesses, for example, depressive disorder, panic disorder,
etc. If any of the latter diagnoses prevails, the classification of adaptive disorder should be
discarded. This implies concluding that ICD11B (W/E), in specific cases and given its great
symptomatic nonspecificity, could also “be within” other mental disorders (for example,
depressive disorder, panic disorder, etc.), provided they were work-related.
P.S.: For ICD-11, the reasoning is the same since adaptive disorder in ICD-11, called adjustment
disorder, is described in the “disorders specifically associated with stress” group. Therefore, if
ICD11B (W/E) were considered a disease by ICD-11, it would often “be within” adaptive disorder.
Specifically, regarding ICD-11, complex post-traumatic stress disorder and prolonged grief
disorder are also part of the “disorders specifically associated with stress” group. For this question
to be complete, let us do the same analysis regarding these entities.
Prolonged grief disorder (PGD)
Question to be answered: If it were considered a disease by ICD-11, could ICD11B
(W/E) be “inside” PGD? Answer: No, it could not.
 Justification: According to ICD-11, PGD is a disorder in which, after the death of a
partner, parent, child, or another person close to the bereaved, there is a persistent and generalized
grief response characterized by longing for the deceased or persistent preoccupation with the
deceased, followed by intense emotional pain (e.g., sadness, guilt, anger, denial, difficulty
accepting death, feeling like you have lost a part of yourself, inability to feel a positive mood,
affective withdrawal, difficulty engaging in social or other activities).
The grief response persists for an unusually long period after the loss (at least six
months). It exceeds expected social, cultural, or religious norms for the individual’s culture and
context. The disturbance causes significant impairment in personal, family, social, educational,
occupational, or other important areas of the individual’s functioning.
Observe that PGD takes place in a completely different context from ICD11B, as the
latter relates explicitly to the occupational context and should not be applied to describe
experiences in other areas of life, for instance, the death of someone close and the consequent
mourning.
Complex post-traumatic stress disorder (complex PTSD):
Question to be answered: If it were considered a disease by ICD-11, could ICD11B (W/E) be
“inside” complex PTSD? Answer: In specific cases, yes.
Justification: Remember that, according to ICD-11, IC11B results from chronic stress in the
workplace. Complex PTSD is a disorder that can develop after exposure to an event or series of
events of a highly threatening or horrific nature, most commonly prolonged or repetitive events
from which it is difficult or impossible to escape (e.g., torture, enslavement, genocide campaigns,
prolonged domestic violence, prolonged occupational harassment, repeated childhood sexual or
physical abuse, among others).
All diagnostic requirements for PTSD are met. Furthermore, complex PTSD is characterized by
severe and persistent problems regulating affect; beliefs about oneself as diminished, defeated, or
worthless, followed by feelings of shame, guilt, or failure related to the traumatic event; and
difficulties maintaining relationships and feeling close to others. These symptoms cause significant
damage in personal, family, and social aspects.
Unfortunately, situations of prolonged occupational harassment, responsible for enormous
chronic stress, exist and seem to be much more frequent than we are aware of. Such situations can
cause complex PTSD as an occupational illness. In these cases, there could be an overlap between
the symptoms of complex PTSD and those of ICD11B (W/E).
Finally: why was the answer to this item “in specific cases, yes” instead of “yes”? Because I am
answering it based on the hypothesis “if ICD11B (W/E) were considered a disease by ICD-11”. If
it were, in situations where complex PTSD is occupational and only in those cases, there could be
an overlap between PTSD and ICD11B symptoms (W/E).
It is worth emphasizing again the great clinical non-specificity of the three dimensions that
integrate ICD11B. Only in the “disorders specifically associated with stress” group, described in
ICD-11, we found the possibility of symptomatic overlapping of ICD11B (W/E) with 3 of the six
disorders listed in this group (adaptive disorder, PTSD, and complex PTSD – remember that ASD
is not referenced in ICD-11), and, without mentioning the same possibility for many other
disorders in other groups of the same document.

64. According to ICD-11, which mental disorders must be excluded before certifying
someone has Burnout Syndrome?
All of them. Let us go to the justifications.
In the literal terms of the concept of Burnout Syndrome proposed by ICD-11 (WHO, 2018),
what I call in this work “ICD-11 Burnout” (ICD11B), before certifying that someone has first, it
is necessary to exclude several groups of diseases and mental disorders, let us see:
“Exceptions:
• Adaptive disorder;
• Disorders specifically associated with stress;
• Disorders related to anxiety or fear;
• Mood disorders.”
Based on ICD-11, we observed that the diagnosis of ICD11B is a diagnosis of exclusion
(also called a residual diagnosis).
A diagnosis of exclusion is understood to be performed only after excluding other diagnostic
hypotheses. It is the residual diagnosis, the “leftover” diagnosis. It means that ICD11B will never
be the first diagnostic hypothesis to be proposed for a patient.
In general terms, these are the disorders or mental illnesses that must be excluded before
diagnosing someone with ICD11B:
I) Disorders related to anxiety or fear
Examples:
• Generalized anxiety disorder;
• Panic disorder;
• Agoraphobia;
• Specific phobia;
• Social anxiety disorder;
• Separation anxiety disorder.
II) Mood disorders
Examples:
• Single-episode depressive disorder;
• Recurrent depressive disorder;
• Dysthymic disorder (dysthymia);
• Mixed depressive and anxiety disorder;
• Cyclothymic disorder (cyclothymia);
• Bipolar disorder type I;
• Bipolar disorder type II.
III) Disorders specifically associated with stress
Examples:
• Post-traumatic stress disorder;
• Complex post-traumatic stress disorder;
• Prolonged grief disorder;
• Adaptive (or adjustment) disorder.
In the literal terms of ICD-11, something calls much attention to describing the exceptions to be
made before the ICD11B diagnosis. Let us see again:
Exceptions:
• Adaptive disorder;
• Disorders specifically associated with stress;
• Disorders related to anxiety or fear;
• Mood disorders.
 Observe that in ICD-11, the adaptive disorder is included in the “disorders specifically
associated with stress” group. Then, there would be no reason to single out adaptive disorder, as
the group “disorders specifically associated with stress” includes it. So, why did ICD-11 do this?
What is the reason for withdrawing adaptive disorder from a group that already included it in the
same description and evidencing it so much?
I can see only one reason for this apparent redundancy of ICD-11: to praise adaptive disorder as
a diagnosis to be excluded before certifying that someone has ICD11B.
It makes sense. Among mental disorders or illnesses, adaptive disorder, if related to work, is
undoubtedly one of the most frequently confused with ICD11B.
According to the same ICD-11, adaptive (or adjustment) disorder is a maladaptive reaction to an
identifiable psychosocial stressor or several stressors (divorce, illness or disability, socioeconomic
problems, conflicts at home or work). The disorder is characterized by concern with the stressor
or its consequences, including excessive worry, recurrent and distressing thoughts about the
stressor, or constant rumination about its implications, as well as the inability to adapt to the
stressor, which causes significant impairment in personal, family, social, educational,
occupational, or other vital areas of the individual's functioning. Another mental disorder cannot
better explain the symptoms (WHO, 2014). I emphasize the last sentence: another mental disorder
cannot better explain the symptoms.
In the same way, DSM-5 states that in adaptive disorder, “the stress-related disturbance does
not meet criteria for another mental disorder, and it is not merely an exacerbation of a preexisting
mental disorder”.
Suppose the symptoms of an adaptive (or adjustment) disorder cannot be better explained by
another mental disorder (WHO, 2018). In that case, they cannot meet the criteria for another mental
illness (APA, 2014), which implies that, before diagnosing the adaptive disorder in someone, it is
necessary to first exclude any other mental disorder or illness in that patient.
Now, follow the reasoning: under ICD-11 definitions, before someone can be diagnosed with
ICD11B, it is necessary first to exclude adaptive disorder, the diagnosis which requires prior
exclusion of any other disorder or mental illness. Therefore, before diagnosing someone with
ICD11B, it is necessary to exclude mental illnesses or disorders.
 So, to get a diagnosis of adaptive disorder, it is necessary to eliminate other mental disorders or
illnesses first. By extension, only after discarding them the hypothesis of ICD11B will also be
possible.
Thus, ICD11B will never be the first diagnostic hypothesis to be suggested to a patient. On the
contrary, this qualification can only be made after the prior and confirmed exclusion of mental
illnesses or disorders, as recognized by ICD-11 and DSM-5. This is the most significant and
striking difference between what I call in this work “Maslach/MBI Burnout” (MMBIB) and
ICD11B.
In addition to the reasons, I described in question n. 55 of this book, it is also because of this
significant difference that I made the personal choice of choosing ICD-11 as the main, less
iatrogenic, and more reliable source of Burnout nowadays.

65. What are the differences between the Burnout Syndrome (BS) proposed by Maslach and
her collaborators and the one proposed by ICD-11?
I observe three fundamental differences between the Burnout Syndrome proposed by ICD-11
(WHO, 2018), which I call in this work “ICD-11 Burnout” (ICD11B), and the one that was
previously proposed by Christina Maslach and her collaborators, “Maslach/MBI Burnout”
(MMBIB).
Before going deeper, I recall the complete concept of ICD11B:
“Burnout is a syndrome conceptualized as a result of chronic stress in the
workplace that has not been successfully managed. It is characterized by three
dimensions:
1. Feelings of exhaustion or energy exhaustion
2. Increased mental distance from work, or feelings of negativism or
cynicism about work
3. A sense of ineffectiveness and lack of accomplishment
Burnout refers explicitly to phenomena in the occupational context and should
not be applied to describe experiences in other areas of life.

Exceptions:
• Adaptive disorder;
 • Disorders specifically associated with stress;
• Disorders related to anxiety or fear;
• Mood disorders.”
To begin with, this concept suggests that the individual's symptomatology with ICD11B
simultaneously encompasses the three dimensions mentioned therein. ICD-11 does not provide
any guidance to the contrary. Therefore, I rely on the basic interpretation of this concept and
consider that, in the diagnosis of ICD11B, the three dimensions described must be considered
simultaneously.
As we have already seen, it is unquestionable that the theoretical basis used to conceptualize
ICD11B rescues the one previously made by Christina Maslach and her collaborators when
proposing MMBIB, especially regarding the three dimensions’ characterization. However, while
I can consider, for hermeneutical reasons, in the diagnosis of ICD11B, the three dimensions must
be contemplated simultaneously. In MMBIB, this does not happen. Maslach, Jackson and Leiter
(2018) state that the three MMBIB dimensions must be evaluated and interpreted individually (see
question n. 35).
The second significant difference between MMBIB and ICD11B is how each is diagnosed. In the
first one, the diagnosis is fundamentally based on self-performing a test, MBI (Maslach Burnout
Inventory), which is highly objectionable from a technical-semiologic point of view.
While psychometric tests are essential in measuring the symptomatologic severity of numerous
illnesses (for example, HAM-D, Hamilton Rating Scale for Depression), no mental disorder
diagnosis, for example, is made through the exclusive use of a test or questionnaire. Mainly as
MBI does, which establishes the definitive diagnosis of MMBIB in a self-administered way,
completely disregarding a possible critical analysis of the reported symptoms by the investigator.
On the contrary, psychiatric diagnoses are supremely supported by a good and detailed
psychological examination. For Correia and Sampaio (2014), the increasing use of scales and
questionnaires as diagnostic tools results in a naive semiology, which weakens current
semiological research.
It is worth mentioning again that Maslach, Jackson and Leiter (2018) state that MBI is not intended
to attest whether someone “has” or “does not have” MMBIB, although this guidance does not seem
to have a practical effect. Remember that the MMBIB concept meets the MBI concept and vice
versa (SHAUFELI; LEITER; MASLACH, 2009). Directly and objectively, MBI measures what
MMBIB is, and MMBIB is what MBI measures (KRISTENSEN et al., 2005). MBI assigns
MMBIB to all workers who undergo the respective test. I repeat: all of them, in 100% of the cases
(see the justification in question n. 35).
In ICD-11B, the evaluator has to observe whether the individual presents all the symptoms
described in the ICD-11B concept (“feelings of exhaustion or energy depletion; increased mental
distance from work, or feelings of negativism or cynicism towards work; and a sense of
ineffectiveness and lack of accomplishment”) and, using the knowledge of psychopathology
(which describes, recognizes, and classifies mental processes compatible with mental illnesses),
discard possible psychiatric disorders and, only afterwards, suggest the diagnosis of ICD11B, if
deemed relevant.
As observed, ICD11B diagnostic method is much more complex than MMBIB simplistic
diagnosis.
The third and most striking difference between MMBIB and ICD11B is related to the fact that
ICD11B diagnosis is a diagnosis of exclusion. In other words, it can only be confirmed after
discarding other diagnostic hypotheses.
Thus, ICD11B will never be the first diagnostic possibility to be suggested to a patient. On the
contrary, this qualification can only be made after the prior and confirmed rejection of mental
illnesses or disorders, as recognized by ICD-11 and DSM-5 (see details in the previous question).
MMBIB is entirely different in this regard, as MBI assigns it to all respondents, with or without
any illness, whether psychiatric (mental) or organic, whether mild or severe. I repeat: from the
healthiest to the sickest, from the happiest to the saddest, from the strongest to the weakest, from
the richest to the poorest, and from the most accomplished to the most dissatisfied, MBI assigns
MMBIB, albeit to a low degree, for all respondent workers.
So, while ICD11B is a diagnosis of exclusion, MMBIB does not exclude anyone. It is a huge
difference.
Being even more didactic, it is as if MMBIB were a big box containing all mental illnesses and
normal experiential reactions (symptoms that do not qualify as a mental disorder). In this analogy,
ICD-11 proposal is as follows: remove all mental disorders or illnesses from this box and then
research whether ICD11B remains among the normal experiential reactions.

66. Is the Burnout Syndrome proposed by ICD-11 a severe condition?

 Conceptually, the Burnout Syndrome proposed by ICD-11 (WHO, 2018), which I call in
this work “ICD-11 Burnout” (ICD11B), cannot be a severe condition. Let us go to justification.
I start by reminding you that neither ICD-11 nor DSM-5 (APA, 2014) place Burnout Syndrome
in the respective chapters of mental disorders or illnesses, including depressive disorder,
schizophrenia, etc. Thus, for these documents, the Burnout phenomenon is not a disease.
Since it is not a mental disorder, ICD11B is classified as a normal experiential reaction, a term
conceptualized by Jaspers (1979). Also, according to the interpretation obtained from ICD-11 and
DSM-5, I emphasize that the significant difference between a disease or mental disorder and a
normal experiential reaction is in the intensity of the harm and suffering that the symptoms cause
in the individual. It is on this parameter that the measurement of the severity of any mental process
is based.

If the damage and suffering caused by ICD11B symptoms were intense, the phenomenon would
be classified as a disease or mental disorder in ICD-11 and, probably, also in DSM-5, which is not
the case.
In this sense, as ICD11B is a normal experiential reaction, we are left with the conclusion that
the damage and suffering that its symptoms cause cannot be intense due to a conceptual issue. In
other words, ICD11B is not a severe condition when compared to any mental disorder or illness.

67. What is the difference between the Burnout Syndrome proposed by ICD-11 and
depression?
To begin with, I remind you that neither ICD-11 (WHO, 2018) nor DSM-5 (APA, 2014) place
Burnout Syndrome in the respective chapters of mental disorders or illnesses, including depressive
disorder, schizophrenia, etc. Thus, according to these documents, the Burnout phenomenon is not
a disease.
The Burnout Syndrome proposed by ICD-11 (WHO, 2018), which I call in this work “ICD-11
Burnout” (ICD11B), is defined as follows:
“Burnout is a syndrome conceptualized as a result of chronic stress in the
workplace that has not been successfully managed. It is characterized by three
dimensions:
1. Feelings of exhaustion or energy exhaustion
 2. Increased mental distance from work, or feelings of negativism or cynicism
about work
3. A sense of ineffectiveness and lack of accomplishment
Burnout refers explicitly to phenomena in the occupational context and should
not be applied to describe experiences in other areas of life.
Exceptions:
• Adaptive disorder;
• Disorders specifically associated with stress;
• Disorders related to anxiety or fear;
• Mood disorders.”
From a medical semiology point of view, I emphasise that the three symptomatologic
dimensions mentioned in this concept are nonspecific and, therefore, do not guide medical
reasoning towards an assertive nosological diagnosis (of a disease) in addition to preventing
differential diagnoses from being made.
According to DSM-5, in depressive disorder (depression), the individual presents, continuously
and frequently, for two weeks or more, the following possible symptoms: depressed mood in most
of the day; markedly diminished interest or pleasure in all or nearly all activities most of the time;
significant weight loss or gain while not dieting or reducing, or increased appetite; insomnia or
hypersomnia (“too sleepy”); psychomotor agitation or retardation (feeling of “being much
slower”); fatigue or loss of energy nearly every day; feelings of worthlessness or excessive or
inappropriate guilt; diminished ability to think or concentrate, or indecisiveness; and recurrent
thoughts of death and frequent suicidal ideation.
These symptoms result in significant distress or impairment in personal, family, social,
educational, occupational, or other important areas of the individual’s functioning.
As ICD11B symptoms are pretty nonspecific, it is very common to admit the possibility of
overlap between the symptomatology of depression and ICD11B.
From a practical point of view, I see two main differences between ICD11B and depression. First:
the cause of ICD11B stems exclusively from chronic occupational stress. Depressive disorder has
an infinite range of stressors that may be related to the disease.
Second: according to the interpretation obtained from ICD-11 and DSM-5, the main difference
between a disease (e.g., depressive disorder) and a normal experiential reaction (in which ICD11B
fits) lies in the intensity of damage and suffering that the symptoms cause. It is on this parameter
that the measurement of the severity of any mental process is based.
If the damage and suffering caused by ICD11B symptoms were intense, the phenomenon would
be classified as a disease or mental disorder in ICD-11 and, probably, also in DSM-5, which is not
the case.
In this sense, as ICD11B is a normal experiential reaction, we are left with the conclusion that
the damage and suffering that its symptoms cause cannot be intense due to a conceptual issue.
However, in depressive disorder, the damage and suffering of the individual are significant, as the
very concept of the disease demands.

68. Between having Burnout or having depression, what do people prefer?

Bianchi et al. (2016) observed that the Burnout label seems less stigmatizing than the depressive
disorder label. For Schaufeli (2017), sometimes the diagnosis of Burnout is used with pride, almost
like a badge of honor: “I had Burnout for getting at my wits’ end”.
According to Maslach and Schaufeli (1993), one of the reasons for the popularity of Burnout is
that it is a socially accepted label that transmits a minimum of stigmatization. On the other hand,
depressive disorder (depression) has multifactorial causes, and individual vulnerability is one of
its important and correct explanations.
In other words, depression carries with it the specific and notable label of the patient's own
constituent vulnerability, which cannot be delegated to anyone. Thus, the patient becomes one of
those responsible for their own mental disorder, as they assume their vulnerability, as every human
being actually is, to a greater or lesser extent.
However, in Burnout, the victim tends to diminish and even reject their own vulnerability to
chronic stress, choosing the supposed source of stress as the main villain, the one who ends up
absorbing, if not all, most of the blame for the phenomenon. Some experts call it the guilt vector
inversion.

69. What is the difference between the Burnout Syndrome proposed by ICD-11 and
generalized anxiety disorder (GAD)?
Remember, neither ICD-11 (WHO, 2018) nor DSM-5 (APA, 2014) place Burnout Syndrome in
the respective chapters of mental disorders or illnesses, which includes, for example, generalized
anxiety disorder (GAD). Thus, according to these documents, the Burnout phenomenon is not a
disease.
As we have already extensively seen in this book, the Burnout Syndrome proposed by ICD-11
(WHO, 2018), which I call in this work “ICD-11 Burnout” (ICD11B), has three very nonspecific
symptomatological dimensions, which do not guide the medical reasoning for any assertive
diagnosis, in addition to preventing a correct differential diagnosis.
According to ICD-11, GAD is characterized by intense anxiety symptoms that persist for several
months and, most days, are manifested by general apprehension (i.e., “floating anxiety”) or
excessive concern focused on different everyday events (most often associated with family, health,
finances, school, and work), along with additional symptoms such as muscle tension or motor
restlessness, sympathetic autonomic hyperactivity, subjective experience of nervousness,
difficulty maintaining concentration, irritability, or sleep disorders.
These symptoms result in significant distress or impairment in personal, family, social,
educational, occupational, or other important areas of the individual’s functioning.
As the symptoms of ICD11B are relatively nonspecific, it is very common to admit the
possibility of overlap between GAD and ICD11B symptoms.
From a practical point of view, I observe two main differences between ICD11B and GAD.
First: the cause of ICD11B stems exclusively from chronic occupational stress. Conversely, GAD
has an infinite range of stressors that may be related to the disease.
Second: according to the interpretation obtained from ICD-11 and DSM-5, the main difference
between a disease (e.g., GAD) and a normal experiential reaction (in which ICD11B fits) lies in
the intensity of damage and suffering the symptoms cause. It is on this parameter that the
measurement of the severity of any mental process is based.
If the damage and suffering caused by ICD11B symptoms were intense, the phenomenon would
be classified as a disease or mental disorder in ICD-11 and, probably, also in DSM-5, which is not
the case.
In this regard, as ICD11B is a normal experiential reaction, we can conclude that the damage and
suffering its symptoms cause cannot be intense due to a conceptual issue. In GAD, however, the
damage and suffering of the individual are significant, as the very concept of the disease requires.
70. What is the difference between the Burnout Syndrome proposed by ICD-11 and panic
disorder?
Remember, neither ICD-11 (WHO, 2018) nor DSM-5 (APA, 2014) place Burnout Syndrome in
the respective chapters of mental disorders or illnesses, which includes, for example, panic
disorder (PD). Thus, according to these documents, the Burnout phenomenon is not a disease.
As we have already extensively seen in this book, the Burnout Syndrome proposed by ICD-11
(WHO, 2018), which I call in this work “ICD-11 Burnout” (ICD11B), has three very nonspecific
symptomatological dimensions, which do not guide the medical reasoning for any assertive
diagnosis, in addition to preventing a correct differential diagnosis.
According to ICD-11, PD is characterized by unexpected and recurrent panic attacks not
restricted to particular stimuli or situations. Panic attacks are relatively brief episodes (often not
longer than 15 minutes) of intense fear or apprehension, simultaneously followed by several
characteristic symptoms (e.g., palpitations or increased heart rate, sweating, tremors, shortness of
breath, pain in the chest, dizziness or vertigo, chills, hot flush, and fear of imminent death).
Moreover, panic disorder is characterized by persistent preoccupation with the recurrence or
significance of panic attacks, or behaviors designed to prevent their recurrence, that result in
significant impairment in personal, family, social, educational, occupational, or other vital areas
of the individual’s functioning.
As the symptoms of ICD11B are relatively nonspecific, it is very common to admit the possibility
of overlapping PD and ICD11B symptomatology.
From a practical point of view, I observe two main differences between ICD11B and PD. First:
the cause of ICD11B stems exclusively from chronic occupational stress. On the other hand, PD
has an infinite range of stressors that may be related to the disease.
Second: according to the interpretation obtained from ICD-11 and DSM-5, the main difference
between a disease (e.g., PD) and a normal experiential reaction (in which ICD11B fits) lies in the
intensity of damage and suffering that the symptoms cause. It is on this parameter that the
measurement of the severity of any mental process is based.
If the damage and suffering caused by ICD11B symptoms were intense, the phenomenon would
be classified as a disease or mental disorder in ICD-11 and, probably, also in DSM-5, which is not
the case.
 In this regard, as ICD11B is a normal experiential reaction, we can conclude that the damage
and suffering its symptoms cause cannot be intense due to a conceptual issue. In PD, however, the
individual’s damage and suffering are significant, as the very concept of the disease requires.

71. What is the difference between the Burnout Syndrome proposed by ICD-11 and adaptive
(or adjustment) disorder?
Remember, neither ICD-11 (WHO, 2018) nor DSM-5 (APA, 2014) place Burnout Syndrome in
the respective chapters of mental disorders or illnesses, which includes, for example, adaptive (or
adjustment) disorder. Thus, according to these documents, the Burnout phenomenon is not a
disease.
As we have already extensively seen in this book, the Burnout Syndrome proposed by ICD-11
(WHO, 2018), which I call in this work “ICD-11 Burnout” (ICD11B), has three very nonspecific
symptomatological dimensions, which do not guide the medical reasoning for any assertive
diagnosis, in addition to preventing a correct differential diagnosis.
According to ICD-11, adaptive disorder is a maladaptive reaction to an identifiable psychosocial
stressor or multiple stressors (e.g., divorce, illness or disability, socioeconomic problems, conflicts
at home or work).
Adaptive disorder is characterized by preoccupation with the stressor or its consequences,
including excessive worrying, recurrent and distressing thoughts about the stressor, or constant
rumination about its implications, as well as an inability to adapt to the stressor, which causes
significant impairment in personal, family, social, educational, occupational, or other important
areas of the individual's functioning.
As the symptoms of ICD11B are relatively nonspecific, it is very common to admit the
possibility of overlapping between adaptive disorder and ICD11B symptomatology.
From a practical point of view, I observe two main differences between ICD11B and adaptive
disorder. First, the cause of ICD11B stems exclusively from chronic occupational stress. Adaptive
disorder, on the other hand, has an infinite range of stressors that, individually or collectively, can
legitimate the disease.
Second, according to the interpretation obtained from ICD-11 and DSM-5, the main difference
between a disease (e.g., adaptive disorder) and a normal experiential reaction (in which ICD11B
fits) lies in the intensity of damage and suffering that the symptoms cause. It is on this parameter
that the measurement of the severity of any mental process is based.
If the damage and suffering caused by ICD11B symptoms were intense, the phenomenon would
be classified as a disease or mental disorder in ICD-11 and, probably, also in DSM-5, which is not
the case.
In this regard, as ICD11B is a normal experiential reaction, we can conclude that the damage
and suffering its symptoms cause cannot be intense due to a conceptual issue. In adaptive disorder,
however, the individual’s damage and suffering are significant, as the very concept of the disease
requires.

72. According to ICD-11, can Burnout Syndrome be related to extra-work issues (e.g., a case
of illness in the family, a conflicted marriage, financial problems, etc.)?
No, it cannot. This is due to the very definition of the Burnout Syndrome proposed by the ICD-
11 (WHO, 2018), which I call in this work “ICD-11 Burnout” (ICD11B). This definition
establishes that ICD11B cannot be related to extra-work issues, such as those mentioned in the
statement of this question. Let us recall parts of the ICD11B concept:
“Burnout is a syndrome conceptualized as a result of chronic stress in the
workplace that has yet to be successfully managed. (...) Burnout refers
specifically to phenomena in the occupational context and should not be applied
to describe experiences in other areas of life.”
From the conceptual description, we observed that ICD11B is necessarily caused by
chronic stress arising from work and from work only. For this reason, although it is difficult to
accurately distinguish the repercussions of the different stressors that act simultaneously in an
individual's life, ICD11B cannot be qualified when this source stems from experiences arising
from an extra-work environment (e.g., unhealthy marital relationship, socioeconomic problems,
etc.). This is what ICD-11 establishes.

73. According to CID-11, which classification is the closest to Burnout, but can be caused by
chronic stress of any origin and not just occupational origin, as is the case of Burnout?
 In my opinion, the classification that is practically equivalent to the Burnout Syndrome proposed
by ICD-11 (WHO, 2018), which I call in this work “ICD-11 Burnout” (ICD11B), is fatigue (ICD-
11 code: MG22). Let us go to the reasons.
I remind you that, due to several causes that are often intertwined (e.g., genetics, personality,
psychological structure, affective sensitivity, among others), it has already been shown that some
are more resilient to chronic stress (no matter where it comes from, whether occupational or extra-
work). Others are more vulnerable.
The most resilient, easier adapt to specific chronic stress. In the face of this particular chronic
stress, the most vulnerable might become ill (ELBAU et al., 2019).
On the path from health to illness, chronic stress (regardless of the source) gradually builds up
its consequences. Some, like ICD11B, are not classified as diseases but are also coded in ICD-11,
for example exhaustion (ICD-11 code: MB22.7) and fatigue (ICD-11 code: MG22).
By the ICD-11 definition, exhaustion is a “feeling of reduced alertness and a concomitant decrease
in mental acuity, in some cases resulting in an urge or tendency to fall asleep”.
Fatigue is understood as a later stage resulting from the accumulation of exhaustion that has not
been resolved. It is “a feeling of exhaustion, lethargy or decreased energy, usually experienced as
a weakening or depletion of physical or mental resources and characterized by a reduced capacity
for work and reduced efficiency in responding to stimuli”. Once the state of fatigue is reached and
the chronic stress that caused it is maintained, depending on individual vulnerability, the next stage
of severity is the development of a physical and/or mental illness. (Figure 4)
 (Figure 4: Illustrative scheme of the continuum of severity of the consequences of chronic
stress – of any origin, occupational or not – maintained over time on an individual)
Let us recall now, part of the ICD11B concept:
“Burnout is a syndrome conceptualized as a result of chronic stress in the
workplace that has not been successfully managed. It is characterized by three
dimensions:
1. Feelings of exhaustion or energy depletion
2. Increased mental distance from work, negativism or cynicism about work
3. A sense of ineffectiveness and lack of accomplishment”

Observe that the three dimensions described in the ICD11B concept are consistent
with fatigue’s concept. (Chart 2)

Burnout (ICD-11 Code: QD85) Fatigue (ICD-11 Code: MG22)

Dimension 1: “Feelings of exhaustion or “Feelings of exhaustion, lethargy, or
energy depletion.” decreased energy.”
Dimension 2: “Increased mental distance “Weakening or depletion of physical or
from work, or feelings of negativism or mental resources” [which may give rise to
cynicism about work.” “increased mental distance from work, or
feelings of negativism or cynicism
regarding work” - my emphasis].
Dimension 3: “A sense of ineffectiveness “A decreased capacity for work and
and lack of accomplishment.” reduced efficiency in responding to
stimuli.”
It is not part of ICD-11 group of mental It is also not part of ICD-11 group of
disorders or illnesses. mental disorders or illnesses.
It belongs to the “work-related problems” It belongs to the subgroup: “general
subgroup of ICD-11. symptoms” of ICD-11.
“Resulting from chronic stress in the It can be caused by any type of chronic
workplace”, according to ICD-11. stress (including occupational stress).
(Table 2: Possible conceptual similarities between ICD11B and fatigue, according to ICD-11)
In summary, and according to the above reasoning, in practice, for ICD-11, ICD11B is equivalent
to fatigue motivated exclusively by chronic occupational stress since the main difference between
ICD11B and fatigue lies in the origin of the chronic stress responsible for the respective
phenomenon.
In the case of ICD11B, the chronic stress that caused it must necessarily and exclusively be of
occupational origin. On the other hand, the chronic stress that causes fatigue is of any origin,
including occupational, for example: troubled marital relationship, problems with children,
socioeconomic difficulties, illness of a family member or loved one, problems at work, etc.
Therefore, broadly, I understand that every ICD11B is fatigue; but not all fatigue is an ICD11B
(Figure 5)

(Figure 5: Illustrative scheme considering the thesis that “all Burnout is fatigue; but not all
fatigue is Burnout”)
An interesting question: Could stress (ICD-11: QE01) also be considered equivalent to ICD11B?
Answer: According to ICD-11, no. The reason is that when describing stress, ICD-11 excludes it
from the possibility of being a problem associated with employment or unemployment, a subgroup
of the classification that includes ICD11B. For this reason, it is impossible to classify equivalence
between stress and ICD11B.
Another interesting question: Are we living in a pandemic state of fatigue? Some experts think
we are.
For Schaufeli (2017), it has currently been suggested that globalization and the liberal economy
cause rapid changes in professional life, such as the need to acquire new skills, the need to adopt
new types of work, the imperative to achieve ever-increasing productivity, which increases the
pressure on individuals and can cause widespread fatigue.
 In the same wake, in Weariness Society, Han (2017) states that, in the unbridled quest for greater
productivity, we voluntarily and collectively surrender to overwork. We are “performance
subjects”, at the same time exploiters and exploited, victims of exhaustion and generalized fatigue.
Let us think about it.

74. According to CID-11, does Burnout have a ‘cure’?

I understand it does. There is a “cure” for the Burnout Syndrome proposed by ICD-11 (WHO,
2018), which I call in this work “ICD-11 Burnout” (ICD11B). Let us see.
Before we delve deeper, I explain why the word “cure” is in quotes. According to, Priberam, a
dictionary of the Portuguese language, one of the meanings of the verb to cure is “to put an end to
a disease”.
Remember, neither ICD-11 nor DSM-5 (APA, 2014) place Burnout Syndrome in the respective
chapters of mental disorders or illnesses, including depressive disorder, schizophrenia, bipolar
disorder, panic disorder, etc. Based on these documents, the term “cure” for Burnout is
inappropriate since it is not a disease. Therefore, the quotes mentioned above.
Continuing, I emphasize that it is not ICD-11’s aim to propose treatments or establish prognoses.
However, considering that I defended in the previous question that ICD11B is equivalent to fatigue
related exclusively to chronic occupational stress, ICD11B has a “cure”, and the best individual
treatment to be prescribed is effective rest, just like fatigue.
Henceforth, we will discuss ICD11B collective (institutional) management.

75. According to ICD-11, is there a causal link between Burnout Syndrome and work?
Yes, there is. There is necessarily a causal link between work and the Burnout Syndrome
proposed by the ICD-11 (WHO, 2018), which I call in this work “ICD-11 Burnout” (ICD11B).
Let us recall parts of the ICD11B concept:
“Burnout is a syndrome conceptualized as a result of chronic stress in the
workplace that has not been successfully managed. (...) Burnout refers
specifically to phenomena in the occupational context and should not be applied
to describe experiences in other areas of life.”
From the conceptual description, we observed that ICD11B is caused, necessarily and exclusively,
by chronic stress arising from work and from work ONLY. Therefore, there is an unquestionable
causal link (and not co-causality, as we will see in the next question) between ICD11B and the
individual's professional activities.
From the above, it is concluded, for example, that it is not even possible to consider the diagnosis
of ICD11B for “someone who does not work” since either ICD11B is caused by work or makes
no sense to talk about its existence.

76. According to ICD-11, what is Schilling’s classification suggested for Burnout Syndrome?
Schilling type I, in other words, the Burnout Syndrome proposed by ICD-11 (WHO, 2018),
which I call in this work “ICD-11 Burnout” (ICD11B), has worked as a necessary cause.
I remind you that there are three groups of work-related injuries, according to the classification
proposed by Schilling (1984). (Table 3)

Schilling’s Group Description Examples

I Work as a necessary cause ICD11B, lead poisoning;
silicosis.
II Work as a contributory factor, Coronary disease; locomotor
but not necessary system diseases (e.g.,
RSI/WRMDs); cancer; lower
limbs varicose veins.
III Work as a latent disorder Chronic bronchitis; allergic
provocateur or aggravator of an contact dermatitis; asthma;
already established disease most mental illnesses.
(Table 3: Schilling’s classification for work-related illnesses - adapted. Source: MS and
PAHO, 2001)

Let us recall parts of ICD11B concept:

“Burnout is a syndrome conceptualized as a result of chronic stress in the
workplace that has not been successfully managed. (...) Burnout refers
specifically to phenomena in the occupational context and should not be applied
to describe experiences in other areas of life.”
 From the conceptual description, we observed that ICD11B is caused, exclusively and
necessarily, by chronic stress resulting from work and work only. Therefore, work is a necessary
cause for ICD11B, which, for this reason, is classified as Schilling type I.
In this case, there is an unquestionable causal link (and not co-causality) between ICD11B and
the individual's professional activities. The noncausal link only happens when work is one of the
reasons for the phenomenon. In other words, when work is not the only cause of the grievance.
The concause institute only exists in Schilling classifications types II and III, and not with ICD11B,
which fits as Schilling type I.

77. According to current literature, who is most likely to develop the Burnout Syndrome
proposed by ICD-11?
As already mentioned in this book, several causes often intertwined (e.g., genetics, personality,
psychological structure, and affective sensitivity, among others) have proven that some people are
more resilient to chronic stress (ELBAU et al., 2019). Therefore, others are more vulnerable and
more likely to develop the Burnout Syndrome proposed by ICD-11 (WHO, 2018), which I call in
this work “ICD-11 Burnout” (ICD11B).
Among the characteristics of people most vulnerable to ICD11B, recent literature draws
attention to two personality traits: neuroticism and perfectionism.
Neuroticism is a personality trait that forms the significant five personality factors (FPF) model,
the so-called Big Five, along with four other traits: extroversion, openness to experience, kindness,
and conscientiousness (MCCRAE, 2009). The FPF model is a reference within the theory of
personality traits, and studies that use it are increasing in number (ANDRADE, 2008; HUTZ et
al., 1998).
According to the theory of personality traits, individuals are characterized according to their
relatively lasting patterns of feelings, affections, actions, and thoughts (JOHN; NAUMANN;
SOTO, 2008; MCCRAE, 2009).
Neuroticism refers to an individual's emotional instability/stability. It is a personality trait
defined as a tendency to experience negative affection (COSTA; MCCRAE, 1992). Therefore, it
is present in people who negatively experience emotional states. Not surprisingly, neuroticism is
consistently associated with lower satisfaction levels in interpersonal relationships (KARNEY;
BRADBURY, 1997).
 As well as to Widiger (2009), for DSM-5 (APA, 2014), neuroticism is linked to the individual
propensity or tendency to experience negative emotions, such as sadness, anxiety, and irritability,
in addition to responding to stressful events in a non-proactive manner.
According to Hutz and Nunes (2001), people with high levels of neuroticism are more likely to
experience emotional distress; ideas dissociated from reality; excessive worry and anxiety; and
challenge to tolerate frustration, having their feelings easily hurt. Additionally, they have low self-
esteem and impairments in their psychological well-being, which, in turn, can increase depressive
symptoms and risk behaviors linked to suicide (ITO; GOBITTA; GUZZO, 2007; WENZEL;
BROWN; BECK, 2009).
For Clark and Watson (1999), neuroticism has more robust, precise, and broader associations
with psychopathology than any other personality trait. It seems no coincidence that elevated
neuroticism is associated with various clinical syndromes, including anxiety disorders, mood
disorders, substance use disorders, somatoform disorders, eating disorders, personality and
conduct disorders, and schizophrenia.
Women consistently exhibit higher neuroticism scores than men (HYDE, 2001). It might be one
of the reasons why the female population has 1 to 3 times more diagnoses of depressive disorders
and two times more diagnoses of generalized anxiety disorders (GAD) and panic disorders than
the male population (APA, 2014).
To Vilas (2021), neuroticism is also a strong predictor of Burnout. Along the same lines, Bianchi
(2018), in a study with 1,759 participants, concluded that Burnout is more strongly linked to
neuroticism than to work environmental factors.
Another personality trait often associated with ICD11B is perfectionism, synthetically defined as
an individual's tendency to set high-performance standards in one or more areas of life (HARING;
HEWITT; FLETT, 2003).
Currently, perfectionism has been studied under two fundamental aspects: adaptive (also
called positive efforts, positive perfectionism, adaptive perfectionism, functional perfectionism,
responsible perfectionism, and perfectionist efforts) and maladaptive (also known as maladaptive
concerns, negative perfectionism, maladaptive perfectionism, dysfunctional perfectionism, self-
evaluating perfectionism, and perfectionistic concerns) (KEEGAN; GALARREGUI; MIRACCO,
2019).
 For Carvalho (2019), the adaptive aspects of perfectionism include high-performance
standards definition but with a realistic and flexible view of these standards. Thus, an athlete can
reach incredibly high goals, but not unattainable ones, be happy with the marks he achieves and
continue working to improve them, feeling motivation and satisfaction throughout the process,
with which he is strongly engaged.
In contrast, the maladaptive aspect of perfectionism is related to an unrealistic and
inflexible view of self-imposed high standards, difficulty in achieving satisfaction with one's own
achievements, and the need to perform exceptionally to avoid negative evaluations by others. (WU;
WEI, 2008).
Neuroticism moderately correlates with perfectionism's maladaptive dimensions (EGAN
et al., 2015; RICE; ASHBY; SLANEY, 2007).
Most studies also suggest a positive association between maladaptive perfectionism and
Burnout. This would explain, for example, symptoms related to ICD11B in individuals who
abandoned the urban, hectic life of subordinate work and exchanged it for a bucolic, peaceful life
in which work is self-managed. In other words, goals are self-imposed. It turns out that, even
though they are self-imposed, the standards of these goals remain high and inflexible, which is
characteristic of the maladaptive perfectionism associated with ICD11B.
On the other hand, adaptive perfectionism does not show a significant correlation with the
syndrome (CARVALHO, 2019). However, Stoeber (2016) attests that when a worker is a
perfectionist, considering the sum of all forms of perfectionism (adaptive and maladaptive), the
result is an increased risk for Burnout. This thesis corroborates, at least in part, Freudenberger's
ideas.
Remember that in the last pages of “Burnout: How to Beat The High Cost of Success”
(1981), writing as someone who had lived with the syndrome, learned from it and overcame it,
Freudenberger warns about the harmful effects of perfectionism when he emphasizes: “Fritz Perls
said: Friend, do not be a perfectionist. Perfectionism is a curse and a weakness”.

78. What can workers do (individually) to avoid Burnout and the unwanted effects of chronic
stress resulting from work?
 Workers can do a lot to avoid the Burnout Syndrome proposed by ICD-11 (WHO, 2018),
which I call in this work “ICD-11 Burnout” (ICD11B), and the unwanted effects of chronic stress
resulting from work.
Perhaps, the first step is the honest answer to the question: “Does this work make sense to
me?”. If the answer is no, the time to act may have come. This is because, in cases involving
conflict of values and/or purposes between worker and institution, the last decision-making
instance and, therefore, resolving the problem is the worker’s own responsibility.
Without going into the merits of the countless and complex variables to be considered, it
is the worker who decides whether or not they want to continue working with something they do
not identify (obviously, assuming that we are not dealing with a situation that, in modern times, is
called work in conditions analogous to slavery).
On the other hand, if the work makes sense for the individual, it does not disagree with
their values and/or purposes, other measures should be observed.
Let us remember that chronic stress (from any source, including occupational) gradually
builds its consequences on the path from health to illness. Some, like ICD11B, are not classified
as diseases but are also coded in ICD-11, for example, exhaustion (ICD-11 code: MB22.7)
and fatigue (ICD-11 code: MG22).
According to ICD-11, exhaustion is a “feeling of reduced alertness and a concomitant
decrease in mental acuity, sometimes resulting in an urge or tendency to fall asleep”.
Fatigue is understood as a later stage resulting from accumulated exhaustion that has not
been resolved. It is “a feeling of exhaustion, lethargy or decreased energy, usually experienced as
a weakening or depletion of physical or mental resources and characterized by a reduced capacity
for work and reduced efficiency in responding to stimuli”. Once the state of fatigue is reached and
the chronic stress that is caused is maintained, depending on individual vulnerability, the next stage
of severity is the development of a physical and/or mental illness. (Figure 4)
(Figure 4: Illustrative scheme of the continuum of severity of the consequences of chronic
stress – of any origin, occupational or not – maintained over time on an individual)
Especially regarding chronic stress resulting from work, it is true that according to Art. 7,
item XXII, of the Federal Constitution of 1988, ultimately, the employer must extinguish or reduce
to the maximum any and all risks arising from work, even if the risk is based on subjective issues
inherent to the worker himself, such as in the case of a possible conflict of values/purposes between
worker and work.
However, thinking beyond legal issues, each worker can and should strive for their own
mental health. After all, they (the employees) are the greatest beneficiary of this state of
psychological health.
One of the simplest ways to fulfil this primary mission is to give balance and rest to the
essential places they have in every individual's life. The rationale behind this thesis is obvious:
Those with a balanced life have time to rest; those who effectively rest do not get mentally fatigued.
They protect themselves from ICD11B and tend to avoid becoming psychiatrically ill due to
chronic stress resulting from work.
In this regard, it is the employee’s responsibility, however committed and engaged they
may be, to diligently exercise disconnection in the sense of the broadest possible range of that
word. I start by remembering postures that can be adopted in the work context, such as:
• in the day's agenda, establish a hierarchy of priorities between the tasks to be performed,
valuing what is most important to the detriment of what is not relevant or urgent (P.S.: the exercise
of prioritizing what really matters can be used not only regarding the day's agenda but in most of
the situations we experience throughout life, whether related to work or not: it is an efficient way
of managing time and stress that affects us);
 • not neglecting breaks during working hours, often given and encouraged by the
institution and not used by the worker under different excuses;
• using relaxing and stretching techniques at certain times of the day as a form of relief
and relaxation;
• especially in home office jobs, establish precise limits for work and domestic activities;
• do not give up your holidays! This period recharges mental and physical energies and
creates new perspectives and sensations.
Outside the work environment, the disconnection must include the necessary and frequent
resting time from any demand that “drains energy” and results in mental exhaustion. A suitable
method for achieving this goal is doing activities that cause the opposite effect: joy and mental
rest.
These activities should also be on the agenda. I refer to the agenda to reinforce that they
must be prioritized rigorously as work-related commitments. Let us face it: it is like that, or the
chance of “leaving it for later” is huge. You must take mental rest seriously.
These activities include, for example:
• spending frequent and exclusive time with family and other social ties, as long as they
are enjoyable;
• prioritizing regular sleep and enough time for effective resting;
• practicing sports and/or other physical activities, preferably pleasurable;
• cultivating entertainment and leisure activities;
• carrying out activities that are merely contemplative;
• exercising altruism and the warm side of spirituality;
• disconnecting, for some moments of the day, from technological sources, such as cell
phones, computers, and social networks, among others;
• feeding the creative side: Try new challenges and projects;
• when unforeseen events happen (and they always do!), remember the maxim “If there
is no solution, it is solved”.
At that moment, it is time to dedicate yourself to the unexpected, solve it in the best possible
way and then start the routine again. No rush and no break.
Even these activities (which are already so many for a day with only 24 hours) need to be
balanced, scheduled, and prioritized. It may not be possible (nor necessary) to do everything. Thus,
each person must choose those activities that provide more meaning in life, pleasure, and mental
rest. However, the argument: "if it is not possible to do everything, I would rather do nothing", is
not valid. It is not! This is playing against your own mental health.
Finally, I remind you that, among the characteristics of people most vulnerable to
ICD11B and the effects of chronic and pathogenic stress resulting from work, recent literature
draws attention to two personality traits: neuroticism and perfectionism.
Neuroticism refers to an individual's emotional instability/stability. It is a personality
trait defined as a tendency to experience negative affection (COSTA; McCRAE, 1992).
Perfectionism is synthetically defined as an individual's tendency to set high-
performance standards in one or more areas of life (HARING; HEWITT; FLETT, 2003). To learn
more about neuroticism and perfectionism, see the previous question.
Although they are personality traits, both neuroticism and perfectionism can be better
managed and have their harmful effects mitigated with the help, for example, of cognitive-
behavioral therapy (CBT).
CBT can enhance coping, defined as a set of cognitive and behavioral efforts used by
individuals to deal with specific internal or external demands that arise in stressful situations and
are assessed as overloading or exceeding their personal resources. (LAZARUS; FOLKMAN,
1984). Ultimately, coping aims to work on each person’s psychological resources, consistently
producing more resilience and reducing personal vulnerability in the face of a stressor, regardless
of what it is.

79. How can institutions act and support themselves (including legally) regarding the
confrontation of Burnout Syndrome and mental disorders among their workers?
This is the famous “ten-million-dollar question”. I dare to answer it.
Instead, I emphasize that the more effective measures implemented, the better when it comes to
health support in the occupational environment (including mental health). There is no maximum
limit to desirable actions. In this matter, I suggest a “combo” of measures that do not intend to
exhaust the possible ways of coping with Burnout Syndrome and mental disorders related to
chronic stress at work.
Despite my numerous disagreements with this researcher, I begin by appealing to Christina
Maslach. I do so because, despite my disagreements, it is necessary to recognize that she is,
currently and worldwide, one of the most excellent references (if not the best) on the controversial
topic of Burnout. More than that: it is necessary to remember that the theoretical basis of the
Burnout Syndrome proposed in ICD-11 (WHO, 2018), which I call in this work “ICD-11 Burnout”
(ICD11B), was considerably obtained by the conceptualization of the Burnout Syndrome proposed
by Maslach and her collaborators, which I name in this book as “Maslach/MBI Burnout”
(MMBIB).
As we saw in question no. 52, in 1998, Maslach and Goldberg proposed a “Burnout-
engagement” continuum. Just as there are the antitheses “8 and 80”, “black and white”, and
“silence and sound”, for these researchers, there are also the opposite poles “, Burnout and
engagement”.
As well as MMBIB (MASLACH; JACKSON; LEITER, 2018), ICD11B has three
dimensions [emotional exhaustion (or simply exhaustion); depersonalization or cynicism; and low
effectiveness or professional achievement]. These authors define engagement as the symmetrical
opposite of Burnout: high energy (instead of exhaustion), engagement (instead of
depersonalization or cynicism), and effectiveness (instead of low effectiveness or professional
achievement).
So, how could an institution leave the ICD11B pole and move towards the engagement
pole? According to an interpretation obtained from Maslach and Leiter (2004), the path is to solve
the six areas of possible disagreements between person and work: work overload, lack of control,
insufficient reward, loss of community, lack of equity (or lack of justice) and conflict of values.
(Figure 3)
[Figure 3: According to Maslach and Leiter (2004), solving the six areas of disagreement
between worker and work, an occupational environment ceases to be a “Burnout causative”
and becomes a source of engagement)]

P.S.: To better understand these six areas and their respective management regarding worker
engagement, see question n. 53.
Let us remember that, in a very summarized way and inspired by the ideas of Cabral (2016), the
causal link between grievance and work is determined by the coexistence of three factors,
summarized in the form of the following equation:

Where:
CL = Causal link between work and injury;
CD = Correct diagnosis of the grievance;
ER = Environmental risk that causes grievance;
TE = Time of exposure to environmental risk that justifies the occurrence of the work-related
grievance.
 For these reasons, an institution with effective and documented policies that resolve the six
areas of possible disagreement between people and work is an organization that promotes
engagement and not its antonym, ICD11B. Therefore, in this occupational environment, there is
no reason for a diagnosis of ICD11B among employees, as interpreted by Maslach and Leiter
(2004). Since there is not even a diagnosis of grievance, there is no need to talk about a causal link
between work and ICD11B, according to the link equation inspired by Cabral’s ideas (2016).
Thus, the practical and documented implementation of effective policies, which can
solve the six areas of possible disagreement between people and work, seems to be an excellent
way for institutions to face Burnout, in addition to supporting themselves (including from a legal
point of view) in this sense.
What about preventing mental illnesses or disorders that, as well as ICD11B, might be
related to chronic stress resulting from work (e.g., depressive disorder, anxiety disorders, adaptive
or adjustment disorder, etc.)? The good news is, for all well-intentioned people interested in the
subject when an institution faces Burnout based on the method proposed here, it is naturally also
facing all the illnesses or mental disorders that might be related to chronic stress resulting from
work. Let me explain.
Chronic stress (regardless of the source, including work) gradually builds up its
consequences on the path from health to illness. Some, like ICD11B, are not classified as diseases
but are also coded in ICD-11, for example, exhaustion (ICD-11 code: MB22.7) and fatigue (ICD-
11 code: MG22).
According to ICD-11, exhaustion is a “feeling of reduced alertness and a concomitant
decrease in mental acuity, sometimes resulting in an urge or tendency to fall asleep”.
Fatigue is understood as a later stage resulting from accumulated exhaustion that has not
been resolved. It is “a feeling of exhaustion, lethargy or decreased energy, usually experienced as
a weakening or depletion of physical or mental resources characterized by reduced capacity for
work and reduced efficiency in responding to stimuli”. Once the state of fatigue is reached and the
chronic stress that caused it is maintained, depending on individual vulnerability, the next stage of
severity is the development of a physical and/or mental illness. (Figure 4)
 (Figure 4: Illustrative scheme of the continuum of severity of the consequences of chronic
stress – of any origin, occupational or not – maintained over time on an individual)

Let us recall now part of the ICD11B concept:

“Burnout is a syndrome conceptualized as a result of chronic stress in the
workplace that has not been successfully managed. Three dimensions
characterize it:
1. Feelings of exhaustion or energy depletion
2. Increased mental distance from work, or feelings of negativism or cynicism
about work
3. A sense of ineffectiveness and lack of accomplishment”

Observe that the three dimensions described in the ICD11B concept are consistent
with fatigue’s concept. (Table 2)

Burnout (ICD-11 Code: QD85) Fatigue (ICD-11 Code: MG22)

Dimension 1: “Feelings of exhaustion or “Feelings of exhaustion, lethargy, or
energy depletion.” decreased energy.”
Dimension 2: “Increased mental distance “Weakening or depletion of physical or
from work, or feelings of negativism or mental resources” [which may give rise to
cynicism about work.” “increased mental distance from work, or
feelings of negativism or cynicism
regarding work” - my emphasis].
 Dimension 3: “A sense of ineffectiveness “A decreased capacity for work and
and lack of accomplishment.” reduced efficiency in responding to
stimuli.”
It is not part of the ICD-11 group of mental It is also not part of the ICD-11 mental
disorders or illnesses. disorders or illnesses group.
It belongs to the “work-related problems” It belongs to the subgroup: “general
subgroup of ICD-11. symptoms” of ICD-11.
“Resulting from chronic stress in the It can be caused by any chronic stress
workplace”, according to ICD-11. (including occupational stress).
(Table 2: Possible conceptual similarities between ICD11B and fatigue, according to ICD-11)

According to the above reasoning, in practice, for ICD-11, ICD11B is equivalent to fatigue
motivated exclusively by chronic occupational stress since the main difference between ICD11B
and fatigue lies in the origin of the chronic stress responsible for the respective phenomenon.
Considering it, and also the continuum severity of chronic stress consequences – of any
origin, occupational or not – maintained over time on an individual (see Figure 4), we conclude
that an institution that prevents ICD11B (here accepted as equivalent to fatigue motivated
exclusively by chronic occupational stress), consequently prevents all disorders or mental illnesses
that might be related to chronic stress resulting from work.
The reasoning is simple: whoever manages to prevent even an experiential situation
resulting from chronic stress at work (ICD11B) will obviously be able to prevent even more
illnesses or mental disorders related to the same stressor.
Making an analogy, it is as if the set of adequate policies that manage to solve the six
areas of possible disagreement between people and work worked as a powerful protection barrier
for the first layer (ICD11B), consequently, even stronger for a second layer (the mental disorders
or illnesses that might be related to chronic stress resulting from work). (Figure 7)
(Figure 7: Scheme illustrating the protective potential of policies that manage to resolve the
six areas of possible disagreement between people and work, proposed by Maslach and
Leiter (2004), regarding disorders or mental illnesses that might be related to chronic stress
resulting from work)

It is worth emphasizing that mental disorders or illnesses (e.g., depressive disorder) have,
as a rule, multifactorial causes and have individual vulnerability as one of their essential and
correct explanations. Stress resulting from work can be one of many causes that, combined or
separately, can be related to a mental illness.
Regardless of any classification analysis, depressive disorder (by many called “the
disease of the century” due to its current high prevalence) is among us, among people around us,
whether in the family, at work, at church, at school, or in any other environment.
In depressive disorder (depression), mental suffering is real and, depending on the
severity of the case can be terrifying, heartbreaking, and disabling. It can take the color out of life
and, in extreme cases, end it. It is severe.
In this sense, and apart from the discussion on the causal responsibility of the depressive
disorder, on the contrary, considering the much needed and regulated social responsibility that
each institution must have, I recall the proven mechanisms for tracking and coping with depression
in the occupational environment.
In short, the practical and documented execution by the institution (I) of the set of
adequate policies that manage to solve the six areas of possible disagreements between person and
work, (II) of mechanisms for tracking and coping with mental disorders in the occupational
environment (regardless of the cause of the illnesses whether or not they are work-related), (III) in
addition to studies or any other complementary measures that contribute to the mental health of
workers, it must be applauded by all actors in good faith interested in the subject, in particular:
workers, trade unions, the Judiciary, the financial market, and other members of organized society.

80. After all, for the author of this book, in practice, does the Burnout Syndrome proposed
by ICD-11 exist, or does it not exist?
Before answering this question, it is worth praising ICD-11’s (WHO, 2018) role in
promoting the discussion on Burnout, especially in recent months. It is undeniable and worthy of
applause. This conversation really needs to happen—the more, the merrier.
Specifically, about the Burnout Syndrome proposed by ICD-11, which I call in this book
“ICD-11 Burnout” (ICD11B): in theory, it exists. It is undeniable and literal: the syndrome is
described in ICD-11 with the code QD85, as I often mentioned in this work.
In practice, I understand that “ICD-11 Burnout” is like an alien: I am not saying it does
not exist, just that I have never seen it.
Based on ICD-11 itself, it is challenging to get a diagnosis of ICD11B. Above all, due
to the fact that, from normal experiential reactions (e.g., ICD11B itself) to disorders or diseases,
nearly all mental processes are already described and codified, with other nomenclatures and much
more solid and traditional bases, in this same classification by WHO (World Health Organization).
Once again: I ask you not to interpret my conclusion as a disdain for workers' mental
health. It is not about that. Mental disorders or illnesses can be severe. Burnout, according to ICD-
11, is something else...
The existence of mental disorders (e.g., depressive disorder, panic disorder, generalized
anxiety disorder, adaptive disorder, post-traumatic stress disorder, etc.) related to work is
unquestionable. The suffering caused by these diseases is real and significant. Preventive actions
by institutions are essential. Such statements were never discussed in this book, as categorically
stated in the first chapters of the work.
Finally, I emphasize that I understand and respect those who think differently regarding
what I have explained about Burnout throughout this book. In fact, it is a highly controversial
subject. Either because of disagreement with the arguments I present, because of the difficulty of
changing one's opinion, or because of personal, technical, corporate, political and/or ideological
convictions: if the divergence is followed by intellectual honesty of those who disagree, I consider
it legitimate and worthy of all my considerations.

CHAPTER 9: THE FUTURE OF BURNOUT

81. What does the future hold for Burnout? (A reflection based on a brief history of
neurasthenia.)
Many blame the current way of life for the hypothetical increase in the prevalence of Burnout
Syndrome (BS) among us. However, blaming “the new times” for what ails us physically and
mentally is nothing new. I now present a little of neurasthenia’s history. Any resemblance to BS
is, perhaps, not a mere coincidence.
George Miller Beard (1839-1883), a New York neurologist, defined neurasthenia in the article
Neurasthenia, or nervous exhaustion, published in 1869. According to him, in the United States,
in the second half of the 19th century, neurasthenia was “more common than any other type of
nervous disease” (BEARD, 1869).
For Beard (1880), neurasthenia was a chronic functional disorder with a diagnosis exclusively
clinical (without the aid of complementary exams). The main symptomatologic presentation was
based on physical and mental exhaustion. Several non-specific signs and symptoms complemented
the clinical presentation, such as gastric and sexual disturbances, generalized pain and headaches,
ringing in the ears, difficulty concentrating, morbid fears, restlessness, sleep disorders, sensitivity
in the scalp, dilated pupils, spinal sensitivity (spinal irritation), among others.
What were the causes of neurasthenia? The most influential physicians of the time saw overwork
as the reason the nervous system became exhausted. For many experts, including George Beard,
neurasthenia was the most visible sign of contemporary life (PORTER, 2001).
Believe it: for Beard, “the steam engine, the press [which began to have daily printed
newspapers at that time - emphasis mine], the telegraph, the sciences, and women’s mental
activity” were the leading causes of the exhaustion that culminated in neurasthenia (BEARD,
1869).
According to the New York neurologist, neurasthenia affected, preferably, the brain workers
(“those who worked with the brain”), whose nervous strength supply was being destroyed by the
impositions of industrialized urban life, and upper-class girls, with their delicate nervous systems
and unfit for the demands of life in big cities (ZORZANELLI, 2010).
Most cases of neurasthenia had a good prognosis and were cured. According to Beard (1880), the
most frequent cures involved: physical exercises (for men), rest, air, sunlight, water, food,
entertainment, hydrotherapy, electricity, diet, and massage.
As a historical summary, neurasthenia, as a clinical diagnosis, was gradually mentioned in
secondary newspapers in the late 1860s. Its status increased as it entered the best homes of
industrialized nations.
Zorzanelli (2010) attests that neurasthenia then became one of the “fashionable diseases”,
receiving the admission and attention of neurologists at the time, and adds: “At the end of the 19th
century, few upper-class families in Europe and the USA had not been hit by neurasthenia, and by
the 1920s, the diagnosis had already spread to factory workers, farmers, and merchants."
However, in the first decades of the 20th century, the diagnosis of neurasthenia gradually
declined in Europe and the United States. Medical scepticism related to the phenomenon grew,
and psychiatry's development made the diagnosis's generality questionable (WESSELY, 1990).
The latest versions of the ICD (International Classification of Diseases) and DSM (Diagnostic and
Statistical Manual of Mental Disorders) confirm the loss of importance of neurasthenia as a
nosological diagnosis (of disease).
In ICD-10 (WHO, 2016), neurasthenia appears with the code F48.0 (in the chapter on mental
disorders or illnesses, in the subchapter “other neurotic disorders”). In ICD-11 (WHO, 2018), the
diagnosis disappears.
In DSM-IV-TR (APA, 2002), neurasthenia appears as a “culture-bound syndrome”. The
diagnosis is no longer found in DSM-5 (APA, 2014).
For some authors, as the diagnosis of neurasthenia lost its scientific force, its nonspecific
symptoms just migrated to other entities, such as fibromyalgia, chronic fatigue syndrome (CFS),
and BS itself.
In summary, neurasthenia had exhaustion as its symptomatologic nucleus. Its primary cause was
attributed to the demands of the new times, including overwork. It mainly affected those who
“worked with the mind, with the brain” (brain workers). It first gained importance in the more
affluent classes of society and at the highest levels of institutions. It became a “fashionable disease”
and gradually lost its diagnostic importance while its prevalence increased in the lower social
classes.
I now suggest an uncompromising reflective exercise. Project yourself into the future, decades
from now. Imagine rereading the previous paragraph and replacing the word neurasthenia
with Burnout Syndrome.

• Will the text be compatible with what history will have already shown?

• Nowadays, we observe that BS is more reported and studied among workers with higher
qualifications and social status. Could it be that, when the diagnosis of Burnout gets (if it gets) to
a major way on the “factory floors”, on low-level organizational workers, on masons, on street
sweepers, on garbage collectors, on cleaning assistants, on maids, on nannies, etc., will the
syndrome also lose its glamour and “diagnostic appeal”, as it did with neurasthenia?

• If BS “disappears”, will other entity(ies), with other nomenclature(s), be created to accommodate

the same and non-specific symptoms of the phenomenon?

The future will answer all these questions.

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