Occupational Medicine. Burnout syndrome

Occup. Med. Vol. 50, No. 7, pp. 512-517, 2000Copyright 2000 Lippincott Williams & Wilkins for SOM

Printed in Great Britain. All rights reserved0962-7480/00

Burnout syndrome: a disease ofmodern societies?A. Weber and A. Jaekel-ReinhardInstitute and Outpatient Clinic for Occupational, Social and EnvironmentalMedicine of the University of Erlangen-Nuremberg, GermanyIn the light of social change and a transformation in the work situation, interest in theproblem of burnout has grown over the past decade. There is a conspicuousdiscrepancy, however, between what is regarded as certain knowledge and what ispublished opinion. To date, there is no generally accepted definition of burnout, orbinding diagnostic criteria. According to the most common description at present,burnout syndrome is characterized by exhaustion, depersonalization and reducedsatisfaction in performance. Because of its aetiopathogenesis, burnout is today mainlyregarded as the result of chronic stress which has not been successfully dealt with. Thispaper gives an overview of the current definition for burnout syndrome and statespossible contemporary hypotheses for its aetiology. By examining diagnostic criteriaand possible therapies, methods of prevention are discussed. There is an urgent needfor further investigations to determine whether burnout syndrome is a work-relateddisease.

Key words: Burnout; disability management; person-environment misfit; stress at theworkplace; work-related diseases.

Occup. Med. Vol. 50, 512-517, 2000

Received 15 March 2000; accepted in final form 21 June 2000.

INTRODUCTION

' . . . I'm under a lot of stress, . . . completely burned out..., I'd like to pack it in ..., my battery is flat...!'. Whohas not heard similar comments when people are talkingabout their work? Are such statements, which are asmuch part of a modern service society as the mobilephone and computer, just everyday phrases, excuses fora lack of performance, or are they symptoms of a diseasewhich can be summarized by the term 'burnoutsyndrome'?

The term 'burnout' was coined in the USA a good 25years ago. The psychoanalyst Freudenberger, for exam-ple, published one of the first scientific descriptions ofthe burnout syndrome as psychiatric and physicalbreakdown.1 In 1981, Maslach introduced a further-reaching definition and an instrument for measuringburnout which is still the most frequently used today, theMaslach Burnout Inventory.2'3

In industrialized countries, public interest in theproblem of burnout has increased over the last fewyears. The subject has enjoyed a boom in the media, butthere is a great discrepancy between published opinion

Correspondence to: Priv.-Doz. Dr. med. Andreas Weber, Schillerstr. 25 +29, 91054 Ertangen, Germany. Tel: +49 9131 8526118; fax: +49 9131 8522317

and what is regarded as certain knowledge. In the lastdecades burnout was a subject of scientific researchmainly among psychologists and sociologists. Majorcontributions for identifying and classifying burnoutsyndrome have been published by psychologists.3'4

Recently, the subject has caught the attention ofdoctors of social and occupational medicine. The centralproblems for science and practice result from the factthat there is no generally accepted definition of burnout.The separation from other health disorders is difficultand potential causal factors are still the subject of muchcontroversy.2'5 ~8 Nevertheless, burnout syndrome is animportant problem in modern working environmentsand is addressed in this paper from the point of view ofoccupational medicine. By considering the importantwork published by psychologists an interdisciplinaryapproach would facilitate the understanding of burnoutsyndrome in the field of occupational health.

DEFINITION: THE CURRENT SCIENTIFICCONSENSUS OF OPINION

According to one of the first more extensive character-izations by Maslach and Jackson, burnout is the result ofchronic stress (at the workplace) which has not beensuccessfully dealt with. It is characterized by exhaustionand depersonalization (negativism/cynicism) and is

by guest on January 3, 2015http://occm

ed.oxfordjournals.org/D

ownloaded from

A. Weber and A. Jaekel-Reinhard: Burnout syndrome 513

found predominantly in caring and social professions(e.g. social workers, teachers, nurses, doctors, dentists).3

A later definition based on the MBI and which is inwidespread use today, describes exhaustion, depersona-lization, and reduced satisfaction in performance as thedecisive elements of burnout syndrome.2'9 In the 10threvision of the International Classification of Diseases(ICD 10) the term 'burnout' was described under Z.73.0as 'Burnout-state of total exhaustion'.10 In addition tothe question of a uniform, generally accepted definition,aetiological and pathogenetic aspects are the subjects ofmuch controversy. It is generally believed today that'negative stress' (distress) probably represents a keyphenomenon in the aetiopathogenesis of burnout. Otherimportant pathogenetic factors are thought to be 'beingswamped by daily routine' and 'disappointed expecta-tions'.2'5'6'8'11'12 Most of the theories and models for thedevelopment of burnout syndrome are published in thepsychological, psychosomatic and psychiatric litera-ture.3'4 This paper will focus on three main models froma social-medical point of view (Box 1).

BOX 1. Burnout syndrome: importantaetiopathogenetic concepts from the social-medicalpoint of view

A. Result of stress that has not been successfullydealt with.Emphasis on strain and society-the 'macrolevel'.

B. Person-environment-misfit.Emphasis on interaction between society and theindividual-the 'mesolevel'.

C. Discrepancy between expectations and reality.Emphasis on strain and the individual-the'microlevel'.

Contrary to earlier observations regarding the epide-miology of burnout, it has been noted that the syndromeis not associated with certain workplaces, circumstances,sex or age. The occurrence of burnout syndrome hasbeen described in diverse occupations, e.g. in socialworkers, advisors, teachers, nurses, laboratory workers,speech therapists, ergo therapists, doctors and dentists,police and prison officers, stewardesses, managers, andeven in housewives, students and unemployed peo-ple.2'11'13"18 Psychological explanations assume that inmost of these occupations the combination of caring,advising, healing or protecting, coupled with thedemands of showing that one cares, is of centralimportance.4'8

The prevalence rates published in the literature forindividual occupations must be regarded sceptically, asthe definitions and diagnostic criteria used are notuniform. Depending on the evaluation instruments andclassification systems used, an incidence of burnout inteachers of up to 30% has been given.17'19 For doctorsand dentists more recent studies give prevalence rates ofup to 10%.5>11'13-15

IMPORTANT ASPECTS IN THEAETIOPATHOGENESIS OF BURNOUT

Despite numerous new discoveries regarding the devel-opment of burnout syndrome, many questions still remainunanswered. Is burnout merely high-level stress at theworkplace or the result of the complex interaction of socialfactors (circumstances) and individual factors (beha-viour)? Without a doubt, the changes in society and workhave led not only to changed demands, but also to agenerally undisputed increase in heterogenic psycho-mental and psychosocial stress.20"22 Occupational psy-cho-mental/psycho-social stress factors are illustrated inFig. 1 and include pressure of time, overtime and shift

Figure 1. Burnout: an interaction between society and the working environment.

Society

individualizationloss of traditionalsupport systemsanonymityeducationalexpectationslack of timemultiple stress factors

Economization

Work environment

mechanization globalization/competition increased work complexity job uncertainty ('hire and

fire') mobility/flexibility specialization

Increase of psychosocial/psychomental stress

Higher burnout risk



ownloaded from

514 Occup. Med. Vol. 50, 2000

work, as well as mobbing, economic pressures, andmultiple tasks such as job, family and leisure activities. Inaddition, the importance of personal competence, parti-cularly in the so-called tertiary sector, is continuallyincreasing (e.g. communicability, being able to work in ateam, frustration tolerance, service orientation, flexibility).

According to the job-strain model, which has beenestablished for many years in occupational medicine as astress - strain concept, a high level of strain can resultfrom the cumulation of psycho-mental/psycho-socialstress and a lower level of stress tolerance, which in thiscontext is to be regarded as 'negative stress'. When'negative stress' becomes chronic and is not dealt withadequately it leads to adverse effects on the health. Notonly do psychological and social factors play a role, butso also do biological and biochemical factors. Above all,hormonal and endocrinological changes, particularly apermanent increase in the cortisol level and disturbancesin the hypothalamic - pituitary -adrenal control system,are under discussion.23"28

Recent research suggests that such influences arepossibly not only relevant for the development ofburnout syndrome, but also in the pathogenesis ofoccupation-related psychiatric/psychosomatic dis-eases.17'29'30 According to the 'person-environment-misfit' concept, an imbalance between psycho-mental/psycho-social stress and individual stress tolerance isdecisive for the development of burnout syndrome. Therisk of burnout is influenced not only by the extent of thestress factors and deficits in personal resources, butabove all by 'social support' systems and 'coping'strategies. In addition to primary personality structure(e.g. idealism, perfectionism, timidity, insecurity, emo-tional instability), negative factors which influence theindividual stress tolerance are inadequate or lackingstrategies to deal with stress, disappointed expectations/negative experiences, and lifestyle (e.g. inadequatesupport due to a lack of social relationships/partner-ships).6

SYMPTOMS

The symptoms of burnout patients are usually multi-dimensional with several psychiatric, psychosomatic,somatic and social disorders. The main psychiatricsymptoms are, in addition to chronic fatigue andcontinuous exhaustion, above all described as 'mentaldysfunction'. This includes concentration and memorydisturbances (a lack of precision, disorganization), alack of drive and personality changes (a lack ofinterest, cynicism, aggressiveness). Severe disturbancesare anxiety and depressive disturbances, which canculminate in suicide. Also the development of addic-tions (e.g. alcohol, medicines) has been associatedwith burnout. Common somatic symptoms are head-aches, gastro-intestinal disorders (irritable stomach,diarrhoea), or cardio-vascular disturbances such astachycardia, arrhythmia, and hypertonia. Figure 2illustrates the dynamic process of developing burnoutsyndrome.

Figure 2. Burnout: a dynamic process ('burnout cascade').

1.

2.

3.

4.

5.

6.

7.

8.

Hyperactivity

Exhaustion

Reducedactivity

Emotionalreactions

Breakdown

Degradation

Psychosomaticreactions

Despair

- chronic fatigue, loss of energy

- withdrawal, resignation

- aggression- negativity- cynicism- cognitive function- motivation- creativity

- emotional distress- loss of social contacts

- sleep disturbances- gastro-intestinal disorders

- susceptibility to infection- sexual disorders- intake of alcohol and drugs

- psychosomatic disorders- suicide

In addition, depending on the duration and severity ofthe burnout, there are often further negative socialconsequences. These include, from the point of view ofthe individual, withdrawal at the workplace (so called'inner resignation') or effects on private life (partner/sexual problems, social isolation). From the perspectiveof society, there is an increased risk of repeated or longperiods of absence from work and early invalid-ity.2,6,8,11,15

DIAGNOSIS, DIFFERENTIAL DIAGNOSIS, ANDTHERAPY

In view of the mainly unspecific symptoms, when itcomes to the diagnosis of burnout syndrome a differ-entiated, all-encompassing approach is necessary. Goodinterdisciplinary co-operation and communication be-tween the parties involved in the diagnostic process(patient, GP, specialist, works physician, psychologist,other disciplines) is just as essential as medical expertise.Box 2 shows a diagnostic approach for diagnosingburnout syndrome from social and occupational medi-cine points of view.

Valid objectification and quantification of healthimpairments and/or functional disturbances must becarried out. This requires medical expertise and shouldnot be carried out by non-medical personnel, even if theyare very enthusiastic about the subject. In addition to ageneral anamnesis to evaluate previous and accompany-ing illnesses, a problem-oriented social and occupationalanamnesis in particular should be carried out. This



ownloaded from


BOX 2. Burnout syndrome: the diagnostic, all-encompassing, interdisciplinary approach

Medical historySocial and occupational historyDrug historySymptomsPhysical examinationPsychosomatic/psychiatric statusPsychometric testsSpecial laboratory tests

Previous and current diseasesIdentification of potential stress factors and possible social consequencesSmoking, consumption of alcohol and drugsCourse and temporal relationshipGeneral examination

Maslach Burnout Inventory'Stress biomonitoring'; hypothalamic - pituitary -adrenal control system

serves both to identify potential stress factors and toevaluate possible negative social consequences in theperson's private life and occupation. In addition, con-sumption of alcohol or drugs must be documented, andif necessary quantified using biological monitoring. Thesubjective symptoms should be described in as muchdetail as possible, noting any changes over time. Aphysical examination (internal status) is also essential,and should be supplemented by results for importantroutine laboratory parameters (e.g. blood count, liverfunction tests, electrolytes, kidney function) if thisinformation is not already available. In addition, inindividual cases, 'stress-biomonitoring' (e.g. cortisollevel/daily profiles) and special immunological and/orendocrinological analyses (e.g. cellular/humeral immunesystem, hypothalamic-pituitary-adrenal control sys-tem) must be considered. Such investigations can,however, only be carried out by specialized centres.

An early psychosomatic/psychiatric consultation andthe carrying out of psychometric test procedures arerecommended. The Maslach Burnout Inventory, intro-duced in 1981, is widely used in the diagnosis ofburnout. It is a self-assessment questionnaire consistingof 22 items to evaluate emotional exhaustion, deperso-nalization and dissatisfaction with performance.3 Inindividual cases further psychometric investigations, alsoto evaluate competing influences, may be necessary. Itmust be remembered, however, that the results of suchtest procedures are only 'pieces in the diagnostic mosaic'and cannot replace qualified psychosomatic/psychiatricinvestigation. Therefore an interdisciplinary team shouldbe required in the diagnosis of burnout syndrome.

Differential diagnosis must be used to first separateprimary psychiatric disorders, i.e. those independent ofexogenous factors, and burnout. Furthermore, chronicsomatic diseases, such as chronic infections (e.g. viralhepatitis), endocrinopathy (e.g. thyroid disorders, Ad-dison's disease), auto-immunopathy, tumours or the so-called chronic fatigue syndrome (CFS) must not beforgotten. Differentiation between burnout and CFScan, however, be rendered impossible by similar symp-toms and a comparable course of the disease.31

In practice, the diagnostic assignment to burnoutsyndrome of the mainly unspecific symptoms describedabove is problematic, even with a differentiated ap-proach. It is very difficult to find temporal and causalrelationships to previous psycho-mental/psycho-socialstress when, as is often the case, the illness has existed

for a long time; there are multiple symptoms and manydifferent influencing factors. Objectification or quantifi-cation of occupational stress factors is almost impossiblefor a GP or specialist, as they usually do not havesufficient information or detailed knowledge of theworkplace situation. But even with optimum co-opera-tion between the patient's doctors, occupational physi-cians and psychologists there are still generalmethodological problems in the evaluation of negativestress at the workplace. In addition, it must be noted thatoccupational and non-occupational stress factors areoften interlinked or cannot be separated from each otheras regards their biological consequences. Therefore, notonly the validity of the diagnosis 'burnout syndrome', butalso the decisive meaning of a harmful work situation stillremains at the centre of criticism.

To date there has been no scientific evaluation of thesuggestions published in the literature concerning thetherapy of burnout. In addition, there is often no cleardivision between treatment and preventive measures.6'7The procedures used and their dependence on the typeand severity of the symptoms are listed in Box 3.

PREVENTION

Measures to prevent burnout can be differentiatedaccording to the preventive approach and levels ofprevention. Preventive approaches to be considered areboth modifications in the working environment (preven-tion of circumstances) and also improvements in theindividual's ability to cope with stress (behaviouralpreventive measures). According to the WHO the levels

BOX 3. Burnout syndrome: therapy suggestions

Pharmacological treatment according tosymptoms, e.g. antidepressants, beta-blockersPsychotherapy, such as relaxation techniques,improvement of self-esteem, concepts for dealingwith stressReorganization of the work environment, such asthe organization of work and the work structure,and the introduction of time managementChange of work environment, combined withrehabilitation and retraining



ownloaded from

516 Occup. Med. Vol. 50, 2000

of prevention can be divided into primary preventivemeasures (avoidance/removal of factors that make thepatient ill), secondary measures (early recognitionin-tervention of manifest disease), and tertiary measures(coping with the consequences of diseaserehabilitationand relapse prophylaxis).32 The concepts for behaviouralpreventive measures presented in the literature focus onprimary prevention and are the 'domain' of psychology.Some of the measures are:

improvements in dealing with stress, the learning of relaxation techniques, the delegation of responsibility (learning to say 'no'), hobbies (sport, culture, nature), trying to uphold stable partnerships/social relation-

ships, frustration prophylaxis (reducing false expectations).4

In addition, some authors regard religion and spiri-tuality as having a potentially preventive function/'6

The strategies discussed at present for preventing thecircumstances in which burnout arises are a combinationof primary and secondary prevention. It can bedifferentiated between activities where the focus is onwork organization and management, and suggestionsaimed primarily at (groups of) persons.33 Workplace-related measures are:

the creation/preservation of a 'healthy working envir-onment' (e.g. time management, communication styleof leadership),

the recognition of performance (praise, appreciation,money),

the training of managers ('key role' of the boss inburnout prevention).

Person-oriented strategies are:

the carrying out of 'suitability tests' before jobtraining,

specific programmes accompanying the work ofpersons from risk groups (e.g. Balint groups forteachers and doctors),

regular occupationalmedical/psychological monitor-ing (e.g. establishment of a special 'job-stress' check-up for the early recognition of burnout).

Suitability tests are not likely to be favourably receivedfrom a socio-political point of view. First of all they donot allow freedom of choice when it comes to occupa-tion, even if, depending on their type and content, theycould be useful from a medical point of view (it is knownfrom practice that persons with the personalities suscep-tible to developing burnout choose the occupations witha higher risk of developing burnout).

Of particular interest is the suggestion of regularoccupational-medical/psychological monitoring of oc-cupational groups at risk of developing burnout. Theoccupational-medical management of persons at riskfrom stress, and burnout patients, would therefore gain astandardized framework. In addition, a general increase

in knowledge could be expected, based on well-foundedobservations.34"36

In times of limited resources, acceptance and feasi-bility also play an important role in the development andimplementation of preventive strategies. In addition, itshould not be forgotten that effective and efficientprevention requires adequate knowledge of the aetio-pathogenesis. The closing of gaps in our knowledgewould also be a great improvement for the prevention ofburnout.33'37

CONCLUSIONS: PROSPECTS

As a result of the gaps in our knowledge, there is agreat temptation to dismiss burnout as merely a'fashionable trend' or an 'invention of the media'. Inaddition, in the era of molecular medicine, it may seemmore sensible to some people to leave psychosocialhealth risks to psychologists, sociologists or 'healthscientists'. It should be warned that this kind ofthinking takes away an important dimension frommedicine (the social dimension).38 Without a doubt themultiplicity of the burnout phenomenon requiresintensive interdisciplinary cooperation with the simul-taneous preservation of its unity. Medical expertise isessential here. Moreover, burnout, as the result of thecomplex interaction of work/society and the individual,calls for social-medical and occupationalmedicalcompetence, and also serves to illustrate the closerelationship of these two disciplines.38 It must also beborne in mind that the numerous possible socialconsequences of burnout (e.g. repeated absence fromwork, early invalidity) are also of 'classical' social-medical and occupational-medical content. Social -medical and occupational-medical 'know-how' shouldnot, however, be limited to the analysis of deficits, butshould lead to the drawing up of constructive,scientifically based solutions. The first priority is toreach a consensus regarding the use of uniformdefinitions and diagnostic criteria. Only in this waycan valid statements be made on prevalence rates incertain occupational groups, and thus on the extent ofthe risk. Furthermore, it is important that epidemiolo-gical studies are planned sensibly to reveal potentialcausal relationships with psycho-social/psycho-mentalstress at work. Merely asking for subjective evaluationsusing a questionnaire does not lead any further.Methodologically valid prospective longitudinal studiesof an interdisciplinary and comprehensive nature,which evaluate both subjective and objective data, areurgently required. In addition, research to reveal thedecisive pathogenetic principles should, of course, notbe neglected. Above all, further research into thebiological, biochemical and molecular effects of chronicexposure to stress (e.g. endocrinological investigationsof the hypothalamic - pituitary -adrenal control system,further development of 'stress-biomonitoring', psycho-immunology) is needed.27

The gaps in our knowledge should not excuse us fromtrying to carry out in practice preventive measures and



ownloaded from


medical care to the best of our abilities. Burnout patientsneed competent help and should feel that their com-plaints are taken seriously. Even in times of limitedresources, comprehensive clarification of the complaints,while avoiding the too early fixation with certain causalrelationships, is important.

On the threshold to the 21st century burnout is achallenge to both research and practice, and not onlybecause doctors can potentially be affected. Specialists ofsocial medicine and occupational medicine should notmiss the chance of acting in interdisciplinary teams withpsychologists to investigate together the problem ofburnout syndrome.

REFERENCES

1. Freudenberger HJ. Staff burnout. JSoc Issues 1974; 30:159-165.

2. Burisch M. Das Burnout-SyndromTheorie der innerenErschopfung 2. Auflage. Berlin, Heidelberg: SpringerVerlag, 1994.

3. Maslach C, Jackson SE. The measurement of experiencedbumout. J Occup Behav 1981; 2: 99-113.

4. Schaufeli W, Enzmann D. The Bumout Companion to Studyand Practice: A Critical Analysis. London: Taylor & FrancisLtd, 1999.

5. v.d. Dammerau-Dombrowski V. Das Burnout-Syndrom.Seminar Hausarztpraxis 1998; 16-18.

6. Ewald O. Das Burnout-Syndrom. ErgoMed 1997; 21: 93-96.

7. Keel P. Psychische Belastungen durch die Arbeit: Burnout-Syndrom. Soz Prdventivmed 1993; Suppl. 2: 131-132.

8. KlieserE,ScharV. Burnout-Syndrom. MMP1996; 19:17-20.

9. Savicki V, Cooley EJ. Theoretical and research considera-tions of burnout. Children and Youth Services Review 1983; 5:227-238.

10. Deutsches Institut Fur Medizinische Dokumentation undInformation (DIMDI) (Hrsg.). 1CD-10Internationalestatistische Klassifikalion der Krankheiten und verwandterGesundheitsprobleme Revision. Band I: Systematisches Ver-zeichnis. Munchen: Urban u. Schwarzenberg, 1994.

11. Felton JS. Burnout as a clinical entityits importance inhealth care workers. Occup Med 1998; 48: 237-250.

12. Goiter RC. Burnout among dentists: identification andprevention. Amsterdam: Thele Thesis, 1999.

13. Chan DW, Hui KP. Burnout and coping among Chinesesecondary school teachers in Hongkong. BrJEduc Psychol1995; 65: 15-25.

14. Cooper CL, Kelly M. Occupational stress in head teachers:a national UK study. BrJEduc Psychol 1993; 63: 130-143.

15. Goner RC, Albrecht G, Hoogstraten J, Eijkman MAJ.Professional burnout among Dutch dentists. CommunityDent Oral Epidemiol 1999; 27: 109-116.

16. Rottenfusser R. Viele Kassenarzte fuhlen sich ausgebrannt.Dt Arztebl 1999; 96: A610-613.

17. Soderfeldt B, Soderfeldt M, Ohlson CG, Warg LE.Psychosomatic syndromes in human service work. ScandJSocMed 1996; 24: 43-49.

18. Spiessbach B, Knebelau M, Bender S. CallcenterHoff-nungstrager oder Belastungstra'ger? ErgoMed 1999; 23:246-252.

19. Scheuch K, Vogel H. Pravalenz von Befunden in ausge-wahlten Diagnosegruppen bei Lehrern. Soz Prdventivmed1993; 38: 20-25.

20. Bourbonnais R, Comeau M, Vezina M, Dion G. Jobstrain,psychological distress and burnout in nurses. AmJIndMed1998; 34: 20-28.

21. Lehnert G, Valentin H. Arbeitsund Betriebsmedizinzwischen Selbstverantwortung und Fremdbestimmung.Arbeitsmed Sozialmed Umweltmed 2000; 35: 14-20.

22. Valentin H. Gesundheit und Krankheit an den Arbeitsplat-zen der Zukunft. Zbl Arbeitsmed 1991; 41: 182-192.

23. Karasek R. Job demands, job decision latitude and mentalstrain: Implications for job redesign. Adm Sci Q 1979; 24:285-306.

24. Kelly S, Hertzman C, Daniels M. Searching for thebiological pathways between stress and health. Annu RevPublic Health 1997; 18: 437^62.

25. v. Oncill J. Stress at work. BMJ 1996; 313: 745-748.26. Orris P, Hartmann DE, Strauss P, et ai. Stress among

package truck drivers. AmJIndMed 1997; 31: 202-210.27. Pruessner JC, Hellhammer DH, Kirschbaum C. Burnout,

perceived stress and cortisol responses to awakening.Psychosomatic Med 1999; 61: 197-204.

28. Scheuch K. Psychomentale Belastung und Beanspruchungim Wandel von Arbeitswelt und Umwelt. ArbeitsmedSozialmed Umweltmed 1997; 32: 289-296.

29. Niedhammer I, Goldberg M, Leclerc A, Bugel I, David S.Psychosocial factors at work and depressive symptoms inthe Gazel cohort. ScandJ Work Environ Health 1998; 24:197-205.

30. Stansfeld SA, Fuhrer R, Shipley MJ, Marmot MG. Workcharacteristics predict psychiatric disorder: prospectiveresults from the Whithall II study. Occup Environ Med1999; 56: 302-307.

31. Goshorn RK. Chronic fatigue syndrome: a review forclinicians. Seminars in Neurology 1998; 18: 237-242.

32. World Health Organization. Ottawa Charter for HealthPromotion. An International Conference on Health Promotion.The Move Towards a New Public Health. Ottawa: WHO,1986.

33. Weber A. Sozialmedizinische Evaluation gesundheitlich be-dingter Fruhpensionierungen von Beamten des FreistaatesBayern. Stuttgart: Gentner Verlag, 1998.

34. Blome O. Arbeitsbedingte ErkrankungenarbeitsbedingteGesundheitsgefahrenein Spannungsfeld fur die Unfall-versicherung. ErgoMed 1998; 22: 168-175.

35. Blome O. Arbeitsbedingte Erkrankungen 3 BKV.ErgoMed 1998; 22: 276-282.

36. Borsch-Galetke E. Arbeitsbedingte Gesundheitsgefahrenund Erkrankungenwo besteht Handlungsbedarf? ErgoMed 1999; 23: 31-33.

37. Kentner M. Gesundheitsreform 2000Welchen Stellen-wert hat die arbeitsmedizinische Prevention? ArbeitsmedSozialmed Umweltmed 1999; 34: 275-276.

38. Weber A, Lehnert G. SozialmedizinWarum eigentlich?Ein Pladoyer fur die soziale Dimension in der Human-medizin. Arbeitsmed Sozialmed Umweltmed 1999; 34: 492-498.



ownloaded from

Documents

Occupational Medicine. Burnout syndrome