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Stress, Burnout, and Happiness


Stress, Burnout, and Happiness David Mays, MD PhD Are Options Good For Us? The more choices we have, the more likely we are to regret our choice. – PowerPoint PPT presentation

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Title: Stress, Burnout, and Happiness

Stress, Burnout, and Happiness
  • David Mays, MD PhD

The Chronobiology of Getting Sick
  • 12 - Gout
  • 1 AM - Gallbladder
  • 2 AM - GERD, peptic ulcer
  • 3 AM - Congestive heart failure, pulmonary edema
  • 4 AM - Cluster and migraine headaches
  • 5 AM - Asthma attacks

  • 6 AM - Death, all causes
  • 7 AM - Allergic rhinitis, colds, flu, rheumatoid
    arthritis, depression
  • 8 AM to Noon - Angina, MI, sudden cardiac death,
    TIA, stroke
  • 1 PM - Stomach ulcer perforation
  • 4 PM - Tension headache

  • 5 PM - Intestinal ulcer perforation,
  • 7 PM - Cholesterol rises
  • 8 PM - Backache
  • 9 PM - Restless legs syndrome
  • 10 PM - Menopausal hot flashes

  • 50-75 of routine medical practice is devoted to
    complaints related to stress.
  • Problems at work are more strongly associated
    with health complaints than any other life
    stressor. 29 of workers report that they feel
    quite a bit or extremely stressed at work.
    (Yale Univ. Survey, 1997)
  • Healthcare expenditures are 50 greater for
    workers who report high levels of stress (J of
    Occ Env Med, 1998)

Stress Response LC/NE Pathway
  • LC/NE The locus coeruleus (LC) secretes
    norepinephrine (NE - related to adrenaline) in
    the cortex, thalamus, limbic system,
    hypothalamus, spinal cord. NE acts as a
    neuromodulator. It also activates the autonomic
    nervous system for fight or flight. Heart rate,
    respiration, and blood pressure increase.

Stress Response HPA Axis
  • Hypothalamic When stress is perceived,
    corticotropin-releasing hormone (CRH) and
    vasopressin are secreted by neurons in the
    hypothalamus. CRH causes the pituitary to secrete
    ACTH. ACTH stimulates the adrenal gland to
    release cortisol which increases glucose levels
    and suppresses the inflammatory/immune response.
    This is the hypothalamus-pituitary adrenal axis

  • The levels of glucocorticoids in the blood
    typically follow a daily rhythm - high early in
    the morning, low later in the day. They increase
    glucose in the blood, control its metabolism, and
    regulate the sleep wake cycle.
  • High levels of cortisol have many deleterious
    effects on the body (Cushings disease).

Stress Memory Effects
  • Short term stress can enhance memory. But chronic
    stress can impair attentional states and learning
    later on. Ultimately, even amnesia can be result.
  • High levels of glucocorticoids lead to impaired
    memory and neuronal cell death.
  • Cortisol dissolves the brain.

Common Physical Symptoms of Stress
  • Headache
  • Back, shoulder, neck pain
  • Sleep problems
  • Difficulty concentrating
  • GI problems
  • Palpitations
  • Skin problems
  • Tics
  • Low energy

Common Emotional Symptoms of Stress
  • Job dissatisfaction
  • Burnout
  • Irritability
  • Anxiety
  • Depression
  • Isolation, withdrawal

Stress or Depression
  • Stress
  • Difficulty falling asleep
  • Poor concentration and memory, and significantly
    lower brain activity during memory tests
  • Depression
  • Early morning awakening
  • Poor concentration and memory, but higher brain
    activity during tests

Stress Reduction
  • You can reduce stress by either reducing your
    exposure to stressful situations (amygdala
    management which effects the autonomic nervous
    system), or learning better skills for coping
    with them (strengthen your prefrontal cortex
    cognitive restructuring.)

Best Evidence for Stress Reduction
  • Exercise
  • Meditation
  • Caffeine reduction
  • Get enough sleep
  • Reappraisal

News Flash!
  • Proceeds of the National Academy of Science, Nov
    23, 2010
  • Rats were placed on a stress increasing paradigm
    and then given sugar. The sugar lowered cortisol
    levels, improved heart rate variability,
    increased friendly behavior toward unfamiliar
    animals, and increased exploration in a maze
    test. These positive effects lasted for 7 days.

The Dimensions of Burnout
  • Exhaustion individual stress component - feeling
    overextended, depleted of ones emotional and
    physical resources
  • Cynicism interpersonal component -negative or
    callous, excessively detached response to job
  • Reduced efficacy/accomplishment feelings of
    incompetence and lack of achievement and

Burnout Effects
  • Burnout is associated with various forms of job
    withdrawal absenteeism, turnover
  • For people who stay on at work, burnout leads to
    lower productivity and effectiveness, poor job
    satisfaction, reduced commitment.
  • Burnout has a negative impact on coworkers,
    creating more interpersonal conflict and
    disruption. It is contagious.

Burnout in the Mental Health Workforce
  • A 2010 review shows that almost all research in
    this area is informal, anecdotal and
  • Findings
  • There are consistently high levels of exhaustion,
    but cynicism and feelings of reduced efficacy are
    usually low.
  • We know nothing about the impact of interventions
    on burnout.

  • The mood of a leader is more powerful than the
    mood of members of the group. In several studies
    that have measured leaders and workers moods
    before and after a task, the leaders mood has
    proven to be very contagious.
  • Interestingly, negative contagion seems to be
    stronger than positive contagion.

Symptoms of Burnout
  • Physical Symptoms fatigue, cognitive impairment,
    sleep disruption, GI problems, headache,
    inflammatory changes
  • Emotional Symptoms alienation, cynicism,
  • Behavioral Symptoms impatience, negativism,
    frustration, irritability

Job/Situational Causes
  • Overload exhaustion
  • Role Conflict competing demands
  • Role Ambiguity lack of training
  • Severity of Clients Problems
  • Lack of Support from Supervisors (more so than

Job/Situational Causes
  • Lack of Feedback
  • Lack of Control
  • Lack of Autonomy
  • Lack of Reciprocal Loyalty
  • Lack of Perceived Fairness

Job/Situational Causes
  • The psychological contractWhen we first begin
    working for an organization, we have certain
    expectations about what that employment will
    entail - the job we will be doing, workload,
    resources, career advancement, job security, etc.
    Larger social and economic forces can bring about
    significant changes in these things.

Personal Causes
  • Personal causative factors are not as strong as
    situational factors
  • Younger, unmarried
  • Gender neutral (although males tend to rate
    higher in cynicism)

The Mismatch Paradigm of Burnout
  • Burnout arises from mismatches between the person
    and the job in six domains. The greater the
    mismatch, the greater the chance of burnout. The
    better the match, the greater the likelihood of
    job engagement.
  • Mismatches arise when the initial psychological
    contract was not clear, or the job changes.
  • The six areas are workload, control, reward,
    community, fairness, and values.

1) Workload
  • Energy can be exhausted to the point that the
    person can no longer recover.
  • Mismatch can also result from the wrong kind of
    work in terms of skills or inclination.
  • Work is especially draining when it requires
    people to display emotions inconsistent with
    their feelings.

2) Control
  • Mismatches occur most often when workers feel
    they do not have control over resources needed to
    do their job most effectively.
  • Workers may also feel overwhelmed by their
    responsibility and feel that their responsibility
    exceeds their authority.

3) Reward
  • Financial rewards
  • Social rewards are even more important to most
    people. Feeling lack of appreciation and having
    ones hard work ignored devalues the work and the
  • Lack of intrinsic reward (pride in work) is also
    critical for burnout.

4) Community
  • People can lose a sense of positive connection
    with others at work. People thrive when they
    share praise, comfort, happiness, and humor with
    those they like and respect. They have a shared
    sense of values.
  • Jobs may isolate workers from one another, but
    what is most destructive is chronic, unresolved

5) Fairness
  • Fairness communicates respect and confirms
    peoples self-worth.
  • Inequity of pay, workload, when there is cheating
    or when promotions and evaluations are
    mishandled, or when grievances are not handled
    appropriately all increase cynicism and emotional
  • This dimension is the most predictive of future
    burnout when it appears.

6) Values
  • Employees may feel that their job requires them
    to act unethically (lie).
  • They may feel that their personal values are at
    odds with their workplace, or that their
    workplace has contradictory goals (maintain a
    high case load, be culturally sensitive.)

Job Mismatch
  • Individuals may place different importance on
    these six factors. If you really support the
    values of the organization, you may be able to
    tolerate problems with reward, for example.
  • Investigating job mismatch is a very fruitful way
    to help supervisors and employees concretely
    discuss burnout and encourage engagement.

Individual Interventions
  • People can learn new coping skills, but it has
    not been shown that they can apply it at work
  • At best, there may be a reduction in exhaustion,
    but generally there is no change in cynicism or
  • The most effective change requires integration of
    workplace and individual needs.

Detachment From Work
  • A recent longitudinal study of 309 human services
    employees showed that high job demands predicted
    emotional exhaustion, psychosomatic complaints,
    and low work engagement over time. Psychological
    detachment from work during off-job time was an
    important factor in protecting employee
    well-being and work engagement.

Reducing 10 Common Stressors
  • 1) Lateness Consider priorities and get rid of
    unnecessary tasks. Give yourself 15 extra minutes
    travel time. Map out the day.
  • 2) Anger Do you magnify problems and make up
    stories about them? Take time to stop, breathe,
  • 3) Unsure of your abilities Dont worry alone.
    Get help.

Reducing 10 Common Stressors
  • 4) Overextended What is truly essential right
    now? Get help with the household chores from
    family or hire help.
  • 5) No time for stress relief Single task. Try
    mini-relaxations. Cut back commitments.
  • 6) Feeling tense Try massage, sauna,
    mini-relaxations, a walk, exercise

Reducing 10 Common Stressors
  • 7) Pessimism recognize cognitive distortions.
    Exercise your sense of humor. Practice gratitude.
  • 8) Conflict State needs directly. Practice
  • 9) Burned out Eat well, engage in creative,
    productive leisure activities. Set priorities.

Reducing 10 Common Stressors
  • 10) Loneliness work at being friendly.
    Volunteer. Join a group. Take an interesting class

Biological Research Where Does It Feel Good?
  • The Biology of Drug Euphoria
  • The ventral tegmentum nucleus accumbens
    prefrontal cortex
  • Dopamine driven
  • Animal studies indicate this is probably a system
    of wanting more than pleasure. Salience.
    Animals will do this until they die.
  • Cocaine stimulates this pathway
  • The Biology of Pleasure
  • Endorphins, widely scattered throughout the brain
  • Positive and negative emotions activate different
    parts of the brain and deactivate each other
  • EEGs show the left prefrontal cortex is more
    active in happy people, the right prefrontal
    cortex when people experience negative emotions

Biological Research
  • Happiness and unhappiness are not on a continuum.
    We seem to have a positive system and a negative
    system that operate separately, but can stifle
    each other.

The Positive and Negative Systems
  • Negative
  • Like Velcro
  • Very sensitive
  • Bitter 12,000,000
  • I HATE to lose
  • Triggered by poverty
  • 1 negative remark
  • Stronger reaction to negative language
  • Strong and damaging stress response
  • Harder to adapt to
  • Positive
  • Like Teflon
  • Not sensitive
  • Sweetness 1200
  • Winning is OK
  • Money has no effect
  • 5 positive remarks
  • Weaker response to positive language
  • Pleasure response not very physically active
  • Fast adaptation

Defining Happiness
  • The Pleasant Life Pleasure and Enjoyment
  • The Good Life Feeling Happy and Flow
  • The Meaningful Life Purpose

The Pleasant Life
  • The pleasant life consists of experiencing as
    many pleasures as possible and learning to
    amplify and savor them
  • Pleasure may range from the basic to the very
  • The ability to experience pleasure seems to be
    very genetic (about 50.) People who are very
    social tend to also experience a lot of this kind
    of happiness.
  • Unfortunately, we tend to habituate/adapt very
    rapidly to pleasure.

US Citizens Necessities
  • Item 1970 2000
  • Second car 20 59
  • Second TV 3 45
  • More than 1 telephone 2 78
  • Car air conditioning 11 65
  • Home air conditioning 22 70
  • Dishwasher 8 44

The Good Life
  • There are two different experiences that
    contribute to the good life
  • being in a good mood
  • the experience of flow.
  • This kind of happiness is usually what is
    referred to when writers talk about our happiness
    set point. We may be born a cheerful person, or
    someone who easily becomes engages in flow.
  • Studies show that people who are happy most of
    the time also tend to be
  • Optimistic
  • Appreciative
  • Social

A Rather Dumb Question...
  • Would you rather win the lottery or become
    disabled in this coming year?

The Data
  • Researchers at UC studied both lottery winners
    and individuals who sustained a physical injury.
    Immediate levels of happiness were higher
    (lottery winners), or lower (physically injured),
    but after eight weeks or less, people returned to
    the level of happiness they had before the event.
  • The data tell us, with a few exceptions, that if
    it happened over three months ago, it has no
    significance to us in terms of happiness.

The Effect of Disability on Happiness
  • Able-bodied Univ. Ill students
  • Happy - 50 of the time
  • Unhappy- 22 of the time
  • Neutral - 29 of the time
  • Univ Ill students with disabilities
  • Happy - 50 of the time
  • Unhappy - 22 of the time
  • Neutral - 29 of the time

Dan Gilberts Happiness Synthesizer
  • Dan Gilbert, Harvard psychologist, says that we
    create our own happiness synthetically if bad
    things happen to us. We unconsciously, and
    automatically make lemonade when life gives us
    lemons. This keeps us within a certain range of
    positive affect our set point. The range
    differs among individuals.

The Good Mood A Summary
  • Some people just feel happier than others, no
    matter what happens to them. They tend to be more
    social, optimistic, and grateful than those who
    are less happy.
  • It almost seems as though people are stuck at a
    certain level of feeling happy, as though they
    had a happiness thermostat. Whether you win the
    lottery or have an accident, you tend to recover
    to your usual state of mind within 3 months. This
    happens because our minds create a certain amount
    of synthetic happiness, especially in
    uncontrollable situations, that bring us back to
    our normal.

The Good Life Flow
  • Another kind of happiness that people
    experience, besides a good mood, is the
    experience of flow.
  • This experience is different than the experience
    of pleasure, or a sense of well-being. In many
    respects, it is the lack of feeling, or emotion
    that defines this kind of contentment. It is best
    captured by the experience of flow a feeling
    of absorption/concentration where time seems to
    stop and you are completely engaged with what you
    are doing.

  • Flow experiences lead to to positive emotions in
    the short run and over the long term, people who
    more frequently experience flow are generally
  • People vary in how much they value having flow
    experiences and how easily they can do it.

  • Recent scans investigating brain-activation
    patterns have compared sensory stimulation to
    self-reflection. Brain regions active during
    self-reflection are suppressed during perception
    and vice versa.
  • We can be aware of about 110 bits/sec of
    information. A person talking to us takes about
    60 bits/sec.
  • In flow, there is no capacity left for attention
    to monitor the body, think about family or
    problems. The ego disappears. Existence is

Characteristics of Flow
  • Effortless concentration
  • Experience outside of everyday reality
  • Inner clarity
  • Knowledge that you are capable of doing the task
  • Sense of serenity/calm
  • Timelessness
  • Not thinking about yourself
  • Intrinsic motivation the activity is its own
  • You want to repeat the experience

The Meaningful Life
  • The meaningful life seems to arise when people
    both know their strengths and use them in the
    service of something larger than themselves.

  • Increase in happiness by having a income increase
    from 20,000 to 80,000 16
  • Increase in happiness from never volunteering to
    volunteering once a week 16.
  • 2008 study employees who gave more of their
    bonus money to charity reported greater happiness
    than those who gave less.
  • Participants were given 5 or 20 to spend on
    themselves or others. Spending even 5 on others
    made participants happier than spending 20 on

What Makes for an Overall Satisfying Life?
  • After interviewing thousands of subjects, it
    appears that pleasure has only a marginal
    contribution to overall life satisfaction. Flow
    contributes much more strongly. Meaning has the
    largest contribution.
  • A survey of 30,000 American households found that
    those who gave to charity were 43 more likely to
    say they were very happy than those who did not

Where We Go Wrong
  • 1) Money
  • 2) Family
  • 3) Not taking into account impact bias and
    adaptation nothing will be as good as we hoped
  • 4) Not taking into account our psychological
    immune system nothing will be as bad as we were
    afraid of
  • 5) Trying to maximize our options
  • 6) The self-esteem movement
  • 7) The comparing mind

Can Money Buy Happiness?
  • The historical research says money can buy
    happiness and it already has.
  • Throughout history, most people have been racked
    by illness, the desperate hunger of their
    children, continual drudgery, and the threat of
    violent animals.
  • However, data suggests that once you have enough,
    more money does not make much difference.

Money and Happiness
  • People who make 50,000/yr are a lot happier than
    those who make 10,000. But people who make 5
    million/year arent that much happier than those
    who make 100,000/yr.
  • The data says that if you are poor, a little
    money can buy a lot of happiness. But if you are
    rich, a lot of money can only buy you a little
    more happiness.

Does Money Buy Happiness?
  • People with lots of money are not happier than
    those with enough. Wealth is like health its
    absence breeds misery, but having it is not
    guarantee of happiness.
  • If people dont worry about money, they worry
    about something else.

Why People Have Children (Pew Research, 2010)
What Would Make You Happy?
  • Most people believe that having children would
    make them happy. As far as children are
    concerned, most parents would say that some of
    their best moments of happiness involved their
    children, but on a day-to-day level, people
    arent particularly happy when theyre
    interacting with their children. Women looking
    after their children are significantly less happy
    than when theyre watching TV. (Children are hard

Marital Satisfaction 4 Studies
Marital Satisfaction 4 Studies
Are Options Good For Us?
  • The more choices we have, the more likely we are
    to regret our choice. It is easy to idealize the
    choice we did not take. We experience an
    escalation of expectations.
  • Some psychologists have concluded that our
    current abundance of choices often leads to
    depression and feelings of loneliness. We have
    only ourselves to blame if we are unhappy with
    what we get.

Can We Be Happier?
  • Freud says, no.
  • But we can turn hysterical misery into ordinary
    human unhappiness
  • Madison Avenue says, yes.
  • Life is short. Let us spend. (inscription on an
    ancient Sumerian coin)
  • David Mays says, yes, but...
  • We can be happier in the same way we can be more
    physically fit. We can do it, but we have to work
    at it, not just wish for it. And some of us have
    to work harder than others.

Happiness as a byproduct of living your life is a
great thing. But happiness as a goal is a recipe
for disaster.
  • Barry Schwartz, Swarthmore College

Increasing Pleasure
  • Learn to savor what is happening now. Single
    task you cant fully pay attention to multiple
    things. (People who multitask are not doing
    anything as well as people who single task.)
  • Plan to take time for yourself and do those
    things that make you feel good. Like taking a
    walk...The natural world makes most humans happy.
    More money is spent worldwide on visiting zoos
    than any other recreational activity.
  • Or listening to music you enjoy. Listening to
    music causes dopamine release in the nucleus
    accumbens, and causes people to synchronize their
    movements together.

Increasing Pleasure
  • Let yourself be happy when you have a good
    moment! Research shows that humans are hard-wired
    to scan for the bad. Aversive events get stored
    more quickly in memory, and are more rapidly
    recalled. Positive events are stored through the
    standard memory systems and need to be held in
    conscious awareness for 10-20 seconds for them to
    be coded and held onto.
  • Help positive events become positive experiences
    by paying extra attention to them. Hold them in
    consciousness longer. Savor them so they sink in.

Increasing Pleasure
  • Frequent small events have a bigger impact than
    occasional large events. This means spending
    fifteen minutes every evening of your life with a
    relaxed drink and a sympathetic friend will make
    you happier than winning the lottery.

Increasing Pleasure
  • Slow down time affluence predicts happiness
    better than monetary affluence. Eliminate some of
    the less enjoyable ways you spend your time.
  • Be active set new goals and plan new activities.
    The boost in happiness you get from a new
    undertaking lasts longer than that brought on by
    simply new circumstances.
  • Simplify too many choices makes us unhappy

Improving the Good Life
  • Recall, the qualities of people who were found to
    be happy most of the time were
  • Extroverted/Social
  • Optimistic
  • Appreciative

Expanding the Social World
  • People with 5 friends outside of immediate
    family are happier than those with fewer friends.
    Work toward spending more time socializing.
  • Can pets increase your happiness?
  • Absolutely!

Increasing Optimism
  • Pessimists who spent one week writing down
    experiences when they felt good about themselves
    and others were happier than controls 6 months

Increasing Gratitude
  • At the end of the day, write down three things
    that went well during the day. Do this every
    night for a week. After each positive event on
    your list, think about why this good thing

Increase the Capacity for Flow
  • People vary in how much they value having flow
    experiences and how easily they can do it.
  • Learn to recognize your strengths and interests
    and re-craft your life (work, play, love) to
    utilize these strengths.
  • Cultivate concentration e.g. meditation
  • Balance challenge with skill
  • Recognize the paradox that most people tend to
    choose relaxation activities that do not lead to
    flow (e.g. TV)

Re-setting our Set Point
  • Meditation
  • In 2003, a study at UW Madison studied the
    effects of an 8 week course of Mindfulness Based
    Stress Reduction on 41 subjects. The results
    demonstrated an increase in pre-frontal left
    anterior brain activation (relative to right
    side) and increases in immune response to flu
    vaccination. Left side activation has been
    related to better positive mood states as opposed
    to more negative mood states associated with
    right frontal activation. These changes continued
    through an 8-month follow up brain scan.

  • The right prefrontal cortex is believed to be
    responsible for the hypervigilance typical of
    people under stress. One of the characteristics
    of people with depression is an excessive
    self-focus, an exaggerated negative
    self-representation, and a tendency to confuse
    ones negative perceptions with actual external
  • It is possible that the meditative state is in
    part a state where the meditator has taught
    himself/herself to dampen right frontal activity
    and cultivate left frontal activity (consistent
    with the goal of losing the self.)

  • Recent studies have shown that subjects who focus
    on their emotional state, rather than just
    thinking globally about themselves, show reduced
    activity in the amygdala and create a calming
    effect. This sort of awareness buffers the
    brains emotional responses to events.

Meaningful Life Exercise
  • Write a eulogy for yourself that describes how
    you spent your life, what your best
    accomplishments were, and what was most
    satisfying to you. Think about any gaps between
    how you would like to be remembered and what you
    have done. Take active steps to reach some new
  • A 2006 study showed that simply counting the
    number of kind acts that you perform each day for
    a week made participants feel happier. (The
    number of kind acts increased as well!)

Take Care of Yourself!
  • Exercise, sleep, diet
  • Avoid violent TV, media, and movies
  • Get yourself into a positive frame of mind before
    your sessions. People who feel good perform
    better and are better liked by others.
  • End sessions with compliments or positive
    remarks. Thats what people remember.
  • Your friends your happiness depends on the
    happiness of others with whom you are connected