Misdiagnosis or Spectrum: Burnout Versus High Functioning Depression Disorder

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Misdiagnosis or Spectrum: Burnout Versus High Functioning Depression Disorder

The current focus on burnout among physicians is critical to understanding its causes and evaluating and instituting effective treatment; however, what if the diagnosis is wrong? What is considered a “normal response” to the situations physicians find themselves in today? Is a physician who has apparently “compensated” for the stresses of practice exhibiting a normal, healthy response or are they still at risk? Finally, what is the relevant differential diagnosis for the symptoms we see and describe as burnout?

Burnout – The Terminology

First, I would reject completely the following terminology as potentially harmful labeling – burned-out physicians. The label, burned-out physicians is completely dehumanizing in the same way as describing a patient as, ‘the tuberculosis in bed two’. I believe that as with other diseases, we need to refer to those who exhibit symptoms of burnout as – physicians suffering from burnout.

Your mind won't diagnose what your eye doesn't see. Akhtar Ashraf, MD

Burnout – The Diagnosis

Physicians, by the very nature of our profession, work in atmospheres of high stress, occasional to frequent degrees of physical or mental exhaustion, feelings of incompetence brought on by malpractice or the fear of allegations of malpractice, punitive or even well-meaning quality assurance programs and high competition. What is the natural/normal response to these situations? In the past physicians who complained of these stressors going too far or being too much, were labeled as complainers or weak. New discussions and research into burnout would now characterize these potentially normal responses quite differently.

Dr. Stephen Diamond, states, “… deciding just where this invisible dividing line lies between "normal" and "abnormal," … has always been an imprecise science to say the least. In reality, psychodiagnosis, much more so than medical diagnosis, is and always has been more an art than a science.” In evaluating physicians for burnout or other more serious disorders, determining what normal responses are to the stress of providing modern healthcare is critical.

As humans, we cannot help but exhibit some of the symptoms of burnout occasionally. Those responses would be considered normal reactions to the stress of everyday practice. As we go beyond our individual endurance, we move to the abnormal responses which lead to worsening performance, decreased quality and increasing levels of dissatisfaction with ourselves and our practices. The next and final step can be to a more pathological state, depression, which can lead to suicide.

The awareness that a problem exists can be the first step in alleviating any job burnout. - Moslach, Jackson, Leiter, Moslach Burnout Inventory, 3rd edition.

The Maslach Burnout Inventory (MBI) and the Burnout Measure (BM) are frequently considered the reference standards to more quantitatively assess burnout. The MBI is a 22-item survey that assesses three areas: 1) Emotional exhaustion i.e. feelings of being emotionally overextended and exhausted, 2) Depersonalization i.e. cynicism and detachment, unfeeling and impersonal responses towards patients and patient care, and 3) Personal accomplishment i.e. feelings of competence or incompetence and successful achievement in one's work. The Burnout Measure (BM) (Pines & Aronson, 1988) is a self-report measure of burnout. The original BM scale included 21 items, evaluated on 7-point frequency scales, assessing the level of an individual's physical, emotional, and mental exhaustion. Some additional research into using the scale suggests that a 10 point scale may be as effective; however. Using the MBI and BM measures, burnout can be partially differentiated from other mental syndromes (e.g., anxiety and depression) and they are capable of discriminating between burned out and non-burned out physicians.

Identifying someone at risk using these tools is similar to utilizing any screening examination. Applying the information obtained to identify physicians suffering from burnout remains, as Diamond says, more art than science. Actually making the diagnosis, considering a differential, recommending and then establishing specific therapy needs hands-on/eyes-on evaluations and monitoring by those trained in this area.

High Functioning Depression – The Terminology

Everyone knows what depression is, right? Depression is when someone suffers from despair and misery and wants nothing more than to stay in bed all day and avoid any interaction. Right? Not always!

It is true the following are symptoms of depression:

  • Feeling sad, anxious, or empty
  • Feeling hopeless or pessimistic
  • Feeling guilty, worthless, or helpless
  • Not enjoying things you used to enjoy
  • Trouble with concentration, memory, or making decisions
  • Sleeping too much or too little
  • Appetite changes
  • Gaining or losing weight
  • Feeling restless or irritable
  • Thoughts of suicide or death

But, what happens if an individual with these symptoms has great personal relationships, no difficulty in getting out of bed, is at the top of their profession or academic class and has high output of work that is of high quality? The answer – this individual may be suffering from high functioning depression (HFD).

High Functioning Depression – The Diagnosis

Many times, even professionals in the field of psychology and psychiatry have difficulty identifying those suffering from HFD. Self-identification of internal issues is critical in identifying these individuals. Externally, everything seems to be great; but “seems” is the operative word. Internally, these individuals are highly self-critical of their accomplishments, place too much pressure on themselves in their work or academics, have feelings of inadequacy in relationships and generally feel sad or empty.

Those suffering with HFD are frequently the highest producing employee, most effective and efficient physician, top of their academic class and the life of the party. They are frequently loved and respected by everyone. They are the quintessential Richard Cory, from the poem by Edward Arlington Robinson.

Unlike burnout, there are no reasonably specific screening examinations or measures beyond the clinical evaluation and interview that can make the presumptive diagnosis of HFD. Professions such as medicine with high degrees of stress, emotional and physical exhaustion and a built-in potential for feelings of incompetence and dissatisfaction can create the atmosphere for HFD or feed the symptoms of HFD.

Burnout Versus High Functioning Depression

Burnout as an entity and HFD as an entity are different; however, differentiation between the two can be difficult, even for the more focused observer. Additionally, one entity could potentially induce or exacerbate the other, and left untreated can result in suicide or self-destructive (alcoholism and/or drug abuse) behavior.


  • Emotional and Physical Exhaustion
  • Depersonalization – cynicism and detachment
  • Feelings of inefficiency, ineffectiveness and lack of accomplishment

High Functioning Depression/HFD

  • Self-imposed high-pressure (frequently in positions associated with high pressure) and needing/expecting high levels of achievement lead to emotional and physical exhaustion
  • Keeps up appearances to some extent but internally feeling pessimistic, a general malaise and hopelessness
  • High self-criticism leads to feelings of inefficiency and ineffectiveness at work and inability to achieve expected results

By the numbers:

Burnout in the medical profession is estimated to affect more than 54% of all practitioners, or greater than 500,000 physicians. Women and younger physicians are more commonly affected. Emergency medicine, urology, physical medicine and rehabilitation, family medicine and radiology comprise the top five medical specialties affected (Shanafelt et al. Mayo Clin Proc 2015). Finally, physicians in private practice, particularly those with incentive-based salary structures and those working longer hours are more frequently affected.

According to the National Institute of Mental Health (NIMH) depression affects more than 15 to 16 million American adults or a proximally 6.7% of the US population. The World Health Organization (WHO) estimates that more than 350 million people worldwide are affected with depression. In the United States it is reported that women and younger adults are more commonly affected with the median age of onset being 32.5 years. 20% of people with major depression develop psychotic symptoms. Suicide results in approximately 45,000 deaths per year, with 50 to 75% of those committing suicide suffering from major depression.

The simple reason for differentiating between burnout and HFD is that treatment of each is significantly different.

The similarities:

When burnout is unrecognized and untreated, physician performance tends to deteriorate leading to decreased quality and professionalism, decreasing concern for patients and themselves. This spiral can lead to major depression and even suicide. With HFD, the spiral takes a somewhat different turn, though the end may be the same. While the person with HFD may be on top for some time, when depression becomes more outward than the high function, decreasing ability to work and keep up high-quality work begins to show. Dissatisfaction with their position and performance increases as the intolerable overachiever/self-critical mentality of HFD collides with lower quality work. Physical and mental exhaustion become inevitable and self-destructive behavior including alcoholism and drug abuse increases in likelihood. If undiagnosed and untreated, feelings of hopelessness, emptiness and sadness mixed with anxiety can then lead to suicide.

The importance of differentiating between burnout and HFD

The simple reason for differentiating between burnout and HFD is that the treatment of each is significantly different. While burnout can be incapacitating and can lead to depression and other pathologic problems leading to suicide, HFD itself is considered pathologic with suicide or other self-destructive activities (alcoholism and/or drug abuse) more likely and more frequently seen. Additionally, HFD can be associated with other more complex psychological issues including depression–anxiety syndromes, manic depression and major depressive disorder.

Treatments considered for burnout:

At an organizational level:

• Be value not volume oriented

• Review and set standards for workplace expectations including hours on service

• Set reasonable expectations for work output and goals for incentive-based salary structures

• Encourage work-life balance and integration

• Provide adequate resources to provide for efficient workflow

• Consider a small working group focus that improves local control and flexibility

At an individual level:

• Cognitive behavioral therapy (CBT)

• Meditation/stress resolution techniques

• Attend workshops for stress management, communication and exercise programs

• Improve collegiality by helping to promote an environment of community in the work setting

Treatments considered for HFD:

  • Cognitive behavioral therapy (CBT)
  • Medication – Antidepressants

Cognitive Behavioral Therapy (CBT) is one of the most effective therapies for depression though it is used for other conditions. CBT is based on the “cognitive model” which suggests that the perception of the situation is more closely related to the individual’s reaction to the situation than the actual situation. In the cognitive theory, stress causes a distorted and dysfunctional perception that then drives the subsequent reaction. In very simplified terms, what I feel or perceive about a specific situation colors my reaction to it.

CBT is designed to be a short-term, goal-oriented treatment that takes a hands-on, practical approach to problem-solving. The goal of CBT is to change patterns of thinking or behavior that are behind people's difficulties, and so change the way they feel. CBT helps the individual become aware of inaccurate or negative thinking so they can view challenging situations more clearly and respond in a more effective way.

Medication, primarily antidepressants, is frequently used in addition to other therapies, including CBT. Medication alone; however, is frequently not as effective as when it is used in conjunction with other forms of therapy.

In Conclusion

Burnout and high functioning depression are real illnesses with real consequences. Knowing they exist and understanding each is critical to differentiating individuals exhibiting symptoms that are very similar, in situations that are nearly identical. The differentiation is key to prescribing the correct treatment.

Burnout and high functioning depression are real illnesses with real consequences.

How many physicians may be affected by one, both or some spectrum including symptoms of both of these entities is unclear, and as yet uninvestigated. We are just now coming to grips with the epidemic proportion of physicians affected by burnout alone.

Adding HFD to the differential of burnout may lead to better outcomes for those not specifically exhibiting the symptoms of burnout but clearly exhibiting dysfunctional behavior. This may also lead to more physicians looking at themselves and asking critical questions about how they feel and how they are coping with the stresses of modern medical care.

In the final analysis, those suffering with either of these entities need to be able to ask for help. Even armed with the right knowledge, from the outside we can only do so much. Simple observation is unreliable until it may be too late. Being ready to help and admitting individually and as organizations we are frail and none of us is immune to the effects of long term stress and mental health disease, will give the encouragement needed for those who need help, to ask for it.


The writer of this article is a radiologist, not a psychologist or psychiatrist, has not received special training in the diagnosis or care of mental illness and is not qualified to diagnose or treat mental health conditions. The content of this article are the writer’s opinions and observations and based on literature review.

This article is designed for discussion, educational and informational purposes. None of the information is intended to be a substitute for informed professional medical care or attention by a qualified medical practitioner.

Readers of this material should not use this information to diagnose or treat any medical problems without consulting a qualified healthcare provider.

If the reader has any questions or concerns about a medical condition, or if the reader is considering any form of treatment, always discuss this with the appropriate medical professional. The writer of this article is not responsible, directly or indirectly, for any form of damages whatsoever resulting from the use or misuse of information contained in or implied within the article.

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Bibliography and more reading:

Maslach Burnout Inventory Manual

Maslach, Christina & Jackson, Susan E & Leiter, Michael P (1996). Maslach burnout inventory manual (3rd ed). Consulting Psychologists Press, Palo Alto, Calif. (577 College Ave., Palo Alto 94306)

The Burnout Measure, Short Version.

Ayala Malach-Pines. International Journal of Stress Management 12(1):78-88 · February 2005

Interventions to Reduce Physician Burnout and Promote Physician Well-Being

November 17, 2015. Presentation by Colin P. West, MD, PhD. Mayo Clinic.

Physician Burnout: Why We Should Care and What We Can Do About It

September 10, 2016. Presentation by Colin P. West, MD, PhD.

Impact of Organizational Leadership on Physician Burnout and Satisfaction

Tait D. Shanafelt, MD, Grace Gorringe, MS, Ronald Menaker, EdD, Kristin A. Storz, MA, David Reeves, PhD, Steven J. Buskirk, MD, Jeff A. Sloan, PhD, Steprhren J. Swensen, MD

Mayo Clinic proceedings. April 2015. Volume 90, Issue 4, Pages 432–440

Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014.

Tait D. Shanafelt, MD, Omar Hasan, MBBS, MPH, Lotte N. Dyrbye, MD, MHPE, Christine Sinsky, MD, Daniel Satele, MS, Jeff Sloan, PhD, Colin P. West, MD, PhD

Mayo Clinic proceedings. December 2015. Volume 90, Issue 12, Pages 1600–1613

On the Clinical Validity of the Maslach Burnout Inventory and the Burnout Measure.

Schaufeli WB1, Bakker AB, Hoogduin K, Schaap C, Kladler A. Psychol Health. 2001 Sep;16(5):565-82. doi: 10.1080/08870440108405527. https://www.ncbi.nlm.nih.gov/pubmed/22804499?dopt=Abstract

Normalcy, Neurosis and Psychosis: What Is a Mental Disorder? Who determines what is "normal" and "abnormal"?

Stephen A. Diamond Ph.D. Posted Mar 11, 2010. https://www.psychologytoday.com/blog/evil-deeds/201003/normalcy-neurosis-and-psychosis-what-is-mental-disorder

Quality of Life, Burnout, Educational Debt, and Medical Knowledge Among Internal Medicine Residents

Colin P. West, MD, PhD; Tait D. Shranafelt, MD; Joseph C. Kolars, MD

JAMA. 2011;306(9):952-960. doi:10.1001/jama.2011.1247


In-Depth: Cognitive Behavioral Therapy

Ben Martin, Psy.D. PsychCentral.


What Is Cognitive Behavior Therapy (CBT)?

Beck, Cognitive Behavior Therapy.


Cognitive Behavioral Therapy.

Mayo Clinic.


The secret battle of high-functioning depression.

Christine Yu.


What Is High-Functioning Depression?

Promises Treatment Center.



Alexa Erickson. October 9, 2016.


What Is High-Functioning Depression, Anxiety? Low-Grade Mood Disorder Can Be Dangerous

Samantha Olson. Aug 9, 2016.


Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis

Colin P West, MD, PhD, Liselotte N Dyrbye, MD, Patricia J Erwin, MLS, Tait D Shanafelt, MD

Published: 28 September 2016


4 Signs Of High-Functioning Depression EVERYONE Should Know!

Brandon Richard.


5 Signs of High-Functioning Depression. Power of Positivity.


High Functioning Depression, a New Breakthrough

Tom Wootton. Feb 23, 2016.



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