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Psychological Treatment of Stress-Induced Exhaustion Disorder: Towards a Contextual Behavioral Approach
Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Psychology.ORCID iD: 0000-0002-4000-2866
2024 (English)Doctoral thesis, comprehensive summary (Other academic)
Description
Abstract [en]

Long-term sick leave due to stress-related disorders has been steadily increasing in Western society. A portion of these sick leave rates is attributed to severe symptoms of exhaustion, assumed to be the result of persistent work stress. In Sweden, this symptomatology is currently classified using the diagnosis of stress-induced exhaustion disorder (ED). There are, however, no evidence-based treatments for ED, nor are there any established theoretical models to guide clinical interventions. Most current treatments revolve around promoting recovery behaviors, as ED is assumed to result from depleted psychophysiological resources. This thesis discusses the merits of this assumption and whether it is compatible with contemporary theories of stress and a contextual behavioral treatment approach. Additionally, a contextual behavioral model of ED is introduced with an accompanying biopsychosocial treatment, aiming to bridge the gap between theories of stress, basic learning principles, and clinically useful methods. The model suggests that ED can be conceptualized as a crisis of engagement rather than a result of depleted psychophysiological resources.

Complementing this theoretical work are empirical studies of different aspects of multimodal interventions (MMI) for ED with the overarching aim of fostering a more theoretically coherent ED treatment that can be made accessible to more patients. Study I was an open clinical trial tracking ED patients (N = 390) participating in a 24-week MMI based on cognitive behavior therapy (CBT). Study II explored sub-groups and predictors of improvements in a large cohort (N = 915) of ED patients participating in the same MMI as Study I. Study III explored mediators commonly suggested to be relevant within ED treatment in the same cohort as Study II: sleep concerns, pathological worry, perfectionistic concerns, and psychological flexibility. Study IV was an uncontrolled pilot trial (N = 26) of the biopsychosocial treatment for ED presented in this thesis, delivered within a 12-week online MMI.  

In summary, the results of this thesis indicate that ED patients participating in CBT-based MMI benefit from treatment and report few adverse effects. Moreover, high degrees of perfectionism and high treatment credibility were identified as predictors of improvement, indicating the importance of addressing perfectionistic behaviors and treatment credibility in ED treatment. With positive results similar to those of Study I, Study IV provides preliminary support that ED can be treated more effectively with fewer clinical resources than more extensive MMIs when a more focused and theoretically stringent approach is utilized. 

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2024. , p. 143
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Social Sciences, ISSN 1652-9030 ; 223
Keywords [en]
Stress-Induced Exhaustion Disorder, Burnout, Cognitive Behavior Therapy, Contextual Behavior Science, Process-Based Therapy, Recovery
National Category
Psychology
Research subject
Psychology
Identifiers
URN: urn:nbn:se:uu:diva-526606ISBN: 978-91-513-2128-8 (print)OAI: oai:DiVA.org:uu-526606DiVA, id: diva2:1851259
Public defence
2024-06-13, Sal X, Universitetshuset, Biskopsgatan 3, Uppsala, 13:00 (English)
Opponent
Supervisors
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2018-00154Available from: 2024-05-23 Created: 2024-04-12 Last updated: 2024-05-23
List of papers
1. Standardized multimodal intervention for stress-induced exhaustion disorder: an open trial in a clinical setting
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2020 (English)In: BMC Psychiatry, E-ISSN 1471-244X, Vol. 20, no 1, article id 526Article in journal (Refereed) Published
Abstract [en]

Background

Long-term sick-leave due to stress-related ill-health is increasing in several economically developed countries. Even though different forms of interventions are administered in regular care for stress-related disorders, such as Stress-induced Exhaustion disorder (SED), the scientific evidence for the effectiveness of such treatments is sparse. The objective of this study was to explore changes in SED-symptoms and return-to-work-rates in a large group of SED-patients participating in a standardized Multimodal intervention (MMI) in a clinical setting.

Method

This open clinical trial tracked 390 patients who fulfilled the criteria for SED undergoing a 24-week MMI, including return-to-work-strategies. Before inclusion, all patients underwent a multi-professional assessment by a team of licensed physicians, licensed psychologists, and licensed physiotherapists. Self-rated questionnaires were administered before treatment, at treatment-start, mid-treatment, post-treatment, and at 12-month follow-up. Within-group change was evaluated over time with mixed-effects models. Beyond different symptoms, working time, sick-leave compensation, and adverse effects were also measured.

Results

There were significant improvements in symptoms of SED, burnout, anxiety, depression, and insomnia, with large within-group effect sizes (d = 0.91–1.76), improvements that were maintained at 12-month follow-up. Furthermore, there was a significant increase in quality of life and large improvements in average working time and sick-leave compensation. Some adverse effects were reported, mainly concerning an increase in stress, anxiety, and worry.

Conclusion

SED-patients participating in this standardized MMI reported large symptom alleviation, increased working time and reduced sick-leave compensation, indicating a beneficial treatment. There were some adverse effects, but no more so than other psychological treatments. This study confirms previous findings that high levels of depression and anxiety decrease to sub-clinical levels during treatment, while symptoms of SED also decline, yet still persists above sub-clinical levels at 12-month follow-up. On the whole, this open clinical trial suggests that a standardized MMI, administered in a clinical setting, improves symptoms and return-to-work rates in a clinically representative SED-population.

Keywords
Stress-induced exhaustion disorder, Burnout, Long-term stress, Rehabilitation, Multimodal intervention, Negative effects
National Category
Psychiatry Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-426336 (URN)10.1186/s12888-020-02907-3 (DOI)000586797900001 ()33153461 (PubMedID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2018-00154
Available from: 2020-12-03 Created: 2020-12-03 Last updated: 2024-04-12Bibliographically approved
2. Predictors and sub-groups in the treatment of stress-induced exhaustion disorder
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2023 (English)In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 52, no 4, p. 397-418Article in journal (Refereed) Published
Abstract [en]

Little is known about psychological interventions for stress-induced Exhaustion disorder (ED), and there is a need for more research to improve the outcomes obtained in treatments. The present study examines predictors of improvement, including sub-group responses, in a large sample of ED patients receiving a Multimodal intervention (MMI) based on Cognitive Behavior Therapy (N = 915). In step one, available variables were explored separately as predictors of improvement in ED symptoms. In step two, sub-groups were explored through Latent Class Analysis to reduce the heterogeneity observed in the larger group and to investigate whether combining the variables from step one predicted symptom improvement. Younger age, no previous sick leave due to ED, and scoring high on anxiety, depression, insomnia, perfectionism, and treatment credibility emerged as separate predictors of improvement. In the sub-group analyses, a sub-group including participants who were single and had a lower income showed less improvement. Overall, people with ED participating in MMI report symptom improvement regardless of characteristics before treatment. However, the present findings do have the potential to inform future treatments for ED, as they highlight perfectionism as a predictor of improvement and the importance of assessing treatment credibility during treatment.

Place, publisher, year, edition, pages
Taylor & Francis Group, 2023
Keywords
Exhaustion disorder, clinical burnout, predictors, sub-groups, multimodal intervention
National Category
Psychiatry Applied Psychology
Identifiers
urn:nbn:se:uu:diva-511388 (URN)10.1080/16506073.2023.2197148 (DOI)000969361600001 ()37039046 (PubMedID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2018-00154Swedish Research Council, 2018-00154
Available from: 2023-09-22 Created: 2023-09-22 Last updated: 2024-04-12Bibliographically approved
3. Mediators during a Multimodal intervention for stress-induced exhaustion disorder
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2024 (English)In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 53, no 3, p. 235-253Article in journal (Refereed) Published
Abstract [en]

Our understanding of the underlying psychological processes of development, maintenance, and treatments for stress-induced exhaustion disorder (ED) remains limited. Therefore, the current study aimed to explore whether sleep concerns, pathological worry, perfectionistic concerns, and psychological flexibility mediate change in exhaustion symptoms during a Multimodal intervention for ED based on Cognitive behavioral therapy principles. Participants (N = 913) were assessed at three time points, and mediation was explored using a two-criteria analytical model with linear mixed-effects models (criterion one) and random intercepts cross-lagged panel modeling (criterion 2). Criterion one for mediation was successfully met, as the findings indicated significant associations between time in treatment, with all suggested mediators, and exhaustion symptoms (significant ab-products). However, criterion two was not satisfied as changes in the mediators did not precede changes in exhaustion symptoms. Therefore, mediation could not be established. Instead, changes in the suggested mediators appeared to result from changes in exhaustion symptoms. Consequently, sleep concerns, pathological worry, perfectionistic concerns, and psychological flexibility appear to improve in conjunction with exhaustion symptoms during treatment, where improvement in exhaustion is indicated as the main driving factor, based on this exploratory analysis. The implications of these findings are contextualized within a broader framework of process-based therapy.

Place, publisher, year, edition, pages
Routledge, 2024
Keywords
Burnout, Exhaustion disorder, multimodal intervention, mediators, process of change
National Category
Psychology
Identifiers
urn:nbn:se:uu:diva-519073 (URN)10.1080/16506073.2023.2295217 (DOI)001129767600001 ()38130175 (PubMedID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2018-00154
Available from: 2024-01-03 Created: 2024-01-03 Last updated: 2024-05-20Bibliographically approved
4. Feasibility of a Novel Biopsychosocial Treatment for Stress-Induced Exhaustion Disorder
Open this publication in new window or tab >>Feasibility of a Novel Biopsychosocial Treatment for Stress-Induced Exhaustion Disorder
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

With the escalating prevalence of stress-related disorders in Western society, disorders such as Stress-Induced Exhaustion Disorder (ED) have garnered increased attention in contemporary scientific and clinical discourse. Despite various treatment studies, evidence-based treatments for ED and established clinical theories are lacking. This uncontrolled pilot study aimed to examine the feasibility, acceptance, and utility of a novel biopsychosocial treatment for ED based on a contextual behavioral approach. Twenty-six patients with ED were included in a 12-week digital multimodal intervention with the biopsychosocial treatment as the primary component. Self-rated questionnaires and independent clinical ratings were administered before and after treatment and at the three-month follow-up. Measures of exhaustion and psychological flexibility were also assessed weekly during treatment. Overall, participants reported significant improvements in symptoms of exhaustion, anxiety, and depression with large effect sizes (d = 0.75-1.10), which were maintained at follow-up. Independent clinical ratings indicated reduced clinical severity and functional disability. There were no dropouts and a high module completion ratio. Few negative effects were reported, and ratings on treatment credibility and client satisfaction were high. Finally, the mediation analysis indicated that increased psychological flexibility mediated improvements in exhaustion symptoms, which aligns with the contextual behavioral model underlying the treatment. These results provide preliminary support for the feasibility, acceptability, and utility of this novel biopsychosocial treatment for ED.  

Keywords
Stress-Induced Exhaustion Disorder, Clinical Burnout, Cognitive Behavior Therapy, Internet, Contextual Behavior Science
National Category
Psychiatry Applied Psychology
Research subject
Psychology; Psychology
Identifiers
urn:nbn:se:uu:diva-526360 (URN)
Available from: 2024-04-09 Created: 2024-04-09 Last updated: 2024-04-12

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