By Emilie Reas, PLOS Neuroscience Community Editor
We’ve all experienced it – the fatigue, stress and irritability after a long day of work. For most, these feelings are fleeting, and are nothing a good night’s sleep or a cup of tea over a good book can’t remedy. But for others, the daily stress extends into weeks and months, and eventually into long-term burnout. The physical toll on the over-worked can be so extreme that occupational burnout is being increasingly recognized as a serious medical condition. While the behavioral symptoms – including problems with memory or concentration, mood imbalances, insomnia and body aches – are well documented, the consequences of chronic burnout on brain function, and how such neural changes give rise to emotional dysregulation, have been inadequately examined. A recent PLOS One study, by Amita Golkar and colleagues from the Karolinska Institute, sought to better understand how chronic work-related stress alters brain function and emotional processing. While their findings confirm that impaired emotional regulation has neurobiological roots, another expert in the field has raised the question of whether stress may affect additional neural circuits undetected here.
Thirty-two individuals with chronic burnout and 61 healthy controls participated. The patients worked 60-70 hours per week, manifested symptoms including sleeplessness, fatigue, irritability, cognitive impairments or impaired working ability for at least a year, and had lost at least six months of work to sickness. Each participant completed two test sessions, including a startle response task to measure emotional regulation, and resting-state functional MRI to evaluate functional brain connectivity.
During the behavioral task, a series of neutral and negative pictures was shown, with each picture flashed before and after an instruction cue (Figure 1). For negative pictures, subjects were told to either up-regulate, down-regulate or maintain their emotional response to the image (i.e., to experience the second presentation as more, less or similarly emotionally charged as the first presentation). Neutral pictures were always paired with the instruction to maintain their emotional response. To assess how the cues affected participants’ physiological responses to the images, during each picture presentation the researchers administered an acoustic startle and measured eye-blink responses using electromyography. This allowed them to compare stress responses to an identical stimulus, differing only in how the participants manipulated their emotional reactions.
Burnout impairs emotional regulation
When they were told to maintain or up-regulate their emotional responses, the burnout and control groups showed similar startle responses (response to the post-cue picture – response to the pre-cue picture). But critically, during the down-regulate condition the burnout group not only exhibited a greater stress response than controls (Figure 2), but also reported less success at implementing the emotional regulation instructions to the negative images. Just from these behavioral findings, it’s clear that chronic stress can dramatically alter how we process negative emotions. In particular, the burnt-out workers demonstrated less control over their reactions to negative experiences, showing signs of elevated distress that they were unable to dampen.
Burnout alters limbic function
Given this strong evidence that something was awry in these patients’ emotional regulation circuitry, Golkar and colleagues next asked whether altered neural function might underlie their symptoms. Naturally, they looked to the limbic system, a brain network involved in processing emotion. They focused particularly on the amygdala, which is known to be critical for evoking fear and anxiety, and is enlarged in people with occupational stress. Here, functional connectivity during rest between the amygdala and several brain regions was altered in patients; most notably, connections were weaker with the prefrontal cortex and stronger with the insula. What’s more, the stronger the correlation of the amygdala with the insula or a thalamic/hypothalamic region, the higher the individual’s perceived stress. Finally, connectivity between the amygdala and the anterior cingulate correlated with participants’ ability to down-regulate their emotional response from the startle-response task.
The findings of Golkar and colleagues help to establish a concrete understanding of the cognitive and neural changes underlying a too-often overlooked serious health condition. These findings add credence to the subjective feeling of being overly sensitive to negativity, or unable to control emotions, when burnt out. Perhaps more importantly, they confirm that such emotional impairments indeed have neurobiological underpinnings – changes that fit in beautifully with our knowledge of how the brain processes emotion. A stress-related disconnect between the amygdala and the prefrontal cortex and anterior cingulate – even at rest – builds upon earlier studies showing reduced volume and altered task-evoked responses in these areas associated with stress. And chronic stress was further related to amygdala hyperconnectivity with the insula and thalamus/hypothalamus, key regions for eliciting a stress response.
Dissociating the neural effects of stress
However, this study leaves several questions unanswered and raises a few more. Given the complexity of the patients’ psychological conditions, there were most certainly numerous other physical and psychological differences between the groups that went undocumented and uncontrolled. In the future, closer examination of these possible confounds will help identify their unique neural and behavioral effects. Furthermore, in addition to functional changes in several expected regions, altered resting connectivity also occurred in two unexpected regions – the cerebellum and motor cortex. Whether these were false positives, or whether occupational stress may have additional underappreciated motor or cognitive consequence, remains to be seen.
Because of the study’s justifiable focus on connectivity with the amygdala, it’s unclear how specific or broad the neural changes associated with chronic stress may be. Tom Liu, a researcher studying resting-state brain connectivity at UC San Diego, who was not involved in this study, explains,
“This begs the question of what other connections might be different between the two groups or perhaps show even better correlation with the stress scores. The issue there is that because of the large number of potential connections, a researcher is very quickly faced with a large multiple comparisons problem – this is an open issue in the field.”
Further work will help clarify whether stress – or other differences between the groups – predominantly affects limbic circuitry or might also contribute to global brain changes. Liu points out,
“One aspect that would have been interesting to look at is whether there were any global differences between the two groups that could have accounted for the differences, as the authors did not perform global signal regression.”
Golkar et al. help to bridge the gap between the emotional dysregulation of workplace burnout and its long-term impact on brain function. Such work is a valuable step towards not only better understanding the brain’s response to stress, but also better equipping us to manage our emotional and brain health – even after a long day of work.
Any views expressed are those of the author, and do not necessarily reflect those of PLOS.
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Emilie Reas received her PhD in Neuroscience from UC San Diego, where she used fMRI to study memory. As a postdoc at UCSD, she currently studies how the brain changes with aging and disease. In addition to her tweets for @PLOSNeuro she is @etreas.