Jayne Jubb

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Did you know that depression could be a symptom of something as simple as infection? Doctors have long viewed depression as a complex disorder. Stress, neurochemical imbalances, physical pain and ill health can all precipitate an emotional collapse. Yet a flurry of research during the past 25 years has linked many of depression’s contributing factors to a single root cause: inflammation

In the short term, inflammation is an important part of our immune system’s built-in ability to thwart disease and injury. But when prolonged, it can prompt fatigue and melancholy. In addition, investigations hint that an upset immune system might underlie a host of other psychiatric illnesses, including obsessive- compulsive disorder, panic disorder and post-traumatic stress syndrome.

With these growing insights, scientists are testing new treatments to heal the psyche by tempering chronic inflammation. Even if the approach may help only some people with depression, the benefit could be enormous. About one in 10 individuals suffers from a serious spell of despondency at least once during their lives, and depression is the most prevalent mental illness among women.

Self-Defense in Overdrive

Our immune system deploys an arsenal of diverse cells to keep us healthy, choreographing their actions by way of messenger molecules called cytokines. Cells attacked by harmful bacteria, viruses, parasites or cancer secrete interferons, a class of cytokines that warn neighboring tissues to bolster their defenses and rally killer cells to engage. Cytokines called interleukins help to coordinate fever (which limits the spread of an infection) and inflammation (which rushes specialised immune cells to the scene). Tumour necrosis factors, yet another large family of cytokines, destroy abnormal cells and activate other cytokines. They also promote swelling, reddening and pain, which have both positive and negative effects.

Working together, these various proteins modulate the type, intensity and duration of an immune response. Across the blood-brain barrier, they also hold considerable sway over our emotional state. When we are unwell, interferons and interleukins announcing the start of an attack flood the brain. Numerous studies have revealed that these proinflammatory cytokines can disrupt the normal functioning of multiple neurotransmitters and dampen the production of serotonin, often called a happiness hormone for its ability to boost mood. As a result, even people with minor colds often lose their appetite, feel tired, seek warmth, avoid others and struggle to concentrate.

Biologically, this sickness behaviour, as it is called, makes sense. Our immune system works more efficiently and we can recuperate faster if we stay in bed. We are also less likely to infect our co-workers and friends. Once an illness has cleared, anti-inflammatory cytokines see to it that our bodies and our brain chemistry reset. But what if an illness drags on and the immune system continues to pump out proinflammatory signals? In that case, sickness behaviour begins to look a lot like depression. Tooth decay, urinary tract infections and sinusitis are all examples of infections that do not always produce obvious symptoms or pain but might perpetuate sickness behaviour for a long period.

To test the idea that depression can sometimes be a kind of extended sickness behaviour, psychology researcher Yekta Dowlati of the University of Toronto and her colleagues evaluated 24 studies in a paper published in 2010, looking at measurements of proinflammatory cytokines in about 400 depressed individuals. Overall, these subjects showed significantly heightened blood levels of tumour necrosis factor alpha (TNF-alpha) and interleukin-6, hallmarks of an ongoing immune reaction. Two years later researcher Simon Gray and psychiatrist Michael Bloch of Yale University conducted another meta-analysis of 12 studies of obsessive- compulsive disorder, often diagnosed alongside depression. They, too, reported elevated blood levels of TNF-alpha in individuals suffering from both depression and obsessive-compulsive disorder.

An overcooked immune response may also trigger anxiety disorders. In 2009 psychiatrist Elizabeth Hoge of Harvard Medical School and her co-workers compared the immunological status of 48 patients suffering from panic disorder or post-traumatic stress disorder with that of 48 age- and gender-matched healthy control subjects. The team tested blood serum levels of 20 different inflammation markers and found 18 of them to be higher in the psychiatric patients. To look for a generalised inflammatory state—indicative of an underlying injury or infection—they measured how many participants had detectable levels of at least six out of nine common proinflammatory cytokines. Some 87 percent of the anxiety sufferers met the criterion, compared with only 25 percent of the controls…..

The Role of Stress

There seems to be little doubt that protracted low-grade inflammation can engender depression and other emotional disorders in some people. Whether or not a person succumbs may depend in part on how aggressive their immune sys- tem is to begin with. In 2013 a meta-analysis was carried out to examine data on genes that predispose humans to depression. It was found that many of these genes are present in individuals with an especially vigorous immune response—which might explain why the genes have persisted in the human population even though they can have a detrimental effect.

Until the advent of good hygiene and antibiotics, infection was arguably the greatest threat to staying alive, so having an overactive immune system conferred a real advantage. Raison and Miller speculate that today, when most of us are not routinely exposed to hazardous microbes, some people’s immune systems habitually overreact to harmless stimuli, leading to a persistent increase in proinflammatory cytokines. This may account for an increased prevalence of not only depression and other emotional disorders but also allergies, autoimmune diseases, cardio-vascular disease, stroke, cancer, diabetes and dementia.

Stress probably plays a crucial role in this nexus of cause and effect. In the short term, the mere anticipation of injury can amplify inflammation. Several experiments have confirmed that animals experiencing moments of acute stress crank out higher levels of proinflammatory cytokines, and prolonged stress can eventually elicit depression-like behaviour in these same creatures. In 2009 psychiatrist Lisa Christian and her co-workers demonstrated a similar phenomenon in humans. They studied 60 women during pregnancy and found an association between depression and blood levels of TNF-alpha and interleukin-6. Proinflammatory cytokines rise during any pregnancy, but the researchers found elevated levels of both cytokines and depression in women under stress and the highest levels of depression in women under presumably the greatest stress—those with unwelcome pregnancies and those who received the least support.

Chronic stress is even more deleterious. Faced with some threat, the body prepares for fight or flight. A hormonal cascade along the so-called stress axis— from the hypothalamus to the pituitary gland to the adrenal gland—jump-starts the production of cortisol. Among other functions, this hormone temporarily suppresses the immune system to guarantee that we focus all of our energy on external dangers. If the stress endures, though, cortisol keeps the immune system offline, and we are more susceptible to illness. Over the course of several years, stress can permanently damage signaling along the axis, and we begin to release too little cortisol—in which case, the immune system reawakens and kicks into overdrive, with proinflammatory cytokines flowing freely.

Stacking the Deck

The sum of this research is a rough mechanism by which inflammation can seed depression: take an immune system prone to overreact and add stress. The chance of physical illness skyrockets, pro-inflammatory cytokines surge and sickness behavior becomes the new normal. Further investigations reveal that trauma in any form primes this pathway. In 2007 psychiatrist Andrea Danese conducted a longitudinal study of people who were rejected or mistreated by their parents during childhood. They found that even 20 years after the abuse, many study participants had greatly elevated blood levels of inflammation biomarkers.

Several other studies suggest that disturbing childhood experiences may permanently unbalance the stress axis and alter the sensitivity of cortisol receptors in the brain. Miller and his colleagues have discovered that compared with emotionally healthy control subjects, depressed men who were distressed as children mount much stronger immune responses when they take a test designed to cause psychosocial stress. Physical pain can also overload the immune system. Scientists have documented especially high levels of TNF-alpha in depressed women who also exhibit an increased sensitivity to pain—itself a symptom of sickness behaviour. Constant pain is a stress factor, creating a vicious circle: pain begets inflammation and stress, leading to more inflammation and depression. Indeed, so complex is the interplay of contributing factors that it may be impossible to determine the degree to which immune reactivity, personality, general physical health and life experiences contribute to depression in any one person. Chronic inflammation in and of itself almost certainly accounts for only a subset of patients with emotional disorders. Yet several trials have shown that patients who do not respond to traditional anti- depressants frequently begin to improve when they take anti-inflammatory medications, from everyday ibuprofen to cytokine inhibitors, on top of their other prescriptions. Interestingly, the reverse is also true. Patients suffering from skin cancer or hepatitis C frequently take the cytokine drug interferon-alpha, which causes inflammation, and many develop symptoms of depression as a side effect. Practitioners are thus pursuing a variety of approaches—from medications to dietary interventions—to tackle unwanted inflammation in psychiatric patients. For instance, in 2011 psychiatrist Janice Kiecolt-Glaser and her colleagues at Ohio State reported that omega-3 fatty acids, which curb inflammation, alleviated anxiety in medical students before an exam. Scientists are hopeful that drugs aimed at blocking cytokine receptors in the brain might also help quell emotional disorders. Several initiatives are under way to develop effective cytokine antagonists. Meanwhile more studies on the role of stress and trauma may reveal better ways to keep inflammation in check, lessening the risk that a chance infection will lead to an intractable disease.

References:

■ Inflammation and Its Discontents: The Role of Cytokines in the Pathophysiology of Major Depression. Andrew H. Miller, Vladimir Maletic and Charles L. Raison in Biological Psychiatry, Vol. 65, No. 9, pages 732–741; May 1, 2009.

■ A Meta-Analysis of Cytokines in Major Depression. Yekta Dowlati, Nathan Herrmann, Walter Swardfager, Helena Liu, Lauren Sham, Elyse K. Reim and Krista L. Lanctôt in Biological Psychiatry, Vol. 67, No. 5, pages 446–457; March 1, 2010.

■ Can Infection Give You the Blues? Erich Kasten in Scientific American Mind, Vol. 26, No. 3; May/June, 2015.

■ The Evolutionary Significance of Depression in Pathogen Host Defense (PATHOS-D).
C. L. Raison and A. H. Miller in Molecular Psychiatry, Vol. 18, No. 1, pages 15–37; January 2013.

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Across cultures and throughout history, music listening and music making have played a role in treating disorders of the mind and body. Much of the power of music-based treatment lies in its ability to meld numerous subtle benefits in a single, engaging package. Music is perhaps unrivaled by any other form of human expression in the range of its defining characteristics, from its melody and rhythm to its emotional and social nature.

The treatments that take advantage of these attributes are rewarding, motivating, accessible and inexpensive, and basically free of side effects, too. The attractive quality of music also encourages patients to continue therapy over many weeks and months, improving the chance of lasting gains. These treatments aim to restore functions lost to injury or neurological disorders by enlisting healthy areas of the brain and sometimes even by reviving dysfunctional circuitry. As evidence accumulates about the effectiveness of these techniques, clinicians and therapists from a variety of fields have begun to incorporate them into their practices, most notably music therapists, who are at the intersection of music and health and important mediators of these interventions, as well as speech therapists and physical therapists. And among the beneficiaries are people diagnosed with stroke, autism, tinnitus, Parkinson’s disease and dementia. As scientists learn more about the effect of music on cognitive and motor functions and mental states, they can tailor these therapies for each disorder, targeting specific brain injuries or dysfunctions.

Music as Medicine

The view that music can be useful in treating neurological impairment gained some scientific heft in a landmark study published in 2008. Psychologist Teppo Särkämö of the University of Helsinki and his team recruited 60 patients who had suffered a stroke in the middle cerebral artery of one hemisphere. They split the patients into three groups: the first participated in daily sessions of music listening, the second listened to audiobooks every day and the third received no auditory treatment. Researchers observed the patients over two months. Those in the group that listened to music exhibited the greatest recovery in verbal memory and attention. And because listening to music appears to improve memory, the hope now is that active music making—singing, moving and synchronizing to a beat—might help restore additional skills, including speech and motor functions in stroke patients.

The Singing Cure

When a stroke affects areas of the brain that control speech, it can leave patients with a condition known as nonfluent aphasia, or an inability to speak fluently. And yet, as therapists over the years have noted, people with nonfluent aphasia can sometimes sing words they cannot otherwise say.

In the 1970s neurologist Martin Albert and speech pathologists Robert Sparks and Nancy Helm recognized the therapeutic implications of this ability and developed a treatment called melodic intonation therapy in which singing is a central element. During a typical session, patients will sing words and short phrases set to a simple melody while tapping out each syllable with their left hand. The melody usually involves two notes, perhaps separated by a minor third (such as the first two notes of “Greensleeves”). For example, patients might sing the phrase “How are you?” in a simple up-and-down pattern, with the stressed syllable (“are”) assigned a higher pitch than the others. As the treatment progresses, the phrases get longer and the frequency of the vocalizations increases, perhaps from one syllable per second to two.

Each element of the treatment contributes to fluency by recruiting undamaged areas of the brain. The slow changes in the pitch of the voice engage areas associated with perception in the right hemisphere, which integrates sensory information over a longer interval than the left hemisphere does; as a consequence, it is particularly sensitive to slowly modulated sounds. The rhythmic tapping with the left hand, in turn, invokes a network in the right hemisphere that controls movements associated with the vocal apparatus. Benefits are often evident after even a single treatment session. But when performed intensively over months, melodic intonation therapy also produces long-term gains that appear to arise from changes in neural circuitry—the creation of alternative pathways or the strengthening of rudimentary ones in the brain. In effect, for patients with severe aphasia, singing trains structures and connections in the brain’s right hemisphere to assume permanent responsibility for a task usually handled mostly by the left.

This theory has gained support in the past two decades from studies of stroke patients with nonfluent aphasia conducted by researchers around the world. In a study published in September 2014 by Schlaug and his group at Harvard Medical School, 11 patients received melodic intonation therapy; nine received no treatment. The patients who received therapy were able to string together more than twice as many appropriate words per minute in response to a question. That same group also showed structural changes, assessed through MRI, in a right-hemisphere network associated with vocalization. The laboratory is now conducting studies to compare the benefits of melodic intonation therapy with other forms of therapy for patients with aphasia.

Because melodic intonation therapy seemed to work by engaging the right hemisphere, researchers then surmised that electrical or magnetic stimulation of the region might boost the therapy’s power. In two recent studies researchers stimulated an area in the right hemisphere called the inferior frontal gyrus, which helps to connect sounds with the oral, facial and vocal movements that produce them. For many participants, combining melodic intonation therapy with noninvasive brain stimulation yielded improvements in speech fluency after only a few sessions.

Music and Motion

Music making can also help stroke survivors living with impaired motor skills. In a study published in 2007 scientists asked patients to use their movement-impaired hand to play melodies on the piano or tap out a rhythm on pitch-producing drum pads. Patients who engaged in this intervention, called music-supported training, showed greater improvement in the timing, precision and smoothness of fine motor skills than did patients who relied on conventional therapy. The researchers postulated that the gains resulted from an increase in connections between neurons of the sensorimotor and auditory regions.

Rhythm is the key to treatment of people with Parkinson’s, which affects roughly one in 100 older than 60. Parkinson’s arises from degeneration of cells in the midbrain that feed dopamine to the basal ganglia, an area involved in the initiation and smoothness of movements. The dopamine shortage in the region results in motor problems ranging from tremors and stiffness to difficulties in timing the movements associated with walking, facial expressions and speech.

Music with a strong beat can allay some of these symptoms by providing an audible rhythmic sequence that people can use to initiate and time their movements. Treatments include so-called rhythmic entrainment, which involves playing a stimulus like a metronome. In neurologist Oliver Sacks’s 1973 book Awakenings, musical rhythm sometimes released individuals from their immobility, letting them dance or sing out unexpectedly.

The use of rhythm in motor therapy gained momentum in the 1990s, when researchers around the world demonstrated a technique called rhythmic auditory stimulation, or RAS, for people who had trouble walking, such as stroke and Parkinson’s patients. A therapist will first ask patients to walk at a comfortable speed and then to an audible rhythm. Tempos that pushed patients slightly past their comfort zone yielded the greatest improvements in velocity, cadence and stride length.

Despite these encouraging outcomes, the neural mechanisms that trigger improvements have been difficult to pin down. Imaging work suggests that during rhythmic auditory stimulation, neural control of motor behaviour is rerouted around the basal ganglia; instead the brain stem serves as a relay station that sends auditory input to motor networks in the cerebellum, which governs coordination, and to other cortical regions that could help synchronize sound and motion.

Recovered Memory

Fewer neurological disorders inspire greater fear than dementia, one of the most common diseases of the elderly. According to some estimates, 44 million people worldwide are living with dementia, a number expected to reach 135 million by 2050. Alzheimer’s disease, a neurodegenerative condition, accounts for more than 60 percent of the cases; multiple strokes can also cause so-called vascular dementia.

Music may be ideally suited to stimulating memory in people with dementia, helping them maintain a sense of self. Because music activates neural areas and pathways in several parts of the brain, the odds are greater that memories associated with music will survive disease. Music also stimulates normal emotional responses even in the face of general cognitive decline. In a 2009 study 12 individuals with Alzheimer’s and 12 without it were asked to judge the emotional connotations of various pieces of music. The Alzheimer’s participants were just as accurate as the others despite significant impairments in different areas of judgment. Other research suggests that taking part in musical activities throughout life keeps the mind young and may even decrease the risk of developing dementia; the continuous engagement of the parts of the brain that integrate senses and motion with the systems for emotions and rewards might prevent loss of neurons and synapses.

The type of therapy that individual dementia patients receive will vary, from receptive (listening) to active (dancing, singing, clapping). Music that the patient selects is most effective because the choice represents a connection to memory and self. The benefits vary, too, and tend to be short-term. But when the treatment does work, it reduces the feelings of agitation that lead to wandering and vocal outbursts and encourages cooperation and interaction with others. Music therapy can also help patients with dementia sleep better and can enhance their emotional well-being.

Music on the Spectrum

Perhaps the most fascinating interplay between music and the brain lies in the case files of people with autism spectrum disorder, a neurodevelopmental syndrome that occurs in 1 to 2 percent of children, most of whom are boys. Hallmarks of autism include impaired social interactions, repetitive behaviours and difficulties in communication. Indeed, up to 30 percent of people with autism cannot make the sounds of speech at all; many have limited vocabulary of any kind, including gesture.

One of the peculiarities of the neurobiology of autism is the overdevelopment of short-range brain connections. As an apparent consequence, children with autism tend to focus intensely on the fine details of sensory experience, such as the varying textures of different fabrics or the precise sound qualities emitted by appliances such as a refrigerator or an air conditioner. And this fascination with sound may account for the many anecdotal reports of children with autism who thoroughly enjoy making and learning music. A disproportionate number of children with autism spectrum disorder are musical savants, with extraordinary abilities in specialized areas, such as absolute pitch.

The positive response to music opens the way to treatments that can help children with autism engage in activities with other people, acquiring social, language and motor skills as they do. Music also activates areas of the brain that relate to social ways of thinking. When we listen to music, we often get a sense of the emotional states of the people who created it and those who are playing it. By encouraging children with autism to imagine these emotions, therapists can help them learn to think about other people and what they might be feeling.

Recently the Music and Neuroimaging Laboratory at Harvard developed a new technique called auditory-motor mapping training, or AMMT, for children whose autism has left them unable to speak. The treatments have two main components: intonation of words and phrases (changing the melodic pitch of one’s voice) and tapping alternately with each hand on pitch-producing drums while singing or speaking words and phrases. In a proof-of-principle study, six completely nonverbal children took part in 40 sessions of this training over eight weeks. By the end, all were able to produce some speech sounds, and some were even able to voice meaningful and appropriate words during tasks that the therapy sessions had not covered. Most important, the children were still able to demonstrate their new skills eight weeks after the training sessions ended.

Quiet, Please

Music-based treatments can also train the brain to tune out the phantom strains of tinnitus—the experience of noise or ringing in the ear in the absence of sound that affects roughly 20 percent of adults. Age-related hearing loss, exposure to loud sounds and circulatory system disorders can all bring on the condition, with symptoms ranging from buzzing or hissing in the ears to a continuous tone with a definable pitch. The sensation can cause serious distress and interfere with the ability to concentrate on other sounds and activities. There is no cure.

The past decade has seen a surge in understanding of the neurological basis of the disorder. In one view, cochlear damage (most likely caused by exposure to loud sounds) reduces the transmission of particular sound frequencies to the brain. To compensate for the loss, neuronal activity in the central auditory system changes, creating neural “noise,” perhaps by throwing off the balance between inhibition and excitation in the auditory cortex, leading to the perception of sounds that are not there. Also at play might be dysfunctional feedback to auditory brain regions from the limbic system, which is thought to serve as a noise-cancellation apparatus that identifies and inhibits irrelevant signals.

Music treatment seeks to counteract this dysfunction by inducing changes in the neural circuitry. For those with tonal tinnitus, one treatment involves listening to “notched music,” generated by digitally removing the frequency band that matches the tinnitus frequency. The notching—pioneered and proved effective by neurophysiologist Christo Pantev and his group at the University of Münster in Germany—might help reverse the imbalance in the auditory cortex, strengthening the inhibition of the frequency band that might be the source

of the phantom sound in the first place. Another approach involves playing a series of pitches to patients and then asking them to imitate the sequence vocally. As the patients refine their accuracy, they learn to disregard irrelevant auditory signals and focus on what they want to hear. In time, the stimulus of effortful attention might help the auditory cortex return to its normal physiological state.

For any novel therapy, enthusiasm can sometimes outpace the evidence, and researchers have rightly pointed out that the new music-based treatments must prove their efficacy against the more established therapies. But of all the techniques for addressing neurological disorders, music-based therapies seem unique in their capacity to tap into emotions, to help the brain find lost memories, to let patients resume their place in the world. We are only now beginning to understand the science behind the belief in the power of music to heal.

References:

• From Singing to Speaking: Why Singing May Lead to Recovery of Expressive Language Function in Patients with Broca’s Aphasia. Gottfried Schlaug, Sarah Marchina and Andrea Norton in Music Perception, 25, No. 4, pages 315–323; April 1, 2008.
• Listening to Tailor-Made Notched Music Reduces Tinnitus Loudness and Tinnitus-Related Auditory Cortex Activity. Hidehiko Okamota
  et al. in Proceedings of the National Academy of Sciences USA,
  107, No. 3, pages 1207–1210; January 19, 2010.
• Auditory-Motor Mapping Training as an Intervention to Facilitate Speech Output in Non-Verbal Children with Autism: A Proof of Concept Study. Catherine Y. Wan et al. in PLOS ONE, 6, No. 9, Article No. e25505; September 29, 2011.
• The Healing Power of Music. Willam F. Thompson and Gottfried Schlaug in Scientific American Mind, Vol.26, No. 2, pages 32-41; March/April 2015.
• Music, Health, and Wellbeing. Edited by Raymond MacDonald, Gunter Kreutz and Laura Mitchell. Oxford University Press, 2012.
• Music, Thought, and Feeling: Understanding the Psychology of Music. Second edition. William Forde Thompson. Oxford University Press, 2014.

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Examples of the desperate midlife-crisis stricken characters abound in popular culture (think, Kevin Spacey in American Beauty, Billy Crystal in City Slickers or Meryl Streep in The Bridges of Madison County), and the concept seems to be entrenched in our collective psyche. But are people of a certain age really more likely to launch a total life reboot?

It would seem so, according to scientists. Some hallmarks of midlife—increased self-reflection, aging, career and family changes—can seed deep dissatisfaction. And studies indicate that our sense of well-being naturally wanes during this stretch of adulthood. But research also shows that many common beliefs about the quintessential fortysomething meltdown are untrue. In fact, malaise can commence at almost any age, men are not more susceptible to dissatisfaction than women, and midlife crises are far from inevitable.

At some point between age 40 and 60, most people will face significant stress in one form or another, but not everyone reacts by chasing after fading youth or, worse, succumbs to depression or substance abuse. Genuine midlife breakdowns appear to be less common than many think, affecting only 10 percent of the population, according to a review in the early 1990s, or 26 percent, according to a 2000 study. For some of that group, these upheavals lead not to ruin but to a welcome second act. And the reasons certain people do fall victim may have more to do with personality and cultural expectations than age.

A Life Half-Empty

If the midlife crisis seems to defy precise definition, consider that midlife itself is a nebulous concept.

In 2011 researchers at Florida State University analysed a questionnaire given to several thousand Americans in the 1990s and found that most participants defined midlife as running from age 44 to 59. Ten years later the same participants described midlife as age 46 to 62. The older the respondents—women in particular—the later they envisioned the debut of their dotage.

Our notion of midlife may be a moving target, but once it starts, our perspective on time shifts. Instead of counting the years from our birth, we begin guessing at how many years we have left. Psychologist Laura Carstensen, founding director of the Center on Longevity at Stanford University, has shown that this subjective sense of a life half-empty influences our goals. The fewer years we think we have, the less expansive our plans become. Instead some individuals focus on family and friends—just as young and old alike seek familiar comforts when epidemics or terrorist attacks remind us of how finite life is.

Other people, though, begin to take stock of their lives and revisit unrealised dreams. Alexandra Freund, a professor of applied psychology at the University of Zurich has found that we seem to retrieve our youthful goals from 20 years before and check off, one by one, what we have achieved. She has noticed that older people typically try to maintain what they have now to avoid future losses and that they focus less on their careers. During this transition, our sense that the demands of work exceed our ability to cope can increase. Occupational psychologist Amanda Griffiths and her colleagues at the University of Nottingham in England have reported that this perceived job stress peaks between the ages of 50 and 55.

Such changes in focus and aspiration may render us less satisfied with life. In 2008 labour economists David Blanchflower of Dartmouth College and Andrew Oswald of the University of Warwick in England reviewed data about well-being collected from half a million people of various ages in 72 countries. They concluded that the happiness level throughout an individual’s life span frequently follows a U-shaped curve, bottoming out in the early to mid-40s. In some locations, this emotional nadir did not appear in the raw data but emerged once Blanchflower and Oswald reanalysed the numbers to consider the potentially confounding contributions of marital status, income, education and other factors on contentment.

Complicating the picture, other researchers have noted the presence of peaks and plateaus of happiness within the midlife period. In 2012 economist John Haisken-DeNew of the University of Melbourne reviewed life satisfaction among Germans using data from the German Socio-Economic Panel, a 30-year-old longitudinal study that surveys some 30,000 people annually. The length of the study allowed Haisken-DeNew to account for individual differences in optimism. For instance, a happiness score of 6 out of 10 might represent an all-time high for a confirmed misanthrope but a crash for a starry-eyed romantic. Haisken-DeNew observed that happiness levels drop continuously, if slightly, throughout adulthood until the early 60s, after which they increase until age 75 and then plummet.

Wrinkles in Time

Still, the subject of much debate is whether the cause of midlife strife lies in our creaturely selves or in our stars. Some researchers argue that life events are most important. In a study published in 2000 sociologist Elaine Wethington of Cornell University conducted a telephone survey of 724 American adults between the ages of 28 and 78 and found that more than a quarter of her respondents—men and women almost equally—admitted to having had a midlife crisis. The majority attributed these spells to upsetting life events such as losing a job or parent and not to age, leading Wethington to conclude that midlife crises are not a natural part of aging.

Yet research into the biology of middle age suggests that at least part of our vulnerability is built in. In 2012 psychologist Alexander Weiss and his colleagues at the University of Edinburgh reviewed accounts from zookeepers, volunteers, researchers and caretakers, who reported that middle-aged chimpanzees and orangutans showed definite signs of disgruntlement, compared with younger and older apes. These observations were subjective; the animal keepers knew the ages of the animals and may have been interpreting their behaviour based on expectations. Nevertheless, Weiss’s team concluded that the biology we share with our fellow great apes could underpin our midlife doldrums.

Gray hair and wrinkles aside, many adjustments associated with aging can cause psychological distress. The rates of cancer and cardiovascular disease, among other illnesses, increase, along with the risk of depression. A 2012 report from the Central Research Institute of Ambulatory Health Care in Berlin revealed that depression cases climb almost linearly until one’s late 50s and peak again at around 85 for women and 90 for men. In the U.S., statistics from the Centers for Disease Control and Prevention reveal that the highest rates of depression among men and women fall between the ages of 40 and 59.

Physically, too, the brain begins to degrade more quickly after age 40. In 2010 neuroscientist Antonio Giorgio of the University of Siena in Italy, then working with colleagues at the University of Oxford, tested 66 subjects between the ages of 23 and 81 using MRI and diffusion-tensor imaging. Their results were consistent with earlier studies: The brain’s white matter volume increased continuously up to the early 40s and then decreased rather rapidly. The volume of gray matter declined steadily over the entire period in most brain regions.

Older brains can usually compensate for these deficits, off-setting lost firepower with greater experience and knowledge. But the effects of hormonal attrition are more unsettling. When male andropause sets in after about age 40, testosterone levels start to decline, and both sexual interest and performance can suffer. For women, the decline of estrogen levels in the 40s leads to menopause, usually in the 50s, and a host of sometimes upsetting symptoms, including insomnia, memory problems and depression.

To Every Season

But whatever its source, midlife stress does not foredoom us to a life out of control, especially in our relationships. A 2011 Kinsey Institute study of more than 1,000 couples in Germany, Spain, the U.S., Japan and Brazil found that middle-aged men and women rate their relationships and sex lives higher the longer they have been married and that people entering middle age with a long-term partner have a good chance of staying together, citing earlier estimates that more than half of marriages in the U.S. and 92 percent in Spain will last more than 20 years. Of the marriages that do break down, the husband is not typically the one to walk out. According to the National Marriage Project at the University of Virginia, women instigate two thirds of all divorces—most likely not because they are having midlife crises but because their husbands are behaving badly.

The empty-nest syndrome appears to be a myth, too. Pasqualina Perrig-Chiello, a professor of developmental psychology at the University of Bern in Switzerland, found in a 2001 study of 260 middle-aged subjects that mothers frequently view their children’s departure optimistically. Fathers more often have mixed feelings, perhaps wishing that they had spent more time with their children. In a 2009 study, sociologist Barbara Mitchell of Simon Fraser University in British Colum- bia asked more than 300 parents from different cultural backgrounds about their children’s departure from home. Only a minority—younger parents with health problems and fewer children—reported emotional suffering. Overall, most parents reported positive feelings, such as pride at having been successful in raising their children so that they could move out.

Perhaps the biggest misconception of all is that the outlook at 40 is grim. The John and Catherine MacArthur Foundation Research Network on Successful Midlife Development, a Harvard University–based interdisciplinary project run by 13 scholars, surveyed more than 7,000 people in the U.S. between the ages of 25 and 74 on aspects of middle age. The results, which have spawned multiple books and scores of research papers, reveal midlife to be largely a period of calm and stability: most relationships hold together, most people stay healthy and many enjoy financial security.

And when Zurich’s Freund asked older people what age they would most like to be again, the majority chose their mid-40s. In some cultures, such as Japan, India, Kenya and Samoa, the concept of the midlife crisis is entirely imported. Maybe knowing that our misgivings about midlife are usually exaggerated— and temporary— can make the passage to late maturity just a bit more manageable.

References:

• Expecting Stress: Americans and the “Midlife Crisis.” Elaine Wethington in Motivation and Emotion, 24, No. 2, pages 85–103; June 2000.
• Is Well-Being U-Shaped over the Life Cycle? David G. Blanchflower and Andrew J. Oswald in Social Science & Medicine, 66, No. 8, pages 1733–1749; April 2008.
• Evidence for a Midlife Crisis in Great Apes Consistent with the U-Shape in Human Well-Being. Alexander Weiss et al. in Proceedings of the National Academy of Sciences USA, 109, No. 49, pages 19,949–19,952; December 4, 2012.
• Debunking Midlife Myths. Hanna Drimalla in Scientific American Mind, Vol. 26, No. 2. Pages 58-61, 2015.
• John D. and Catherine T. MacArthur Foundation Research Network on Successful Midlife Development: http://midmac.med.harvard.edu

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“Eye tracking for marketing purposes?!”

I was flabbergasted, and not in a good way.

This was my reaction a couple of years ago when I attended a training for a machine I was going to be using as part of the neuroscience research I was carrying out. I wanted to measure skin conductance and heart rate of volunteers whilst they were in the scanner. The company who had developed the machine proudly told how they were using eye tracking software for marketing purposes.

I’d become familiar with eye tracking during different research studies I’d been connected with. We’d hooked volunteers up to eye trackers during brain scans in the fMRI (function magnetic resonance imaging) when investigating autism, empathy and pain circuits. I also knew from my natural medicine background that eye movements are an integral part of some therapies: NLP (neuro-linguistic programming) practitioners observe the eyes to assess how a client stores and retrieves information (and can tell even if they are lying), and EMDR (eye movement de-sensitisation and reprocessing) uses eye movements to rework trauma.

The idea that monitoring my eye movements when entering a virtual supermarket to see if I went for branded products, or if my eyes went more to the health food section in order to gather information to push more products on us was one that made my flesh crawl. It all felt very science fiction to me, and far too invasive. This was just two years ago….Now Google has launched its Google Glass. So it seemed like a good time to dive into this whole subject for ‘On the Border’. In doing so I’ve had my own eyes opened and my resistance challenged to some advantages as well as manipulative disadvantages.

Loosely defined, eye tracking refers to any technology that can monitor the direction of our gaze and the behaviour of our eyes, in the process generating data that give clues to our intentions. Interactions with devices equipped with eye-tracking sensors and software can seem intuitive and effortless, as if our gadgets are reading our minds.

Not so incidentally, as the technology advances, researchers are learning ever more about the workings of our eyes and unobservable aspects of the mind: our thoughts and mental focus and the pathways into our consciousness. Eye tracking can reveal whether we are processing the things in front of us or are mentally adrift, whether we recognise a face or have never encountered it before— or whether we did encounter it but then forgot. Our new understanding of eye movements is also spurring development in a host of industries, especially gaming, computers and health care. Marketers are eager to tap into our gaze patterns, too, with implications for privacy.

Researchers developed eye tracking primarily to learn about basic visual processing (say, how we meld independent streams from each eye into a single mental image). Clinicians were also interested in how eye movements relate to disorders involving vision problems, such as vertigo. Initially eye tracking was a matter of simple observation. The experimenter would sit across from a person and take notes about the behaviour of the subject’s eyes.

Early findings were surprising. Despite our subjective experience of vision as a smooth sweep across a stable landscape, the movement of our eyes is anything but steady. In most instances, our eyes stay relatively still for extremely short periods (usually around a third of a second), followed by rapid jerks until they alight on their next target. The short, still periods are known as fixations, and the quick jumps are called saccades.

The main reason for the jerky behaviour is that our visual sweet spot is very small. Indeed, the part of the visual field that delivers a sharp image is about the size of a small coin held at arm’s length, with quality falling off sharply toward the periphery. So we move our eyes constantly to bring new pieces of information into central focus. That herky-jerky motion posed a puzzle for investigators: How, despite the constant movement, do we experience vision as stable?

Hence the quest for hardware that can track every movement of the eyes, no matter how fleeting. Early in the 20th century psychologist Edmund Huey of the Western University of Pennsylvania created a device that could correlate eye movements with the words on a page as someone reads. It was a rather invasive apparatus, involving a plaster cup, worn on the eyeball, with a tiny hole through which the subject could see. A lever was attached to the eyecup and to the lever a pen, which made contact with a rotating drum as the participant read. To minimize irritation, the eyeball was anesthetized with cocaine, and the head was held in place using clamps and a bite bar. Other early contraptions used combinations of contact lenses, suction cups, embedded mirrors and magnetic field sensors to triangulate the focus of the viewer’s attention.

Nowadays researchers rely on the way the cornea reflects light to chart the rotation of the eyeballs. In a typical experiment—say, to study reading or attention—a participant sits in front of a computer with her head on a chin rest. A small camera at the base of the computer zooms in on one (or both) of the eyes as diodes emit near-infrared light (people cannot perceive light at that wavelength, so they experience no discomfort). The light bounces back to the camera, and computer algorithms convert the reflection data into a real-time gaze path of the eye. By combining information about the pattern of corneal reflectance, the displacement of the pupil and the location of the computer in relation to the participant, tracking systems can tell precisely where the participant’s gaze falls on the computer screen. A greater challenge came when research moved beyond the laboratory. Spatial accuracy is critical in eye tracking because a minute error in measuring the orientation of someone’s gaze will throw off any interpretation of what the person is seeing. Achieving that precision is harder in the outside world because head and body movements can interfere with measurements of gaze location. So researchers developed devices that superimposed information about the gaze onto the environment, such as a helmet topped by a camera that melded a recording of eye movements with a real-time video of the subject’s field of vision. Today’s wearable tracking devices take the form of light-weight goggles, but the principle remains the same: a small sensor tracks the dark spot of the pupil to pinpoint the direction of the gaze, and a tiny camera mounted directly between the eyes records the scene.

Knowing What We See

Besides exposing the mechanics of vision, eye tracking can also help us understand the invisible elements of cognition: what we remember, how we feel, and what we are paying attention to, whether we are aware of it or not. For instance, eye movements can reveal when we are looking at something we have seen before, even if we have no memory of encountering it. In a 2012 study led by psychologist Deborah Hannula, subjects were asked to memorise an image of a face. When shown a panel of faces that included the original, the subjects spent more time examining the image they had seen before than those they had not. If the images instead included a slightly manipulated version of the original face, the subjects still tended to identify the altered image as the real thing. Yet their eyes were not fooled. The subjects spent less time looking at the manipulated images than the original, suggesting that the eyes recognized them as fakes. These findings have important implications for interpretation of eyewitness testimony— say, in gauging whether someone looking through a book of mug shots has seen one of the faces before.

Patterns in eye movements can also give us insights into thinking and emotion. In a 2009 study, researchers used eye tracking to examine how people regard threats. They discovered that the subjects’ eyes moved faster toward threatening faces and body postures than benign ones, suggesting that our oculomotor system is primed to detect imminent danger. Individuals who are scared or anxious also show a bias toward threatening objects and faces and have a harder time moving their eyes away from the threats than other people do. Reinforcing this finding, a 2014 study found that people are quicker to focus on an angry face in a crowd of happy faces than they are on a happy face in a crowd of angry faces, suggesting that danger more than singularity is what draws the eye.

Our eyes are also markers of mental effort. Eckhard Hess, a pioneer of pupillometry (the measurement of pupil size) in the 1960s, found that the pupils of his participants dilated when they performed challenging multiplication problems, much as our pupils widen when we enter a dimly lit room. The pupils are an ideally objective structure for research. Unlike our eye-balls, which we can consciously direct—say, by looking one way or another—we have no voluntary control whatsoever over our pupils. Researchers hope that analysis of pupil measurements will help reveal when workers are overtaxed, especially those in risky jobs such as air traffic controllers, baggage screeners, truck drivers and surgeons.

Similar research can help the desk-bound pay attention to what they are doing, too. Psychologist Erik Reichle is working on a system that can let people know when they are zombie reading—that phenomenon by which we move our eyes over text for a while without taking in a word we are seeing. In a 2010 study, Reichle had discovered that our eyes behave differently when we lose mental focus. If we are concentrating, our fixations tend to be shorter when we look at familiar words and longer when we look at less common ones. That variation is absent when we read mindlessly, even though our eyes are still hitting the mark. Now Reichle is trying to develop algorithms that can sift eye-tracking data and alert readers as soon as their attention wanders.

Practical Tracking

As we learn more about the relation between eye movements and the mind, eye-tracking technology is finding its way into real-world applications, especially in the control of digital devices, gaming and health care. Eye trackers can already replace the mouse for such tasks as clicking, zooming and scrolling. Users might click by staring at an icon for a period of time, zoom in or out by fixing on a location and pressing a controller key, and scroll by moving their eyes up or down.

Adding an eye-tracking system to a computer or tablet is apparently fairly simple. The devices, which incorporate a light source and sensor, are small and sleek and adhere to the bottom of a monitor or the frame of a laptop or tablet, connecting through a USB port. They are relatively affordable, with models from companies such as the Eye Tribe and Tobii costing approximately €100. Users install the relevant software and complete a quick calibration procedure (usually a training program that teaches the software the characteristics of the user’s eyes). Current devices require the user to do some programming (such as creating drivers), so they are not (yet) plug and play. Computers and tablets with built-in eye-tracking technology are expected to reach the market soon, including, according to rumours, an Apple iPad Pro. Indeed, Apple submitted a patent in 2013 for eye-tracking technology that would address the tendency of an image to fade from our perception if we stare at it too long.

Mobile devices that monitor eye movements are also making their way into the market. If you want a fumble-free shutter button on your iPhone, one app already lets you take photographs by winking. Google Glass will do the same. The Samsung Galaxy S4 and S5 phones already let users pause videos by looking away from the screen or turn pages on an e-book with a tilt of the head.

The industry most eager to adopt eye-tracking technology may be gaming. An eye-tracking version of a shooter game, for instance, would let players move their avatar around a virtual world by looking at the spot where they want to advance. Pressing a key might open a menu of weaponry; players would select items by blinking and attack by looking at the target and pressing the trigger key. According to an online story in the January 2014 Gizmag by Jonathan Fincher, gamers who tested early versions of the technology said that using it was a little uncomfortable at first, with the urge to reach for the mouse especially hard to resist, but in the end they found that aiming and shooting with their eyes was faster and more accurate. Eventually players equipped with eye-tracking gear will likely have a speed advantage over those using standard mouse controls, and nothing drives a technology like an arms race.

Good Medicine

Eye tracking is also on its way to becoming an important tool in health care. Already the technology has streamlined the screening and diagnosis of a variety of disorders with visual components, and it will soon help people with disabilities navigate the world.

On the diagnostic frontier, eye tracking is particularly useful in detecting Parkinson’s disease, schizophrenia, and a host of childhood maladies, including autism, attention-deficit hyperactivity disorder (ADHD) and dyslexia. People with these disorders have unique patterns of eye movements that simple computer tests can spot. In pioneering work at the University of Southern California, for example, neuroscientist Laurent Itti’s lab devised algorithms that have helped identify people with Parkinson’s with 90 percent accuracy and people with ADHD with nearly 80 percent accuracy. A 2014 study by psychologist Eva Nouzova of the University of Aberdeen and her colleagues reported progress in using eye tracking to diagnose major depression. And in work published in 2012 psychologist Philip Benson, also at Aberdeen, and his colleagues developed tests that can distinguish patients with schizophrenia from healthy controls with nearly perfect accuracy.

The schizophrenia test takes advantage of an anomaly in eye movements: when we track a moving object like a ball flying through the air, we follow the object smoothly, without saccades. The implication is that smooth pursuit uses different neural circuitry than activities such as reading. When people with schizophrenia try to follow moving objects, however, their eye movements are jerky. So to screen for schizophrenia, technicians ask subjects to follow a dot as it moves around a computer screen and flag anyone whose eyes show telltale saccades. (Benson’s team won an award for its research and will use the prize money to bring the program to market.)

Beyond diagnostics, researchers are using eye tracking to help people with physical disabilities live independently. Individuals with neurological disorders and brain and spinal cord injuries often have limited ability to communicate. Computers equipped with gaze-interaction technology would let people use their eyes to open a browser, find their e-mail inbox and “type” by selecting words on the screen. For those who cannot talk, voice-output systems would play the text through speakers. For most, the systems would likely supplant so-called BCI (short for brain-computer interface) spellers, in which a person observes a grid of letters while wearing a cap studded with electrodes that can identify brain activity. To select a letter in the grid, the user must focus on it for several seconds. Eye tracking, in contrast, can detect the location of a viewer’s gaze instantaneously.

Do You See What I See?

Like many new technologies, eye tracking raises a host of ethical and privacy concerns. In this increasingly data-driven age, we have cause to wonder who will have access to the kind of information our technology collects. Any number of people could be looking over our shoulders as we browse the Internet with an eye-tracking PC or drive a car with a tracker installed (such as Hyundai’s HDC-14 concept car). Could advertisers get hold of this information? What about insurance companies or the police?

Currently advertisers use cookies to track the Web sites you visit so they can serve you ads for products that might interest you. When computers come with eye-tracking systems, these advertisers could use information about where you are looking on a page to tailor the ads even more. Some users might find the fine-tuning helpful, but imagine if pop-up ads moved around a page with your gaze or the video ads on YouTube “knew” when you were not watching them and paused until you looked at them again. These tricks are well within the scope of the technology, and clashes with consumers are bound to occur.

In 2012, for instance, Microsoft patented eye-tracking technology for its Kinect gaming devices to let the company collect information about where users were looking on a screen while playing, causing worries that Microsoft would be tracking which ads gamers were looking at and for how long. The company got into hot water over privacy concerns the following year, with rumours that the company would sell Kinect data to marketers and use Kinect for targeted advertising. Microsoft was also planning to tailor ads to the mood of the user by running the images captured by the eye-tracking system through facial- expression analysis. Some Kinect users voiced concern that the device would be always on and always listening, like Big Brother. Microsoft responded with a series of statements in October 2013 assuring users that they would be able to turn off the device and ad-tracking features and that the company would not collect the data unless the user wanted it to.

The use of eye tracking as a means of identification is evoking more uneasiness. Researchers in the computer science department at Texas State University are testing biometric systems that can identify people from their unique eye-movement patterns as they read text or view a picture. In recent studies, the accuracy of eye tracking in identifying subjects was a little more than 70 percent. That rate is far below the accuracy of iris scans (90 to 99 percent) or fingerprints (up to 99 percent). As computing systems and tracking technologies develop, however, the gap will likely narrow. Even now the technology has clear benefits for home security and protection of technology. For example, intruders would be locked out of your computer because the system would know from their eye movements that they were not the owners. The technology is also easier on the subject than iris scans, which require the user to hold still. The worry, however, is that an eye-tracking ID system is amenable to covert and invasive deployment.

No gadget has more potential for invasiveness and general spookiness than Google Glass, a wearable computer that projects images through a series of lenses onto the user’s retina. Like most portable devices, it will have a camera, too, facing outward. Although the current beta version of Glass does not have built-in eye tracking, Google has filed a patent to incorporate the technology into head-mounted devices. The patent, which covers the ability to track gaze and measure pupil size, suggests that Google plans to assess user engagement when people look at ads. Gaze tracking would tell Google what the users were seeing (ads, objects, people); pupillometry would measure their emotional response to these objects and to people in the environment. Armed with these data, Google could deploy a “pay per gaze” system in which advertisers paid the company for each look at one of their ads. The technology would work with anything in the user’s field of vision, including billboards, magazines and other print media, as well as images displayed on Glass.

The ethical concerns are obvious: the device could potentially identify not only where people were when they were wearing it but also what, and whom, they encountered. Google’s patent addresses privacy issues by making the data collection anonymous and letting users opt out of this form of tracking. Yet will these assurances hold if someone on the NSA watch list happens to pass before your gaze?

In the end, even when eye-tracking technology lets us control the devices that are tracking us, our sense of command may be illusory. If the eyes are the windows to our souls, we need to know who else is looking through them.

References:

• The Moving Tablet of the Eye: The Origins of Modern Eye Movement Research. Nicholas Wade and Benjamin Tatler. Oxford university Press, 2005.
• The Oxford Handbook of Eye Movements. Edited by Simon Liversedge, Iain Gilchrist and Stefan Everling. Oxford university Press, 2011.
• High-Throughput Classification of Clinical Populations from Natural Viewing Eye Movements. Po-He Tseng et al. in Journal of Neurology, 260, No. 1, pages 275–284; January 2013.
• Look Into My Eyes. Arryn Robbins and Michael C. Hout. Scientific American Mind, Vol. 26, No. 1, pages 54-61; January/February 2015.

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You lie in bed in the morning, reluctant to get out from under the warm embrace of your duvet. After several bleary minutes, you finally rouse yourself, throw on some clothes and head to the office. Having arrived at your desk, you stare blankly as e-mail loads on your screen. When you first started this job, you derived deep satisfaction from addressing the day’s challenges efficiently and artfully. Yet the optimism that used to buoy you is long gone. Now your morning coffee gives you the only jolt of energy you’ll feel all day….

The details differ by profession, but this state of being is the essence of burnout. It undoes a person’s ability to pursue a happy, healthy and productive professional life. Given that many of us spend the bulk of our waking hours at work, burnout can pose a real threat to overall well-being.

Often it begins with pure exhaustion. When you are worn out, you invest less in your job. As a result, you accomplish fewer things and feel less effective than you did before. Because work has ceased to offer the same psychological rewards, you start to feel cynical about your role. This set of emotions— exhaustion, feelings of inefficacy and cynicism—feed off one another, producing a vicious cycle of deepening burnout.

So do you just quit? Quitting is probably not the answer, although you might want to look for a different job. To recover a professional joie de vivre, it helps to understand the basics of burnout from a psychological perspective. Decades of research have revealed several core truths about the syndrome. First, banish the idea that it arises from a personal failing. People who face burnout do not lack some essential quality, such as work ethic, resilience or self-confidence. When all goes well, we naturally tend to bring dedication and pride to our work. Burnout represents the erosion of these noble qualities. Research has consistently pointed to management practices and poor job designs as the leading causes. The ways supervisors lead, and the structure of employees’ workdays, fail to bring out the best in people.

If you suffer from burnout, your relationship with your job has gone sour. Just as a fight with a partner or close friend can exhaust you and cause you to pull away from that person, so can a soured relationship with your job sap your enthusiasm and alienate you. Relationships are complicated things, however, so there is no single solution, no magic bullet, no “one size fits all” approach. Yet with patience and optimism, anyone can find a path back to engagement.

The Rise of Burnout

The use of the term “burnout” began gaining popularity in the 1970s, especially among people working in human services. Herbert Freudenberger, a psychologist at an alternative mental health agency, and Christina Maslach, professor of psychology at the University of California, Berkeley, wrote early articles describing idealistic young professionals in health care and social work who were overextending themselves. They felt discouraged because they did not have sufficient resources to do their jobs well. Instead of building a better world, they felt they were marking time in a dysfunctional system.

Psychologists’ understanding of burnout has since broadened to include any job and a wide range of causes. The most familiar reason for burnout is exhaustion from working too hard with insufficient rest. Yet that condition alone does not cause burnout, nor is it the only route. New entrants to the workforce can find their hopes dashed on entering jobs incompatible with the values they have been taught. Midcareer employees can feel disappointed that they have not advanced as they had hoped. People in service jobs are susceptible because of the high tedium and inflexibility of their workdays. Any environment where conflict or incivility is rampant can also produce burnout.

Dozens of studies support the idea that burnout has three main components: exhaustion, cynicism and inefficacy. Experiencing one of these dimensions alone is a risk factor, but qualities of the workplace can conspire to produce the other two facets, pushing a person into true burnout. The three feelings tend to be related—for example, you would not stay in a purely cynical state over the long term. Either you would start to feel exhausted and ineffective, or something breaks the trend and you find a way to reengage with your work.

Ultimately the true culprit is a mismatch between a person and a job. You might not have the resources you need, or your bosses might expect you to complete a task in a way that clashes with your principles. For example, health care providers in surveys often cite tensions between their professional ideals—to be emotionally supportive to their patients—and the constraints that undermine that goal, namely insufficient staffing and outsized workloads. The
quantity of work is important, but the real trouble arises from an employee’s perception of his or her performance.

Another type of mismatch stems from lack of control. Letting people make decisions about how they spend their days is vital to a healthy work arrangement, but a sense of control can be easily eroded. Managers who set unrealistic expectations for an employee contribute to its loss. So do colleagues who do not communicate well. We all rely on others while doing our jobs, and poor communication can make our workdays more difficult and unpredictable than they need to be. When people feel that they lack control over their own work, they are particularly prone to feeling cynical and ineffectual.

Bosses who fail to express their appreciation also contribute to workers’ feelings of inefficacy. Indeed, research has shown that negative interactions with a supervisor incline a person toward burnout. Yet not all praise is created equal. For example, in the studies reported, there was one organisation in which employees resented an employee-of-the-year award. The rank and file perceived the accolade as an indicator of who was in the good graces of company leaders and little else. Seemingly inequitable promotions can similarly harm engagement. In a 2014 survey conducted by Leiter of people’s feelings of burnout, one respondent wrote, “It is difficult to watch the randomness of why some are promoted and others are ignored. It drains the spirit from you.” That interviewee directly linked a feeling of being unappreciated with a loss of energy—a strong indication of burnout.

Early Warning Signs

The emotional distress of this syndrome can persist for years. Because it can become chronic, researchers have investigated if it would be possible to predict—and thus potentially ward off—the emergence of burnout. In a study published in 2008, 446 employees were surveyed from an administrative department at a large university, first at the beginning of the investigation and then again a year later. Numerous areas of their work life were probed to assess burnout. The researchers were curious to see how people who scored high on only one of the three dimensions— say, only high cynicism or only high exhaustion—would rate a year later. If they became more burned out, the investigators wanted to know what tipping point might send them in that direction.

As it turned out, one such indicator was found: workplace fairness. People who perceived favouritism, cheating or other inequities were more likely to be burned out by the end of the study. Conversely, employees who viewed the workplace as a just environment tilted back toward engagement. A coincidental event during the year of the study brought the issue of fairness into stark relief. Investigators uncovered members of the department who were stealing from it. The final survey occurred soon after a few employees were apprehended and dismissed, so the researchers could assess how disruptive this event had been. The thefts undermined trust among colleagues, weakened employees’ sense of job security and, as a result, deepened burnout.

In a follow-up study of more than 4,000 forestry workers, published in 2013, Leiter and colleagues at the Finnish Institute of Occupational Health found that other factors could also be triggers for burnout. In this case, employees experiencing cynicism (but who retained high energy and efficacy) were more likely to re-engage if they felt their organisations communicated with them well, keeping them in the loop on important developments. Those without this belief slid into exhaustion and solidified their incipient burnout. For workers whose early-warning sign was feeling ineffective, the key factors were whether they could exercise diverse abilities and whether the job was predictable. What these results tell us is that there is not just one recipe for burnout. The context or culture of a workplace plays a major role.

The data further suggest that symptoms of burnout should be taken seriously. As part of the Finnish study, data was collected on participants’ purchase of psychotropic drugs, mainly antidepressants, between 2000 and 2008. The people who experienced increasing burnout were more likely than others to use these drugs in the subsequent decade. So if you notice yourself feeling chronically cynical, exhausted or ineffective at work, take a careful look at the characteristics of your job. It might be time to take some preventive action.

The Social Solution

Because burnout depends heavily on the specific relationship between a person and job, broad guidelines for recovery are hard to come by. Nevertheless, it now seems that improving the quality of workplace relationships may be one general way to intervene. Social exchanges between colleagues play a role in many facets of burnout.

First, your co-workers have the skills, information, materials and influence needed to get things done. As you might expect, people share more readily with individuals they admire and trust. Conversely, hostile workplaces eat away at a person’s ability to focus on his or her work. Consider, for example, this anecdote, also from Leiter’s 2014 survey, in which one person articulates the energy tax of negative interactions: “I love my work. I am an avid learner and a very positive person. But I work in a toxic workplace. This is a highly political environment that encourages competition between colleagues, backstabbing, gossiping and hiding information. I find going to work very difficult and come home exhausted.” Other participants in studies have similarly cited the emotional toll of unpleasant interactions. They describe feeling upset for days following a few rude words from a colleague and losing sleep over the incident—both factors that make it difficult to engage in what otherwise might be pleasurable tasks.

An opportunity to try to alleviate burnout arose in a meeting with the leaders of a hospital in 2008. These executives had taken reasonable action to strengthen the sense of community in struggling work groups, including changing team leaders and reassigning or dismissing identified troublemakers. Managers had brought in inspirational speakers and conducted team-building exercises, with minimal success.

To tackle this problem, Leiter and his research team made use of a promising approach already in place within the Veterans Health Administration (vha). In response to similar problems throughout the vha’s hospitals, a team led by Sue Dyrenforth, then director of the agency’s National Center for Organization Development, devised an intervention called CREW, which stands for civility, respect and engagement in the work-place. Knowing that burnout has a social angle, Leiter decided to deploy a version of CREW in several units of the hospital. Some of these units had a long history of problems, others were uncommunicative, and some functioned well but aspired to collaborate more.

Employees were divided into groups of 10 to 15 people from their same unit, and one person agreed to be the head facilitator. Because every team had its own sources of tension, a collection of activities was provided for the groups to choose from rather than instructing them to follow a single script. Before the experiment began, they researchers surveyed all the participants on their perceptions of civility in their unit as well as their own conduct, so their impressions could be compared at the beginning and the end of the program.

Over six months the teams met about once a week. The facilitator might kick off a session by asking a question such as “How do we show respect (or disrespect) for one another here?” Then attendees might do an exercise to help settle a dispute between two people. The meetings gave employees an opportunity to work through strained relationships and practice more productive ways of defusing emotions. During the rest of the week, participants were encouraged to practice specific civility behaviors and log any acts of kindness they witnessed.

In 2011 the results were published from applying CREW to a group of Canadian hospitals. These confirmed that improving workplace civility decreases burnout. Even more encouraging, the same researchers have since found that these gains remained when they were followed up one year later. The results suggest that CREW had esta lished new, self-sustaining patterns of social interaction.

Yet the reviews were not all glowing. The hospitals found the personnel cost of implementing CREW to be a burden. Participants had to go out of their way to fit the sessions into their workdays. Applying the lessons to their day-to-day work life also required sustained effort. Given the occasionally irksome nature of the program, it is actually pretty impressive that CREW can be effective at all ;=)

Finding Engagement

Given that not every company is about to start implementing CREW, what is an individual worker to do? Many corporations may see squeezing every bit out of employees to be to their advantage. Organisations by and large do not expect to retain their employees forever, so they are unlikely to serve their workers’ long-term interests. Employees thus must shoulder the responsibility of maintaining a sustainable work environment themselves.

The “company of one” perspective encourages individuals to think of themselves as independent contractors even when they are in an employment situation. Employees’ primary focus should remain on preparing themselves for the next career opportunity that may arise. Doing so will require establishing work habits that depart from an employer’s vision. In short, thriving in today’s work world—where cost cutting is a prime objective and employees are routinely stretched too thin—requires serious self-management. You will need to stick to a routine, even when pressured to behave otherwise.

Because burnout is a relationship issue, the individual has some, but not complete, control over circumstances. What follows are a few basic strategies for improving your contribution to the relationship. The good news is that many of these suggestions happen to be good for life in general, so you will benefit in many ways from developing these habits.

First up is fitness. A healthy way of life increases your resilience. A combination of sufficient exercise, nutrition and sleep will reduce your vulnerability to exhaustion. Although the job will not change, you will increase your endurance—and maybe even learn to thrive.

Closely related to fitness is a habit of integrating recovery cycles into your life. Demanding work depletes your physical, emotional and cognitive resources. As the saying goes, there is a reason it is called work. Your personal life should afford opportunities to enjoy relationships, catch up on sleep and take time for reflection. To reverse a trend toward burnout, a key step is to establish a firm structure for recovery activities. Lacking a structure, you will not make time for recovery in the course of a busy life.

You can incorporate small amounts of exercise and recovery into the workday, too. The strategy here is simple: get off your arse! Set an alarm every 30 minutes as a signal to get up and walk around. You can devise some activities that would convince an observer that this meandering is a necessary part of your work.

Now let us incorporate the social angle. As demonstrated with CREW, improving the quality of day-to-day exchanges among colleagues reduces burnout. You do not need your entire team to join you on this journey, but if you can recruit a friend or two to share a burnout-reduction project (a short midday walk, perhaps) the mutual support can be powerful.

Receiving good vibes from others is an uplifting experience, but so, too, is expressing them to others. Keep a tally of your own acts of kindness toward colleagues. To whom did you express appreciation today? Collaborating with a companion will, again, help you get the most out of this project.

Last, consider something the Americans call job crafting. You very likely have more latitude in your work than you think. Job crafting is an analytic approach that involves identifying the duties you find tedious and the aspects you find fulfilling. You can develop a plan to spend a bit more of your day on the good parts. Those increments can add up over time. Just ensure that the additional time you are spending on the fulfilling tasks makes a meaningful contribution, so you keep aligned with your colleagues and supervisor/boss.

These ideas may sound like a big investment, but the truth is that burnout can be hard to shake. Once the syndrome has set in, you must commit to a deliberate practice to find your way back to a healthy, fulfilling relationship with work. Yet it can be done, so let’s put that out as a New Year’s Resolution.

References:

■ Early Predictors of Job Burnout and Engagement. Christina Maslach and Michael P. Leiter in Journal of Applied Psychology, Vol. 93, No. 3, pages 498–512; May 2008.

■ The Impact of Civility Interventions on Employee Social Behavior, Distress, and Attitudes. Michael P. Leiter, Heather K. Spence Laschinger, Arla Day and Debra Gilin Oore in Journal of Applied Psychology, Vol. 96, No. 6, pages 1258–1274; November 2011.

■ Organizational Predictors and Health Consequences of Changes in Burnout: A 12-year Cohort Study. Michael P. Leiter et al. in Journal of Organizational Behavior, Vol. 34, No. 7, pages 959–973;
October 2013.

■ Conquering Burnout. Michael P. Leiter and Christina Maslach in Scientific American Mind, Vol. 26, No. 1, pages 30-35; January/February 2015.