Physical signs of burnout that we blame on everything else

He put the headache down to not drinking enough water. His digestion to the new canteen at work. The third cold of the winter to the children bringing it home from nursery. His heart pounding at night to the coffee he’d drunk too late. The pain in his lower back to a bad chair. Each explanation made perfect sense. And each was probably partly true.

Only when he once listed them all aloud, in a single sentence, did he fall silent. “When I say it like that, it sounds as if something is wrong with me. But each one on its own is completely normal.”

This may be the most accurate description of how people experience the physical signs of burnout. Any single sign can always be explained by something else. Only the pattern — several signs at once, lasting for months and not settling — tells you that the body is not talking about the canteen or the chair, but about having been on standby for too long.

I have written about how to recognise burnout in general in Burnout is not laziness: signs your nervous system is asking for a break. Here I focus only on the body — and on the question of when you need to see a doctor first.

Why the body speaks first

When we are under pressure, the body triggers the stress response. The sympathetic branch of the autonomic nervous system speeds up the heart and breathing, the muscles tense, digestion slows. The adrenal glands release cortisol, which helps mobilise energy. All of this is extremely useful when it is short-lived: before an exam, during an argument, in danger on the road.

The trouble begins when the response does not switch off. The neuroendocrinologist Bruce McEwen used the term allostatic load for the price the body pays for adapting to stress over a long period. Systems that are meant to work in short waves start working all the time — and slowly wear out. You can read more under the concept of chronic stress.

The body often speaks before the mind does. The head has many ways of persuading itself that it can keep going: “it’s not that bad”, “everyone works like this”, “it’ll be better after the holiday”. The body doesn’t listen to these stories. When the reserves are used up, it has its own way of saying so.

In 2017 Brazilian researchers led by Denise Salvagioni reviewed 61 prospective studies — studies that follow people over time — on the consequences of job burnout. Among the physical consequences that burnout predicted, they found high cholesterol, type 2 diabetes, coronary heart disease, musculoskeletal pain, prolonged fatigue, headaches, digestive and respiratory problems, and serious injuries. Burnout, then, is not only “in your head”. It is a state that writes itself into the whole body.

Headaches and muscle pain

The most common is the tension headache — the one people describe as a band around the head or as pressure on the forehead and temples. It often starts in the afternoon and grows stronger towards evening. Under prolonged strain, the muscles of the neck, shoulders and jaw don’t relax even at night — many people only find out that they grind their teeth from their dentist.

It is similar with back and lower-back pain. Tension that in the short term is part of being ready for action becomes a permanent posture. And the pain is not only mechanical: prolonged stress also changes how the nervous system processes pain, so it is felt more strongly and for longer. There is more on this connection under the concept of pain and emotion.

Why do we put this down to something else? Because for pain there is almost always a physical reason available that is tangible and fixable: a new pillow, a new chair, more water. It is easier to buy a new pillow than to admit that your job has you by the throat.

Digestion: the second brain under pressure

The gut is one of the organs that responds most strongly to stress. When the body is on standby, digestion slows down or — for some people — speeds up. In periods of heavy strain, people describe bloating, cramps, diarrhoea or constipation, nausea in the morning, a burning feeling in the stomach, loss of appetite or, on the contrary, a constant need for food.

Digestive problems are especially misleading because they really do have many possible causes — food, infections, intolerances, medication. That is why seeing a doctor is particularly important here. But it is worth noticing whether the problems settle down during a holiday and come back on Sunday evening. That pattern says a lot.

There is a constant conversation between the gut and the brain, in which the vagus nerve plays an important role. When the nervous system is in a state of alarm for a long time, this conversation changes: the gut becomes more sensitive and its signals louder. That is why, in periods of exhaustion, people often feel a stomach they had never even noticed before. This is not imagination, but a body that has switched into a different mode of functioning.

Frequent infections: when the immune system gets tired

Short-term stress even gives the immune system a slight boost. Long-term stress weakens it. In a well-known study, Sheldon Cohen and colleagues deliberately exposed healthy volunteers to cold viruses and found that those who reported more stress fell ill more often.

In burnout this shows up as colds that follow one after another, sore throats, cold sores that keep coming back, wounds that heal more slowly. A Dutch study of employees found that people with more signs of burnout more often reported common infections such as colds and flu-like illnesses.

Here the explanation “the kids brought it home from nursery” is often completely true. The only question is why every infection now takes hold when before it didn’t.

Heart and blood pressure

A pounding heart, the feeling that your heart is skipping beats, tightness in the chest, raised blood pressure in an otherwise young person — these are the signs that frighten people most and most often bring them to A&E. The results are then often normal, which is both a relief and a source of confusion.

The confusion is understandable. If the heart is healthy, why is it pounding? The answer is often that the heart is not ill, but it is constantly under the influence of stress hormones and the sympathetic nervous system, which keep driving it on. Some people also experience panic attacks, which at first, because of the physical sensations, they mistake for a heart attack. It is right that they are examined at such times — and it is right that, after normal results, they ask themselves what has been keeping them on standby for so long.

Research shows, however, that the link between burnout and the heart is not only in how it feels. Israeli researchers led by Sharon Toker followed almost nine thousand employees for several years and found that burnout was associated with a higher risk of coronary heart disease — even after taking other known risk factors into account.

Important: pain or tightness in the chest spreading to the arm, neck or jaw, difficulty breathing or fainting are not things to put down to burnout. Call 112 in Slovenia straight away.

Sleep that doesn’t refresh

People with burnout often sleep enough hours but wake up tired. Or they fall asleep exhausted and wake at three with a full head. A study by Galit Armon and colleagues showed that burnout and insomnia predict each other: those who sleep badly burn out more often, and those who are burning out more often start sleeping badly.

The background is a constant arousal of the nervous system that cannot settle down in the evening. I wrote about this in more detail in Hyperarousal: why chronic insomnia is not a sleep problem but an arousal problem. Afternoon coffee is rarely the real culprit. It is more an attempt to overcome the tiredness that the poor sleep itself creates.

Why we put the signs down to everything else

It is no accident that people explain away the physical signs of burnout for so long. There are several good reasons for it.

The signs come gradually. Nobody falls ill with burnout in a week. A headache comes once a month, then once a week, then every day. People get used to gradual decline, and the new state becomes “normal”.

A physical explanation carries less shame. Saying “I have a sensitive stomach” is easier than saying “I can’t cope any more”. In a culture that values productivity, physical illness is an acceptable reason to rest, while mental exhaustion often isn’t.

We hear our own body poorly. The ability to perceive the body’s inner states is called interoception. People who have learned to override tiredness, hunger and pain because they had to keep working often notice a physical sign only when it is very loud.

We don’t know where to look. A doctor deals with one organ at a time, and a specialist only with their own. The headache goes to the neurologist, the stomach to the gastroenterologist, the heart to the cardiologist. Each finds that their organ is fine, and nobody sees the whole picture. That is why it is so important that you or your GP put the signs side by side.

This is how a conversation might look when these explanations begin to crumble (a composite, not a real person):

“I’ve been to my GP five times this year. Each time for something different.”
“What did she say?”
“That the results are fine. That I should get some rest.”
“And did you?”
A smile. “When? That’s why I went to her — so she’d give me something to keep me working.”

That short sentence contains the whole problem: the body has become an obstacle to be removed so that work can carry on. Not a message worth listening to.

When to see a doctor first

I want to be very clear here, because this may be the most important part of the article. Don’t put physical signs down to burnout before a doctor has ruled out physical causes. Tiredness, feeling unwell and difficulty concentrating are shared by very different conditions.

Depending on your symptoms, your GP may check whether it might be:

• thyroid disease — an underactive or overactive thyroid can cause tiredness, weight changes, a pounding heart, restlessness or low mood;
• anaemia or iron deficiency, which shows itself in tiredness, breathlessness and pallor;
• a deficiency of certain vitamins, for example vitamin B12;
• diabetes and other metabolic disorders;
• the after-effects of infections, including prolonged fatigue after viral illnesses;
• breathing disorders during sleep, which cause unrefreshing sleep;
• depression or an anxiety disorder, which can also show up mainly in the body — more on this in Depression and the body: pain, fatigue and digestion.

The list is not complete and is not meant for self-diagnosis. It is meant to get you to the doctor and to tell them about all your signs together, not just the one that bothers you most this week.

Exercise: a two-week body diary

This exercise helps you see the signs as a pattern rather than as random events. It is also very useful for a visit to the doctor, because you can show them concrete notes instead of the vague “I haven’t felt well for a while”.

1. Every evening, write down three things: how you slept the night before, what physical problems you had during the day (head, stomach, muscles, heart, throat) and how strong they were on a scale from 0 to 10.
2. Next to each problem, note what was happening that day. A meeting, an argument, a deadline, a day with no obligations. No explanations, just facts.
3. After a week, look for repetitions. Does the headache appear on certain days? Does your stomach settle at weekends? What happens on Sunday evening?
4. Write all the signs on one sheet, with how long and how often, and take it to your GP.
5. Once physical causes have been ruled out, take the sheet out again and ask yourself: if my body were a colleague, what would it have been trying to tell me for months?

The last step is not meant for diagnosing yourself. It is meant to help you start listening to your body as a source of information rather than as a machine that has broken down. If that is hard, a simple exercise such as breathing with a longer out-breath can help, letting your nervous system know, at least for a few minutes, that it is not in danger.

Many people, at this point, ask themselves for the first time which stage of burnout they are actually in. I wrote about how burnout develops over time and what helps in each stage in The three stages of burnout: where you are now and what you need.

Where this explanation doesn’t apply

Because I am writing about the link between burnout and the body, I also need to say where the limits of this explanation lie.

Not every physical sign is burnout. The greatest danger of this article would be for someone to read the list, recognise their headaches and conclude that their job is to blame — while it is something that needs treatment. Physical illnesses often begin with exactly such non-specific signs as tiredness and feeling unwell.

Doctors can also get it wrong in the opposite direction. People, especially women, sometimes hear “it’s just stress” before all the tests have been done. If the signs persist and get worse, you have the right to ask what has and hasn’t been ruled out, and to ask for a second opinion.

Burnout and physical illness don’t exclude each other. Someone can have an underactive thyroid and be burnt out at the same time. Treating one does not resolve the other.

“Psychosomatic” does not mean “made up”. Pain caused by prolonged stress is just as real as pain from an injury. There is more on this in “The tests are normal, but it still hurts”: what therapy knows about psychosomatics and under the concept of psychosomatics.

What to remember

• The physical signs of burnout are real — research links burnout with pain, digestive problems, infections, poor sleep and cardiovascular disease.
• Each sign on its own has another explanation. A pattern of several signs lasting for months says more.
• See a doctor first: thyroid problems, anaemia, vitamin deficiencies, blood sugar and other conditions can look similar.
• Chest pain, difficulty breathing or fainting: call 112 in Slovenia at once.
• Once physical causes have been ruled out, your body is not a broken machine, but a message worth listening to.