Stress

The International Journal on the Biology of Stress

ISSN: 1025-3890 (Print) 1607-8888 (Online) Journal homepage: http://www.tandfonline.com/loi/ists20

Executive function and attention in patients with

stress-related exhaustion: perceived fatigue and
effect of distraction

David Krabbe, Susanne Ellbin, Michael Nilsson, Ingibjörg H Jonsdottir & Hans
Samuelsson

To cite this article: David Krabbe, Susanne Ellbin, Michael Nilsson, Ingibjörg H Jonsdottir & Hans
Samuelsson (2017): Executive function and attention in patients with stress-related exhaustion:
perceived fatigue and effect of distraction, Stress, DOI: 10.1080/10253890.2017.1336533

To link to this article: http://dx.doi.org/10.1080/10253890.2017.1336533

Accepted author version posted online: 29

May 2017.

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Executive function and attention in patients with stress-related exhaustion:
perceived fatigue and effect of distraction

David Krabbe1, Susanne Ellbin2, Michael Nilsson3,4,5, Ingibjörg H Jonsdottir2, Hans

Samuelsson,1,6,7.

1. Neurorehabilitation Unit, Sahlgrenska University Hospital, 400 43 Gothenburg, Sweden.

2. Institute of Stress Medicine, Carl Skottsbergsgata 22B, 413 19 Gothenburg, Sweden.

3. Center for Brain Repair and Rehabilitation, Department of Clinical Neuroscience, Institute of Neuroscience
and Physiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.

4. Florey Institute of Neuroscience and Mental Health, Parkville, Melbourne, Australia.

5. Hunter Medical Research Institute (HMRI) and University of Newcastle, Newcastle, Australia.

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6. Department of Psychology, University of Gothenburg, Gothenburg, Sweden.

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7. Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation, the
Sahlgrenska Academy at the University of Gothenburg, 413 45 Gothenburg, Sweden.
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Correspondence to:

David Krabbe
Neurorehabilitation Unit
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Sahlgrenska University Hospital,

400 43 Gothenburg, Sweden.
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Tel: +46 31 3425687

email: david.krabbe@vgregion.se
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Keywords: Burnout, Exhaustion disorder, cognitive function, neuropsychological, tiredness,

effort approach.
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Abstract

Cognitive impairment has frequently been shown in patients who seek medical care for stress-

related mental health problems. This study aims to extend the current knowledge of cognitive

impairments in these patient by focusing on perceived fatigue and effects of distraction during

cognitive testing. Executive function and attention was tested in a group of patients with

stress-related exhaustion (n=25) and compared with healthy controls (n=25). Perceived

fatigue was measured before, during and after the test session, and some of the tests were

administered with and without standardized auditory distraction. Executive function and

complex attention performance was poorer among the patients compared to controls.

Interestingly, their performance was not significantly affected by auditory distraction but, in

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contrast to the controls, they reported a clear-cut increase in mental tiredness, during and after

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the test session. Thus, patients with stress-related exhaustion manage to perform during
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distraction but this was achieved at a great cost. These findings are discussed in terms of a

possible tendency to adopt a high-effort approach despite cognitive impairments and the
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likelihood that such an approach will require increased levels of effort, which can result in
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increased fatigue. We tentatively conclude that increased fatigue during cognitive tasks is a

challenge for patients with stress-related exhaustion and plausibly of major importance when

returning to work demanding high cognitive performance.

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Lay summary

Patients with stress-related mental health problems frequently show cognitive impairments.

Here we show that patients with stress-related exhaustion report increased fatigue compared

to controls when performing cognitive tasks. Distraction does not affect cognitive

performance but achieving results on cognitive tests comes at a great cost for the patients. We

tentatively conclude that increased fatigue during cognitive tasks is a challenge for patients

with stress-related exhaustion and plausibly of major importance when returning to work

situations demanding high cognitive performance.

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Introduction

Patients seeking care for stress-related mental health problems often report cognitive

dysfunction as a main problem. The relationship between burnout and cognition has been

addressed in previous research and several studies suggest a connection with cognitive

deficits (Eskildsen, Andersen, Degn Pedersen, Kjaer Vandborg, & Hviid Andersen, 2015;

Jonsdottir et al., 2013; Oosterholt, van der Linden, Maes, Verbraak, & Kompier, 2012;

Rydmark et al., 2006; Sandström, Nyström Rhodin, Lundberg, Olsson, & Nyberg, 2005; van

Dam, Keijsers, Eling, & Becker, 2011; van der Linden, Keijsers, Eling, & van Schaijk, 2005;

Öhman, Nordin, Bergdahl, Slunga Birgander, & Stigsdotter Neely, 2007). In particular,

inferior performances have been demonstrated for executive functions, attention and memory

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(Deligkaris, Panagopoulou, Montgomery, & Masoura, 2014). Here we extend the current

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knowledge of cognitive problems in patients with stress-related mental health problems, by
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studying the fatigue related to performing cognitive tasks and the effects of including

concurrent disturbing stimuli during testing.

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Many patients seeking medical care for stress-related exhaustion are highly
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educated and thus most probably holding positions that are cognitive demanding (Glise,

Ahlborg, & Jonsdottir, 2012). The cost of performing cognitive demanding tasks is thus an

important issue and plausibly a major challenge for these individuals (Oosterholt, Maes, van
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der Linden, Verbraak, & Kompier, 2014.

Increased sensitivity to disturbing sounds could constitute a problem during

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stress exposure and exhaustion (Hasson, Theorell, Bergquist, & Canlon, 2013; Horner, 2003).

In clinical practice the patients often describe it as difficult to concentrate when exposed to

disturbing auditory stimuli. Background sounds, such as overhearing people talking are

thought to be particularly bothersome. To our knowledge the present study is the first to
include concurrent disturbing human voices during the performance of demanding cognitive

tasks.

The primary aims of this study were to explore perceived fatigue and the effects

of distraction when performing executive and complex attentional tasks. The main hypothesis

is that patients with stress-related exhaustion will report higher levels of fatigue during

cognitive test session compared to healthy controls. We also hypothesize that the patients in

comparison with controls will be more affected by auditory distractions during their test

performance.

Method

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Participants

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This study consists of 50 participants (25 patients and 25 healthy controls). All
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patients fulfilled the criteria for Exhaustion disorder (ED) (Table 1). These criteria were

established by the Swedish National Board of Health and Welfare in 2005 and assigned the
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F43.8A code of the International Classification of Diseases and Related Health Problems
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(ICD-10; World Health Organization 1992).

[Table 1 near here]

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Burnout and ED seem to be closely related in terms of symptoms and it has been shown that
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most patients who meet the diagnostic criteria for ED also can be defined as burned out

(Jonsdottir, Hägg, Glise, & Ekman, 2009; Glise et al., 2012). One major difference between

ED and burnout is that ED is defined by clinical criteria whereas burnout is a psychological

construct based on self-reports using different rating scales. The clinical manifestation of
patients with stress-related exhaustion is comprehensively reviewed in a recent paper by

Grossi and wo-corkers (Grossi, Perski, Osika, & Savic, 2015).

The patients in this study were referred to an outpatient stress clinic in the

Region Västra Götaland, Sweden, from primary care units or occupational health care centers.

The referral criteria were (1) “probable ED” with no apparent somatic disorder or abuse that

could explain the exhaustion and (2) a maximum duration of sick leave of 6 months.

Consecutive inclusion was applied, i.e. all patients who entered the stress clinic (during

August 2010 to January 2011) and eligible to participate in this study were asked to

participate, until the intended number of patients was reached. Of the eligible patients eight

were not included in the final sample: one moved to another part of the country, one did not

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respond to our calls, and six declined participation. The patients not included (n=8) did not

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differ from the patients included (n=25) with regard to level of burnout, depression and
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anxiety (data not shown). The diagnostic procedure was conducted by a senior physician at

the stress clinic, based on an extended anamnesis and a clinical examination. Co-morbid
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depression and/or anxiety were allowed, but patients with recurrent depression were not
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included in this study. Antidepressants were used by 46% of the patients at the time of the

study. One patient came from another clinic and data concerning antidepressants and self-

reported symptoms of depression and anxiety was missing for this patient.
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Twenty-five healthy controls were recruited from three different sources, mainly

from an ongoing longitudinal cohort study predominantly including health care workers.
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Several controls were also recruited from a private company in Gothenburg or among students

at the University of Gothenburg in order to recruit controls that matched the patient group.

These participants were offered financial compensation for participating. A first screening of

eligibility was made by telephone, based on age, level of education, and the exclusion criteria.

The exclusion criteria were 1) neurological disease that could affect neuropsychological
outcome, 2) current somatic disease causing fatigue, 3) previous or ongoing ED, and 4)

anxiety and/or depressive symptoms during the last six months requiring health care. Three

individuals were excluded based on these criteria; one met the first and two met the third

criterion. One person was not able to visit the clinic during the study period and thus did not

participate in the study. At the beginning of the test session the eligibility was further

investigated, using a standardized questionnaire, and another four controls were then

excluded; three were found to meet the third exclusion criterion and one met the fourth. The

control group was matched to the ED-group by age and sex, and a maximum level of years of

education was set for the controls, corresponding with the maximum level observed in the

patient group. The study was conducted in accordance with the Declaration of Helsinki and

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approved by the regional ethical review board in Gothenburg, Sweden. All subjects gave

written informed consent to participate in the study. TE

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Measurements
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Self-reported burnout and symptoms of depression and anxiety

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Self-reported burnout was measured with the Shirom-Melamed Burnout

Questionnaire (SMBQ). The questionnaire includes 22 items (graded 1-7) measuring different

aspects of burnout syndrome (Melamed, Kushnir, & Shirom, 1992; Lundgren-Nilsson,

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Jonsdottir, Pallant, & Ahlborg, 2012). A mean score >4.4 has previously been used as cut-off

for clinical burnout (Lundgren-Nilsson et al., 2012). Stenlund et al. (2007) reported the mean
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score of the total scale in patients with burnout to be 5.7 for women and 5.6 for men.

Cronbach´s alpha for the SMBQ burnout total score was 0.82. Symptoms of anxiety and

depression were measured on the Hospital anxiety and depression scale (HADS), defined as

scores ≥8 on anxiety and/or depression (Zigmond & Snaith, 1983). Cronbach´s alpha for

HADS was 0.84 for anxiety and 0.57 for depression.

Self-reported fatigue and cognitive function

Level of fatigue was measured with the Swedish version of the Fatigue Impact

Scale (FIS; Flensner, Ek, & Söderhamn, 2005). The FIS consists of 40 items describing how

fatigue affects daily life situations. Participants rate the impact and consequences of fatigue in

these situations on a five-level scale, ranging from no problem (0) to extreme problem (4).

Total range in score is 0-160.

Subjective cognitive function was assessed with a Swedish version of the

Prospective and Retrospective Memory Questionnaire (PRMQ; Rönnlund, Mäntylä, &

Nilsson, 2008) and with the Cognitive Failures Questionnaire (CFQ; Broadbent, Cooper,

FitzGerald, & Parkes, 1982). The PRMQ consists of 16 items measuring the frequency of

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memory failures. Answers are given on a 5-point Likert-type scale, ranging from never (1) to

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very often (5). Total range is 16-80. The CFQ consists of 25 items measuring the frequency of
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cognitive failures in daily life. A 5-point Likert-type scale is used for answering, ranging from

never (0) to very often (4). Total range is 0-100.

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Estimate of general cognitive ability

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In order to estimate the general cognitive level, a Swedish version of the

National Adult Reading Test (NART; Tallberg, Wenneborg, & Almkvist, 2006) was used,

measuring the ability to pronounce irregularly spelled words (ISW). This ability relies on
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implicit memory processes and is thought to be stable during normal aging and after brain

damage or disease, and it is positively related to general cognitive level. Tallberg et al (2006)
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have shown that the ISW-score in combination with gender and years of education in a

regression-based formula improves the estimate of general cognitive ability. This regression

model was used in the present study in order to compute predicted WAIS-full scale IQ-score.
Neuropsychological tests

Executive functions

Verbal fluency in a divided attention condition. A modified version of the

Controlled Word Association Test (COWAT) was used. COWAT is a test of verbal fluency,

where the participants are asked to generate as many words as possible beginning with the

letters F, A, and S (Lezak, Howieson, Bigler, & Tranel, 2012). The time available for this task

is one minute for each letter. The COWAT was modified in that a card-sorting task was

administered simultaneously with the main task. For each generated word, the participants

were to pick a playing card from a deck of cards and then sort it according to the principle

even/uneven into two different piles (the jacks, queens, and kings were removed from the

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deck, and the aces could correspond to either 1 or 14). This modification was adapted from

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Öhman et al (2007). The score obtained in this test was total number of generated words.
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Working memory. The 2-back condition subtest from the Test of Attentional

Performance Version 2.1 (TAP; Zimmerman & Fimm, 2007) was used. A sequence of single
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digit numbers is presented at the centre of a monitor. The digits are presented one by one at
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three-second intervals. The participants are required to respond when the current digit is the

same as the one shown two steps back. The test contains 15 target stimuli and the duration is

five minutes. The task is considered a test of working memory and a high degree of
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attentional control is also required in the test. The number of omissions is the most important

parameter of performance, since it is related to lack of control in the flow of information. The
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number of errors may also indicate lapses of attention. The numbers of omissions and errors

were selected for analysis in this study.

Complex attention. A modified version of the Paced Visual Serial Addition Test

(PVSAT) was used in this study. PVSAT (Fos, Greve, South, Mathias, & Benefield, 2000) is

an analog of the Paced Auditory Serial Addition Test (PASAT). In these tests of complex
attention, working memory and information processing speed, the participants are presented

with a sequence of numbers and asked to add each number to the one immediately preceding

it, and to say the answer out loud. In the PVSAT specifically designed for this study, the

numbers were presented one by one in the centre of a 15 inch PC-laptop screen. The font was

Times New Roman with font size 96. Each number was presented for 2 sec, and was then

immediately replaced by the subsequent number. A series of 61 numbers were presented,

which gives a possible maximum score of 60 correct additions.

Standardized distraction (2-back and PVSAT): Both the 2-back test and the

PVSAT were administered twice, the second time a CD-recording with a female and a male

voice was played simultaneously with the test administration. The voices read out different

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numbers (0-9), and the reading of numbers was intermittently interrupted by “Hello!”,

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“You!”, and “Hello you!” Numbers were chosen because of the potential interference with the
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main task. The readings were varied by using low and high voices and different intervals. The

numbers were read from a standardized protocol and recorded. There was one reading for the
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2-back and one for the PVSAT, and the same standardized recordings were used for all test
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administrations. Before patients and controls were tested, the sound level was tested in the

different test rooms, and no differences were found. When the second administration of the 2-

back test had been in progress for one minute, the disturbing sound was gradually introduced
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and then lasted for the remainder of the test. The disturbing noise was started at the same

time as the main task in the administration of the PVSAT. A difference score was given for
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the scores with and without distraction (subtracting one score from the other). The difference

scores were computed so that a negative score always meant an inferior performance during

distraction.
Basic attention

The three measures of hit reaction time, commission errors and omissions from

the Conners´ Continuous Performance Test II (CPT-II; Conners, 2004) were used for

investigating aspects of basic attention. The CPT-II lasts for 14 minutes and measures

different components of attention. The participants are required to respond to letters appearing

on the monitor, except for the letter “x”. The inter-stimulus intervals are 1, 2, or 4 seconds.

The display time is 250 milliseconds. The variable hit reaction time (the mean response time

for all target responses) measures general processing speed. The variable commissions

measure basic selective attention and inhibition and the variable omissions measure attention.

Sustained attention/performance

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The Continuous Performance Test II (CPT-II) also includes measures of the

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consistency of performance over time. The results from the test (as described above) can be
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partitioned into six equal blocks and the performance can thus be examined by block, which

enables assessment of change over time in the individual responses. The following three
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measures were included for describing different aspects of variability across time/block: 1)

variability of standard error, a measure of “within respondent” variability – the degree of

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variation in response speed between the different blocks throughout the test, 2) hit reaction

time by block, which measures change in reaction time at the initial blocks compared to the
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final blocks, and 3) standard error by block, a measure of changes in response variability

when comparing initial blocks with final blocks.

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Mental tiredness during and after the test administration

A self-rating scale of fatigue was specifically designed for this study, measuring

the participants´ perceived mental weariness before, during (i.e. in the middle of), and after

the testing session. The participants were asked to rate their mental tiredness on a scale

consisting of the following 7 levels: “No tiredness”, “Mild”, “Moderate”, “Average”,

“Severe”, “Very severe”, and “Worst thinkable tiredness”. The scale did not contain numbers,

and all the three ratings (before, during and after) were on the same paper; thus the

participants could see their previous ratings. For statistical analyses, the ratings were given

numerical values ranging from 1 (“No tiredness”) to 7 (“Worst thinkable tiredness”).

Procedure

Each participant was tested on one occasion by the same psychologist. The

administration of the computerized tests included an introductory practice run. The sessions

lasted for 1.5-2 hours, including a short break and feedback. Prior to the testing session, the

questionnaires FIS, PRMQ and CFQ were sent to the participants by post, completed at home

and brought to the testing session. General cognitive ability was investigated before the

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testing of executive and attentional functions. The tests and self-ratings of mental tiredness

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were administered in the following standardized sequence: an initial self-rating of tiredness,
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modified COWAT, 2-back test, 2-back test with distraction, the second self-rating of

tiredness, a short break, CPT-II, PVSAT, PVSAT with distraction, the third self-rating of
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tiredness. The test session also comprised a test of prospective memory but this measurement
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was not included in this study.

Statistical analysis
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Non-parametric statistics were used due to the small size of the groups and

skewed distributions. Between-group comparisons were made with Mann-Whitney U-tests,

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and for categorical data Pearson Chi-square and Fisher´s exact test were used. Holm–

Bonferroni correction for multiple comparisons (1979) was used for the analyses of the effects

of distraction and of experienced tiredness during testing to counteract the probability of a

Type I error. Correction was also made for post-hoc subgroup comparison of commission

errors in CPT-II. No correction was applied for demographic background data. Effect sizes
were given as η2 based on the Chi-square from nonparametric two-sample comparisons, using

the formula: Chi-square/N-1 (Green & Salkind, 2008). The interpretations were: 0.01=small

effect, 0.06=moderate effect, and 0.14=large effect (Cohen, 1988). In all analysis, p<0.05 was

considered statistically significant. Estimates of population means were made by 95%

confidence intervals (CI); bias-corrected bootstrap CI with 5000 resamples were used in order

to obtain more robust and accurate estimates. No CI was given for variables with few levels

and a narrow interval of the observed scores.

One subject in the ED-group found the 2-back test too difficult, and did not

complete the task – neither the standard condition nor the condition with distraction. For the

same reasons, another subject in the ED-group did not do the condition with distraction. For

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data analysis of these two tasks, values of one point below the lowest recorded performance in

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the ED-group were used (i.e. one error more and one omission more). The patient that found
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the two tasks difficult also found the PVSAT administration with the distraction-condition too

difficult, and did not complete the task. For this subject, a value of one point below the lowest
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recorded performance in the ED-group was used (i.e. one less correct answer).
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Results

Demographics and self-report outcome

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The mean score of SMBQ was 5.9 (range 4.7-6.7) for the ED group. Thus, all

the patients scored above the cut-off for clinical burnout previously defined by the research
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group (cut-off > 4.4; Lundgren-Nilsson et al., 2012). Ninety-two per cent of the patients had

co-morbid anxiety and/or depression. Patients and controls did not differ with regard to sex,

age or estimate of general cognitive ability (table 2). On the other hand, a significant

difference was seen between patients and controls on all the ratings of fatigue and subjective
cognitive functioning (p˂0.001, η2 between 0.52 and 0.75), in that the patients felt more

fatigued (FIS) and reported more cognitive problems (PRMQ and CFQ; table 3).

[Table 2 and 3 near here]

Neuropsychological results

Executive functions

There was a significant difference in test performance between groups for the

modified COWAT task that measured verbal fluency in a divided attention condition (table

4); the controls generated more words than the patients. In the 2-back working memory test,

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the patient group showed significantly more omissions than the control group, but no

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differences for number of errors. This pattern was observed both with and without distraction.
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For complex attention (PVSAT), no significant difference between groups was seen in the

condition without distraction, but with distraction there was a significant difference, in that
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the control group made more correct additions. For the difference scores that described
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differences in performance with and without distraction (see table 4), no significant group

differences were obtained for any of the measures (errors and omissions in working memory

and correct additions in PVSAT).

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[Table 4 near here]

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Basic attention

The basic attentional performance was described by three measurements of the

overall performance in the CPT-II; the mean reaction time, total number of commissions, and
total number of omissions. No significant differences between groups were obtained for any

of these three measurements (table 5).

[Table 5 near here]

Sustained attention/performance

The potential variability in attentional performance over time (over test blocks)

was investigated by three measurements included in the CPT-II. Significant group differences

were observed for measurements of the variability of standard error and hit reaction time by

block (table 5). These results illustrate that patients showed a higher variation throughout the

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test in the variability of the response speed than controls and that the change in reaction time

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(initial blocks vs final blocks) was greater for patients compared to controls.
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Since a different response pattern by test blocks was indicated for the patients

relative to controls, we further explored performance over time. A plot of the hit reaction
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times of the six consecutive blocks of the CPT-II revealed that the ED group had faster
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responses at the beginning of the test compared to controls (figure 1). In order to investigate

the tentative effect of an unexpectedly fast start in the test, the ED group was divided into two

subgroups according to the response speed in the first block. One group (n=9) was classified
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as unexpectedly fast (UEXF), defined as a response time ≤ the 16th percentile of the control

group (a response at least 1 SD faster than the controls). The other group (n=16) was
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classified as expected fast (EXF) (a response time > the 16th percentile of the controls). When

commissions and omissions in the test were compared between these subgroups, the UEXF

group had more commission errors (figure 2) during the test (Mann-Whitney: z= -2.809,

p=0.01). No difference was observed for omissions (data not shown).

 [Figure 1 and 2 near here]

Mental tiredness during and after the test administration

The group difference in experience of tiredness during and after testing was

analyzed in terms of change (a change score) from baseline to each measurement point

(during and after testing). In contrast to the controls, the patients reported an increase in

mental tiredness during the testing with significant group differences in the change score of

tiredness; baseline-during testing (Mann-Whitney, z=-3.22, p <0.005, η2=0.21; M (SD)

patients 0.8 (0.9) controls 0.0 (0.9)) and baseline-after testing (z=-3.02, p <0.005, η2=0.19; M

(SD) patients 1.5 (1.2) controls 0.4 (1.2). These group differences in self-reported tiredness

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are illustrated in figure 3. An additional post-hoc analysis between the two subgroups UEXF

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and EXF described above was made. Ratings of tiredness after testing were categorized as
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either “low fatigue score” (ratings ≤average tiredness; n=13) or “high fatigue score” (ratings

>average tiredness; n=12), and it was found that the UEXF group was more tired compared to
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the EXF group (Fisher’s exact test, p=0.041).

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[Figure 3 near here]

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Discussion
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The main finding of the study is that individuals with stress-related exhaustion

report increased mental tiredness during and after neuropsychological test session. The other

main finding is that, distraction does not affect cognitive performance which is contrary to our

hypothesis. Thus, similar levels of performance in working memory and complex attention

were observed with and without distraction. However, the clear-cut observation of increased
tiredness concomitantly with unaffected performance during distraction indicates that patients

suffering from stress-related exhaustion manage to perform with cognitive load during a

restricted period, but such a high level of performance comes at a great cost. This novel

finding raises several important questions related to cognitive demands in patients with stress-

related mental health problems. One important issue is the seemingly poor adaptation to

available mental resources. Van Dam, Keijsers, Eling, and Becker (2015) found that neither

perception of fatigue or a strategic low-effort approach to demanding tasks could explain the

level of performance in individuals with burnout. Instead, they observed a typical tendency to

adopt a high-effort approach despite cognitive impairments. They proposed that the strive to

maintain acceptable or high performance levels despite impairments require increased levels

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of effort, which result in increased fatigue. The results of our study seem to be in line with

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this proposal and it is also in line with the clinical experience of the patients, i.e. that
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individuals with stress-related exhaustion often struggle with a high-effort approach. Our

results implicate that perspective such as behavioral patterns and ability to adjust is as
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important to consider as the cognitive impairment itself. This is particularly important for
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individuals returning to work with high cognitive demands. Response style and ability to

adjust to available resources may also be related to an increased vulnerability to developing

symptoms of exhaustion. This is important since extended studies of preventive measures are
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needed. Another interesting aspect of our results is offering a plausible explanation why some

patients may exhibit marked subjective cognitive complaints in spite of relatively fair results
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on objective tests. The explanation may be that individuals who adapt to a high-effort

approach despite cognitive impairments may manage to maintain acceptable levels of

performance but will perceive cognitive problems due to the effort of performing the task. Of

particular interest is the somewhat unexpected behavioral pattern of faster response among the

patients at the beginning of the task and greater inconsistency in the responses throughout the
test. These unexpected rapid responses at the start of the test were also associated with a

higher error rate across the entire test. This is interesting because normally a gradual

adjustment of performance over time is seen for this type of continuous task in trying to

obtain a balance between speed and accuracy (Conners, 2004). The current subgroup, with an

unexpected fast start, did not reach such an adjustment – they began the task with a high

response speed and were unable to find an optimal adjustment as they continued to

demonstrate a high level of error. Also, this subgroup experienced the highest level of fatigue

after the test session.

In the present study, age, sex and general cognitive level were well balanced

between patients and controls. Even though anxiety and/or depressive symptoms during the

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last six months requiring health care were exclusion criteria for controls, the lack of measure

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of symptoms of depression for this group is a limitation. Further, a majority of the patients
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had symptoms of anxiety and depression, and many had antidepressant medication. In other

studies depression was excluded even in the burnout group. However, our intention was to
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investigate cognition and fatigue in patients with exhaustion/clinical burnout in a clinical

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setting, where depressive symptoms are common. This implicates the possibility of the results

being influenced by depression but at the same time reflects the actual situation for these

patients as they usually have depression. Previous studies show that level of depression does
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not seem to explain the cognitive impairment in patients with ED (Jonsdottir et al 2013). The

findings described in this study were based on small samples and larger studies are needed.
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We can cautiously conclude that increased fatigue during cognitively demanding tasks is a

challenge for patients with stress-related exhaustion and plausibly a major obstacle when

returning to work situations that encompass high cognitive demands. Many patients with

stress-related exhaustion seem to strive to perform at high cost and show a poor ability to
adapt to the situation. These behavioral patterns are important to pay attention to during

rehabilitation in order to ensure sustainable return to work.

Acknowledgements

The authors thank all the patients and controls for participating in this study.

The authors also thank Sandra Pettersson, Agneta Lindegård Andersson and Emina

Hadzibajramovic for valuable help with administration and statistics. Special thanks also go to

Jerry Larsson, Thorleif Thorlin and Patrik Säterö for their support and advice in the initial

stages of this study. This study was funded by grants from The Healthcare sub-committee,

Region Västra Götaland (Hälso- och sjukvårdsutskottet), The Anna Ahrenberg Foundation for

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Scientific and other Purposes, The Local Research and Development Council, Göteborg and

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Södra Bohuslän, and Wilhelm and Martina Lundgrens Scientific Foundation.
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Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for
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the content and writing of the paper.

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Legends to figures

Fig 1. Mean response time (in milliseconds) with ± SEM for targets in the six consecutive

blocks of the CPT-II test for the ED group (n=25) and controls (n=25).

Fig. 2. Average number of commission errors (with ± SEM) across six test block of the CPT-

II test for patients with stress-related exhaustion (Exhaustion Disorder (ED)) and controls

(n=25). The ED group is divided into patients with an unexpected fast response speed at the

beginning of the test (UEXF; n=9) and those with expected fast response speed in the first

block (EXF; n=16). The UEXF-group had more commission errors during the test compared

to the other groups.

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Fig. 3. Mean mental tiredness (with ± SEM) reported by patients with stress-related

exhaustion (Exhaustion disorder (ED) (n=25) and controls (n=25) before, during and after the
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administration of the neuropsychological tests. The scale is graded as; 1=No tiredness,

2=Mild, 3=Moderate, 4=Average, 5=Severe, 6=Very severe. None of the participants rated
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7=Worst thinkable tiredness.

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Table 1. Diagnostic criteria for exhaustion disorder according to the National Board of Health and
Welfare
(A) Physical and mental symptoms of exhaustion with minimum 2 weeks duration. The symptoms have developed in response to one or
more identifiable stressors which have been present for at least 6 months.
(B) Markedly reduced mental energy, which is manifested by reduced initiative, lack of endurance or increase of time needed for recovery
after mental efforts.
(C) At least four of the following symptoms have been present most of the day, nearly every day, during the same 2-week period:
1. Persistent complaints of impaired memory.
2. Markedly reduced capacity to tolerate demands or to work under time pressure.
3. Emotional instability or irritability.
4. Insomnia or hypersomnia.
5. Persistent complaints of physical weakness or fatigue.
6. Physical symptoms such as muscular pain, chest pain, palpitations, gastrointestinal problems, vertigo or increased sensitivity to sounds.
(D) The symptoms cause clinically significant distress or impairment in social, occupational or other areas of functioning.
(E) The symptoms are not due to the direct physiological effects of a substance (e.g. a drug abuse and a medication) or a general medical
condition (e.g. hypothyroidism, diabetes and infectious disease).
(F) If criteria for major depressive disorder, dysthymic disorder or generalised anxiety disorder are met, ED is set as co-morbid condition.

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Table 2. Demographics, general cognitive level, SMBQ, and HADS for patients and controls
Patients (n=25) Controls (n=25) p-valuea

Sex (male/female) (7/18) (7/18) 1.000

Age (years) 43.6 (SD 9.4) 43.0 (SD 10.8) 0.620

Education (years) 13.9 (SD 2.6) 15.2 (SD 1.9) 0.061

General cognitive level

ISW test, number correct 28.2 (SD 4.7) 28.8 (SD 4.1) 0.763

Prediction of full scale IQ (WAIS)b 109.6 (SD 8.4) 111.7 (SD 7.2) 0.273

SMBQ, mean scorec 5.9 (SD 0.6) -

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HADS score ≥8 on anxiety and/or depressiond 92% -

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HADS score ≥8 on anxietyd 88% -

HADS score ≥8 on depressiond 88% -

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Notes: a For continuous data Mann-Whitney test was used. For category data Pearson Chi-Square was used; Irregularly Spelled Words
(ISW); b Prediction of score on Wechsler Adult Intelligence Scale (WAIS) based on the ISW-score, gender, and years of education; c Results
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on the Shirom-Melamed Burnout Questionnaire (SMBQ) were available for 22 patients; d Results on the Hospital Anxiety and Depression
Scale (HADS) were available for 24 patients.
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Table 3. Ratings of fatigue and subjective cognitive functioning in patients (n=25) and controls (n=25)
Controls mean (SD) Patients mean (SD) z Value Pa η2b
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95% CIBoot 95% CIBoot

FIS 18.5 (20.0) 117.3 (26.7) -6.043 ˂0.001 0.75
11.4-26.7 106.4-127.3
˂0.001
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PRMQ 33.0 (7.4) 52.0 (12.5) -5.060 0.52

30.1-35.8 47.2-57.0
CFQ 33.8 (9.7) 60.6 (15.7) -5.320 ˂0.001 0.58
29.8-37.2 54.9-66.9
Notes: a Data were analyzed using Mann-Whitney U-tests; b Effect sizes were given as η2 based on the Chi-square from nonparametric two-
sample comparisons; 95% bootstrap confidence interval (CIBoot); Fatigue Impact Scale (FIS); Prospective and Retrospective Memory
Questionnaire (PRMQ); Cognitive Failures Questionnaire (CFQ).
Table 4. Neuropsychological test results of executive function and complex attention in patients (n=25)
and controls (n=25)

Controls mean (SD) Patients mean (SD) z Value Pa η2b

Fluency: Modified COWAT

No. of words 39.4 (8.7) 31.3 (9.5) -3.147 0.008 0.20
95% CIBoot 36.0-42.8 27.9-35.4
Working Memory: 2-back test
No. of errors
Without distractionc 1.8 (3.5) 1.4 (1.8) -0.203 0.839 0.00
With distractiond 1.5 (1.9) 1.2 (1.3) -0.061 0.951 0.00
Difference 0.3 (2.4) 0.2(1.6) -0.45 0.652 0.00
No. of omissions
Without distractionc 1.1 (1.4) 2.9 (2.5) -2.773 0.018 0.16
d
With distraction 1.6 (2.0) 4.0 (3.4) -2.741 0.018 0.15

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Difference -0.5 (1.7) -1.1 (2.7) -0.890 0.746 0.02
Complex attention (PVSAT)
No. correct
Without distraction
95% CIBoot
49.9 (11.0)
45.2-53.7
44.4 (10.6)
40.2-48.3
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With distractionc 51.3 (10.2) 44.8 (9.9) -2.461 0.028 0.12
95% CIBoot 47.0-54.7 41.1-48.6
Difference 1.4( 4) 0.4 (6.3) -1.054 0.876 0.02
95% CIBoot -0.08 - 3 -1.8 - 3.2
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Notes: a Data were analyzed using Mann-Whitney U-tests ; b Effect sizes were given as η2 based on the Chi-square from nonparametric two-
sample comparisons; 95% bootstrap confidence interval (CIBoot), no CI were given for variables with a narrow interval of scores; Difference:
The difference between the scores with and without distraction (subtracting one score with the other). The difference scores were computed
so that a negative score always meant an inferior performance during distraction; Holm-Bonferroni corrections for multiple comparisons
were applied respectively for 4 measures without distraction, 3 measures with distraction, and 3 measures of the difference. The p-values
shown in the table are corrected. Controlled Word Association Test (COWAT); Paced Visual Serial Addition Test (PVSAT). The test was
found to difficult and was not completed and values one point below the lowest recorded performance was used for: c n=1 and d n=2
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individuals in the ED-group.

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Table 5. Neuropsychological test results of basic and sustained attention in the CPT-II in
patients (n=25) and controls (n=25)
Controls mean Patients mean (SD)
(SD) 95% CIBoot 95% CIBoot
z Value Pa η2b

Basic attention
Mean reaction time 353.7 (51.4) 345.9 (46.2) -0.243 0.808 0.00
335.1-374.6 328.4-363.4
No. of commission errors 11.6 (6.4) 14.5 (8.6) -1.021 0.614 0.02
9.2-14.2 11.3-17.8
No. of omissions 1.4 (2.3) 2.6 (3.3) -1.677 0.282 0.06
- -
Sustained attention
Variability of standard error 5.3 (2.3) 7.2 (2.5) -3.027 0.006 0.18
4.5-6.2 6.4-8.3
Hit reaction time by block -0.0072 (.0175) 0.0044 (.0147) -2.382 0.034 0.12
-0.014-0.000 -0.0008-0.0108

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Standard error by block -0.0112 (.0540) -0.0012 (.0602) -0.583 0.560 0.01
-0.034-0.008 -0.0252-0.0208

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Notes: aData were analyzed using Mann-Whitney U-tests ; b Effect sizes were given as η2 based on the Chi-square from nonparametric two-
sample comparisons; 95% bootstrap confidence interval (CIBoot), no CI were given for variables with a narrow interval of scores; Conners´
Continuous Performance Test II (CPT-II). Holm-Bonferroni corrections for multiple comparisons were applied respectively for 3
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comparisons of basic attention, and for 3 comparisons of sustained attention. The p-values shown in the table are corrected.
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