Questionnaire data
Lund University Checklist for Incipient Exhaustion (LUCIE) consists of 28 items describing behaviors and feelings associated with the prodromal stages of exhaustion disorder. LUCIE is intended to be a tool for identifying the prodromal stages of work-stress-related exhaustion and is based on qualitative analyses of ED patients’ interviews/narratives concerning their earliest signs of ED. (See Persson et al. [
11] for a detailed description of the basic development of LUCIE and item contents). In LUCIE, the instruction to the respondent is: “For the past month, to what extent have you felt or observed the following?” The response to each item is made on a 4-point scale: 1 = not at all, 2 = somewhat, 3 = quite a bit, and 4 = very much. The LUCIE items cover six domains: (a) sleep and recovery, (b) separation between work and spare time, (c) sense of community and support in the workplace, (d) managing work duties and personal capabilities, (e) private life and spare time activities, and (f) health complaints.
The detection of incipient exhaustion in LUCIE builds on two algorithms comprising two separate, supplementary scales: the
Stress Warning Scale (SWS), which is sensitive to milder signs of incipient exhaustion, and the
Exhaustion Warning Scale (EWS), which is intended to reflect more severe signs of exhaustion
. The general difference between the SWS and the EWS algorithms concerns the
intensity of the replies, as the EWS score is based mainly on replies at the highest level (“very much”), while replies on the next lower level (“quite a bit”) are also included in computation of the SWS. A wide range of stress signs on the next lower level is thus only reflected in a high SWS score, while the extent of replies on the highest level are recorded on the EWS scale. The purpose with this division on two scales is to enable the clinician to easily assess whether the LUCIE result indicates a slight to moderate state of stress (high SWS and low EWS) or if signs are so intense that ED might be suspected (high EWS) [
11]. The SWS and EWS computation algorithms are presented in detail in Additional file
1.
The scores on both scales range from 0 to 100. A low SWS score (≤ 17.00; ‘the green zone’) is intended to indicate normal/negligible long-term stress symptoms. A slightly higher SWS score (between 17.01 and 38.50; ‘the yellow zone’) suggests possible slight stress symptoms. A rather high SWS score (≥38.51; ‘the red zone’) indicates mild to moderate stress symptoms. When the SWS score reaches the red zone, it is recommended to start checking the EWS score for more severe symptoms of stress, possibly indicating exhaustion. A low EWS score (≤ 21.50; ‘the EWS green zone’) indicates that signs of exhaustion are mostly absent or mild, while a higher score (> 21.50; ‘the EWS red zone’) suggests severe symptoms that might indicate exhaustion disorder, in that case overriding any SWS score. In practice, the combined scores on the SWS and the EWS provide a 4-step severity ladder of stress symptomatology:
1.
Step 1-GG (SWS green zone and EWS green zone) = no or negligible lasting stress symptoms
2.
Step 2-YG (SWS yellow zone and EWS green zone) = possible slight lasting stress symptoms
3.
Step 3-RG (SWS red zone and EWS green zone) = mild to moderate lasting stress symptoms, but less severe than ED
4.
Step 4-RR (SWS red zone and EWS red zone) = lasting stress symptoms of a severity indicating possible ED.
Because the other theoretically plausible combinations of scores (i.e., SWS green zone or SWS yellow zone in combination with EWS red zone score) are extremely rare in clinical settings and in population samples [
11], the four ranking steps above are practical simplifications. In cases where a high SWS score is observed, the supplementary EWS measure will indicate whether the stress symptomatology is of an intensity indicative of ED (Step 4-RR), or is more benign in nature (Step 3-RG).
Changes in the situation at work and in private life were assessed using two newly constructed items that addressed perceived positive or negative changes in (a) the work situation or (b) private life. The items read: “Has your situation at work changed in a positive or negative direction during the past couple of months?” and “Has the situation in your private life changed in a positive or negative direction during the past couple of months?” Responses to both items were made on a 5-point scale: 1 = Yes, in a highly positive direction, 2 = Yes, to some extent in a positive direction, 3 = No, no significant change, 4 = Yes, to some extent in a negative direction, 5 = Yes, in a highly negative direction. As a supplement, participants were also encouraged to fill in an optional text field (480 signs) with free-text commentaries.
The Karolinska Exhaustion Disorder Scale (KEDS) was used to validate that a prospective elevation of LUCIE scores (see
Identification of cases
below) reflected genuine signs of exhaustion. KEDS is a recently developed tool for screening for the presence of ED; it contains nine items selected to correspond with the ED criteria specified by the NBHW in 2003 [
13]. The item contents are: (1) ability to concentrate, (2) memory, (3) physical stamina, (4) mental stamina, (5) recovery, (6) sleep, (7) hypersensitivity to sensory impressions, (8) experience of demands, and (9) irritation and anger. Each item has seven response alternatives, ranging from 0 to 6, with higher values reflecting more severe symptoms. The sum of item scores constitutes the outcome (range 0 – 54). A sum of item scores ≥ 19 is the recommended cutoff criterion for ED, which was shown to optimize both sensitivity and specificity [
13].
Personality traits were assessed at baseline (T0) with a Swedish version of the 44-item Big Five Inventory (BFI), which includes the dimensions: Neuroticism, Extraversion, Openness, Agreeableness and Conscientiousness [
14,
15]. The items of the BFI are short and easily understandable phrases, and each BFI item is rated on a 5-point scale with verbal labels ranging from “Disagree strongly,” (score 1), “Disagree a little,” “Neither agree nor disagree,” “Agree a little,” and “Agree strongly” (score 5). Each of the Big Five personality dimensions was calculated as the mean score of the 8–10 items covering the dimension.
Interview data
Telephone interviews were carried out to collect data on the substance of LUCIE indications and the perceived sources of stress. Specifically, participants showing a prospective elevation of LUCIE scores (see
Identification of cases
below) were informed by letter that unspecified changes in their questionnaire replies had been observed and told we would contact them by telephone for a brief interview. The interviews were carried out by an experienced clinical psychologist and psychotherapist (N.V.). When we reached the participant by phone, he/she was informed that we had seen, during the past two quarters, increased ratings on a set of questions that
might be related to work stress. The interviewer then asked the participant the following two questions, one regarding work stressors and the other concerning stressors outside work (private life). The first question read “
In your opinion, have you experienced more stress at work lately (during the past six months) than previously and, if so, to what extent?” The second question read “
Do you think there are other reasons (outside work) for the changes in your questionnaire replies and, if so, to what extent?” In practice, these two questions were not given in verbatim, and were often conveniently combined into one question; “H
ave you experienced more stress at work during the past quarters, or do you think there are other reasons (outside work; e.g., private stress) for the changes in your questionnaire replies?” The reply obtained within each area was scored by the interviewer as: 3 = a substantial increase; 2 = a moderate increase; 1 = a slight increase; 0 = no increase or a decrease. After the interview, the balance between reported work and private life stressors was scored as: 1 = work stressors only; 2 = predominantly work stressors but also some private life stressors; 3 = roughly equal shares of work stressors and private life stressors; 4 = predominantly private life stressors but also some work stressors; 5 = private life stressors only. Of the 56 participants we were able to reach by phone, 26 also accepted a clinical consultation with the psychotherapist, which provided a richer background which, however, only in a few cases led to minor adjustments in the interviewer ratings.