to a sabbatical. Ultimately, it was used to describe everything from fatigue to a major depression and now seems to have become an alternative word for depression, but with a less serious significance" (p. 434). The authors equate burnout with adjustment disorder with depressed mood. Kakiashvili et al., however, argued that although burnout and depression have overlapping symptoms, endocrine evidence suggests that the disorders' biological bases are different. They argued that antidepressants should not be used by people with burnout because the medications can make the underlying hypothalamic–pituitary–adrenal axis dysfunction worse. Despite its name, depression with atypical features, which is seen in the above table, is not a rare form of depression. The cortisol profile in atypical depression, in contrast to that of melancholic depression, is similar to the cortisol profile found in burnout. Commentators advanced the view that burnout differs from depression because the cortisol profile of burnout differs from that of melancholic depression; however, as the above table indicates, burnout's cortisol profile is similar to that of atypical depression. It has previously been hypothesised that Chronic Fatigue Syndrome (CFS), also known as Myalgic Encephalomyelitis (ME), is caused by burnout. It is suggested that the "burning out" of the body's stress symptom (by any of a wide range of causes) can lead to chronic fatigue. However, the very nomenclature of "Chronic Fatigue Syndrome" is viewed as problematic by both patients and healthcare professionals specialising in the condition, as it fails to encompass the wide range of non-fatigue related symptoms present in ME/CFS, or to differentiate between the so-named condition and the symptom of chronic fatigue which is present in many unrelated conditions or diseases. Furthermore, more up-to-date research has shown that ME/CFS is a multi-systemic condition that is not psychological in etiology and so comparison to occupational burnout is now less prudent. Overtraining syndrome is also known as "chronic fatigue," "burnout" and "overstress" in athletes. It has been conceptualised as adjustment disorder, a common diagnosis for those burnt out. Recovering alcoholics often have a blunted cortisol response to stress, as do some cancer patients and survivors. This symptom is a particular feature of people suffering burnout. Altered cortisol response is experienced by up to 80% of people with depression. Risk factors Evidence suggests that the etiology of burnout is multifactorial, with personality factors playing an important, long-overlooked role. Cognitive dispositional factors implicated in depression have also been found to