Dysregulation of the hypothalamic–pituitary–adrenal
(HPA) axis may also be implicated in the development of
burnout, although results have been conflicting, with baseline
cortisol levels observed to be decreased [12,13] and more
recently elevated [14,15] in different studies. However,
irrespective of baseline cortisol levels, the increase in cortisol
upon awakening appears to be blunted [16]. HPA hyporesponsivity
has been associated with several medical disorders such
as chronic fatigue [17] and posttraumatic stress disorder [18].