Cherniss and Fawzy et al. conceptualized burnout as a transactional process. The first of the three stage transactional model ocuurs when an individual appraises specific demands as taxing his or her resources. Such demands come from external factors (environment, relationships, community, goals, achievements) or internal factors (self-concept, identity, roles, life style, development issues). There are initial responses to this appraisal of demand and resource imbalance. Feelings of tension and anxiety as well as fatigue and exhaustion are common. The second stage involves coping attempts to balance between demands and resources. If these attempts are unsuccessful burnout occurs. In the stage 3 common physical and emotional responses to burnout occur. This should be a warning sign. The most serious of these is depression with suicidality (3-6).