PSYCHOLOGY

Psychiatric distress and symptoms of PTSD among victims of bullying at work

STIG BERGE MATTHIESEN & STÅLE EINARSEN Division of Work and Organisational Psychology, Department of Psychosocial Science,

University of Bergen, Christiesgate 12, N-5015 Bergen, Norway

ABSTRACT Distress and symptoms of Post-Traumatic Stress Disorder (PTSD) were investigated

among targets of experienced bullying at work, that is, the exposure to persistent or recurrent

oppressive, offensive, abusive behaviour where the aggressor may be a superior or a colleague. The

participants in the present study were all recruited from two associations of bullied victims (n�/102, response rate�/57%). A high level of distress and symptoms of PTSD was revealed in the sample, both according to recommended cut point scores for HSCL-25, PTSS-10 and IES-R, and when

comparing the sample with traumatised samples. Three out of four victims reported an HSCL-25 level

higher than the recommended threshold for psychiatric disease. Sixty and 63% of the sample reported

a high level of IES intrusion and IES avoidance, correspondingly. The level of bullying,

operationalised as the frequency of negative acts the individual had been exposed to at work, showed

a stronger interconnection with distress and PTSD than a more unspecified, subjective measure of

bullying, as well as the time since the bullying took place and the duration of the bullying episode.

Those still being pestered reported a higher level of distress and PTSD than victims in which the

bullying episodes were terminated more than 1 year ago, but the findings were somewhat mixed.

Positive affectivity (PA) and especially negative affectivity (NA) contributed significantly to the

explained variance of distress and PTSD in various regression analysis models, but did not interact

with measures of bullying. Nor were mediator effects found between bullying, PA/NA and traumatic

stress reactions. Implications of the findings are discussed.

During the last decade there has been a growing awareness of the detrimental effects

on employee health and well-being caused by exposure to bullying and non-sexual

harassment in the workplace (Einarsen, 1999; Einarsen et al ., 2003; Hoel et al .,

1999). Although studied by the use of many different concepts, such as ‘emotional

abuse at work’ (Keasly, 1998), ‘harassment at work’ (Brodsky, 1976; Einarsen &

Raknes, 1997), ‘bullying at work’ (Vartia, 1996), ‘mistreatment’ (Spratlen, 1995),

‘mobbing’ (Leymann, 1996; Zapf et al ., 1996), ‘workplace aggression’ (Baron &

Neuman, 1996) or as ‘workplace incivility’ (Andersson & Pearson, 1999), compar-

able conclusions seem to be reached. Exposure to systematic and long-lasting

British Journal of Guidance & Counselling, Vol. 32, No. 3, August 2004

ISSN 0306-9885/print/ISSN 1469-3534/online/04/030335-22 # 2004 Careers Research and Advisory Centre

DOI: 10.1080/03069880410001723558

verbal, non-physical, and non-sexual, abusive and aggressive behaviour at the

workplace may cause a host of negative health effects in the target. Although single

acts of aggression and harassment do occur fairly often in everyday interaction, they

seem to be associated with severe health problems when occurring on a regular basis

(Einarsen & Raknes, 1997; Leymann, 1987). Bullying at work is claimed to be an

extreme form of social stress at work (Zapf et al ., 1996). It is referred to as a more

crippling and devastating problem for employees than all other work-related stressors

put together (Wilson, 1991).

Bullying can be described as a certain subset of conflicts (Zapf & Gross, 2001),

and may be defined as the exposure to persistent or recurrent oppressive, offensive,

abusive, intimidating, malicious, or insulting behaviour by a superior or a colleague.

Feelings of being victimised from bullying at work seem to be associated with the

experience of (a) bullying behaviours being intentional, (b) a lack of opportunities to

evade it, and (c) these behaviours or sanctions as unfair or over-dimensioned

(Matthiesen et al ., 2003). To be a victim of intentional and systematic psychological

harm by another person, real or perceived, seems to produce severe emotional

reactions such as fear, anxiety, helplessness, depression and shock (Mikkelsen &

Einarsen, 2002a,b). These reactions seem to be especially pronounced if the

perpetrator is in a position of power or the situation is an unavoidable or inescapable

one (Einarsen, 1999; Niedl, 1996). The workplace seems to be a setting where

people are especially vulnerable when facing aggression, abuse, or harassment

(Einarsen & Raknes, 1997). Victimisation, such as exposure to intense bullying at

work, may change the individual’s perceptions of their work-environment and life in

general to one of threat, danger, insecurity and self-questioning (cf. Janoff-Bulman,

1992), which may result in pervasive emotional, psychosomatic and psychiatric

problems (Leymann, 1990a).

In an interview study among 30 Irish victims, O’Moore and associates found

that all subjects reported anxiety, irritability, feelings of depression and paranoia as a

consequence of experiences of bullying at work (O’Moore et al ., 1998). Also very

common were symptoms like mood swings, feelings of helplessness, a lowered self-

esteem, and a range of physical symptoms. Clinical observations of victims of

harassment at work have also shown other grave effects such as social isolation, social

maladjustment, psychosomatic illnesses, depressions, helplessness, anger, anxiety,

and despair (Leymann, 1990a). A study among a representative sample of

Norwegian assistant nurses showed a significant relationship between exposure to

on-going workplace harassment and an elevated level of burn-out, as well as a

lowered job satisfaction and a lowered psychological well-being (Einarsen et al .,

1998).

On the basis of clinical observations and interviews with American victims of

work harassment, Brodsky (1976) identified three patterns of effects on the victims.

Some expressed their reaction by developing vague physical symptoms such as

weakness, loss of strength, chronic fatigue, pains and various aches. Others reacted

with depression and related symptoms such as impotence, lack of self-esteem, and

sleeplessness. A third group reacted with psychological symptoms such as hostility,

336 Stig Berge Matthiesen & Ståle Einarsen

hypersensitivity, memory problems, feelings of victimisation, nervousness, and the

avoidance of social contact.

In view of the particular symptom constellation presented above, it has been

argued that many victims of long term bullying at work may in fact suffer from Post-

Traumatic Stress Disorder (PTSD) (Björkqvist et al ., 1994; Einarsen & Hellesøy,

1998; Leymann, 1992). In a Finnish study of 350 university employees, 19 persons

subjected to victimisation by harassment were interviewed as a follow-up study

(Björkqvist et al ., 1994). The victims experienced high levels of insomnia, various

nervous symptoms such as anxiety, depression and aggression, melancholy, apathy,

lack of concentration and socio-phobia, leading the authors to conclude that these

victims portrayed symptoms reminiscent of PTSD. In his 1992 report, the Swedish

psychiatrist Heinz Leymann argued that PTSD probably was the correct diagnosis

for approximately 95% of a representative sample of 350 victims of bullying at work

(Leymann, 1992).

A host of studies (see e.g. Creamer, 2000) have suggested that victimisation

caused by the aggressive and violent behaviour of other fellow human beings

may produce high levels of distress and symptoms of post-traumatic stress even

long after the event actually happened. Studies also suggest that psychological or

physical abuse seems to be at least as traumatising as for example physical and

criminal forms of violence. Experiencing sexual assault made a larger impact on

PTSD symptomatology than combat exposure, according to a study of 160 army

women after returning from the Persian Gulf (Wolfe et al ., 1998). In another

investigation, 100 victims of harassment by stalking were interviewed to assess

the impact of the experience on their psychological, social, and interpersonal

functioning (Pathe & Mullen, 1997). The majority of the victims were subjected

to multiple forms of harassment such as being followed, repeatedly approached,

and bombarded with letters and telephone calls for periods varying from 1 month

to 20 years. Threats were perceived by 58%, whereas 34% were physically or

sexually assaulted. Increased levels of anxiety were reported by 83%. Intrusive

recollections and flashbacks were reported by 55%, while nightmares, appetite

disturbances, and depressed mood were commonly experienced. The criteria for a

diagnosis of Post-Traumatic Stress Disorder (PTSD) were fulfilled in 37% of the

cases.

Fontana and Rosenheck (1998) studied the relative impact of stress

from military duty and exposure to sexual harassment on the development of

PTSD among 327 female veterans. Sexual abuse and harassment were almost

four times as influential in the development of PTSD compared to other kinds

of duty-related stress. Using a liberal cutoff score, Vitanza et al . (1995) diagnosed

73% of a group of psychological abused women as having severe symptoms of PTSD.

A Swedish study of PTSD in a group of 64 victims attending a rehabilitation

programme for victims of bullying at work revealed that most of these victims

were troubled with intrusive thoughts and avoidance reactions (Leymann &

Gustavson, 1996). A Danish study of 118 bullied victims found that 76% portrayed

symptoms indicating post-traumatic disorder (Mikkelsen & Einarsen, 2002a).

Interpersonal conflicts in general may also be linked to PTSD symptoms. In a

Bullying and PTSD 337

Canadian study of 51 emergency personnel, a significant relationship was found

between the level of interpersonal conflicts, and symptoms of PTSD (Laposa et al .,

2003).

Only a few studies (Leymann & Gustavson, 1996; Mikkelsen & Einarsen,

2002a) have been published on the relationship between exposure to bullying and

symptoms of PTSD using a community sample. The aim of community studies is to

assess specific disorders, in this case symptoms of post-traumatic stress, among a

specified population, regardless of whether they have sought treatment or not

(Schlenger et al ., 1997). The aim of the present study is therefore to examine the

level of psychiatric symptoms and symptoms of PTSD among former and current

victims of bullying at work, who has not necessarily sought medical or psychological

treatment.

The literature on post-traumatic stress focus primarily on factors such as

life-threatening menaces, object loss, physical harm and how hideous the critical

incident turned out to be, as the main risk elements in development of PTSD

(Davidson & Foa, 1993). This notion is however somewhat different from Dahl and

his colleagues (Dahl et al ., 1994), who claim that Post-Traumatic Stress Disorder

evolves if an event is perceived as threatening, scaring or awful, beyond a certain

level. The risk of PTSD is claimed to increase if the incident(s) are prolonged,

especially if adequate leadership is non-existent or social connections are lacking.

Traumatic episodes connected to man-made aggressive acts (injustice, assaults,

harassment) are argued to pose a greater risk than to incidents caused by accidents or

disasters (Dahl et al ., 1994). A study of post-traumatic stress among women abused

by their husbands concluded that psychological abuse even in rather subtle forms

seems to produce clear cut symptoms of PTSD (Vitanza et al ., 1995). On the basis of

case studies, Scott and Stradling (1994) argue that enduring psychosocial stress in

the absence of one single acute and dramatic trauma may produce full symptoma-

tology of PTSD.

In a theoretical framework of trauma at work, Williams (1993) argues that

individual variables in personality and coping styles may have some overlap with

PTSD as in regard to emotional distress. Although the causal relationship between

individual differences and victimisation from bullying is a debatable one (Einarsen,

1999, 2000; Leymann, 1990a, 1996), victims of bullying at work do differ from non-

bullied workers on a range of factors. For instance, Vartia (1996) found a high level

of negative affectivity among a group of Finnish victims of bullying at work, while

Zapf (1999) found German victims of bullying to be high on negative and low on

positive affectivity compared to a control group. Experiences of negative social

interactions in general seems to be associated with an increase in negative affectivity

as well as low self-esteem and many dysfunctional attitudes (Lakey et al ., 1994).

While Zapf (1999) argues that these characteristic may have caused bullying in the

first place, other researchers (Mikkelsen & Einarsen, 2002b) claim that negative

affectivity acts as a mediator and thus accounts for the relation between the

victimisation and symptomatology by explaining how bullying takes on a psycholo-

gical meaning. In a study of battered women the relationship between exposure to

abuse and PTSD to a certain degree depended on vulnerability factors of

338 Stig Berge Matthiesen & Ståle Einarsen

psychological dysfunctions such as cognitive failure and private self-consciousness

(Saunders, 1994). The former is defined as the tendency to have perception and

memory failures as well as engaging in misdirected action, while the latter refers to

people who tend toward a self-analysis manner, focusing on their own perceptions,

feelings and thoughts. Both concepts are considered to result from the excessive

worry and anxiety caused by a highly threatening situation, hence they may be seen

as partial mediators of the relationship between the experience of abuse and the

evolving post-traumatic stress symptoms.

In the present study we will include the concepts of negative and positive

affectivity as such possible mediating factors. Research has demonstrated those two

independent dispositional variables to comprise the dominant factors of emotional

experience (Watson, 1988). Negative affectivity (NA) is seen as a general factor of

subjective distress and comprises a broad range of aversive mood states, including

distress, nervousness, fear, anger and guilt. Individuals high in negative affectivity

often focus on the negative sides of life and tend to have negative views of themselves,

other people and the world in general. Positive affectivity (PA) reflects one’s level of

pleasurable engagement with the environment. High PA is composed of terms

reflecting enthusiasm, energy, mental alertness and determination (e.g. excited,

active, attentive, determined). Low PA is best defined by descriptors reflecting

fatigue and depression (e.g. sluggish, sad). Positive and negative affectivity

correspond roughly with the dominant factors extraversion and anxiety/neuroticism

(Watson et al ., 1988).

The idea followed in many studies of work-related stress is that the tendency to

experience positive and negative affect represents a stable, dispositional trait which

may confound relationships between stressors and strain (Watson & Clark, 1984).

However, exposure to bullying may also justify, enhance or even create a negative

world-view and a negative emotional state, as proposed by the framework presented

by Janoff-Bulman (1992). The core problem of bullying at work is that it undermines

the target’s sense of being a valuable and competent person living in a safe and caring

environment (Keasly et al ., 1997; Leymann, 1990a). Distressed and dissatisfied with

themselves, victims may focus on and magnify potential threats from their

surroundings. Enhanced levels of state negative affectivity, as well as a lowered state

of positive affect, may then initiate increased use of maladaptive coping strategies in

turn causing higher levels of reported psychological symptoms and psychosomatic

complaints (Costa & McCrae, 1980). Evidence that major stressful life events may

increase symptomatology by increasing negative evaluations of others and self has

been presented by Lakey and Edmundson (1993) and may easily be derived from the

work of Janoff-Bulman (1992) as proposed by Mikkelsen and Einarsen (2002a). The

aim of this study is to examine the level of psychiatric symptoms and symptoms of

PTSD among current and former victims of bullying at work using a community

sample. Second, we inquire how the PTSD symptoms relate to the kinds of bullying

experienced by the victim and the duration of and time since the termination of the

bullying. And third, we examine the role of state negative and positive affectivity as

possible mediators or moderators in this stressor�/strain relationship.

Bullying and PTSD 339

Method

Procedure

The 102 participants in the study were recruited among members of two Norwegian

national associations against bullying at work. In total, 180 victims of on-going or

prior exposure to bullying at work were members of these associations, by the onset

of the survey. They all got a survey questionnaire, distributed by the two associations

(by mail). Attached to the questionnaire was a letter of recommendation from the

heads of the associations. The questionnaires were anonymously returned directly to

the researchers.

Subjects

Mean age of the sample was 51.6 years (range 30�/74 years). Seventy-four percent of the sample were women. The major part of the participants worked or had worked in

administrative or clerical jobs (38%), health services (28%), or education (13%).

Only a limited part of the sample were in fact still employed (33%), whereas 17%

were on sick-leave, 12% were unemployed (the unemployment rate in Norway was

only some 3% at that particular time) and 10% had retired. In addition, one out of

four (26%) were disabled pensioners. The sample had a high educational level,

where 60% had a university degrees or college degree, mostly on an undergraduate

level. Sixty-three percent of the respondents had been exposed to bullying for a

period of 2 years or more. Almost one in four (22%) were still exposed to bullying, or

the bullying took place less than 6 years ago (6%) when the survey was carried out.

Almost one in three (30%) were hit by bullying more than 5 years ago. The most

frequent kinds of bullying reported were ostracism (social isolation), being

devaluated, holding back information, calumniation, and frequent attacks or

criticism against one’s person.

Instruments

Bullying was measured in two ways. First, the following definition of workplace

bullying was introduced to the respondents:

‘Bullying takes place when one or more persons systematically and over

time feel that they have been subjected to negative treatment on the part of

one or more persons, in a situation in which the person(s) exposed to the

treatment have difficulty in defending themselves against them. It is not

bullying when two equal strong opponents are in conflict with each other’

(Einarsen et al ., 1994).

Following this, the respondents were asked, ‘Have you been exposed to bullying at

work?’ with three response alternatives (no, yes to some extent, and yes to a great

extent). A quantitative measure of bullying, the Norwegian version of the 22-item

340 Stig Berge Matthiesen & Ståle Einarsen

Negative Acts Questionnaire (NAQ; Einarsen & Raknes, 1997; Einarsen et al .,

1994), was also used. The NAQ consists of 22 items referring to specific kinds of

bullying behaviours, such as exposure to excessive teasing, insulting remarks, social

exclusion, verbal abuse, threats of being fired or redundant, and slanders or rumours

about oneself. The respondents were asked if they had been exposed to any of these

behaviours during the time they were targets of bullying, with the following response

alternatives: never, occasionally, weekly, or daily.

Factor analysis has earlier revealed that the NAQ scale consists of two

distinct subfactors, which were labelled ‘personal derogation’ and ‘work-related

harassment’ (Einarsen & Raknes, 1997). In the present study, however, the

NAQ score of each person was summed up to a single total measure of the intensity

of the experienced bullying behaviours. Cronbach’s alpha for NAQ was found to be

0.85.

Symptoms of post-traumatic stress were measured by the Impact of Event Scale,

IES-R, the 22-item version (Weiss & Marmar, 1997), and the Post-Traumatic Stress

Scale, PTSS-10 (Raphael et al ., 1989). The Impact of Event Scale Revised is a 22-

item scale assessing three dimensions of symptoms often reported after trauma. The

intrusion dimension consists of symptoms like intrusive memories, thoughts and

emotions. The avoidance dimension measures symptoms related to avoiding

memories and places, as well as denial. The newly added third dimension of the

scale reflects hyperarousal, a strong kind of mental and bodily alertness. The four

categories of IES was scored as 0, 1, 3, 5 according to standard scoring procedures

(Horowitz, 1979; Weiss & Marmar, 1997). Cronbach alpha for the three subscales

was found to be 0.81, 0.90 and 0.82, respectively. Horowitz (1979) divides the scores

of IES (both intrusion and avoidance subscales) into three groups, with low,

moderate and high level of post-traumatic stress (with respectively 0�/9 points, 9�/19 points, and 20 or more stress points). The cut point scoring procedures for the IES

were applied, since IES-R does not have established separate cut point scores for the

three subscales. In addition, the three subscales of IES were summed up to a single

measure of post-traumatic stress. Here, a cut point threshold of 35 was applied, in

line with Neal and associates (Neal et al ., 1994). Cronbach’s alpha for the overall

summed up scale was 0.94.

The PTSS-10 is a questionnaire assessing 10 common symptoms of PTSD

(Raphael et al ., 1989). The measure range is from 1 (never/seldom) to 7 (very often).

Cronbach’s alpha was found to be 0.91 in the present study. Raphael et al .

operationalise PTSD to be a PTSS-10 score of four or more on at least four items.

Psychiatric symptoms was measured by the Hopkins Symptom Checklist,

HSCL (25-item version) originally developed by Derogatis and his co-workers

(Derogatis et al ., 1974). The scale measures psychological symptoms of anxiety,

depression and somatisation and was used as a measurement for psychiatric distress

in the present study. The items in this scale are scored on a 4-point scale ranging

from not at all, a little bit, quite a bit and very much. The scale had a very high

internal stability in the present study with a Cronbach’s alpha of 0.96. A convention

is to use 1.75 as the cut point threshold of ‘cases’, indicating severe psychological

distress (Winokur et al ., 1984).

Bullying and PTSD 341

Positive and negative affect was investigated by the use of the Positive and

Negative Affectivity Scale (PANAS), which consist of respectively 10�/10 items to measure the two affect concepts (Watson et al ., 1988). Both of the two affectivity

scales had a Cronbach’s alpha of 0.90. The respondents were asked about their

reactions for the last couple of weeks. Hence, the inventory measured a state

condition of positive and negative affectivity.

Comparison groups

The level of post-traumatic stress and psychiatric symptoms among victims of

bullying was compared with several other contrast samples, by the means of IES and

HSCL. The contrast samples were:

a. A contrast group of medical students, exposed to a high level of temporary stress

(their first autopsy); 96 students (58% female) participated (Eid et al ., 1999).

Eid and his associates conducted their study to establish a Norwegian control

group which can be contrasted against other groups. They argue that their

sample is stressed, but not traumatised.

b. Postal employees (n�/144, 88% female), all affected by a organisational downsising process (Myrvang & Stokke, 1997).

c. Recently divorced persons living in five different counties in Norway received a

six pages questionnaire along with their official divorce decree during a period of

4 months. In total, 658 separated persons (58% female) participated (Thuen,

2000).

d. A population study, in which 2,015 individuals were personally interviewed

(53% female) from a borough in Oslo and the islands of Lofoten in northern

Norway (Sandanger et al ., 1998). Out of these, 797 (40%) were classified as

‘possible psychiatric cases’, after a HSCL-25 recommendation of 1.55�/ (Richels et al ., 1976). Of these, 617 participated in a follow-up study. Thus,

the follow-up study comprise the comparison group for the present study.

e. Thirty-six parents (50% female) of children in a major bus disaster, in which 12

school children and three accompanying parents died (Winje, 1996). The post-

traumatic stress responses of these parents 1 year after the accident will be

compared with the victims of bullying.

f. War zone personnel (n�/213, United Nation observers/medical helpers), all from Norway, interviewed about 1 year after their service in the Bosnia conflict

(Andersen & Tysland, 1998).

The bullied victims were compared to group (a) on PTSS-10, groups (b)�/(d) on HSCL-25, and to groups (e)�/(f) by the use of IES-R.

342 Stig Berge Matthiesen & Ståle Einarsen

Statistics

The statistical analyses were conducted by the use of SPSS, version 8. The following

statistical procedures were used: frequency, one way ANOVA, correlation and partial

correlation analysis, and multiple linear regression.

Results

Mean PTSS item stress scores of the bullied victims is compared with the

comparison group of medical students (Fig. 1, part A). The bullied victims score

markedly higher on all items (p B/0.001 for all t -test comparisons). It is also

worthwhile to note that post-traumatic symptoms with the highest scores are

depressive thoughts, isolation tendencies, fluctuating feelings, fear for reminding

situations and general bodily tension.

Level of psychiatric distress in the bullied sample, as measured by the HSCL-25,

was then compared with postal employees experiencing organisational transition, a

sample of separated/divorced persons, and a group of possible psychiatric cases

(Myrvang & Stokke, 1997; Raphael et al ., 1989; Sandanger et al ., 1998). Bullied

victims reported higher levels of psychiatric distress than the three contrast groups

(part B of Fig. 1). The bullied group reported a mean HSCL-25 level of 2.25,

whereas the mean scores for the other three groups were 1.51, 1.43 and 1.30,

correspondingly. Parts C and D of Fig. 1 comprises mean post-traumatic stress

scores for Impact of Event Scale (intrusion and avoidance sub-indexes). The victims

of bullying were compared with the parents of school children involved in a bus

FIG. 1. PTSD symptoms (PTSS-10, IES intrusion IES avoidance) and psychiatric symptoms (HSCL-

25) among bullied victims, as compared with several other Norwegian samples.

Bullying and PTSD 343

accident, United Nation personnel 1 year after returning from war zone, and the

group of medical students (Andersen & Tysland, 1998; Eid et al ., 1999; Winje,

1996). Bullied victims report a mean intrusion and avoidance level of 24.16 and

21.05, respectively. The post-traumatic stress scores among victims of bullying were

higher than for all the other three groups.

Table 1 constitutes an estimate of how many of the bullied victims who are

troubled with psychiatric distress and PTSD, according to critical cut point scores.

The overall picture given by HSCL-25, PTSS-10 and IES-R is quite the same. A

majority of the sample, between 60% and 77%, score above the cut point threshold,

indicating severe psychiatric distress and PTSD (scores of distress indicating PTSD).

Using IES as an overall measure (the three subscales added together) revealed that

72% of the respondents exceeded the recommended cut point threshold.

The second aim of this article was to investigate the association between

characteristics of the bullying experience, and the level of reported psychiatric

distress and PTSD (Table 2).

Weak interrelationships were found between the subjective feeling of being

victimised, number of reported bullies, if one were bullied by a leader or not, the

length of the bullying episode and the chosen post-traumatic stress indicators (r�/ varies between 0.19 and 0.05, p�/ns for all of the correlations). However, the amount and kind of specific behaviours experienced in connection with bullying (summed up

to an index) showed stronger interrelationship with psychiatric distress and PTSD.

Victims reporting the highest exposure to specific negative acts during the bullying

episode reported more post-traumatic stress and psychiatric distress than respon-

dents exposed to fewer negative acts (all rs are significant, and varied between 0.28

and 0.41). Victims with the longest time interval since the bullying occurred were

troubled the least (r�/ �/0.24, p B/0.05). Exposure to negative acts was more thoroughly investigated, correlating each of

the 22 specific negative acts with psychiatric distress and PTSD (Table 3). Seven of

the negative acts correlated significantly with the stress indices. Ridiculing, hostile or

dismissive attitude, ignoring, downgrading or declaring the person incapable due to

age or gender, exploitation and sanctions due to working style (working to much or

TABLE 1. Estimated PTSD and psychological distress among bullied victims; conventional cut

point scores for IES-R, PTSS-10 and HSCL-25

Scales n %

HSCL-25 Low 23 23.5

High 75 76.5

PTSS-10 Not PTSD 26 25.5

PTSD 76 74.5

IES intrusion Low 12 12.0

Moderate 25 25.0

High 63 63.0

IES avoidance Low 14 14.0

Moderate 26 26.0

High 60 60.0

344 Stig Berge Matthiesen & Ståle Einarsen

to little) were the only negative acts that were significantly linked to the psychiatric

distress and PTSD (rs varied between 0.21 and 0.37). Downgrading or declaring the

person incapable due to gender had the most consistent relation with the measures of

psychiatric distress and PTSD (p B/0.01 for all of the correlations).

Time passing by

The possible effect of the passing of time is an interesting one in relation to PTSD.

Only one in five (22%) of the sample reported to be bullied at present. This group

was compared with victims exposed to bullying more than 1 year ago (66%). The

group in between (bullied less than 1 year ago but not being bullied at present) was

excluded from this analysis.

Those bullied at present reported a higher level of IES intrusion and IES

hyperarousal than those bullied more than 1 year ago (p B/0.05 for the two t -tests).

No significant differences were found in PTSS-10, HSCL-25 or IES avoidance

(Table 4). An interesting point is that the mean levels of psychiatric distress and

PTSD pass the critical cut point score for both the dichotomised groups of bullied

victims (HSCL-25, IES intrusion, IES avoidance). Multivariate analyses were also

conducted, to achieve an overall picture of the association between PTSD symptoms

and the time variable (consisting of six categories, not dichotomised). The three IES

measures were added as dependent variables. The overall association was not found

to be significant (p �/0.05).

The final issue addressed in this study is whether positive and negative affectivity

(state PA and state NA) may moderate or mediate the association between bullying

and psychiatric distress/PTSD. The possible moderating effects of state PA and state

NA were investigated by the use of multiple regression, whereas the mediator effects

were examined by partial correlation analysis. Table 5 gives an overview of a series of

regression models, in which psychiatric distress and PTSD were applied as

TABLE 2. The relationship between bulling, post-traumatic stress and mental distress (Pearson’s r

correlations)

PTSS-10 IES

intrusion

IES

avoidance

IES

hyperarousal

HSCL-25

Feeling of being bullied a

0.15 0.19 0.12 0.16 0.12

Negative acts b

0.39*** 0.41*** 0.36** 0.35** 0.28*

Number who bullied 0.20 0.14 0.15 0.19 0.08

Bullied by leader(s) c

0.15 0.06 0.05 0.09 0.09

Length of bullying 0.08 0.09 0.16 0.09 0.05

Time period since bullying �/0.21 �/0.24* �/0.14 �/0.29* �/0.21

Note : *p B/0.05, **p B/0.01, ***p B/0.001.

1) Feeling of being bullied is a dummy-variable, and comprises two levels: bullied to a certain

extent, and strongly bullied.

2) Negative acts consists of 22 negative acts, summed to an index.

3) Dicotimised variable (bullied exclusively by leader(s) vs. bullied by others).

Bullying and PTSD 345

dependent variables. Time since bullying and negative acts is stepwise entered into

various regression models as predictors, followed by PA and NA.

Time since bullying occurred and the specific negative acts explain between 8%

and 12% of the variance in the criteria variables. Positive and especially negative

affectivity gives substantial contribution to the regression models (all beta values for

NA were in the range 0.34 to 0.57, the amount of explained variance increased

between 13 and 53%, when PA and NA was added to the models). Reversed multiple

regression models were also conducted, that is, with positive and negative affectivity

entered into the models as step 1 and the two bullying variables as step 2. Controlled

for the positive and negative affect, the variable combination amount of bullying and

time since bullying took place gave a significant increase in the regression models

predicting post-traumatic stress symptoms: IES (p B/0.05, R 2

change, all three

subscales) and PTSS. Bullying did not, however, predict psychiatric distress

measured by HSCL-25. At most, the two bullying predictors added 9% increase

to the models (IES avoidance). All five regression models were tested for an

interaction between PA and NA and the two measures on bullying (all combina-

tions). Only one interaction turned out to give a significant contribution to explain

variance. The interaction effect between PA and time since bullying occurred gave a

2% increase in the explained variance of psychiatric distress.

Zero-order and second-order partial correlation analysis (pr ), respectively, were

conducted to examine possible mediator effects of PA or NA related to the link

between bullying and traumatic stress reactions. The partial control thus consists of

the PA and NA variables in the second-order partial analysis. A considerable

difference between the two correlation coefficients may be interpreted as mediator

effects of PA and NA. The difference between zero-order and second-order

correlations were found to be modest, however: PTSS (r�/0.27, pr�/0.23), IES avoidance (r�/0.31, pr�/0.28), IES intrusion (r�/0.24, pr�/0.19), IES hyperarousal (r�/0.26, pr�/0.22) and HSCL-25 (r�/0.20, pr�/0.14). Thus, in sum our study does

TABLE 3. The relationship between various negative acts, psychological functioning and post-

traumatic stress; zero-order correlations (Pearson’s r )

PTSS-10 IES

intrusion

IES

avoidance

IES

hyperarousal

HSCL-25

Ridiculing 0.33** 0.12 0.09 0.15 0.31**

Hostile/dismissive

attitude

0.21* 0.23* 0.20 0.28** 0.07

Ignoring 0.15 0.20 0.11 0.24* 0.10

Downgrading

due to age

0.20 0.20 0.10 0.08 0.23*

Downgrading

due to gender

0.32** 0.33*** 0.37*** 0.27** 0.37**

Exploiting 0.26** 0.22* 0.21* 0.21* 0.36**

Negative reactions because

of working too much/too little

0.28** 0.21* 0.05 0.18 0.22*

Note : *p B/0.05, **p B/0.01, ***p B/0.001; n varies between 90 and 100.

346 Stig Berge Matthiesen & Ståle Einarsen

TABLE 4. Post-traumatic stress and psychological distress; comparison of victims bullied at present

vs. victims bullied one year ago or later (Student’s t tests)

Bullied now Bullied before t df p

M SD M SD

HSCL-25 2.45 0.49 2.15 0.69 1.79 1/83 ns

PTSS-10 45.81 14.74 39.00 16.27 1.74 1/86 ns

IES intrusion 27.04 6.44 20.76 10.90 2.55 1/85 B/0.05

IES avoidance 22.61 9.24 19.52 10.12 1.24 1/85 ns

IES hyperarousal 25.07 7.72 18.97 11.01 2.35 1/85 B/0.05

TABLE 5. Multiple regression models with time since bullying occurred, negative acts, positive

affectivity (PA) and negative affective (NA) as predictors, and with measures of psychological

distress and post-traumatic stress as criteria variables; strongest (if significant) interactional term is

included in each model

beta R 2

R 2 Change

F Change

PTSS-10

Time �/0.23 0.05 0.05 5.73* Amount of bullying 0.29 0.12 0.07 9.61**

PA �/0.43 0.30 0.18 26.06*** NA 0.50 0.49 0.19 37.66***

IES intrusion

Time �/0.17 0.02 0.02 2.96 Amount of bullying 0.33 0.12 0.10 12.31***

PA �/0.20 0.16 0.04 4.58* NA 0.35 0.24 0.08 11.74***

IES avoidance

Time �/0.38 0.06 0.06 7.72** Amount of bullying 0.11 0.11 0.05 6.13*

PA �/0.11 0.21 0.10 13.96*** NA 0.34 0.43 0.22 37.66***

IES hyperarousal

Time �/0.25 0.05 0.05 6.87** Amount of bullying 0.28 0.12 0.07 8.92**

PA �/0.34 0.24 0.10 15.09*** NA 0.57 0.48 0.24 46.63***

HSCL-25

Time �/0.24 0.05 0.05 6.09* Amount of bullying �/0.20 0.09 0.04 4.37* PA �/0.57 0.36 0.27 44.24*** NA 0.57 0.61 0.25 62.44***

PA�/time �/0.44 0.64 0.03 6.69*

*p B/0.05, **p B/0.01, ***p B/0.001.

Bullying and PTSD 347

not confirm moderating or mediating effect of state PA and state NA regarding the

bullying�/traumatic stress connection.

Discussion

Information about the prevalence of PTSD among victims of bullying may be useful

in order to inform health care professionals as well as the legal system of the possible

extreme consequences of such experiences. The description of specific symptoms

may also benefit victims directly by informing them of symptoms experienced by

others. In itself this may reduce any anxiety and fear of ‘going crazy’ (Saunders,

1994). Practitioners also need to be informed of the symptoms displayed by victims

of bullying, thus preventing the misdiagnosis that often seems to occur when victims

seek medical or psychological treatment (Einarsen, 2000; Leymann & Gustavson,

1996). Many victims may be incorrectly diagnosed by professionals receiving

diagnoses such as paranoia, manic depression, or character disturbance (Leymann

& Gustavson, 1996) which may give rise to further stigmatisation. The frequency

and intensity of post-trauma symptoms diminish gradually over time, although the

symptoms may never completely disappear (Foa & Riggs, 1995). This decline was

demonstrated in two research studies examining changes in the prevalence of PTSD

following assault (Foa & Riggs, 1995; Rothbaum et al ., 1992). In both studies female

victims of rape and non-sexual assault were assessed repeatedly over a period of 3

months, with the onset of assessment starting about 14 days after the traumatic

event. It was found that 94% of rape victims and 76% of non-sexual assault victims

met symptom criteria for PTSD at the initial assessment, diminishing to,

respectively, 47% and 22% after 11 weeks.

Several studies have demonstrated that bullying at work poses a serious threat to

the health and well-being of those at the receiving end (Einarsen et al ., 1996; Zapf et

al ., 1996). Delayed injuries of bullying, in which the victim perhaps has retired from

active work, has been investigated to a very limited extent so far. The notion that

victims of bullying are exposed to such health hazards causing Post-Traumatic Stress

Disorder has, with a few exceptions (see e.g. Leymann & Gustavson, 1996;

Mikkelsen & Einarsen, 2002a), not been investigated. The present study indicates

that psychiatric distress and PTSD may be widespread among victims of bullying at

work. Some three out of four respondents scored above the recommended IES and

PTSS threshold for PTSD. Comparison with a host of other samples, like separated

or divorced people, war zone personnel, postal employees after an organisational

downsize, and a sample of possible psychiatric cases, indicates that our sample of

bullied victims portrays an especially high level of stress. The findings should not be

interpreted as indicating that exposure to bullying is worse than the aftermath of

losing your kids in a bus accident, or being traumatised in a war zone.

According to Janoff-Bulman (1992), post-traumatic stress following victimisa-

tion is largely due to the shattering of basic assumptions victims hold about

themselves and the world, in which the feeling of personal invulnerability constitutes

an important part. The sense of invulnerability is tied to the three core beliefs: (a) the

348 Stig Berge Matthiesen & Ståle Einarsen

world as benevolent, (b) the world as meaningful, and (c) the self as worthy. Also, the

just world hypothesis (Lerner, 1980), that is, our need to believe that we live in a

world where people get what they deserve and deserve what they get, seems to be

shattered by the experience of being bullied. The belief in a just world and the three

core beliefs enables the individual to confront the physical and social environment as

if it were stable, orderly, coherent, safe and friendly. A traumatic event presents

information that is incompatible with these existing mental models, or schemas

(Horowitz, 1975, 1979).

This incongruity gives rise to stress responses requiring reappraisal and revision

of the schemas. The person tends to use avoidance strategies in order to ward off

distressing thoughts, images and feelings caused by the incident, thus giving the

control system tolerable doses of information. Phases of intrusion and avoidance

occur as the person attempts to process or ‘work through’ the experience (Horowitz,

1975). The bullied victim may repeatedly re-experience the most humiliating or

frustrating aggressive events for his/her ‘inner eye’, or the person may systematically

avoid certain work situations, be it lunch breaks, meetings or other people while at

work. They may even experience it as difficult to approach or pass a former

workplace, as described in one particular case study (Einarsen & Hellesøy, 1998). A

traumatised and stigmatised person may, due to excessive bullying at work, have a

strong shattered experience of the world as not being a just, meaningful and

benevolent place, with a strong anticipation of future misfortune to come. These

experiences can be induced later on, for instance, after the person has ended his/her

job or even the job career. Following may be a state of extreme anxiety and

hyperarousal, in the long run causing a breakdown of basic psycho-biological

systems.

It is tempting to assume that the bullied victims are particularly hit by the

shattering of the world as not being a benevolent place, and poor self-esteem after the

devastating incidents. Another important assumption is the just world hypothesis

(Lerner, 1980). People have a need to believe that they live in a world where people

get what they deserve and deserve what they get. The belief in a just world enables

the individual to confront the physical and social environment as if it were stable and

orderly. A traumatised person experiencing bullying at work may have a strong

shattered experience of the world as not being a just place, with a strong anticipation

of future misfortune to come (Mikkelsen & Einarsen, 2002a). Traditionally, PTSD is

regarded as a postponed negative health effect after the exposure to one shocking,

stultifying stressor, e.g. an accident. The traumatic event can usually not be

predicted, with natural disasters, mechanical failures or human errors typically

being the triggering factors.

Bullying, at work or at school, is a somewhat different phenomenon, since it is a

cumulative trauma (type 2 trauma). Jarring personal chemistry, escalating conflict

episodes and dismissive interpersonal behaviour may gradually turn into mortifying

bullying (Einarsen, 1999). The disaster is socially created, and at least on the

psychologically level the victim feels that s/he cannot escape from this devastating

traumatic situation. Other studies have demonstrated that being forced to stay in a

life situation filled with traumatic episodes for a long time may result in PTSD, e.g.

Bullying and PTSD 349

study findings from concentration camp survivors (Eitinger & Strøm, 1973).

Learned helplessness (Seligman, 1975), a sense of being unable to cope with

destiny, may be a reaction bullied victims and concentration camp prisoners have in

common, with PTSD as a negative health after effect.

Respondents who reported exposure to many different kinds of specific negative

acts are troubled the most with post-traumatic stress. A somewhat surprising finding

was the modest relationship between ‘being bullied by leaders’ and post-traumatic

stress. Other studies have found that individuals to a great extent are struck by health

complaints when bullied by their superiors (Björkqvist et al ., 1994). Leaders are

influential and possess more power than colleagues, which means that they can exert

sanctions against the victim as part of a conflict process. Bullying by superiors seems

to be widespread among the participants of this study. It is possible that modest

interrelationships between leadership harassment and post-traumatic stress was due

to a relatively homogenous sample. Length of bullying was not associated with post-

traumatic stress, which could be explained with a homogeneous sample, with low

between subject variance.

Victimisation from bullying comprises a subjective experience. All types of

situations can in principle be experienced as conflict episodes, according to Thomas’

(1976) conflict definition. Most kinds of behaviours perceived as negative and

directed at a person with a perceived aim to be hurtful may also lead to a perception

of being bullied, at least if they are exhibited over a prolonged period of time

(Einarsen et al ., 2003). Irrespective of this is it of crucial importance to gather

information about negative acts that causes perceptions of being bullied, and PTSD

in the next round. In his work Leymann (1990b) lists 47 negative acts potentially to

perceived as precursors of bullying, whereas this survey maps 22 negative acts (the

measure of NAQ), chosen from clinical and empirical experience. It is possible,

however, that certain kinds of negative acts are experienced as more stressful than

others. In the present study downgrading or incapasiting due to gender correlates

quite strongly with post-traumatic stress. An adjacent finding is the revealed link

between working style and traumatic stress. Downgrading due to gender and bullying

because of working style could be seen as different expressions of tension between

male and female employees at work.

Post-traumatic stress implies that the health weakening symptoms persist, or

emerge with new intensity long after the actual trauma has ceased. Although this

survey revealed that symptoms weakened somewhat as time goes by, the effect of

time relationship was moderate. The small differences between victims exposed to

present bullying and victims in which the bullying ceased more than a year ago

support a notion that time only to a limited extent heals all wounds. The relationship

between bullying and positive and negative affectivity has been demonstrated in

previous research (Mikkelsen & Einarsen, 2002a). Negative affectivity has been seen

as an important source of ‘emotional dissonance’ in organisations, and is linked to

role conflict (Abraham, 1998). It has been found, furthermore, that negative

affectivity also co-varies with interpersonal conflicts (Spector & O’Connell, 1994).

Positive affectivity corresponds with, for example, organisational commitment

(Cropanzano et al ., 1993) and prosocial behaviour (Lawton et al ., 1997). It has

350 Stig Berge Matthiesen & Ståle Einarsen

been argued that negative affectivity should be applied as a control variable within

stress research, because NA could reveal spurious relationship between strain and

stress reactions, as stated by Watson and Clark (1984) in their seminal work. An

example of such interrelationships could be the perception of exposure to negative

acts at work, as seen in bullying. In this study it was unveiled that weak (non-

significant) interaction effects between all combinations of PA, NA and the most

important bullying predictors related to post-traumatic stress. The mediator effects

of PA and NA were also modest. These findings stultify the notion that NA modifies

most interconnections between strain and reaction measures, and is in line with

Mikkelsen and Einarsen (2002b).

Still, NA seems to have a stronger direct effect on the PTSD-indicators than

does PA. These findings support previous research, where NA co-varies the most

with stress and health indicators, and PA with satisfaction and well-being indicators

(Watson, 1988). Also found is a stronger interrelationship between post-traumatic

avoidance and hyperarousal reactions, compared with post-traumatic intrusional

thoughts and flashbacks. This could indicate that it is particularly bullied victims

characterised by an evasive behaviour, and strong stress arousal, who are struck by

PTSD problems.

Conclusion

Using established tests of PTSD, a very high level of post-traumatic stress symptoms

was revealed in the present study. This finding corresponds with previous research

(Leymann & Gustavson, 1996; Mikkelsen & Einarsen, 2002a). A majority of the

respondents exceed recommended threshold-values indicating PTSD. It is important

to underline that our findings are only indicators of PTSD problems among the

victims, since we did not undertake diagnostic interviews with the respondents. It

remains a debatable question whether PTSD is an appropriate psychiatric diagnosis

in the case of bullying at work, at least according to the criteria of DSM-IV. In our

opinion, one should evaluate this aspect in an open-minded manner, since the PTSD

diagnosis and DSM have undergone several revisions over the course of time.

Other methodological constraints must also be considered in the interpretation

of the present findings. The participants comprise a selected group: they have all

been recruited from two associations of bullied victims. The sample could consist of

more injured people than what is typical for victims of bullying. It is reasonable, on

the other hand, to assume that many individuals exposed to bullying at work do not

have sufficient go-ahead spirit or strength to seek allies, e.g. by forming or contacting

a bullying association. Many bullied victims express feelings of emotional constric-

tion after being a victim of bullying. They refuse to confide in someone what they

experience at work, male victims in particular (Einarsen et al ., 1994). The present

sample consists on average of quite educated people, most women, working in white

collar professions. However, an other study revealed that blue collar workers are

more exposed to bullying than others (Einarsen & Skogstad, 1996). Hence, the

participants of this study may not comprise a representative sample. Social

Bullying and PTSD 351

desirability (Crowne & Marlowe, 1964) represents another issue to be taken into

consideration. Sceptics may claim that it is reasonable to assume that the participants

in the present study, being members of bullied victims associations, consciously or

unconsciously will express their feelings in a particularly negative light, in order to

finally gain the attention their problems deserve.

As illuminated by this article, PTSD related to bullying at work constitutes a

research field with scarce research attention so far. The field deserves follow-up

studies. Longitudinal research should be conducted in particular, since the time

factor is essential for our understanding of the progress of PTSD. A suggestion for

follow-up studies, also, is that diagnostic interviews are implemented as part of the

research design, as, for instance, performed by Dyregrov and associates in their

studies among war children (Dyregrov et al ., 2000, 2002).

Irrespective of PTSD, the topic of bullying at work lacks longitudinal research

designs, which should be applied during the forthcoming years. Particularly,

personality issues should be investigated. Some victims of bullying may be more

vulnerable than others, as indicated in a previous study (Matthiesen & Einarsen,

2001). Correspondingly, the strong direct link found between negative affectivity and

PTSD symptoms in this study may indicate that there is a strong personality

component in the phenomenology of bullying.

Acknowledgements

The authors want to thank the respondents who participated in the study, and the

members of two bullying associations in Norway. We also owe appreciation to Atle

Dyregrov, Michael Sheehan, and two anonymous reviewers for helpful suggestions

and comments, and Jarle Eid for providing some of the contrast group data.

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(Accepted 9 April 2004)

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