Individual Consequences of Being Exposed to Workplace Bullying

Eva Gemz0e Mikkelsen, Ase Marie

Hansen, Roger Persson, Maj Fosgrau Byrgesen and Annie Hogh

Introduction 163

Empirical Studies on Individual Consequences of

Workplace Bullying 164

Qualitative Studies on Individual Consequences 164

Quantitative Studies on Individual Consequences 167

Frameworks for Understanding Individual

Consequences of Workplace Bullying 184

Transactional Stress Models 185

Schema Theory of Trauma 186

The Cognitive Activation Theory of Stress (CATS) 187

Evolutionary Social Psychology 188

Concluding Discussion 191

Bibliography 193


Research into the individual consequences of workplace bullying, defined as the long-lasting and systematic mistreatment of an employee by other organization members (Nielsen et al., 2017), has gone through a tremendous development. Since the early studies by American psychiatrist Brodsky (1976), Swedish-German psychologist Leymann (1988, 1996) and psychologists from Bergen University in Norway (Einarsen et al., 1994; Matthiesen et al., 1989) continuous interest and methodological and theoretical developments have generated a large number of studies in various occupational and national settings. Recently, several meta-analytical studies (i.e., studies of studies) have emerged and started to tie studies on similar themes together (e.g„ sickness absence, health complaints etc.). Collectively, these studies have rendered important insights and documented the many potentially devastating psychological, physiological, social and socio-economic effects that may follow workplace bullying (c.f. Hansen, 2018; Nielsen and Einarsen, 2012; Nielsen. Einarsen et al., 2016; Verkuil et al., 2015).

In this chapter, we aim to consolidate and outline insights from more than 30 years of multifaceted research on individual outcomes of workplace bullying. First, we review research on individual outcomes that relate to (1) psychological distress reactions, (2) physiological stress reactions, (3) physical health problems and (4) social- and socio-economic consequences. Second, we direct attention to four meta-theories that may help organize and inform thinking when designing future studies and/or interpreting existing studies on workplace bullying. Finally, we conclude and briefly sum up some empirical, methodological and theoretical developments, suggesting some possible directions for future research.

Empirical Studies on Individual

Consequences of Workplace Bullying

When studying the individual consequences related to workplace bullying, interview studies of targets have become increasingly common (Carter et al., 2013; Karatuna, 2015; Lewis, 2006; Lovell and Lee, 2011; Lutgen-Sandvik, 2008; O'Neill and Borland. 2018; Strandmark and Hallberg, 2007). However, the bulk of studies comprises quantitative cross-sectional studies employing non-random sampling methods and self-report questionnaires with forced choice answers (Neall and Tuckey, 2014; Nielsen and Einarsen. 2018). In the following section, we will first summarize results obtained from qualitative studies after which we recap results from quantitative studies with either cross-sectional or longitudinal design, as well as results from meta-analytical studies.

Qualitative Studies on Individual Consequences

Spanning three decades, qualitative studies of different designs have yielded important contributions and in-depth insights into the passage of events, the breadth of the targets’ symptoms as well as the factors underlying workplace bullying. While most interview studies have reported adverse outcomes (e.g.. psychological distress and physical symptoms), a few studies have in fact reported that targets of bullying may become more resilient in response to the bullying episode (van Heugten, 2013).

Psychological Distress, Self-Images and Impact on Chronic Disease Interview studies from the 1990s and noughties indicate that targets report various psychological distress symptoms as well as reduced self-confidence, low self-worth, guilt, shame, worthlessness and self-contempt (Lewis, 2004; Macintosh, 2005; O' Moore et al., 1998; Price Spratlen, 1995; Thylefors, 1987). An illustrative Swedish interview study (n = 20; Hallberg and Strandmark, 2006) showed how targets rapidly develop psychological and/or psychosomatic symptoms with participants reporting sleep problems, concentration difficulties, mood swings, fear, anxiety and depressive symptoms already a few months after the bullying started. While initially disappearing when the targets were off work, the symptoms would eventually become more consistent and chronic. Some of the targets who had a pre-existing chronic disease (e.g„ asthma, diabetes and hypertension) reported that their chronic condition deteriorated. Other targets conveyed a strong fear of the bullies, felt being subjected to rumours concerning their character or reported feelings of terror if the phone rang or somebody called their name. Consistent with findings from other qualitative studies (e.g„ Lewis, 2004) was the targets’ beliefs that the experience of bullying had left them with ‘an internal scar or vulnerability, which would never heal completely, but would easily reopen and continue to cause harm" (Hallberg and Strandmark, 2006, p. 112).

A similar extensive and serious symptomatology was observed in a Canadian study that entailed semi-structured interviews with 18 women (32-62 years of age), all of whom had been on sick leave due to workplace bullying (O'Donnell et al., 2010). The women had been targets of a range of bullying behaviours (e.g., incivility, criticism, exclusion, verbal and physical aggression, etc.) mainly by female superiors and/ or bosses. The most commonly reported psychological consequences were self-described and/or professionally diagnosed stress, anxiety, and depression. In addition, the women reported experiencing anger, frustration, irritability, lowered self-confidence, self-doubt, powerlessness, hopelessness, fear and isolation. Reported physical and/or somatic consequences included concentration difficulties, insomnia, nightmares, exhaustion, headaches, gastrointestinal issues, cardiac issues and deterioration of chronic illnesses (O'Donnell et al.. 2010).

Sometimes qualitative approaches are used in combination with quantitative research approaches. For example. Carter et al. (2013) conducted semi-structured telephone interviews with 43 British targets of bullying in connection with a large quantitative study (n = 2950). The qualitative results confirmed the quantitative findings as targets reported high levels of psychological distress such as worry, fear, sleep problems, difficulties concentrating and psychosomatic symptoms. Likewise, a quantitative study of medical specialists in New Zealand (Chambers et al., 2018, n = 1759) included qualitative data in the form of comments from 563 self-identified targets of bullying. Some of these reported feelings of disillusion, isolation, fear and distrust, while others described having depressive episodes and feelings of burnout.

Observably, the results from qualitative studies suggest that targets of workplace bullying in short time develop an extensive and serious psychosomatic symptomatology with an increasing risk of having their basic cognitive schemas such as self-worth shattered (c.f, Janoff-Buhnan. 1989). In addition, the targets seem to acquire a negative outcome expectancy as regards their possibilities of achieving optimal well-being in the future, which increases the likelihood of triggering unhealthy physiological stress responses (c.f., Ursin and Eriksen. 2004).

Sickness Absence and Other Social Outcomes Although not necessarily representative, qualitative studies may also shed light on the pathways linking workplace bullying to absenteeism. As illustrated by the quote below, for targets of bullying, calling in sick or extending an actual short sick-leave may offer a temporary way of coping with the destructive working environment:

She could really scare me. I was terrified inside—and that’s not normal for somebody my age. But I was literally shaking with fear. And when I was sick. I wasn’t really in a hurry to go back to work again. If I could drag it one more day, well then I wouldn't have to go out there again.

(Male target; in: Mikkelsen et al., 2007, p. 242)

Calling in sick or staying home a few days more may offer short havens of peace from continual accusations, scolding, critique or ostracism. Moreover, some targets may feel compelled to go on a longer sick-leave, especially if the prolonged abuse have resulted in symptoms like anxiety, depression, concentration difficulties and extreme fatigue. However, the tactic to withdraw from the social context to alleviate the bullying exposure is not without problems or risks. For example, besides possibly resulting in a reduced income, being sick-listed and staying at home often implies fewer social contacts and thus reduced possibilities of social support from colleagues and supervisors. Indeed, while the target is absent, the perpetrator(s) may actively seek allies who would support them and not the target upon the latter’s return. In any event, in the above-mentioned Canadian study by O'Donnell and colleagues (2010), the focus was on understanding the process of sickness absence as experienced by some female targets of bullying. Results showed that for some of the 18 targets, a deteriorating mental and physical health made them unable to perform their work duties let alone turn up at work. As such, for targets in this study, taking sickness absence became a psychological necessity (O'Donnell et al., 2010).

Similar to results from Eriksson et al. (2008), who examined long-term sickness absence in relation to burnout in a Swedish sample of 32 individuals, the respondents in O'Donnell et al.’s (2010) study displayed an ambivalence related to their sickness absence. The women were plagued by feelings of guilt, shame, failure and embarrassment and worried about damaging side effects such as a negative impact on personal and career standings. Pointing to a conditional pathway, the study also shows how access to, or lack of, for example organizational support, affects the targets’ coping process including their return to work. With respect to the latter, only in situations with a positive change in the bullying situation, was sickness absence considered an effective coping strategy in relation to health improvement and a positive return to work. As demonstrated in other studies (e.g.. Chambers et al., 2018; O'Neill and Borland, 2018), including studies on cyberbullying (D'Cruz and Noronha, 2013; Forssell, 2019), the psychological distress symptoms could spill over to the targets’ family lives and professional work and as such, add to the felt distress.

Quantitative Studies on Individual Consequences

Since the 1980s, quantitative studies of different designs have provided information on associations between workplace bullying and a wide range of individual outcomes. In this section, we summarize reported results from quantitative cross-sectional and longitudinal studies as well as systematic reviews (including meta-analytical studies).

Psychological Distress Reactions Psychological distress reactions encompass studies that link workplace bullying with short-term and/or chronic reactions that are manifested psychologically. Examples are general stress symptoms, psychosomatic complaints, anxiety, burnout, depression and symptoms of trauma (e.g., post-traumatic stress disorder (PTSD) symptoms). The early quantitative studies on psychological distress reactions were mainly of a cross-sectional nature. Because cross-sectional research typically cannot disclose the direction of cause and effect, they are often considered less interesting than longitudinal studies. Yet, cross-sectional studies have consistently contributed by establishing associations between workplace bullying and indicators of psychological distress reactions, which is a first step on the journey to understanding causality. Early cross-sectional studies linked bullying to a wide range of distress reactions such as general stress (e.g., Vartia, 1996), anxiety and depression (e.g.. Björkqvist et al., 1994; Gandolfo, 1995; O'Moore et al., 1998; Quine, 1999), burn-out/chronic fatigue (e.g., Matthiesen et al., 1989), psychosomatic complaints (e.g., Einarsen et al., 1996; Zapf et al., 1996), symptoms of post-traumatic stress (Björkqvist et al., 1994; Leymann and Gustafsson, 1996) and suicidal ideation (Einarsen et al., 1994). Likewise, later cross-sectional studies, from approximately 2000 onw'ards, have extended the empirical body of data and have shown workplace bullying to be associated with mental and psychosomatic symptoms (Agervold and Mikkelsen, 2004; Meseguer et al., 2008), anxiety (Bilgel et al., 2006; Melia and Becerril, 2007; Moreno-Jimenez et al., 2007), depression (Bilgel et al., 2006; Demir et al., 2013; Hansen et al., 2011; Niedhammer et al., 2006), tiredness, exhaustion or burnout (Law et al.. 2011; Lpkke and Bysted, 2016; Matthiesen et al., 2008; Melia and Becerril, 2007; Sä and Fleming, 2008; Tong et al., 2017), symptoms of post-traumatic stress (Balducci et al., 2011; Matthiesen and Einarsen, 2004; Mikkelsen and Einarsen, 2002; Nielsen et al., 2005) and suicidal ideation (Sterud et al., 2008).

While the early studies primarily were situated in North American and the Scandinavian countries, throughout the noughties and onwards, additional confirming results have been obtained in cross-sectional research across a wide range of countries, for example, Canada (Lee and Brotheridge, 2006), France (Niedhammer et al., 2006), Spain (Melia and Becerril, 2007; Meseguer de et al., 2008; Moreno-Jimenez et al., 2007), Italy (Pompili et al., 2008), Portugal (Sä and Fleming, 2008), Turkey (Bilgel et al., 2006), Switzerland (Tong et al., 2017), Korea (Park and Masakatsu, 2017; Park and DeFrank, 2018) and New Zealand (Chambers et al., 2018; Gardner et al., 2013).

The impressive geographical spread of studies underlines that workplace bullying is phenomena that is deeply rooted in human behaviour and the human tendency to form social groups.

Below we will review the associations between exposure to workplace bullying and some of the more serious psychological symptoms of distress displayed by targets, that is, suicidal ideation, depression, anxiety, PTSD symptoms and burnout.

Suicidal Ideation Thirty years ago, Leymann (Leymann, 1988) warned of suicidal ideation and actual suicide as ultimate reactions to workplace bullying. While suicide is the deliberate act of ending one's own life (World Health Organization [WHO], 2014), suicidal ideation is to have thoughts or desires to end one’s own life. Suicidal ideation is also represented in the DSM-5 as a depressive disorder (APA, 2013). Worldwide, more than 800,000 people decide to end their own lives each year and the yearly suicide rate in Europe has been estimated to circa 15.4 persons per 100,000 (c.f. Milner and La Montagne, 2018; WHO, 2018). Many suicides occur in occupationally active ages and men more often commit suicide than women do (WHO, 2014). According to Interpersonal Theory of Suicide (IPTS; originally developed by Joiner (2005)), people may come to have suicidal thoughts or wishes if their need to belong to valued groups is thwarted and if they at the same time perceive themselves as being a burden on others with little hope of change (Van Orden et al., 2010). The quote below is one example of a manifestation of suicidal ideation experienced by a middle-aged woman exposed to workplace bullying:

I remember one day I was driving to work. It was at the end of this process. A huge truck came towards me and I remember thinking ‘I wish it would drive into me. then I wouldn't have to go there’. It was a very shocking thought . . . because I’ve always been so fond of life.

(Mikkelsen et al., 2007, p. 175)

Nevertheless, despite Leymann’s (1988) early concerns, the subsequent research on workplace bullying and suicide and/or suicidal ideation has been relatively limited. A review by Leach et al. (2017) identified eight studies that had examined the association between workplace bullying and suicidal ideation. A further four studies assessed suicidal ideation among bullied individuals with the purpose of accounting for the frequency of suicidal thoughts in bullied targets. All studies showed positive association between workplace bullying and suicidal thoughts. Similar to the pattern of other systematic reviews, the studies used a variety of methods to measure both the antecedents and outcomes (e.g„ LIPT, NAQ and the self-labelling method—see Nielsen etal., this volume'). Although Leach etal. (2017) noticed a lack of high-quality epidemiological studies of a prospective nature that could better rule out alternative explanations of the identified associations, they identified two Norwegian longitudinal studies of higher quality. The first of these comprised a three wave-study based on a randomized nationwide sample of 1,846 employees (Nielsen, Nielsen et al., 2015). The results indicated that victimization from bullying was associated with subsequent suicidal ideation (OR = 2.05; 95% CI = 1.08 to 3.89). The second study comprised a three-wave study across five years with 2,062 individuals participating at least twice, and 1,291 individuals participating at all three time points. This study focused on the associations between different kinds of bullying behaviours and suicidal ideation as assessed with a one-item measure from the ‘Hopkins Symptom Checklist’ (Nielsen, Einarsen et al., 2016). The prevalence of suicidal ideation was 4.0%, 5.0% and 4.2% across the three waves of sampling. After statistical adjustments, the authors concluded that being exposed to physically intimidating bullying behaviours increased the risk of displaying suicidal ideation two years later (OR = 10.68 [95% CI = 4.13 to 27.58] and five years later [OR = 6.41 (95% CI = 1.85 to 22.14]). Yet, exposure to person related and/or work-related bullying behaviour at work did not increase the risk for suicidal ideation.

Depression and Depressive Symptoms Depressive symptoms, or even a full-blown depression, are other potentially serious consequences when exposed to workplace bullying. Depression is in many countries a public health concern and costly in both human and economic terms (Ekman etal., 2013). Accordingly, an increasing number of studies have focused on understanding the association between workplace bullying and depression and/or depressive symptoms. In the forthcoming International Classification of Diseases 11th revision (ICD-11), depressive disorders are classified under ‘Mood disorders’ and described to be characterized ‘by depressive mood (e.g., sad, irritable, empty) or loss of pleasure accompanied by other cognitive, behavioural, or neurovegetative symptoms that significantly affect the individual's ability to function' (ICD-11 for Mortality and Morbidity Statistics, 2018, Depressive disorders). Noticeably, in workplace bullying research, depression and/or depressive symptoms have been addressed broadly without paying much attention to the many existing facets and subtypes of depressive disorders (c.f., ICD-11, 2018). On the other hand, many facets and subtypes of depression are arguably less interesting when considering working populations.

An early Finnish study, by Kivimaki et al. (2003), entailed 5,432 hospital employees (primarily women) and two rounds of measurement with circa two years apart. In this study the authors observed a strong association between workplace bullying and subsequent diagnosed depression as verified via a self-report question. Specifically, incident cases of depression were identified if the respondent reported that a medical doctor had diagnosed him or her as having depression. However, after statistical adjustment for sex, age, and income the association between workplace bullying and incident depression was estimated to be OR = 4.2 (95% CI 2.0 to 8.6) (Kivimaki et al., 2003).

In two Norwegian studies that used the Negative Acts Questionnaire (NAQ) (Einarsen et al.. 2009) to measure exposure to workplace bullying, depression was assessed using either a one-year follow-up (Reknes et al., 2014) or a five-year follow-up period (Einarsen and Nielsen, 2015). The results from these two studies showed that workplace bullying was associated with an increased risk of depression, irrespective of the measurement of depression or depressive symptoms or length of follow-up.

In a Danish study by Rugulies and colleagues (2012), the frequency of workplace bullying was positively associated with the onset of depression. Rugulies et al. (2012), reported OR’s of 2.22 (95% CI: 1.31-3.76) for occasionally bullied and 8.45 (95% CI: 4.04-17.70) for frequently bullied, when compared to non-bullied employees. In three subsequent prospective studies (Bonde et al., 2016; Gullander et al., 2014; Hogh et al., 2016) entailing large and occupationally diverse study samples, depression was investigated through interview-based diagnoses (e.g.. Schedules for Clinical Assessment in Neuropsychiatry (SCAN), [Wing et al., 1990]). Gullander et al. (2014), who studied new cases of depression, reported an increased risk of depression for occasionally bullied (OR = 2.17; 95% CI: 1.11 to 4.23) and frequently bullied (OR = 9.63; 95% CI: 3.42 to 27.1). The latter three studies found that even when adjusting for changes in the status of bullying during follow-up, selflabelled workplace bullying was associated with depression up to four years after baseline. However, the association was only significant in those reporting being bullied frequently (i.e.. daily, weekly or monthly), not in those who reported occasional bullying (i.e., now and then). In addition, and using the NAQ to assess bullying, Hogh et al. (2016) found that the association between frequent and occasional exposure to bullying at baseline and diagnosis of depression two years later disappeared when adjusting for sense of coherence and depression at baseline.

The general pattern has been confirmed in a Danish metaanalysis of longitudinal studies on workplace bullying and depression or depressive symptoms, in which an overall OR of depression or depressive symptoms was calculated to be 4.14 (95% CI: 2.61; 5.98) (Hansen, 2018). Likewise, in a Swedish meta-analysis (Theorell et al., 2015) addressing longitudinal associations between work environment factors and depressive symptoms during the period 1990 to 2013, three bullying studies were identified altogether comprising more than 15,000 participants (i.e., Kivimaki et al., 2003; Rugulies et al., 2012; Stoetzer et al., 2009). The results indicated that workplace bullying was a significant risk factor for developing later depressive symptoms and the average OR across the three studies was reported to be 2.82 (95% CI = 2.21 to 3.59) (Theorell et al., 2015).

Anxiety and PTSD Symptoms and Studies on Simultaneous Occurrences In comparison to depression and depressive symptoms, there have been fewer studies on anxiety and PTSD, or the simultaneous occurrence of various symptoms and/ or problems. However, in one Australian longitudinal cohort study, a significant association between workplace bullying and 2-3 times greater odds of depression and anxiety was observed when controlling for risk factors outside the workplace and when only including participants with no mental illness previously measured (Butterworth et al., 2015). In addition, Nielsen, Tangen, Idsoe et al. (2015) showed a mean correlation of 0.44 (95% CI = 0.36-0.48) between workplace bullying and an overall score on symptoms of posttraumatic stress. A recent study by Nielsen et al. (2017) found that exposure to workplace bullying was associated with an increased risk of PTSD symptoms while PTSD symptoms may be a potential antecedent of bullying. A prospective Japanese study (Taniguchi et al., 2016) using a sample of employees working within welfare facilities found a significant association between onset and chronic exposure to person-related negative acts and subsequent elevated risk of psychological stress reactions two years later (using the Brief Job Stress Questionnaire).

Burnout Burnout is characterized by feelings of exhaustion, cynicism (or depersonalization) and a lack of professional efficacy (Maslach et al., 2002). Burn-out will be represented in the forthcoming ICD-ll system as ‘QD85’. As such, it is positioned under the major ancestor ‘24 factors influencing health status or contact with health services’ and the minor ancestors ‘factors influencing health status’ and ‘problems associated with employment or unemployment’, respectively (ICD-ll for Mortality and Morbidity Statistics, 2018). While burnout is an appealing construct, it is considered a specific occupational phenomenon. It is also a construct known to overlap with depression (c.f., Bianchi etal., 2015). Despite that burnout research started in the 1970s, the relationship between burnout and workplace bullying seems only to have intersected more frequently in later years. A recent systematic review on the health consequences of workplace bullying in the health care sector (Lever et al., 2019) identified 11 studies that all reported a positive statistical association between bullying and burnout, yet only two had a longitudinal design. In the tw'o longitudinal studies encompassing 205 (Laschinger and Fida, 2014) and 508 nurses (Trepanier et al., 2016), respectively, the correlations between bulling at baseline and burnout at follow-up varied between r = 0.25 and r = 0.42. Burnout was measured with subscales from the Maslach Burnout Inventory in six of the 11 studies (Lever et al., 2019).

In any event, two longitudinal studies yield evidence that workplace bullying may be predictive of later burnout. The first study, not identified in the review above, investigated retail workers in Australia in a two-wave study and found that baseline exposure to negative acts had a predictive association with increased emotional exhaustion six months later when controlling for baseline levels (Tuckey and Neall, 2014). The second study, identified in the above-mentioned review, compiled a sample of new graduate nurses from Canada (Laschinger and Fida, 2014). In this study, negative acts were found to predict increased emotional exhaustion as well as cynicism at a one-year follow-up when controlling for initial levels.

Systematic Reviews and/or Meta-Analytic Studies of Several Psychological Distress Reactions Recent meta-analytic studies have summarized much cross-sectional research on psychological distress reactions following exposure to bullying. A meta-analytic study from the Netherlands identified 42 cross-sectional and 21 longitudinal studies when examining the bi-directional relationship between workplace bullying and mental health, primarily in terms of symptoms of depression, anxiety and stress (Verkuil et al., 2015). The meta-analyses of the cross-sectional relationships between bullying and mental health (48 samples [from 42 articles]; 65 effect sizes; N = 115.783) identified positive associations between workplace bullying and symptoms of depression (r = 0.28, 95% CI = 0.23 to 0.34), anxiety (r = 0.34, 95% CI = 0.29 to 0.40) and stress-related psychological complaints (r = 0.37, 95% CI = 0.30 to 0.44) and burnout (r = 0.51, 95% CI 0.39 to 0.62). In contrast, the longitudinal analyses (26 effects sizes [from 22 samples and 21 studies]; N > 54.000), which had a mean follow-up time of 28 months, showed an overall positive association between workplace bullying and mental health problems (22 samples: r = 0.21, CI 95% = 0.13 to 0.28, p < 0.001). Subdivided on types of symptoms: Depression (7 samples: r = 0.36, CI 95% = 0.17 to 0.56), anxiety (four samples: r = 0.17 CI 95% = 0.08 to 0.25), and stress-related symptoms (15 samples: r = 0.15, 95 % CI = 0.10 to 0.20).

A meta-review by Harvey et al. (2017) identified 37 previous reviews that had investigated work-related risk factors for common mental health problems such as anxiety and depression. Seven were judged to be of at least moderate quality according to the AMSTAR system (Shea et al., 2017). While five meta-analyses entailed conflict and or bullying, only tw'o of the reviews were judged to be of at least moderate quality (i.e., Theorell et al., 2015 and Verkuil et al., 2015). The results confirmed that workplace bullying was associated with depression and other psychological distress indicators. Even so, according to Harvey et al. (2017), several studies in Verkuil et al. (2015) were not able to trustworthy account for residual confounding. Harvey etal. (2017) also noted a large heterogeneity across studies which was amplified when Verkuil et al. (2015) created an overall correlation coefficient by averaging correlations across the symptom categories. Collectively, the research articles and the meta-analytic studies reviewed in this section of the chapter suggest that workplace bullying is associated with increased psychological distress in both cross-sectional and longitudinal studies. According to Cohen’s effect-size criteria the observed associations are often in the medium to strong range.

Physiological Indicators of Stress Physiological indicators of stress entail studies using biomarkers (primarily salivary cortisol concentrations) as well as indicators of sleep, as sleep is a central physiological state for human survival. As exemplified in the quote below, the body and bodily reactions to workplace bullying may take different forms and may not necessarily be something that the target apprehends directly.

My husband was probably a bit shocked. He had never seen me like that in the 29 years we’d been married. He told me to calm down and that it would probably pass. . . . Saturday my daughter arrived, and I looked like a shivering wreck. I had cried all through Friday night and all through Saturday. I don’t think I’ve shed so many tears in my life. I continued crying all Sunday. Every time I cried my husband would say: ‘Go talk to him'. But I said: i will not. I am not going up there. That’s why I’ve been like this’. It was at that moment I realized what my body had been trying to tell me.

(Mikkelsen et al., 2007, p. 171)

When it comes to physiological indicators, research has pointed to a functional link between stress, disturbed sleep, psychiatric disorders, aging, and neuroendocrine dysfunctions (Rodenbeck and Hajak, 2001). Because sleep is important in order to maintain homeostasis (i.e., our requirement to maintain an internal equilibrium of the body in order to survive), sleep deprivation may be regarded as a stressor with potentially serious consequences for the brain’s functionality, for instance memory and cognitive functions as well as the regulation of neuroendocrine systems (McEwen. 2006). Moreover, sleep problems may affect daytime functioning, overall well-being and may potentially lead to serious consequences (e.g., accidents). Related to sleep are the homeostatic systems and mediators (e.g., the hypothalamo-pituitary-adrenal (HPA) axis) which together have been referred to as ‘the stress-system’ (Chrousos, 2009). It is known that activation of the stress system suppresses sleep and that loss of sleep may inhibit the stress-system However, it is the indicators of the hypothalamo-pituitary-adrenal axis (e.g., adrenocorticotropic hormone [ACTH] and cortisol) that have been most strongly related to conditions of poor health (Chrousos. 2009). For example, elevated plasma cortisol levels have been shown in physiological ageing and patients with psychiatric disorders. Salivary cortisol has also been used to study occupational stress and the responsiveness of the HPA-axis in both field studies and experimental studies (Aardal-Eriksson et al., 1999; Evans and Steptoe, 2001; Kirschbaum et al., 1989; van Eck et al., 1996; Zeier, 1994). However, since cortisol secretion in saliva exhibits a seasonal variation (Persson et al., 2008) and a distinct diurnal variation (Bjorntorp and Rosmond, 2000; Kirschbaum and Hellhammer, 1994; Nikolajsen et al., 2003) measuring cortisol concentrations in an adequate way may be both logistically complicated and resource demanding (Hansen et al., 2008).

Sleep Problems Several studies from the noughties and onwards have shown that targets of workplace bullying are more likely to have sleep difficulties (Rafnsdottir and Tomasson, 2004), a lower sleep quality (Notelaers et al., 2006), and to use more sleep-inducing drugs and sedatives (Vartia, 2001) than do non-bullied respondents. Poor sleep (e.g., sleep that is too short or otherwise disturbed) is a well-known response to increased physiological and psychological activation that most people have experienced on occasion. Several studies have shown that both short (OR: 1.12 [95% CI: 1.06 to 1.18] and long sleep length (OR 1.30 [95% CI: 1.22 to 1.38] are associated with an increased risk of diabetes (Cappuccio et al., 2010; Nilsson et al., 2004), cardiovascular disease (Cappuccio et al., 2011), all-cause mortality (Cappuccio et al., 2010), and the common cold (Cohen et al., 2009). A few of the more recent cross-sectional studies found that workplace bullying was associated with sleep problems (Kostev et al., 2014; Ziemska et al., 2013). Kostev et al. (2014) excluded previously bullied and found sleep problems among targets who were bullied for the first time. A few longitudinal studies have been carried out using follow-up times of two years and found OR for disturbed sleep among occasionally bullied of 3.77 (1.34-10.65) and among frequently bullied of 1.98 (0.64-6.13) (Hansen et al., 2014). These findings were supported by a later study in 2016 (Hansen et al., 2016). In a Dutch study, workplace bullying was associated with sleep problems five years later with ORs among women of 1.69 (1.30-2.20) and among men 3.17 (1.85-5.43) (Lallukka et al., 2011). The association attenuated when factors related to the social environment, work environment, and health were taken into account (Lallukka et al., 2011). In summary, the included follow-up studies showed sufficient evidence for a relationship to exist between workplace bullying and sleep problems.

Salivary Cortisol Only a few studies have addressed the physiological consequence of workplace bullying with biological measurements among occupationally active targets (Hansen et al., 2006; Kudielka and Kern, 2004). In a small (n = 16) intervention study, Kudielka and Kern (2004) presented tentative evidence of an altered circadian cycle of cortisol secretion among targets of workplace bullying. In a larger study (n = 437), Hansen et al. (2006) observed signs of an altered HPA-axis activity among targets. In both studies, the altered circadian rhythm was manifested as lower excreted amount of salivary cortisol in the morning. Similar results were reported among American undergraduate students exposed to experimentally induced acute stress: Salivary cortisol levels and systolic blood pressure were lower among previously bullied male participants who reported having no feelings of anger about their bullying experience, compared to non-bullied controls and those bullied who reported anger related to their previous exposure to bullying (Hamilton et al., 2008). While these observations of salivary cortisol excretion among targets of workplace bullying are interesting and potentially clarifying as regards how-bullying might get ‘under the skin’, the employed study designs and methods have limitations. For example, in the Hansen et al. (2006) study, the definition of bullying did not account for frequency or duration.

More recent studies encompassing larger study samples have been designed to counter some of the methodological weaknesses inherent in previous studies involving salivary cortisol. Thus, the frequency of w-orkplace bullying has been included (Hansen et al., 2011) and bullying have been operationally defined in a more fine-grained way by using the NAQ-R (23 items, Hogh. Hansen et al., 2012). Results from these studies showed that frequently bullied employees, irrespective of gender had poorer psychological health and a lower level of salivary cortisol compared to a non-bullied reference group (Hansen et al., 2011). In Hogh, Hansen et al.'s study (2012), bullying behaviours were further divided into work-related and person-related negative behaviour and intimidating behaviour, with person-related behaviour being divided into two additional categories; direct harassment and social isolation. The results indicated that the reporting of bullying behaviours was associated with low-er concentrations of salivary cortisol (Hogh. Hansen et al.. 2012) and that negative acts such as direct harassment (e.g., being ridiculed or humiliated) and intimidating behaviour (e.g., finger pointing or invasion of personal space) appeared to be especially detrimental with respect to the physiological stress response (Hogh, Hansen et al., 2012). Four out of five studies showed lower cortisol in saliva, pointing in the direction of a chronic stress response.

Taken together, the total volume of studies dealing with physiological indicators and workplace bullying is fairly low'. However, the reviewed studies suggest that workplace bullying is associated with indicators of poor sleep and salivary cortisol concentrations. Since a larger number of cross-sectional and longitudinal studies have used sleep indicators an outcome, the pattern of associations is more robust for the sleep indicators.

Physical Symptoms and Physical Illness The below review of physical health problems comprises results from studies linking workplace bullying to physical problems (e.g., headache and pain) and diseases (e.g., fibromyalgia, cardiovascular disease and Type 2 diabetes). While the root causes and subsequent pathological processes behind physical health problems and disease may vary, prolonged stress reactions including sleep problems may contribute to the development, manifestation and/or the progression of specific health problems.

Headache and Bodily Pain Headache is probably a health complaint every living person has experienced at one time or another. Globally, the percentages of the adult population with an active headache disorder are 46% for headache in general, 11% for migraine, 42% for tension-type headache and 3% for chronic daily headache (Stovner et al., 2007). Various psychosocial factors at work may be a risk factor of headache (Tynes et al., 2013) and bodily pain (Saastamoinen et al., 2009). Workplace bullying was found to be associated with headache and migraine in a three years follow-up Norwegian study with an OR of 2.09 (1.01-4.32)(Tynes et al., 2013), an association that, however, may be depending on genetic variability as shown by a Norwegian study (Jacobsen et al., 2018). In a study by Saastamoinen et al. (2009), workplace bullying was associated with chronic pain (OR = 1.49 [1.04-2.15]). Furthermore, another Norwegian study showed that exposure to workplace bullying was related to the development of subsequent pain in the back and neck, and that men rather than women develop pain complaints in the aftermath of bullying (Glambek et al., 2018). Finally, a Norwegian systematic review that addressed original studies reporting longitudinal associations between workplace bullying and health (Nielsen et al., 2014) found two studies addressing the association between workplace bullying and general physical symptoms (Hooblerei«/., 2010; Hogh el al., 2011). The other two studies focused on fibromyalgia (Kivimaki et al., 2004) and chronic neck pains (Kaaria et al., 2012). An overall meta-analytic estimation across five studies and more than 19,000 individuals showed an average OR of 1.77 (95% CI = 1.41 to 2.22) (Nielsen et al., 2014).

All studies on physical health support that workplace bullying is associated with poorer physical health.

Cardiovascular Disease Few studies exist linking workplace bullying with cardiovascular disease. Yet, a longitudinal study from Finland, which primarily examined female hospital employees (Kivimaki et al., 2003), showed an increased risk of cardiovascular disease for targets of prolonged bullying compared to non-targets (OR = 2.3). Adjustment for overweight at baseline attenuated the OR to 1.6. In addition, a more recent study involving nearly 80 000 employed men and women from Denmark and Sweden indicated that workplace bullying was associated with a higher risk of new-onset cardiovascular disease, with a OR of 1.59 (95% CI: 1.28-1.98) (Xu et al., 2019). Both studies support that targets of workplace bullying are at higher risk of developing cardiovascular disease.

Diabetes-2 Type 2 diabetes is nowadays a public health concern characterized by high blood glucose levels and insulin resistance or relative insulin deficiency (ICD-11). There are many risk factors for Type 2 diabetes such as genes, metabolic factors, obesity, environmental factors and lifestyle (Bellou etal., 2018). Presumably, workplace bullying may contribute to the development, manifestation and/or progression of this disease by influencing metabolic factors via physiological stress reactions and/or altered behaviours (e.g., eating and sleep). Results of a large, multinational, multi-cohort study, where approximately one in ten employees reported being exposed to bullying, showed that participants exposed to workplace bullying had a higher risk of being diagnosed with Type 2 diabetes four years later (HR = 1.46 [95% CI 1.23, 1.74]) compared to their non-bullied colleagues (Xu et al., 2018). More research is needed on the association between workplace bullying and diabetes.

All in all, the total volume of studies dealing with the association between workplace bullying and physical symptoms or physical illness is limited. How'ever, the reviewed studies suggest that workplace bullying is associated with headache and bodily pains, cardiovascular disease and diabetes. Yet, the empirical support for associations between workplace bullying and indicators of physical illness should currently be regarded as tentative.

Social and Socioeconomic Consequences In this fourth and final category of individual consequences, we address empirical findings concerning the associations between workplace bullying and indicators such as sickness absence, presenteeism, turnover and early/disability retirement.

Sickness Absence Although administrative and legal rules for sickness absence vary across countries, a commonality is that sickness absence is absence from work that is associated with rules for economic compensation to individuals who, for various health reasons, cannot perform their work as expected. Common differentiations in empirical studies occur between short-term and long-term sickness absence as well as whether assessment was made with self-reported or register-based approaches. Early cross-sectional studies (Kivimaki et al., 2000; Vartia, 2001) showed targets of workplace bullying to report more sickness absence than non-bullied employees. In a large, representative study from France on psychosocial factors (n = 46,962, Lesuffleur et al., 2014), workplace bullying was found to be associated with sickness absence. In addition, among employees with sickness absence, those reporting low social support and bullying were more likely to have longer absences. Two Swedish longitudinal studies among postal workers (n = 2.628, Voss et al., 2004) and female public sector employees (n = 6.246, Vingard et al., 2005) found an increased risk of taking sickness absence among female targets. Self-reported sickness absence has also been found to be prospectively associated with workplace bullying in a large Danish study (n = 7502, Bonde et al., 2016). Other studies have focused on long-term sickness absence obtained from registers (>28 days) and found similar positive associations (Grynderup et al., 2016; Nabe-Nielsen et al., 2016; Strpmholm et al., 2015). Results from a register-based study entailing 9,949 Danish eldercare employees showed that the risk of long-term sickness absence (six weeks or more) was twice as high among frequently bullied than among non-bullied workers (Ortega et al., 2011). Another Danish study (n = 3182), combining cohort data from 60 companies with registry data, found that compared to non-bullied workers, targets of workplace bullying had a significantly higher level of long-term sickness absence in the first three years after bullying was first observed (Eriksen et al., 2016). Yet, when statistically controlling for gender, workplace bullying was only significantly associated with increased sickness absence for women. This finding remained significant even after further statistical adjustments for personality and work environment characteristics.

In a meta-analytical study comprising 17 prospective studies and mainly registry data on sickness absence (15 studies of the 17), Nielsen, Indregard et al. (2016) explored a theoretical model entailing direct, indirect (mediated), conditional (moderated), as well as reverse associations between workplace bullying and sickness absence. It was theorized that direct effects could represent a demonstration of sickness absence being used to cope with ongoing bullying. In contrast, indirect effects could point to bullying leading to sickness absence through health complaints and reduced workability, while conditional effects would be individual (e.g., gender, coping strategies, personality) and situational variables (e.g., social support, leadership) moderating the relationship between bullying and sickness absence. In their meta-analysis Nielsen, Einarsen et al. (2016) found support for a direct association between exposure to bullying and more sickness absence in 16 of the 17 included studies. While five studies yielded support for the influence of moderators—for example, educational levels and number of overweight participants—no robust gender differences were observed. Overall, based on 10 independent studies, targets were estimated to have 58% higher odds (OR 1.58) for having had registered based sickness absence compared to non-bullied employees. Workplace bullying was also found to be more strongly associated with sickness absence when compared with other work factors, for example, job demands (OR 1.15) or low'job control (OR 1.28).

Taken together, the results from the above-mentioned studies support both a direct relationship between exposure to workplace bullying and indirect effects. The latter suggest that the relationship between workplace bullying and sickness absence is mediated by disturbed sleep and difficulties awakening (12.8% [95% CI = 8.1 to 19.8%]; Nabe-Nielsen et al., 2016) and perceived stress (13% [95% CI = 6 to 23%]; Grynderup et al., 2016). Thus, there appears to be sufficient evidence for workplace bullying and an increased risk of sickness absence.

Presenteeism Although many targets feel compelled to take sickness absence, especially following prolonged exposure to bullying, some of these may previously have chosen, or felt obliged to, show' up at work even though they were anxious, depressed or suffered physical exhaustion. Such presenteeism happens ‘w’hen a w'orker turns up at work despite feeling so ill that he or she judges that sick leave would have been appropriate’ (Janssens et al., 2016, p. 331). In contrast to absenteeism, presenteeism is more difficult to spot and the costs are often difficult to estimate. Yet, being at work w’hile suffering from pain, allergies, depression etc. will typically translate into reduced work performance. Looking at the yet limited research, a Dutch cross-sectional study (Janssens et al.. 2016) found significant relationships between high levels of bullying (OR = 1.32, 95%

CI = 1.09 to 1.61) and presenteeism. Two Danish studies showed that compared to non-bullied employees, more targets went to work even when they were sick (Hpgh etal., 2007; Ortega et al., 2011). In Ortega et al. (2011), as compared to non-bullied health care workers, targets went to work when sick to a higher degree the more they were bullied (OR = 2.4 among frequently bullied, and OR = 1.5 among occasionally bullied when adjusted for gender, age, occupational group and poor health at baseline). Thus, while long-term sickness absence puts targets at risk of being fired, presenteeism may, in the long run, increase targets’ levels of stress (Janssens et al., 2016), resulting in a deterioration of their mental and physical health. Conway et al. (2016) found that frequently bullied individuals turned up at work more often when ill as compared to non-bullied individuals, yet these results became insignificant when controlling for baseline presenteeism. Finally, Eriksen et al. (2016) failed to find evidence that linked workplace bullying with presenteeism. However, there was a statistical tendency in the data pointing to men reporting higher levels of presenteeism. Finally, the results of a large-scale meta-analytical study (N = 175,965, 109 samples) by Miraglia and Johns (2016) showed that abuse and harassment were positively related to presenteeism. The sample size weighted correlations were r = 0.20 and r = 0.16, respectively.

Thus, to some extent and under certain circumstances, being bullied seems to increase presence at the workplace. However, more research is needed on the association between workplace bullying and presenteeism.

Intent to Leave and Turnover Given that targets risk developing mental and physical health problems which may have significant negative effects on their private and professional lives, it comes as no surprise that many targets consider quitting their job and that many end up doing so (see also Hoel et al., this volume). A Swiss cross-sectional study (Tong et al., 2017) including 5,311 care workers from 162 nursing homes showed that targets of workplace bullying, when compared with nonbullied employees, had more than five times higher odds of reporting intention to leave (OR: 5.12, 95% CI = 3.81 to 6.88). In a longitudinal study employing a representative sample of the Norwegian workforce (n = 1,775). Berthelsen et al. (2011) indicated that workplace bullying (whether assessed with the self-labelling method or via the behavioural experience method) was positively associated with reports of intentions to leave. The OR for the self-labelling method were 2.46 (Tl) and 2.06 (T2). The OR for the behavioural experience method when facing severe bullying was 5.52 (Tl), and 1.60 at follow up (T2), respectively. Moreover, employees reporting exposure to bullying behaviours at time 1 were more likely to report having changed employer at T2 (OR = 1.96, 95% CI = 1.21 to 3.16). Employing the same baseline data as Berthelsen et al. (2011). Glambek et al.'s (2015) prospective study included a five-year time lag. Results showed that exposure to bullying behaviours (OR = 1.77) and self-labelled bullying (OR = 2.42) were related to an increased probability of having changed employer during the five-year period after reporting exposure to bullying. Finally, a three-wave prospective cohort study of 2154 Danish healthcare workers showed a strong relationship between exposure to bullying at T2 and turnover at T3 (odds ratio [OR] for frequently bullied = 3.1) (Hogh et al., 2011). Hence, workplace bullying appears to be associated with subsequent turnover.

Early Retirement and Disability Pensioning An early retrospective case-control study (Delive et al., 2003) showed that Swedish home-care workers receiving disability pension were approximately twice as likely to report exposure to workplace bullying as compared to employees in general, both five and 15 years earlier. A later longitudinal study (Berthelsen et al., 2011) showed that compared to non-targets, employees who self-labelled as targets of bullying at time one had a significant higher chance of reporting being on rehabilitation or disability pension on time two (OR = 5.62 [95% CI 1.76-18.02]). In their prospective study, Glambek et al. (2015) found that exposure to bullying behaviours (OR = 2.81 [95% CI 1.32-6.01]) and self-labelled bullying (OR = 2.95 [95% CI 1.22-7.15]) were significantly associated with receiving disability benefits five years later. Regarding unemployment, the study showed that exposure to bullying behaviours was related to unemployment five years later (OR = 4.60 [95% CI 1.43 - 14.78]).

A prospective registry study by Nielsen et al. (2017) on Norwegian employees found that bullying was a significant predictor of disability retirement (hazard ratio = 1.55; 95% CI 1.13-2.12) also when controlling for job demands and missing job control. Both men and women had a higher risk of disability when bullied compared to employees who were not bullied, but women had a higher risk than men. A recent Danish study showed that workplace bullying predicted risk of disability pensioning and that quality of leadership moderated this association (Clausen et al., 2019). In conclusion, targets of workplace bullying are at higher risk of early retirement and disability pension.

To summarize, the number of studies dealing with social and economic consequences that look beyond indicators of sickness absence, such as early retirement and disability pension, seems to be increasing. The reviewed studies on social and economic consequences suggest an association with workplace bullying (see also chapter 5 by Hoel et al in this volume on the costs of bullying). The associations are clearest for sickness absence indicators, which often make use of national or company register data. Regarding presenteeism and intention to leave, there also seems to be positive associations with workplace bullying.

Frameworks for Understanding Individual Consequences of Workplace Bullying

While the empirical research on the individual consequences of workplace bullying has flourished, theoretical developments outlining causal links between workplace bullying and its individual health consequences have been scarcer (Nielsen and Einarsen, 2012). Even if some extant frameworks are comprehensive (, Samnani and Singh, 2012), they typically contain no proposition of psychological and/or physiological mechanisms that may explain how exposure to workplace bullying transmutes into physiological, psychological and/or social effects on the individual level. Nevertheless, at a fundamental level, researchers within the field of workplace bullying seem to embrace a stimuli-organism-response (SOR) way of thinking. From this perspective, bullying is for the most part viewed as a stimulus that operates on a target. The reactions and/or symptoms expressed by the target are considered responses that can be influenced by more or less modifiable factors tied to the target (e.g., the target’s access to support, his or her age, attitudes, coping behaviours, gender, genes, socioeconomic position in society etc.). For an overview on findings on such moderating factors, see the chapter on coping with bullying by Nielsen and colleagues (this volume). However, drawing on previous research, we will now present four theoretical frameworks that may inform the understanding of how workplace bullying may lead to physiological and psychological health effects which in turn drive social consequences on the individual level (e.g., sick-leave and disability retirement). The frameworks are: Transactional stress theory (exemplified by Lazarus’ appraisal theory, 1999), schema theory (exemplified by Janoff-Bulman’s theorizing, 1992), the Cognitive Activation Theory of Stress (CATS), Ursin and Eriksen, 2004) and finally a set of theories from evolutionary social psychology including the Temporal Need-Threat Model of Ostracism (Williams, 2009). While the first two frameworks primarily operate on the psychological level, the latter tw'o frameworks also include theorizing on a physiological level.


Stress Models

With respect to psychological and cognitive mediation processes, workplace bullying researchers seem, in general, to have favoured transactional stress models (Lazarus and Folkman, 1984; Nielsen and Einarsen. 2012). Essentially, transactional stress models describe the experience of stress or other negative emotions (e.g., anger, frustration, irritation) that arise from workplace bullying as a function of the dynamic interplay between event characteristics and individual appraisal and coping processes (Folkman and Lazarus, 1991; Lazarus, 1999). Indeed, a basic premise in appraisal theory is that human beings continuously evaluate their environment with respect to implications for their well-being (Lazarus, 1999). In this process, the concepts of primary-, secondary- and re-appraisal and coping are central. Primary appraisal refers to cognitive processes that evaluate whether what is happing is relevant in relation to one’s goals, beliefs, values and intentions. Primary appraisal ends in subjective classification of the event as representing harm, loss or challenge (i.e., three different forms of stress). Secondary appraisal refers to cognitive processes that evaluate the possibilities of actions to deal with the experienced specific type of stress. Re-appraisal essentially underscores that the processes of primary and secondary appraisal are iterative. Coping, on the other hand, concerns how' the individual deals with the situation in order to remedy the stressful experience. Sometimes two types of coping behaviour are discerned, that is, problem focused coping (e.g., collect information, act to change the situation) and emotion focused coping (e.g., avoid thinking about the problem, re-evaluate the situation [re-appraisal] without changing the actual situation) (Lazarus, 1999). Applied to bullying situations, Lazarus' appraisal theory underlines the individual variation in the creation of meaning as regards both the interpretation of negative behaviours in the social work environment as well as the range of available alternatives to deal with these behaviours. However, as pointed out by Zapf and Einarsen (2005), the severity and force of many bullying behaviours may make primary and secondary appraisal processes of lesser concern. Yet, as regards various bullying behaviours related to social exclusion (e.g., not being invited to a meeting) primary and secondary appraisal processes may be important determinants of the subsequent psychological stress response. Accordingly, appraisal theory in its full range may often be the most interesting theory to draw upon with respect to understanding and describing individual appraisal processes and coping behaviour in situations in which experienced negative behaviours are ambiguous and/or vague and resembles daily hassles (as opposed to critical events).

Schema Theory of Trauma

Lazarus (1999) distinguishes between normal and traumatic stressors, the latter being so overwhelming that the individual feels incapable of dealing with them without help. According to Lazarus (1999), traumatic events essentially destroy or shatter central meaning structures. In line with this, Janoff-Bulman’s (1989, 1992) schema theory of shattered assumptions and post-traumatic stress reactions posits that traumatic events threaten to shatter basic cognitive schemas, involving fundamental positive beliefs on the benevolence and meaningfulness of the world and assumptions of the self as worthy, capable and deserving of other people’s affection and support (Janoff-Bulman, 1989). These self-assumptions contribute to maintaining a sense of meaningfulness and control as well as a basic sense of invulnerability and safety. However, since traumatic events contradict the core positive assumptions, the latter needs to be modified (Gillihan et al., 2014; Janoff-Bulman, 1989). This modification may give rise to assimilation and accommodation processes as reflected in the four core symptoms of traumatic stress; Intrusion symptoms, avoidance, negative alterations in cognitions and mood as well as alterations in arousal and reactivity (American Psychiatric Association [APA], 2013).

As argued by Mikkelsen and Einarsen (2002), systematic and prolonged exposure to work- and person-related negative acts, with which the targets cannot cope, may threaten hitherto existing assumptions of the benevolence of the other people and the world, as well as the targets’ assumptions of themselves as worthy individuals who are able to exert control over events that happen to them. Moreover, when targets’ experience bystanders who are passive or even colluding (Pouwelse et al., 2018) and/or organizational support systems which fail (Shallcross et al., 2013), this may give rise to feelings of injustice and betrayal which may threaten their assumptions of a meaningful world (Mikkelsen and Einarsen, 2002). Janoff-Bulman’s schema theory of trauma has been widely used to understand and explain the chronic symptoms of distress displayed by many targets of bullying (Conway et al., 2018; Hogh et al., 2011; Mikkelsen and Einarsen, 2002; Adoric and Kvartuc, 2007; Rodriguez-Munoz et al.. 2010).

The Cognitive Activation Theory of Stress (CATS)

A theoretical consolidation that may further the understanding of the link between exposure to bullying, bodily stress reactions and symptoms is CATS (Ursin and Eriksen, 2004). Several researchers have used this theoretical framework to understand workplace bullying (Hogh, Mikkelsen et al., 2012; Reknes et al., 2016). Primarily developed within the physiological and psychological disciplines, the CATS theory provides a detailed description of the cognitive mechanisms that trigger physiological processes that may lead to subsequent health effects. According to Ursin and Eriksen (2004, p. 567), a stress response is a natural and general, non-specific alarm response causing a general increase in w'akefulness and brain arousal, and specific responses to deal with the reasons for the alarm. In accordance with the notion of homeostasis (i.e„ our requirement to maintain an internal equilibrium of the body in order to survive) (Ursin and Eriksen, 2004), the stress response arises if the individual experiences that something is missing, represents a threat, or connotes a discrepancy between a perceived ideal state and reality. The concept of expectancy is central to CATS and may take the form of stimuli expectancies or response outcome expectancies (Ursin and Eriksen, 2004, p. 573). It is presumed that the intensity and duration of physiological arousal will depend on the individual’s expectations of the likely outcome of a given stimuli, including the coping responses he or she believes to be available. According to theory, acquired response outcome expectancies may be positive, negative or none and mirror three conditions: coping, hopelessness and helplessness, respectively (Ursin and Eriksen, 2004). In relation to workplace bullying, the coping condition can be interpreted to represent the target’s acquired expectancy that most or all his or her attempts to manage the situation will lead to a positive result. Conversely, the condition of helplessness can be interpreted as the acquired expectancy that whatever the target does to alleviate the situation, this will have no effect on the bullying. Finally, the hopelessness condition can be interpreted as representing the target’s acquired expectancy that most, or everything, he or she does will have a negative result. Because outcome expectancies will affect the physiological arousal, targets of bullying who expect to be able to positively influence the situation will experience a short-term and harmless arousal. In contrast, targets who expect to have no—or a negative—influence on the bullying behaviours will experience sustained physiological arousal that may lead to pathology. With respect to the bullying process, coping (i.e., positive outcome expectancy) seems more likely to occur in the very early stages and if the situation is characterized by infrequent and low intensity negative acts. In later stages, the prolonged exposure to systematic person- and/or work-related negative acts seems more likely to generate none or negative outcome expectancies and thus reflect a continuous failure to cope effectively, which epitomizes the phenomenon workplace bullying (Zapf and Einarsen, 2005). Indeed, being the target of long-term bullying is likely to lead to the acquired expectation that any attempts to redress the situation will lead to negative results or will have no effect at all. Increased sensitization in neural circuits and an acquired cognitive bias for negative outcome expectancies as well as ruminations about bullying situations and their personal consequences could, according to the theory (Brosschot et al., 2005; Eriksen and Ursin. 2006; Meurs and Perrewe, 2011), lead to prolonged physiological activation, even after the bullying has ended, resulting in chronic stress and reduced physical health.


Social Psychology

Another set of theories used to explain individual effects of workplace bullying stems from evolutionary social psychology and elucidates the importance of social relationships to human well-being and survival (Allen and Badcock, 2006; Baumeister etal., 2001; Wesselmann etal., 2012; Williams and Nida, 2011). It is known that many targets of bullying are subjected to the silent treatment (Chambers et al., 2018; Tong et al., 2017). This type of ostracism may entail colleagues that cease to communicate in words or in writing with the targets or otherwise exclude them from the work group. In any event, ostracism exists among both humans and sub-human species and may serve as a means of securing both social control and group survival (Wesselmann et al., 2012). A central tenet in this theorizing is how evolution has shaped human physiology and psychology to increase both species and individual adaptiveness. Interestingly, researchers have suggested that the pain mechanisms involved in spotting and preventing physical danger were co-opted by the more recently evolved social attachment system to detect and prevent social separation (Eisenberger and Lieberman, 2004, p. 294; Wesselmann et al., 2012). This resulted in the development and capacity to feel social pain defined as 'the distressing experience arising from the perception of actual or potential psychological distance from close others or a social group’ (Eisenberger and Lieberman, 2004, p. 294). Social pain is thus an evolutionary adaptive negative emotional state that is evoked when an individual experiences exclusion or devaluation in interpersonal relationships (Wesselmann et al., 2012).

Like CATS, and building on findings from social cognitive neuroscience, the theory locates the neural alarm system in the area of the brain called the dorsal anterior cingulate cortex (dACC) which, in keeping with the concept of homeostasis, detects deviations (e.g., exclusion) from a desired standard (e.g., inclusion) and signals that the imbalance needs attention (Eisenberger and Lieberman, 2004). How social stressors via psychological mechanisms can trigger unfavourable activations of the stress response and change into physiological effects and subsequent health problems is currently best explained by psychobiological theories such as allostasis (Sterling and Eyer, 1988) and CATS (Ursin and Eriksen, 2004). In these theories, the stress response is essentially a life promoting general, nonspecific alarm response that causes a general increase in wakefulness and brain arousal, and specific responses to deal with the reasons for the alarm (Ursin and Eriksen, 2004). The stress response is primarily mediated by the sympathetic-adrenal medullary axis (SAM-axis) and the hypothalamus pituitary adrenal axis (HPA-axis) (Ursin and Eriksen, 2004). If the stress response is inadequate, too frequent, or too long, negative effects will occur (McEwen, 1998).

The mechanism evolved to detect ostracism would again produce a ‘lifelong need for social connection and a corresponding sense of distress when social connections are broken’ (Eisenberger and Lieberman, 2004, p. 298). In extension, this may lead to either cognitive (over)attention to negative events, including information that could signal exclusion (Baumeister et al., 2001; Wessehnann et al., 2012), or cognitive and behavioural efforts that would increase the chance of reconnecting with a significant person or group (Allen and Badcock, 2006; Williams and Nida, 2011).

Following Eisenberger et al. ’s (2003) classic Cyberball study which yielded experimental evidence for the neural overlap between physical and social pain, subsequent studies employing the Cyberball paradigm consistently show that even very brief (i.e„ 2-3 minutes) experiences of being excluded, irrespective of the medium, source, or various situational factors, will induce strong negative feelings and a reported negative impact on four basic human needs: sense of belonging, self-esteem, sense of control and sense of meaningful existence (Williams and Nida, 2011, p. 72).

Temporal Need-Treat Model of Ostracism According to Williams’ (2009) Temporal Need-Threat Model of Ostracism, there are three stages of social ostracism: The immediate stage. the coping stage and the long-term stage (Williams and Nida. 2011). The different stages reflect a progressive development in which different needs are in focus. In the immediate stage of experiencing ostracism, contextual factors and individual differences are thought to have little impact on the reactions of the ostracized individuals who typically feel pain, sadness and anger, and a threat to basic needs. In the coping stage, targets of ostracism will be attentive to the meaning and subjective relevance of the situation and act in ways to buttress the threatened need(s) (Williams and Nida, 2011, p. 71). At this stage, context and individual factors will act to magnify or minimize the targets’ reaction and thus their attempts to change the situation. Corresponding to central tenets of CATS, the Temporal Need-Threat Model holds that the targets’ coping strategies will reflect the perceived possibilities of coping success, i.e„ reinclusion (Williams and Nida, 2011). When there is a perceived prospect of re-inclusion, belonging and self-esteem needs will direct the targets’ attempts to redress their situations, leading to socially conformist behaviour expected to increase the chance of re-inclusion. As such, targets may be more attentive to social information, act to encourage positive reactions from coworkers including trying to co-operate and comply with requests, or consciously or unconsciously mimicking others.

Unlike other forms of aversive behaviours, ostracism involves a unilateral form of aggression (Einarsen and Mikkelsen, 2003), which communicates the targets having lost their ‘social place’ (Clark, 1990) conferring to ‘discursive power and/or the right to define social reality’ (Bloch, 2010, p. 113), or that they have even ceased to exist. According to Williams and Nida (2011), when there is little hope of re-inclusion, control and meaningful existence needs influence the targets’ coping behaviours and they may choose to withdraw from work colleagues, confront them or behave aggressively with the purpose of regaining a sense of control. This behaviour may be a way to reinstate themselves as individuals through trying to force their colleagues to recognize their existence. If deemed subjectively successful, regaining a sense of control could also increase their self-esteem.

Nevertheless, targets who suffer long-term ostracism may undergo a depletion of their coping resources resulting in feelings of alienation, depression, helplessness and unworthiness (Williams and Zadro, 2005). Adding to the psychologically injurious effect of ostracism, and bullying in general, is the possibility of targets continually ruminating over the bullying and/or its perceived effects. The ability to relive negative interpersonal experiences of being yelled at, ignored or physically excluded may sometimes set in motion a destructive cycle leading to perpetual physiological arousal and eventually the depletion of resources that precedes the stage of psychological resignation. As long-term social exclusion may be perceived as a form of social death, it may lead to suicidal ideation and suicide attempts (Williams and Nida, 2011).

Concluding Discussion

Since the first studies on workplace bullying in the 1970s and 1980s, a large body of knowledge has accumulated. In this chapter, we have primarily reviewed and addressed how bullying may have serious consequences and outcomes on the individual level. For pedagogical purposes, we focus on workplace bullying solely as an antecedent to individual consequences. However, it should be acknowledged that in several of the reviewed studies the question of reverse causation has been evoked and sometimes underpinned with empirical evidence. This entails, for example, associations between bullying and depression (Hogh et al., 2016; Loerbroks et al., 2015), mental health symptoms (Verkuil et al., 2015) and poor health (Kostev et al., 2014) (see also Nielsen and Einarsen, 2012). That pre-existing poor mental health and/or physical illness may increase the likelihood of reporting workplace bullying at a later date, adds to the complexity of the phenomenon. Importantly, however, different causal directions may in theory co-exist simultaneously within a given study sample and need not to be mutually exclusive on a sample and/or population level. That said, in the following concluding discussion we will pursue our analytical choice and thus direct attention to workplace bullying as an antecedent of individual consequences.

Observably, the research documented in this chapter relies heavily on assessing bullying by asking targets about either their individual experiences of being bullied or their individual experiences of being repeatedly subjected to negative acts at work. Irrespective of method, research underlines that individuals who report being subjected to workplace bullying, or to systematic negative acts at work, have a high likelihood of reporting a symptomatology of distress that strongly suggests detrimental effects on their health and well-being. Moreover, research underlines that individuals who report workplace bullying, or even systematic yet less frequent negative acts at work, are more likely to report various forms of exclusion from work and working life (e.g., sickness absence, presenteeism, intention to leave and early retirement). Furthermore, individuals subjected to workplace bullying may display signs of poor physical health, yet relatively few studies have examined ‘hard-outcomes’ of physical health (e.g., cardiovascular disease. Type 2 diabetes etc.).

Given the methodological shortcomings of the early research such as for example the use of cross-sectional studies and nonrepresentative populations, the more recent evidence from longitudinal studies, physiological studies and/or meta-analytical studies yield invaluable contributions to the research field as do an increased number of studies on individual mediator and moderator variables (see chapter 5 on coping with bullying in this volume for an overview of these studies). Nonetheless, there is a need for more multi-wave longitudinal, theory-driven quantitative and qualitative research exploring the dynamic interplay between event and individual characteristics in determining the impact on bullying as well as individuals’ relative risk of developing psychological and physical health problems (see for example Nielsen et al., 2013; Park and DeFrank, 2018; as well as Nielsen and Einarsen, 2018). Focusing on physiological reactions to workplace bullying, more physiological studies are needed as they provide an under-researched link between workplace bullying and health outcomes.

In evaluation of the presented theories to further our understanding of the links between workplace bullying and its individual consequences, Lazarus’ transactional model forms a basic model. Yet, its stressor-model is ‘neutral’, and the theory does not explicate in detail the links between cognitive processes and physiological reactions. This is, however, the main focus of CATS and to a certain degree also of the theories based in evolutionary social psychology. The latter also contribute with sound theory on the basic role of social relationships. Positive social relations form the basis of human existence, wherefore evolution has led humans to be cognitively and emotionally attuned to negative social events. Accordingly, in situations where individuals are subjected to social exclusion, they will quickly develop strong emotional and physiological reactions, with long-term exposure to bullying in the form of social exclusion essentially representing the annihilation of the individual person—a social ‘death’.

Knowledge of the processes involved in the relationship between workplace bullying and reactions such as anxiety, depression or PTSD will enable professionals to supply high quality treatment of targets founded in empirical research (see Ferris et al., 2019). With respect to facilitating a successful return to work or job transfer, further research on return to work processes and the value of employment for targets’ psychosocial rehabilitation(s) is also needed. Moreover, knowledge of the effect of workplace bullying on human physiology may serve to underpin targets’ subjective complaints and thereby help estimate the potential health consequences in a more ‘objective’ way, thereby possibly also paving a road to economic compensation for more targets.

From the point of view of prevention, we need more theory development and empirical research on why workplace bullying leads to reduced psychological and/or physical health. The reviewed results illustrate the need for organizations to further a constructive climate for conflict management in order to prevent bullying and alleviate its negative outcomes (see Einarsen et al.. 2016) supported by a robust ethical infrastructure (Einarsen et al.. 2017) and strong, competent and ethical leaders who prioritize the management of conflicts and cases of workplace bullying. With targets themselves enduring the socio-economic consequences of workplace bullying such as long-term sickness absence and unemployment. the societal costs of treating targets for mental and physical health problems in addition to the public benefits due to unemployment, disability pensioning and early retirement will be considerable. Accordingly, to reduce individual, organizational and societal costs, regulations at the state, national and international level should effectively support organizational-level initiatives to prevent and effectively manage bullying at work.


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