Complaints about bullying at the workplace are related to fantasies of aggression in psychosomatic patientss

Abstract

BACKGROUND:

The workplace can be associated with social stressors like vilification, humiliation, and breach of trust. A common emotional response is embitterment and aggressive behavior.

OBJECTIVE:

Aim of the study is to investigate the relation between work-related problems, including bullying, and fantasies of aggression.

METHODS:

Therapists of a department of behavioral medicine routinely had to fill in a diagnostic checklist whenever they saw signs of embitterment and/or aggression in their patients. The type of aggressive fantasies was categorized in no fantasy, minor harm, serious harm without bodily harm, or bodily harm. Independent of this interview, social workers assessed problems at work (duration of sickness absence, workplace insecurity, bullying at workplace, ability to work, expectation of pension). Patients were also asked to fill in an embitterment questionnaire and the Symptom-Checklist-90. Further sociodemographic and clinical information was taken from the hospital routine documentation.

RESULTS:

A total of 3211 patients were admitted to the hospital during the observation period. Therapists saw the indication for an in-depth interview because of aggressive fantasies in 102 (3.2%) patients. Aggressive ideations refer to “minor harm” in 27%, “serious harm” in 37%, and “bodily harm” in 35%of patients, respectively. There is a significant relation between the severity of aggressive ideations and bullying and duration of sick leave. There was also a significant correlation between ideas of aggression and feelings of embitterment.

CONCLUSION:

Aggressive ideations are interrelated with psychosomatic distress and workplace problems and feelings of embitterment. This is of importance for prevention and interventions in regard to workplace bullying.

Keywords

Social stressors workplace bullying aggressive ideations embitterment non-psychotic patients

1 Introduction

The workplace can be associated with many social stressors such as rivalries, conflicts, and demands [1 –3]. About 10%to 15%of employees in Europe report to have experienced bullying, often resulting in serious consequences for the person and the environment [1 , 4–6]. Bullying at work “means harassing, offending, or socially excluding someone or negatively affecting someone’s work” [6, p. 22]. The victim “ends up in an inferior position and becomes the target of systematic negative social acts” [6, p. 22]. This behavior “has to occur repeatedly and over a longer period of time“ [6, 7]. Bullying is not only seen in the workplace but can also occur in schools, families, relationships, prisons, and cyberspace [8].

Psychological processes of bullying include injustice, vilification, humiliation, and breach of trust. All people hold the “belief in a general just world” and the “belief in a personal just world” [9, p. 31], which is a resource in mastering the world [10, 11]. Injustice is experienced as an aggression and threatens the inner standards and values of a person, who afterwards has to fight back in order to restore justice and one’s self-worth [12 –15]. Organizational justice or injustice are of great importance at the workplace [16, 17]. Vilification includes negative behavior (verbal aggression, disrespectful or exclusionary behavior, isolation/exclusion, threats or bribes, and even physical aggression) towards others [18, p. 436] and a form of emotional abuse, relational victimization, and aggression at the workplace [18 –20]. Humiliation is a “traumatic emotional state triggered by narcissistic injury of disrespect” [21, p. 657]. Breach of trust is the experience that others do not stick to their commitments and instead take advantage of the person when there is an opportunity [22].

Reactions to workplace conflicts such as bullying can manifest themselves at a group or organizational level with endangered team and organizational performance, and at societal level with unemployment or legal costs. Consequences on an individual level with impairment of psychological and physical well-being, absenteeism, intent to leave, job satisfaction, aggression, and even suicide are of importance [5, 23]. Victims of workplace conflicts can become sick and possibly require professional help because of posttraumatic stress disorder [2 , 24–26], depression, anxiety [2 , 28], and persisting embitterment [29 –34]. Embitterment is of special importance, as it is a burning feeling of having been treated unfairly, with an urge for revenge, impairment of well-being and even dysfunctional aggressive behavior [35 –37].

The aim of the present study was to investigate the relation between work-related problems and fantasies of aggression. The hypothesis is that aggressive acts like bullying are reflected in aggressive fantasies of the victim, in contrast to non-aggressive workplace problems like job insecurity.

2 Method

2.1 Setting and patients

The study was conducted in an inpatient and day-care department of psychosomatic rehabilitation [38]. Costs are covered by the German Pension Fund when the ability to work is endangered. Patients can ask for admission themselves or come on the initiative of health and pension insurance. The hospital provides medical and psychotherapeutic care, occupational training, and social support.

Our analyses are based on anonymized data from the routine documentation of the hospital. There was no interference with the treatment of patients. Retrospective analyses of these data for internal quality assurance and scientific purposes were approved by the hospital management.

We compared patients with and without aggressive ideation. We excluded patients suffering from schizophrenic disorders (ICD-10 F20-29), as these may have aggressive impulses by themselves without outer reasons.

2.2 Interview checklist

After admission, patients were seen and assessed by their therapists (licensed clinical psychologists or specialists in psychiatry or psychosomatic medicine). When there were signs of embitterment and / or aggressive fantasies, therapists were routinely obliged to do an in-depth exploration based on an interview checklist, which is an internal interview guideline for routine purposes and not an otherwise published instrument.

The interview checklist asks for the object of aggression, the emotional intensity, feelings of satisfaction or shame when thinking about the aggressive fantasy, willingness to report the aggressive ideations, planning, probability of execution, and suicidal or homicide ideations.

Aggressive ideations are coded as 1) “no problem” 2) “banality”, 3) “minor problem”, 4) “serious life events”, 5) “major property damage, no bodily harm”, 6) “personal injury”, and 7) “threat to life”.

For the calculations, categories 2) and 3) were combined into “minor harm” (for example: defamation or damage to a car), categories 4) and 5) into “ideations of serious harm without bodily harm” (for example: bankruptcy, divorce, destruction of machinery, financial ruin), and categories 6) and 7) into “ideas of bodily harm” (for example personal injury, or killing).

2.3 Embitterment scale

Patients with clinical signs of embitterment and / or aggressive ideations were given the 19-item Posttraumatic Embitterment Disorder (PTED) self-rating scale [39]. The scale starts with the question, whether the person remembers a negative life event during the past years and then asks for feelings of embitterment, injustice, for wishes of revenge, intrusions, and emotional arousal in regard to the life event, restrictions in everyday life, or avoidance behavior. Ratings are made on a five-point Likert scale from 0 = not true at all to 4 = extremely true. An average sum score = >2.5 indicates a clinically relevant degree of reactive embitterment.

2.4 Problems at work and routine medical documentation

Patients were also routinely interviewed by social workers in regard to the employment status and problems at the work place. It was described in detail whether there were problems with prolonged sickness absence and expectation of early retirement, impaired work performance, workplace insecurity, and bullying at the workplace. The social workers had no knowledge about the results from the interview checklist.

Additional data were gathered from the clinical routine assessment and documentation, including for example information on gender, age, marital and living status, and education. Intelligence was routinely measured with the Intelligence Basic Factor Test (IBF), a multidimensional standardized performance test [40]. All patients routinely also filled in the Symptom-Checklist-90 (SCL-90). The global severity index (GSI) of the SCL-90 displays a mean score across all symptoms, indicating global psychological distress. The subscale “aggression/hostility” is also included in the evaluation of the data. Diagnoses were taken from the clinical discharge summary of the hospital.

2.5 Statistical analyses

Statistical analyses were carried out with SPSS. We divided patients in those (1) without aggression ideations, (2) “minor harm”, (3) “serious harm”, and (4) “bodily harm”. These groups were compared by χ²-Test or analysis of variance in regard to clinical diagnoses, sociodemographic data, work-relevant factors, and psychosomatic distress.

3 Results

A total of 3300 patients were admitted to the hospital during the observation period. Out of all patients, 106 (3.2%) showed clinically relevant signs of aggression. Three patients had missing values in regard to aggressive ideations and one patient a clinical diagnosis of “schizophrenic disorders” (ICD-10 F20-29). There were 102 patients with aggressive ideation left for our analyses, and another 3109 without.

Of the 102 patients with aggressive ideations 27.5%had fantasies of “minor harm”, 37.3%patients ideations of “serious harm without bodily harm” and 35.3%ideas of “bodily harm”.

Patients had on average a very high score of 3.04 (SD = 0.68, n = 91 because of 11 missing data on the PTED scale) on the embitterment scale. Furthermore, we found a significant correlation between the sum score of aggressive ideations in the interview and the embitterment scale (r = 0.250, p = 0.017).

There were significant differences between control patients and patients with aggressive ideation for age (F_(3,3207) = 3.27, p = 0.021) and intelligence (F_(3,2892) = 3.18, p = 0.023) with no significant difference according to the post hoc Scheffé tests between aggression groups. There were no group differences for the other sociodemographic data (Table 1). Differences emerged with aggression patients suffering less often from “affective disorders” (χ²₍₃₎ = 12.19; p = 0.007) and more often from “neurotic, stress-related and somatoform disorders” (χ²₍₃₎ = 27.35; p < 0.001).

Table 1
Severity of aggressive ideations in relation to sociodemographic data, work-relevant factors and psychosomatic distress

N = 3211 No aggressive ideations n = 3109 Minor harm n = 28 Serious harm n = 38 Bodily harm n = 36 Statistics

Socio-demographic data

Mean

Age 48.25 51.64 51.82 49.22 F_(3,3207) = 3.27 p = 0.021^*

Intelligence quotient/capability 100.7 96.16 99.66 92.96 F_(3,2892) = 3.18 p = 0.023^*

Frequencies

Female 2052 (66%) 18 (64.3%) 27 (71.1%) 19 (52.8%) χ²₍₃₎ = 3.26 p = 0.353

Higher education 1082 (34.8%) 8 (28.6%) 13 (34.2%) 12 (33.3%) χ²₍₃₎ = 0.516 p = 0.915

Married 1697 (55.3%) 18 (64.3%) 23 (60.5%) 22 (61.1%) χ²₍₃₎ = 1.78 p = 0.618

Living alone 1056 (34.4%) 11 (39.3%) 16 (42.1%) 12 (33.3%) χ²₍₃₎ = 1.28 p = 0.733

Employed 2195 (71.8%) 18 (66.7%) 27 (71.1%) 19 (52.8%) χ²₍₃₎ = 6.69 p = 0.082

Diagnoses Frequencies

ICD-10 F00-09 88 (2.8%) 0 (0%) 2 (2.1%) 4 (11.1%) Exact Fisher test p = 0.034^*

ICD-10 F30-39 1491 (48%) 11 (39.3%) 12 (31.6%) 9 (25%) χ²₍₃₎ = 12.19 p = 0.007^

ICD-10 F40-48 1271 (40.9%) 20 (71.4%) 27 (71.1%) 20 (55.6%) χ²₍₃₎ = 27.35 p < 0.001^

Psychosomatic distress Mean

GSI-pre 1.2039 1.3957 1.3958 1.6392 F_(3,3187) = 6.92 p < 0.001^

Aggression/hostility-pre 0.9268 1.2196 1.0529 1.5744 F_(3,3183) = 11.94 p < 0.001^

Work-relevant factors Mean

Sick leave in the last 12 weeks 23.99 26.96 29.13 33.67 F_(3,3170) = 3.80 p = 0.01^*

Frequencies

Workplace insecurity 375 (25.6%) 8 (42.1%) 5 (22.7%) 7 (41.2%) Exact Fisher test p = 0.174

Bullying at workplace 587 (40.2%) 13 (68.4%) 19 (86.4%) 16 (94.1%) bmchi²₍₃₎ = 44.2 p < 0.001^**

Ability to work 1580 (52.5%) 13 (46.4%) 19 (50%) 11 (33.3%) χ²₍₃₎ = 5.30 p = 0.151

Expectation of pension 640 (20.9%) 5 (17.9%) 7 (18.4%) 13 (37.1%) χ²₍₃₎ = 5.81 p = 0.121

N = 3211	No aggressive ideations n = 3109	Minor harm n = 28	Serious harm n = 38	Bodily harm n = 36	Statistics
Socio-demographic data
	Mean
Age	48.25	51.64	51.82	49.22	F_(3,3207) = 3.27 p = 0.021^*
Intelligence quotient/capability	100.7	96.16	99.66	92.96	F_(3,2892) = 3.18 p = 0.023^*
	Frequencies
Female	2052 (66%)	18 (64.3%)	27 (71.1%)	19 (52.8%)	χ²₍₃₎ = 3.26 p = 0.353
Higher education	1082 (34.8%)	8 (28.6%)	13 (34.2%)	12 (33.3%)	χ²₍₃₎ = 0.516 p = 0.915
Married	1697 (55.3%)	18 (64.3%)	23 (60.5%)	22 (61.1%)	χ²₍₃₎ = 1.78 p = 0.618
Living alone	1056 (34.4%)	11 (39.3%)	16 (42.1%)	12 (33.3%)	χ²₍₃₎ = 1.28 p = 0.733
Employed	2195 (71.8%)	18 (66.7%)	27 (71.1%)	19 (52.8%)	χ²₍₃₎ = 6.69 p = 0.082
Diagnoses	Frequencies
ICD-10 F00-09	88 (2.8%)	0 (0%)	2 (2.1%)	4 (11.1%)	Exact Fisher test p = 0.034^*
ICD-10 F30-39	1491 (48%)	11 (39.3%)	12 (31.6%)	9 (25%)	χ²₍₃₎ = 12.19 p = 0.007^**
ICD-10 F40-48	1271 (40.9%)	20 (71.4%)	27 (71.1%)	20 (55.6%)	χ²₍₃₎ = 27.35 p < 0.001^**
Psychosomatic distress	Mean
GSI-pre	1.2039	1.3957	1.3958	1.6392	F_(3,3187) = 6.92 p < 0.001^**
Aggression/hostility-pre	0.9268	1.2196	1.0529	1.5744	F_(3,3183) = 11.94 p < 0.001^**
Work-relevant factors	Mean
Sick leave in the last 12 weeks	23.99	26.96	29.13	33.67	F_(3,3170) = 3.80 p = 0.01^*
	Frequencies
Workplace insecurity	375 (25.6%)	8 (42.1%)	5 (22.7%)	7 (41.2%)	Exact Fisher test p = 0.174
Bullying at workplace	587 (40.2%)	13 (68.4%)	19 (86.4%)	16 (94.1%)	bmchi²₍₃₎ = 44.2 p < 0.001^**
Ability to work	1580 (52.5%)	13 (46.4%)	19 (50%)	11 (33.3%)	χ²₍₃₎ = 5.30 p = 0.151
Expectation of pension	640 (20.9%)	5 (17.9%)	7 (18.4%)	13 (37.1%)	χ²₍₃₎ = 5.81 p = 0.121

There is a significant difference in regard to overall psychological distress. Analyses of variance showed a significant difference between severity of aggressive ideations and the GSI (F_(3,3187) = 6.92, p < 0.001). The post-hoc Scheffé test shows that preferably patients with ideas of bodily harm (p = 0.001) differ from controls. Similar differences are found for the subscale “aggression/hostility” of the SCL-90 (F_(3,3183) = 11.94, p < 0.001). Post-hoc Scheffé test shows that patients with ideas of bodily harm have higher values than controls (p < 0.001) and patients who reported ideations of serious harm without bodily harm (p = 0.017) have lower values than patients with ideas of bodily harm.

There are significant differences between the severity of aggressive ideations and sick leave in the last 12 weeks (F_(3,3170) = 3.80, p = 0.01) (Table 1). Patients with aggressive ideations reported more workplace bullying than patients without aggressive ideations (χ ² ₍₃₎ = 44.2, p < 0.001). For “sick leave” and “workplace bullying”, there is a linear increase with the severity of aggressiveness.

4 Discussion

The data show no differences between patients with and without aggressive ideation in regard to gender, education, family and living status. This suggests that the reported differences can be attributed to the workplace and cannot be explained by common sociodemographic factors. A difference in this regard is that lower intelligence, as measured with the standardized IBF, is related to more aggressive tendencies. This result is consistent with findings which show that low intelligence can be a risk factor for aggression [41, 42].

As one might expect, there are significant overall differences between groups in regard to aggression/hostility on the respective SCL-90-subscale. Most important is the relation with bullying. The more intensive aggressive ideations are, the more patients complain about bullying. This suggests that bullying can be a trigger for aggressive fantasies. This is in contrast to other workplace problems such as job insecurity and inability to work. Aggression is mostly a “reactive emotion”, so that it is not surprising that bullying leads to aggressive fantasies in the victim. This is also supported by the differences in clinical diagnoses. The more severe aggressive fantasies, the more frequent the clinical diagnoses has been “stress-related disorders” (F40-48), while depression (F30-39), which in contrast commonly includes giving up and withdrawal, is less frequent in aggressive patients. The results of the GSI show that aggressive patients are suffering themselves. There is also a prolonged duration of sick leave. This can be explained by the fact that patients, who suffer because of maltreatment by others, expect an improvement of their situation by a change in the behavior of others. They do not see the need to ask for help themselves. At the same time, being out of work may vice versa stimulate even more aggression [43]. Furthermore, it is well known that bullying and also organizational injustice in particular can be associated with absenteeism [44]. In this context, one can explain the higher age of aggressive patients by the fact that older employees may have higher aspirations in regard to what they deserve or how they should be treated. This may be a risk factor for disappointment, feelings of injustice, and conflicts.

When talking about aggressive fantasies, special attention should be paid to the severity. Fantasies are not real actions. However, fantasies can be a risk factors for acting out such ideas [45 –48]. Minor aggressive acts such as scratching along the side of a car are bad, but in the end only a nuisance. Severe aggression like sabotage and destruction of machinery are severe criminal acts which can harm not only other parties, but the patients themselves. This has to be taken seriously. This is even more important, when there are fantasies to attack the other persons physically. Of our patients with aggressive ideations, 72%had dangerous and very dangerous fantasies. This aspect has so far found no sufficient recognition in the literature, but is of utmost importance. It is unclear and in need of further research when fantasies become real actions and how this can be prevented. In any case, these findings are in accordance with other publications which argue that bullying at the workplace must be taken serious and that organizational measures should be implemented to prevent such negative occurrences [49].

Limitations of the study are that the study was done in a rehabilitation hospital and therefore with a special group of patients. A generalization of the data to other populations is therefore only possible to a limited extent. Assessments were made under conditions of routine care and data were analyzed retrospectively, so that rigorous procedural controls were not possible. In any case, further research should include other patient samples and more sophisticated measurements.

5 Conclusion

In summary, our data suggest that aggressive fantasies in psychosomatic patients are associated with bullying and increased general suffering. Due to the increased suffering, aggressive fantasies should be addressed in diagnostic interviews specifically with the patients who complain about work problems in order to recognize possible dangers early on and to be able to initiate interventions. This should be recognized in the treatment of patients with workplace problems and especially those who complain about bullying.

Footnotes

Acknowledgments

The authors would like to thank the statistician Dipl. Psych. Christoph Droß for his support.

Conflict of interest

The authors declare no conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

None to report.

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