Int Arch Occup Environ Health (2015) 88:131–142
DOI 10.1007/s00420-014-0944-7
ORIGINAL ARTICLE
Workplace bullying as an antecedent of mental health problems:
a five-year prospective and representative study
Ståle Einarsen • Morten Birkeland Nielsen
Received: 10 October 2013 / Accepted: 30 April 2014 / Published online: 20 May 2014
 Springer-Verlag Berlin Heidelberg 2014
Abstract
Purpose The present study investigates the proposed
long-term relationship between exposure to workplace
bullying and subsequent mental health in the form of anx-
iety and depression with a time lag of 5 years, exploring
potential gender differences in these relationships.
Methods The study employs a prospective design with a
5-year time lag in a representative sample of the Norwe-
gian workforce. A cohort of 1,613 employees reported on
their exposure to workplace bullying and their symptoms
of anxiety and depression at both measurement times.
Results The results showed exposure to workplace bul-
lying to be a significant predictor of mental health prob-
lems 5 years on, even after controlling for baseline mental
health status, gender, age, job-change, job demands and job
control, yet for men only. Baseline levels of mental health
problems in terms of symptoms of anxiety and depression
did not predict subsequent exposure to bullying at follow-
up among women, but anxiety did in the case of men.
Conclusion Workplace bullying poses a serious long-
term threat to the health and well-being of workers, at least
for men. The results of the study pinpoint the need for
mental health treatment as well as for preventive measures
in relation to workplace bullying, and pinpoint the need for
a gender perspective in these studies.
Keywords Workplace bullying
Harassment
Mental
health at work
Prospective design
Well-being at work

Social stress at work
S. Einarsen (&)
M. B. Nielsen
University of Bergen, Bergen, Norway
e-mail: stale.einarsen@psysp.uib.no
M. B. Nielsen
National Institute of Occupational Health, Oslo, Norway
Introduction
Workplace bullying, in the form of long-term and sys-
tematic exposure to increasingly harsher forms of aggres-
sion, incivility and social exclusion by other organization
members, has been theorized to mount to an ongoing
trauma for targets with severe long-term outcomes for
those exposed (Bowling and Beehr 2006). Consistent with
stress theory, a growing body of research has documented
exposure to workplace bullying as a major source of dis-
tress at work associated with subsequent health problems
and reduced well-being both in a shorter and longer time
perspective (Hoobler et al. 2010). More specifically,
workplace bullying has been related to reduced job satis-
faction and engagement (Rodriguez-Munoz et al. 2009),
lowered commitment and turnover (Berthelsen et al. 2011;
Høgh et al. 2011a), as well as to increased levels of sick-
ness absenteeism (Kivimäki et al. 2000; Ortega et al.
2011), psychosomatic complaints and a range of mental
health problems (Kivimäki et al. 2003; Lahelma et al.
2012).
Despite the fact that workplace bullying is considered as
a long-lasting process (Einarsen et al. 2011), most empir-
ical studies have employed cross-sectional and correla-
tional research designs with only a handful studies
employing longitudinal designs (e.g., Finne et al. 2011;
Høgh et al. 2011a; Rugulies et al. 2012). Among those
studies that have, the majority has generally employed
relatively short time lags of 12–24 months (see also Niel-
sen and Einarsen 2012a), which is no longer than an
average duration of a bullying case (Zapf et al. 2011).
Employing a prospective research design in a representa-
tive sample, the present study contributes to the literature
by investigating the role of earlier exposure to workplace
bullying as an etiological factor for mental health problems
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5 years later. As studies with shorter time lags have sug-
gested baseline mental health problems to be associated
with later exposure to bullying, thus indicating an
unhealthy or vulnerable worker mechanism or a vicious
circle, we will also investigate the possibility of reversed
causation between the variables.
Definitions and theoretical background
The concept of workplace bullying, sometimes referred to
as worker harassment, describes situations in the workplace
where an employee persistently and over a long time per-
ceives him- or herself to be mistreated and abused by other
organization members, and where the person in question
finds it difficult to defend him/herself against these actions
(Einarsen et al. 2011). While no definitive list exists of the
specific behaviors involved, common acts of workplace
bullying include angry outbursts, verbal hostility, hostile
acts of humor like being made a laughing stock, as well as
illegitimate and highly stressful changes in ones tasks and
work situation such as undue work pressure, being given
unreasonable deadlines or being exposed to a dangerous
work situation. Quite often, bullying is conducted with acts
of social exclusion or social isolation in combination with
such direct attacks described above. Yet, it is the accu-
mulated number of acts over time, and the summarized
pattern of behaviors, and not the particular and individual
acts involved, that constitutes the menace. As isolated acts
of aggression, such incidents may be mildly offensive and
even tolerable. However, when accumulated over time,
these acts will be highly destabilizing and a distressing
situation to those exposed (Leymann 1990). Following
from this notion, bullying does not seem to be an either-or
phenomenon, but rather a slowly escalating process with
increasingly more harsh treatment of the target. Estimates
based on meta-analytical evidence suggest that at least
15 % of the global working population is exposed to
negative behaviors in the workplace that can be experi-
enced as bullying, whereas 11 % label themselves as vic-
tims of bullying according to the above definition (Nielsen
et al. 2010).
Exposure to such treatment while at work has long been
claimed as a more crippling and devastating problem for
employees than all other work-related stress put together
(Wilson 1991), with much empirical evidence as support
(see also Høgh et al. 2011b; Nielsen and Einarsen 2012a
for overviews). According to the cognitive trauma theory
of Janoff-Bulman (1992), one may deduce that victims of
systematic psychological hostility from other human
beings, be it real or perceived, react with shock, fear,
anxiety and depression, and may even alter their percep-
tions of their surroundings and future to one of threat,
danger, insecurity and self-questioning (Mikkelsen and
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Einarsen 2002). In line with this, clinical observations have
described grave outcomes of workplace bullying such as
social isolation and maladjustment, psychosomatic ill-
nesses, depressions, compulsions, helplessness, anger,
anxiety and despair (Leymann 1990). Cognitive trauma
theory further holds that it may not be the external event
itself that causes the trauma, but rather the more or less
permanent effect these events have on the perceptions and
cognitions of the target (Janoff-Bulman 1992). Hostile
social events or series of such events threaten our basic
cognitive schemas and fundamental beliefs about the world
being benevolent and meaningful, and that we, as indi-
viduals, are worthy, decent and capable human beings
deserving affection and support by our friends and fellow
citizens (Janoff-Bulman 1989). Under normal circum-
stances, these beliefs and assumptions enable us to operate
effectively in our daily lives securing us that no harm will
affect us, and providing us with a sense of invulnerability
as well as some confidence in our ability to cope with the
challenges of life (see also Einarsen and Mikkelsen 2003).
When facing workplace bullying, victims will instantly or
at least gradually and painfully become aware of the fra-
gility of these assumptions, giving rise to a strong stress
responses and possibly a long-lasting state of fear, cogni-
tive confusion, anxiety and depression.
As described above, the repeated hostility involved in
bullying is often combined with acts of social exclusion
and ostracism, which in itself tend to create instant
symptoms of confusion and anxiety in those excluded, over
time interfering with the immune system and brain func-
tions relating to aggression and depression (Williams
1997). The underlying mechanisms are described in social
psychological theories where social exclusion or rejection
from important social relationships is claimed to threaten a
range of basic social needs, including the need to belong,
the need for a worthy self and the need to perceive the
world as predictable and controllable. Exposure to bullying
is assumed to profoundly question the focal persons sense
of being a capable and worthy individual, again reminding
them of their fragile existence, hence constituting a severe
source of social pain and even symbolizing a kind of
‘social death’ (Mikkelsen and Einarsen 2002; Williams
1997). As for short-term effects, evidence from a study
examining the neural correlates of social exclusion through
the use of functional magnetic resonance brain imaging
(fMRI) showed that social pain actually activates similar
brain bases to those of physical pain (Eisenberger et al.
2003). In the long run, perceptions of exclusion are seen to
cause extreme anxiety, depression and even psychotic
reactions. Based on clinical observations, Leymann (1990),
described how exposure to social isolation or social
ostracism gradually reduces the victim’s ability to cope
with the demands of daily living, reinforcing other people’s
Int Arch Occup Environ Health (2015) 88:131–142
negative attitude toward the focal person, putting gradually
more strain on the victim’s self-esteem and self-confidence.
Generally, mainstream work stress models hold that
‘long-term exposure to high work stress without having
sufficient possibilities for recovery affects health in the long
run via sustained activation of the autonomic nervous sys-
tem and enhanced neuroendocrine responses’ (Kompier and
Taris 2011). Hence, based on such theories of work stress,
cognitive trauma theory and social psychological theories
on ostracism and social exclusion, we may put forward the
hypothesis that exposure to workplace bullying is associ-
ated with subsequent elevated reports of anxiety and
depression in those targeted, even within long-time spans.
In a meta-analysis of 33 cross-sectional studies on the
relationship between bullying and mental health outcomes,
it was established that the mean correlation between
exposure to bullying and self-reports of lowered mental
health was .34 (Nielsen and Einarsen 2012a). Employing a
prospective design with a 2-year time lag and a sample of
1971 Norwegian workers recruited from some 20 organi-
zations, Finne et al. (2011)showed that baseline exposure to
workplace bullying was associated with a subsequent
increase in mental health problems 2 years later, even when
controlling for baseline mental distress and job demands. In
the aforementioned meta-analysis, a mean correlation of .20
was revealed between exposure to workplace bullying and
subsequent reports of mental health problems in 7 studies
employing prospective designs.
Yet, an important limitation of the existing longitudinal
studies is that they employ relatively short or intermediate
time lags between measurement points. Most time lags are
only 1 or 2 years, which actually is the typical length of a
bullying episode. Hence, little is known about the after effects
of workplace bullying over longer time-periods. A study by
Stoetzer et al. (2009), employing a representative sample of
the Swedish work force, showed that being socially excluded
at work was associated with an increased risk of depression
3 years later. Lahelma et al. (2012) found elevated risks of
having a common mental disorder 5–7 years later among a
group of Finnish victims of workplace bullying, an effect that
was strongest for male participants.
Yet, the mobilization–minimization hypothesis of Tay-
lor (1991) holds that while the effects of negative experi-
ences and events may be stronger than the effects of
positive events in the short run, the potential effects of
negative experiences will quickly wane and hence be less
profound as time goes by, questioning whether bullying has
such strong and long-lasting effects. Hence, more evidence
is needed on the long-term outcomes of workplace
bullying.
In addition to the stressor–strain model described above,
there is also theoretical and empirical evidence for reversed
associations between workplace bullying and psychological
133
health, suggesting that a strain–stressor model exists parallel
to or sequentially with the stressor–strain model. For
instance, Finne et al. (2011) showed that baseline levels of
mental distress predicted bullying at follow-up, with an odds
ratio of 2.30, suggesting a reversed causation between bul-
lying and mental health problems. According to Kompier
and Taris (2011), unhealthy (e.g., depressive) employees
evaluate their environment more negatively than do other
employees. Reported environmental ‘changes’ are therefore
mainly a matter of changed perceptions. Furthermore,
‘… distressed employees may underperform and therefore
receive less support from colleagues or supervisors, they
may not participate in social meetings with colleagues,
prefer to remain alone and therefore become isolated and
ridiculed, be given the ‘silent treatment,’ and so forth—all of
which may well be considered forms of bullying’ (Kompier
and Taris 2011). Hence, some sort of vicious circle of events
may exist where bullying leads to mental health problems,
which may act to worsen the situation for the target or at least
worsen the perception the targets make of their work situa-
tion. Employing a longer time interval between measure-
ment points such as the 5 years employed in the present study
may, however, be particularly helpful in order to indicate
where it all starts: In mental health problems or in exposure to
harsh treatment by peers or superiors at work?
Aim of study
Few studies exist on the longitudinal relationships between
exposure to workplace bullying and mental health distress
in the form of symptoms of anxiety and depression, and
those that exists mainly look at intermediate time lags of
1–2 years (Nielsen and Einarsen 2012a). Yet, theoretically,
bullying is claimed to constitute a traumatic series of
events with possible life-changing effects. By employing a
prospective design with a 5-year time lag between mea-
surement points, the present study investigates the rela-
tionship between exposure to workplace bullying and
subsequent mental health problems. In order to purify the
association between workplace bullying and subsequent
mental health problems, we will control for the stability of
the outcome variables, as well as other well-known
stressful aspects of the target’s job role such as high
demands and lack of control. These control variables are
included as they are empirically established as important
predictors of mental health (Stansfeld and Candy 2006),
and because workplace bullying generally takes place
in situations where employees are plagued with such
unhealthy work characteristics (Baillien et al. 2011; Hauge
et al. 2007, 2010). Hence, we investigate the long-term
outcomes of bullying purified of the possible overlapping
effects of a general stressful work situation. We will test
the assumption both for a compound measure of mental
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distress as well as for anxiety and depression separately. In
addition, we will investigate the possibility of reversed
causation between the variables, accounting for any
unhealthy or vulnerable worker mechanisms in explaining
the occurrence of workplace bullying. The two following
hypotheses will be tested:
H1 Exposure to workplace bullying is related to sub-
sequent increased reports of mental health problems in the
form of symptoms of anxiety and depression 5 years later,
even when controlled for base line reports of mental health
problems, as well as a work situation characterized by high
job demands and lack of control.
H2 Premorbid levels of such mental health problems are
related to later reports of being bullied at work, even when
controlled for baseline indicators of a bullying and a
stressful working environment in the form of high job
demands and lack of control.
In line with methodological recommendations relating
to the measurement of workplace bullying (Mikkelsen and
Einarsen 2001; Nielsen et al. 2011; Salin 2003), we will
employ two measures of workplace bullying; systematic
exposure to bullying behaviors and the perception of being
victimized by bullying. While the former measures expo-
sure to actual negative acts while at work, the latter mea-
sures to what extent a respondent self-labels as a victim of
bullying. By employing both measures, we may differen-
tiate the effect of mere exposure to perceived negative acts
from the effect of the subjective identity of being a victim.
A study based on the same baseline data as in the present
study, but with a 2-year time lag between measurement
points, showed that it was the subjective feeling of being a
victim, rather than ones actual exposure to bullying
behaviors, that predicted subsequent increases in mental
health problems (Nielsen et al. 2012). This suggests that
self-labeling as a victim may function as a mediator
between exposure and mental health problems. Such a
finding would be in line with the cognitive trauma theory
and most stress theories that hold that it is not the actual
events per se that causes the observed stress reaction, but
rather the effects events have on the inner world of the
recipient. Yet, a study by Vie et al. (2011) showed that
when exposure to bullying behaviors is high, such persis-
tent exposure have a considerable harmful effect on the
target’s health independently of whether the experience is
labeled as bullying or not. Hence, the present study
explores the possible different long-term relationship with
mental health problems for these two important aspects of
the bullying experience when testing the two above
hypotheses. In addition, we will explore if gender differ-
ences may be traced in these hypothesized relationships.
Although there are not necessarily gender differences in the
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exposure to workplace bullying (Zapf and Einarsen 2011),
the exposure outcome relationships may still be different
for men and women. This possibility is surprisingly seldom
explored in this line of enquiry as documented in the
review by Høgh et al. (2011b) and the meta-analysis by
Nielsen and Einarsen (2012a). An earlier two-year pro-
spective study on the relationship between exposure to
sexual harassment (SH) and subsequent psychological
distress did reveal such gender effects (Nielsen and Ein-
arsen 2012b) in that SH contributed to subsequent psy-
chological distress among women while psychological
distress predicted SH among men, possibly indicating
either a vulnerability factor or a negative perception
mechanism among these men.
Method
Design and procedure
The present study is based on assessment 1 and assess-
ment 3 of a longitudinal survey in a nationwide sample
of the Norwegian working force. Data were collected
with a time lag of approximately 5 years. In 2005
(baseline), a random sample of 4,500 employees was
drawn from The Norwegian Central Employee Register
(NCER) by Statistics Norway (SSB). The sampling cri-
teria were adults between 18 and 67 years of age that
were registered in the NCER as employed during the last
6 months before the survey, in an enterprise with a staff
of five or more, and with a mean working hour of more
than 15 h per week.
Questionnaires were distributed through the Norwegian
Postal Service to the respondents’ home addresses. Altogether
2,539 questionnaires were returned (response rate 57 %), a
response rate slightly higher than what is typically the case in
these kinds of workplace survey studies (Baruch and Holtom
2008). Using the same procedure, the follow-up data were
collected in 2010. All respondents from the baseline survey
were asked to participate in the follow-up. The response rate
for the follow-up survey was 64 % (N = 1,613). With the
exception of a somewhat skewed gender distribution, the
cohort sample can be considered as representative for the
Norwegian working population with regard to demographic
characteristics (Høstmark and Lagerstrøm 2006). The project
was approved by the Regional Committee for Medical
Research Ethics in Western Norway.
The cohort
Among the 1,613 respondents, women were slightly
overrepresented (54 %). The mean age at baseline was
45.23 years. About 91 % of the respondents were
Int Arch Occup Environ Health (2015) 88:131–142
employed in a full-time (72 %) or part-time (19 %) posi-
tion, whereas the remaining respondents were on tempo-
rary sick leave, paid leave or vocational rehabilitation. A
total of 81 % had a regular day time working arrangement.
Mean working hours per week was 37.3.
Instruments
Exposure to bullying behaviors in the workplace was
measured with the 22-item Negative Acts Questionnaire-
Revised (NAQ-R) inventory (Einarsen et al. 2009). NAQ-R
describes behaviors that may be perceived as bullying if
occurring on a regular basis. All items are formulated in
behavioral terms and hence focus on the mere exposure to
inappropriate behaviors while at work. The NAQ-R con-
tains items referring to both direct (e.g., openly attacking
the victim) and indirect (e.g., social isolation, slander)
behaviors. It also contains items referring to personal as
well as work-related forms of bullying. For each item, the
respondents were asked how often they had been exposed
to the behavior at their present worksite during the last
6 months. Response categories range from 1 to 5 (‘never,’
‘now and then,’ ‘monthly,’ ‘weekly’ and ‘daily’). In
accordance with recent advances on the use of cutoff cri-
teria with regard to estimating targets of bullying (No-
telaers and Einarsen 2012), respondents with a summarized
score of C33 on the NAQ-R were classified as targets of
workplace bullying. Cronbach’s a for the NAQ-R was high
at both baseline (.90) and follow-up (.88).
In line with previous studies (Nielsen et al. 2010, 2011),
perceived victimization from bullying was measured by
asking the respondents to indicate whether they considered
themselves to have been victimized by bullying at work
during the last 6 months according to the following defi-
nition (Einarsen and Skogstad 1996; Olweus 1991): ‘Bul-
lying takes place when one or more persons systematically
and over time feel that they have been subjected to nega-
tive treatment on the part of one or more persons, in a
situation in which the person(s) exposed to the treatment
have difficulty in defending themselves against them. It is
not bullying when two equally strong opponents are in
conflict with each other.’ The response categories were
‘no,’ ‘yes, rarely,’ ‘yes, now and then,’ ‘yes, once a week’
and ‘yes, several times a week’. Respondents answering
‘yes’ to this question were categorized as self-labeled
victims of workplace bullying.
Eight items from the ‘Questionnaire on the Experience
and Assessment of Work’ (Van Veldhoven et al. 1999)
were employed to assess job demands (Cronbach’s a .86)
and control in the form of decision latitude (Cronbach’s a
.75). The items were scored using a 4-point scale ranging
from ‘never,’ ‘sometimes,’ ‘quite often,’ ‘through’ ‘very
often/nearly always.’
135
Mental health was assessed with the Hopkins Symptoms
Checklist-25 (HSCL-25; Derogatis et al. 1974), which
covers the most common psychiatric symptoms in the area
of anxiety and depression. The HSCL-25 is scored on a
severity scale from 1 (‘not at all’) to 4 (‘extremely’) using
the ‘last week’ as a frame of reference for answering.
Following Derogatis et al. (1974), six items assess symp-
toms of anxiety, whereas 11 items symptoms of depression.
Mental caseness, that is the need for treatment, is calcu-
lated by having an average score on the HSCL-25 items
C1.75 (Nettelbladt et al. 1993). The same cutoff value
applies for the anxiety and depression subscales (Stammel
et al. 2012). The comparison of scores on the HSCL-25 to
physician ratings of emotional distress has yielded a con-
cordance rate of 86.7 % (Hesbacher et al. 1980). The
HSCL-25 has satisfactory validity and reliability as a
measure of psychological distress (Nettelbladt et al. 1993;
Strand et al. 2003). High internal consistency, as measured
with Cronbach’s a, was found for the total scale (.92/.93),
as well as for the two subscales of anxiety (.79/.79) and
depression (.87/.88), at both baseline and follow-up.
Attrition analyses
Attrition analyses of demographic data at baseline,
including dropouts, revealed that the cohort respondents
(M = 45.23; SD = 11.23; N = 1,613) were somewhat
older than dropout respondents (M = 41.30; SD = 11.60;
N = 926) (t = -8.38; df = 2,537; p \ .001). Systematic
gender differences (v2 = 3.97; df = 1; p \ .05) were
revealed between cohort (54 % women) and dropouts
(50 %) at baseline. No differences were established with
regard to leadership responsibility, but a higher percentage
of the cohorts (15 %) compared with dropouts (11 %) was
elected as a shop steward or other form of employee rep-
resentative. Compared with the cohort sample (11 %),
significantly more of the dropouts (15 %) reported expo-
sure to bullying behavior at baseline (v2 = 5.77; df = 1;
p \ .05). No differences between cohort and dropouts were
found with regard to self-labeled victimization from bul-
lying. Finally, a significantly higher percentage of the
dropout (16 %) than among cohorts (12 %) reported
symptoms of psychological distress above the recom-
mended cutoff value of mental caseness (v2 = 9.23;
df = 1; p \ .01).
Statistical analysis
Statistical analyses were conducted using IBM SPSS Sta-
tistics 21.0. Logistic regression analyses were conducted in
order to examine longitudinal relationships between bul-
lying and psychological distress. The level of significance
was set to .05. In order to determine gender differences in
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Table 1 Crude (unadjusted) Baseline (T1) Follow-up (T2)

Odds ratios between baseline
predictors and measures of Psychological distress Bullying behaviors Self-labeled
distress and bullying at follow- victimization
up
OR 95 % CI OR 95 % CI OR 95 % CI

Psychological distress (no) 10.73** 7.2–15.98 3.87** 2.48–6.03 3.78** 2.04–7.00

Age .97** .95–.99 .98 .97–1.00 1.01 .98–1.03
Gender (male) 1.5* 1.06–2.13 .97 .67–1.41 .76 .44–1.30
Leadership position (no) 1.24 .79–1.93 1.22 .75–2.00 1.08 .54–2.19
Changed position (no) 1.07 .73–1.57 1.01 .66–1.54 .98 .53–1.82
Job demands 1.41* 1.05–1.90 1.53* 1.11–2.11 .96 .59–1.57
Reference categories in brackets Decision latitude .81 .61–1.08 .59** .43–.81 .73 .46–1.15
OR Odds ratio, 95 % CI 95 % Bullying behaviors (no) 4.10** 2.70–6.20 11.65** 7.63–17.79 7.85** 4.42–13.91
confidence interval
Self-labeled victimization (no) 3.37** 1.83–6.18 6.41** 3.57–11.49 11.50** 5.86–22.56
* p \ .05; ** p \ .001

the etiology of workplace bullying and psychological dis-
tress, separate analyses were conducted for men and
women.
Results
At baseline, 13.4 % of the cohort reported symptoms of
psychological distress above the threshold for mental
caseness. The corresponding number at follow-up was
11.4 %. At both baseline (v2 = 16.35; df = 1; p \ .001)
and follow-up (v2 = 5.18; df = 1; p \ .05), significantly
more women (baseline 16.1 %/follow-up 13.2 %) than
men (baseline 10.5 %/follow-up 9.2 %) reported symp-
toms of distress above threshold for caseness.
A total of 12.5 % of respondents at baseline, and 9.2 %
at follow-up, reported exposure to workplace bullying
behaviors above the cutoff value suggested by Notelaers
and Einarsen (2012). In total, 4.6 % labeled themselves as
victims of bullying at baseline, while 4.1 % self-labeled at
follow-up. No gender differences were found with regard
to the two indicators of bullying.
Bivariate, unadjusted associations between predictor
variables at baseline and psychological distress, exposure
to bullying behaviors, and self-labeled victimization from
bullying at follow-up for the total sample are presented in
Table 1. The findings show that baseline distress, being
young, being female, having high levels of job demands,
reporting high exposure to bullying behaviors, and claim-
ing victimization from bullying, all predicted subsequent
distress, with baseline distress and the two measures of
bullying as the strongest predictors. Exposure to bullying
behaviors at follow-up was predicted by baseline exposure
to bullying behavior, self-labeled victimization, psycho-
logical distress, job demands and decision latitude. Sub-
sequent self-labeled victimization was predicted by earlier
victimization, exposure to bullying behaviors and psycho-
logical distress at baseline.
Prospective associations between workplace bullying at
baseline and psychological distress at follow-up, adjusted
for control variables (baseline distress, age, leadership
position, changed position, job demands and decision lat-
itude), are presented in Table 2. In the adjusted analysis for
the total sample, baseline psychological distress (OR 9.05;
95 % CI 5.80–14.13), being young (OR .97; 95 % CI
.95–.99) and exposure to bullying behaviors (OR 1.77;
95 % CI 1.02–3.07) emerged as significant predictors of
subsequent distress five years later. Based on the Cox &
Snell R-Square and Nagelkerke pseudo R-Square values,
the predictors explained between 11 and 21 % of the var-
iance in psychological distress. The regression model was
supported by a significant chi-square test (v2 = 14.17;
df = 8; p \ .001) and by a nonsignificant Hosmer and
Lemeshow test (v2 = 5.54; df = 8; p [ .05). Yet, gender
differences in the etiology may exist, as a significant
association between bullying behaviors at baseline and
subsequent psychological distress was only found among
men (OR 4.22; 95 % CI 1.91–9.32), and not among women
(OR .90; 95 % CI .40–2.02).
Table 3 displays longitudinal effects of baseline psy-
chological distress on exposure to bullying behaviors at
follow-up adjusted for control variables at baseline. When
adjusting for baseline bullying behaviors (OR 9.36; 95 %
CI 5.54–15.80) and the other control variables, psycho-
logical distress was not related to exposure to bullying
behaviors at follow-up (OR 1.55; 95 % CI .90–2.69) in the
total sample. Similarly, no association was established
between self-labeled victimization at baseline and sub-
sequent exposure to workplace bullying behaviors (OR
1.61; 95 % CI .78–3.30) in the total sample. The predictors
explained between 10 and 21 % of the variance in exposure
to bullying behaviors. The tests for model fit supported the

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Table 2 Longitudinal Baseline variables Men Women Total

relationships between baseline
workplace bullying and OR 95 % CI OR 95 % CI OR 95 % CI
psychological distress follow-up for OR for OR for OR

Psychological distress (no) 6.47** 3.05–13.73 12.47** 6.88–22.61 9.05** 5.80–14.13

Age .97 .94–1.01 .96* .94–.99 .97* .95–.99
Leadership position (no) .91 .45–1.84 1.68 .74–3.81 1.15 .69–1.91
Changed position (no) .97 .48–1.96 .52* .28–.98 .71 .45–1.13
Reference categories in
brackets. Age, job demands and Job demands 1.52 .88–2.60 .89 .56–1.41 1.13 .80–1.59
decision latitude are continuous Decision latitude 1.60 .92–2.79 1.07 .69–1.67 1.17 .84–1.64
variables Bullying behaviors (no) 4.22** 1.91–9.32 .90 .40–2.02 1.77* 1.02–3.07
OR Odds ratio, 95 % CI 95 % Self-labeled victimization (no) 1.57 .51–4.89 1.04 .33–3.23 1.34 .60–2.97
confidence interval
Constant .02* .21 .12*
* p \ .05; ** p \ .001

Table 3 Longitudinal Baseline variables Men Women Total

relationships between baseline
psychological distress and OR 95 % CI OR 95 % CI OR 95 % CI
exposure to bullying behaviors for OR for OR for OR
at follow-up
Bullying behaviors (no) 17.88** 7.98–40.5 5.61** 2.71–11.61 9.36** 5.54–15.80
Age 1.00 .97–1.03 .99 .96–1.02 1.00 .97–1.02
Leadership position (no) 1.43 .62–3.30 1.09 .49–2.43 1.23 .70–2.17
Changed position (no) .74 .33–1.66 .58 .28–1.19 .62 .37–1.06
Reference categories in
brackets. Age, job demands and Job demands .76 .40–1.43 1.19 .72–1.97 .98 .66–1.44
decision latitude are continuous Decision latitude .99 .54–1.82 .89 .55–1.43 .89 .62–1.30
variables Psychological distress (no) 2.92* 1.23–6.96 1.11 .53–2.32 1.55 .90–2.69
OR Odds ratio, 95 % CI 95 % Self-labeled victimization (no) 1.17 .38–3.59 2.05 .79–5.34 1.61 .78–3.30
confidence interval
Constant .11* .09 .07*
* p \ .05;** p \ .001

model with a significant chi-square test (v2 = 124.27;
df = 8; p \ .001) and an insignificant Hosmer and Leme-
show test (v2 = 9.97; df = 8; p [ .05). Again, gender
differences were found as exposure to bullying at follow-up
was significantly predicted by psychological distress
among men (OR 2.92; 95 % CI 1.23–6.96), but not women
(OR 1.11; 95 % CI .53–2.32).
The adjusted relationship between baseline psychologi-
cal distress and self-labeled victimization at follow-up is
presented in Table 4. For the total sample, the findings
show that self-labeled victimization at follow-up is pre-
dicted by baseline victimization (OR 4.58; 95 % CI
1.91–10.97) and baseline exposure to bullying behaviors
(OR 5.32; 95 % CI 2.40–11.79), but not baseline psycho-
logical distress (OR 1.27; 95 % CI .57–2.85). In this
model, the predictors explained between 4 % and 15 % of
the variance in subsequent victimization from bullying. A
significant chi square (v2 = 51.76; df = 8; p \ .001) and a
nonsignificant Hosmer and Lemeshow test (v2 = 7.23;
df = 8; p [ .05) yielded support to the model. No gender
differences were found with regard to the association
between baseline psychological distress and victimization
at follow-up. However, exposure to bullying behaviors at
baseline predicted subsequent victimization among men
(OR 9.93; 95 % CI 3.13–31.51), but not women (OR 1.61;
95 % CI .78–3.30).
Relationships between bullying and anxiety
and depression subscales
In order to further add to the understanding of how bullying
is related to psychological distress, supplementary analyses
were conducted for the HSCL-25 subscales of anxiety and
depression. In line with the main analyses, all supple-
mentary analyses were adjusted for the stability of the
outcome variable baseline from baseline to follow-up, age,
leadership responsibility, changed position, job demands
and decision latitude.
In the analyses of relationship between baseline bullying
and anxiety at follow-up in the total sample, significant
associations with the outcome variable emerged for base-
line anxiety (OR 9.32; 95 % CI 5.70–15.23) and exposure

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138 Int Arch Occup Environ Health (2015) 88:131–142

Table 4 Longitudinal Baseline variables Men Women Total

relationships between baseline
psychological distress and self- OR 95 % CI for OR 95 % CI for OR 95 % CI for
labeled victimization from OR OR OR
bullying at follow-up
Self-labeled victimization 6.77** 1.89–24.28 9.36* 5.54–15.80 4.58** 1.91–10.97
(no)
Age 1.01 .97–1.06 1.00 .97–1.02 1.01 .98–1.04
Leadership position (no) .85 .29–2.43 1.23 .70.–2.17 .92 .42–2.01
Changed position (no) .46 .14–1.56 .62 .37–1.06 .56 .25–1.24
Reference categories in
brackets. Age, job demands and Job demands .32* .12–.84 .98 .66–1.44 .56 .31–1.01
decision latitude are continuous Decision latitude .78 .33–1.85 .89 .62–1.30 .97 .56–1.67
variables Psychological distress (no) .55 .14–2.25 1.55 .90–2.69 1.27 .57–2.85
OR Odds ratio, 95 % CI 95 % Bullying behaviors (no) 9.93** 3.13–31.51 1.61 .78–3.30 5.32 2.40–11.79
confidence interval
Constant .58 .07* .10
** p \ .001

to bullying behaviors (OR 2.15; 95 % CI 1.17–3.94). The
other included control variables, as well as self-labeled
victimization from bullying (OR 2.03; 95 % CI .89–4.59),
was not related to subsequent anxiety. In the separate
analyses of male respondents, anxiety at follow-up was
significantly predicted by anxiety (OR 8.23; 95 % CI
3.90–17.40), exposure to bullying behaviors (OR 3.87;
95 % CI 1.65–9.06) and victimization (OR 3.11; 95 % CI
1.00–9.65) at baseline. Baseline anxiety (OR 12.52; 95 %
CI 6.23–25.14) emerged as the only significant predictor of
anxiety at follow-up among women.
As for the relationship between bullying and subsequent
symptoms of depression in the total sample, significant
associations was found for age (OR .97; 95 % CI .95–.99)
and baseline depression (OR 9.60; 95 % CI 6.38–14.44),
whereas the two indicators of bullying were not related to
depression. When separating on gender, depression at fol-
low-up was significantly predicted by depression at base-
line (OR 12.34; 95 % CI 6.21–24.51) and baseline
victimization from bullying (OR 4.12; 95 % CI
1.37–12.39) among men. Neither exposure to bullying nor
victimization from bullying was related to depression
among female respondents.
With regard to the relationships between anxiety and
depression at baseline and the indicators of bullying at
follow-up, findings showed that exposure to bullying
behaviors at follow-up was significantly predicted by
exposure to bullying behaviors (OR 9.08; 95 % CI
5.42–15.21) and anxiety (OR 1.89; 95 % CI 1.03–3.46),
but not depression (OR 1.30; 95 % CI .73–2.34), at base-
line. No gender differences were established for the rela-
tionship between anxiety and depression at baseline and
exposure to bullying behaviors at follow-up.
Victimization from bullying at follow-up was predicted
by victimization (OR 4.36; 95 % CI 1.84–10.46), and
exposure to bullying behaviors (OR 5.13; 95 % CI
2.34–11.23) at baseline. Baseline anxiety (OR 1.33; 95 %
CI .54–3.23 and depression (OR 1.31; 95 % CI .57–3.00)
was not related to subsequent victimization from bullying.
No significant gender differences were found for this
association.
Discussion
Exposure to workplace bullying has been claimed to be a
serious social stressor with detrimental long-term health
consequences for those exposed (see Høgh et al. 2011b for
a review). Still, as the vast majority of existing longitudinal
studies on outcomes of workplace bullying have been
based on relatively short time lags (\ 24 months), the
empirical basis for real long-term consequences of expo-
sure to bullying is relatively scarce. In order to add to the
understanding of how bullying is related to individual
health and well-being over longer time-periods, the aim of
the current study was to determine associations between
bullying and psychological distress in the form of anxiety
and depression in a representative sample of the Norwegian
workforce with a five year time lag between measurement
points.
The results showed that exposure to bullying behaviors
while at work predicted elevated levels of distress even five
years later. This main finding is in line with the rather
limited body of existing evidence showing that exposure to
bullying is associated with psychological distress in a long
timeframe (Høgh et al. 2005; Lahelma et al. 2012).
Extending previous research, the findings of this study
further showed that the association between exposure to
bullying behaviors and subsequent psychological distress
persisted over a five year period, even after controlling for
the subjective feeling of being victimized by bullying and
for having a generally stressful work situation plagued with
high demands and low control. As a second contribution,
our findings indicated gender differences in that the

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Int Arch Occup Environ Health (2015) 88:131–142
relationship between bullying and later symptoms of dis-
tress was valid among male, but not female, respondents.
As for the specific indicators of distress, the findings
showed that perceived exposure to actual demeaning
behaviors predict both subsequent anxiety and depression,
whereas the perceived identity as a victim of bullying only
predicted subsequent levels of depressive symptoms, and
among male respondents only. The results are thereby
leaning toward Vie et al. (2011) who found that self-
labeling as a victim did not add to the explained variance in
mental health under conditions of high exposure to bully-
ing behaviors.
Taken together, these findings partly support the first
study hypothesis, which claimed that exposure to bullying
is associated with subsequent distress five years later. This
evidence for a stressor-strain model, where exposure to
bullying behavior influences subsequent symptoms of
anxiety and depression among these targeted men, is in line
with general stress theories, as well as the Cognitive
trauma theory of Janoff-Bulman (1992) and social psy-
chology theories on ostracism and social exclusion. For
instance, following the basic tenets of the cognitive acti-
vation theory of stress (CATS) by Ursin and Eriksen
(2004), repeated or chronic cognitive activation created by
stressors, such as bullying, may lead to prolonged physi-
ological activation, which again may lead to impairment in
health, especially when coping efforts fails.
As for our second hypothesis, which proposed that
psychological distress at baseline is associated with an
elevated risk of subsequent exposure to bullying, the
findings from the overall sample provided no overall evi-
dence for this kind of strain-stressor model in a five-year
perspective. Yet, when analyzing men and women sepa-
rately, baseline anxiety predicted subsequent exposure to
bullying among males. Hypothesis 2 was therefore rejected
for women but not for men, thus suggesting that the idea of
a gloomy perception mechanism or a vulnerable worker
mechanism within such long-time frames (de Lange et al.
2005; Kompier and Taris 2011) may exist among men.
This may be in line with earlier studies showing that dis-
tressed males elicit more rejection from others than do
females (see Segrin 1998).
Earlier studies on reversed relationships between
symptoms of distress and bullying have not investigated
gender differences and have mainly employed time lags of
1–2 years (Finne et al. 2011; Kivimäki et al. 2003; Rugu-
lies et al. 2012), something which coincide with the typical
length of a bullying case. Hence, our findings advance
previous research by adding to the understanding of how
timeframes and gender influences the etiology of work-
place bullying. That is, taking findings from all studies
together, the total evidence suggests that there may be a
reversed causation between bullying and mental health
139
problems in a shorter time-frame, whereas in a longer
timeframe, the effect of distress on bullying diminishes and
disappears for females, but not necessarily for men. While
anxious men seem to have the tendency to report elevated
levels of exposure to bullying behaviors even as long as
five years down the road, no such relationship is found
among women. An implication of this finding is that it
questions the notions about a vicious circle between bul-
lying and distress, which has been set forward in previous
research (Kivimäki et al. 2003; Nielsen and Einarsen
2012a). Specifically, our findings indicate that a reversed
effect of distress on bullying may only be valid for a
limited time period for women, whereas psychological
distress in the form of anxiety increases the risk of being
bullied in the long run among men as discussed above.
Yet, given the long time between measurement points,
we do not know exactly when bullying affected the health
of those exposed or when existing health problems influ-
ence the likelihood of being bullied. What we do know
from the results of the present study is that any longitudinal
relationship between bullying and mental health is trace-
able five years later, at least among male targets. Hence,
the individual consequences of bullying do not necessarily
disappear with time. We furthermore know that it is not so
that bullying is merely a part of a general stressful work
situation, nor can the relationship be explained by the
subjective identity of someone being a victim of bullying.
However, as a reversed model only received partial sup-
port, and since we controlled for baseline levels of psy-
chological distress, we can rule out some of the impact of a
vulnerable worker effect or a gloomy perception mecha-
nism in the long run, although such an effect may exist
among male targets in relation to anxiety.
To add to our knowledge on short- and long-term indi-
vidual outcomes of exposure to bullying, future studies
should employ longitudinal designs with multiple mea-
surement points and with samples large enough to look
more closely into potential gender differences. Such studies
may also add to our knowledge on the mechanisms
involved in this observed relationship. In this large scale
samples are needed as bullying is a low-base rate phe-
nomenon in most countries. With regard to mechanisms,
we suggest that the Cognitive Trauma Theory of Janoff-
Bulman (1992) could account for the observed relationship
by predicting shattered cognitions and basic assumptions
among targets of bullying (see Mikkelsen and Einarsen
2002), whereas the Affect Events Theory (AET; Weiss and
Cropanzano 1996) can explain the relationship by showing
that bullying leads to psychological distress via an increase
in one’s negative emotional state. This latter perspective, as
well as general stress models, such as the CATS (Ursin and
Eriksen 2004), is supported by a cross-sectional study by
Vie et al. (2012) where it was showed that negative
123
140
emotions and in particular, the feeling of being stressed
mediated the relationship between bullying and mental
health outcomes,
Limitations
The present study poses some notable strengths. It employs
well-established and validated measures, testing its
hypotheses in a representative nationwide sample with a
prospective design and with response rates above the mean
of organizational surveys in general (Baruch and Holtom
2008). Hence, our findings should be seen as more robust
and valid than are those from cross-sectional studies who
have dominated this field for many years (see Nielsen and
Einarsen 2012a for an overview). The findings may also be
generalized to a wide working population. The long time
lag between measurement points, as well as the inclusion
of control variables, such as job demands and control, puts
the hypotheses on a strong test, in line with the theoretical
and conceptual notion that bullying may be a long-lasting
and life-changing situation for many of those exposed and
with long-term detrimental outcomes.
Yet, some limitations should also be mentioned. First of
all, all variables are based on self-report. Hence, we do not
know the objective level of exposure to bullying, nor do we
have objective markers of mental health problems such as
medically certified diagnoses. Furthermore, the observed
relationship between bullying and subsequent mental
health problems may be inflated due to problems with
common method variance (Podsakoff et al. 2003). Yet, the
long time lag between the measurement points would tend
to reduce this problem. Furthermore, these effects have
been questioned based on empirical evidence raising doubt
about whether the method itself produces systematic vari-
ance in observations that inflates correlations to any sig-
nificant degree (Spector 2006). Although the sample
employed is a large one, the number of targets is still rel-
atively few, particularly when investigating men and
females separately. Confirmation of the null hypothesis is
difficult in such small samples. Therefore, the gender dif-
ferences found in the present study should be seen as
mainly tentative and indicative and followed up in studies
with an even larger sample.
In line with this, as the attrition analyses showed that
targets of bullying tended to participate less in the follow-
up than did other respondents, the observed relationship
between bullying and mental health symptoms may even
be somewhat underestimated, a tendency that may be fur-
ther strengthen by the fact that we now look at rather
healthy employees who are still active in working life five
years later, of which some have faced other stressors and
health problems than bullying along the way. As females
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Int Arch Occup Environ Health (2015) 88:131–142
have a stronger tendency to go on sick leave as well as
being on disability benefits than do men, a potential
‘healthy worker effect’ may be somewhat stronger for
women than for men, potentially explaining why our
findings mainly hold for men.
Conclusion and practical implications
In conclusion, the present study shows that exposure to
workplace bullying is related to psychological distress five
years later even when controlling for base line levels of
distress and a general stressful work situation. Yet, gender
differences seem to exist, as an association between
exposure to bullying and symptoms of distress only holds
for male targets. As for the reversed association between
distress and bullying, the study findings indicate that
baseline anxiety is related to later exposure to bullying, yet
among male respondents only. Taken together, the findings
suggest a reciprocal relationship between bullying and
anxiety among male respondents, although the strength of
the associations seems to indicate that that the long-term
causal path between bullying and distress goes from the
former to the latter, in line with theoretical frameworks on
the outcomes of trauma and social exclusion. Furthermore,
in a long-term perspective, it seems to be the perception of
the mere bullying behaviors that matter the most for sub-
sequent mental health and somewhat less the subjective
identity of being a victim of such bullying. In this, the
causal path between the two aspects of bullying goes from
exposure to self-labeling, suggesting that it all starts with
exposure to bullying behaviors.
The finding of a stressor-strain, and less so a strain-
stressor relationship between exposure to bullying and
mental health, has important implications for preventive
measures against workplace bullying and for treatment of
victims. First of all, in line with studies questioning the role
of individual characteristics as an antecedent of workplace
bullying (Glasø et al. 2009; Lind et al. 2009), the lesser
evidence of a strain-stressor association shows that pre-
ventive measures against bullying should be directed
against situational factors rather than individual ones. That
is, as long as mental health problems to a lesser extent
predict subsequent bullying than vice verse, there must be
other factors that cause bullying. Similarly, with regard to
the treatment of victims, it is important for practitioners to
make victims understand that their exposure to bullying has
little to do with them as persons. Hence, following the
aforementioned cognitive theory of trauma, victims should
be able to rebuild their assumptions about themselves, the
world and others in a positive manner, something which
may help them deal with the bullying. Yet, both managers
and therapist should take note of the fact of earlier studies
Int Arch Occup Environ Health (2015) 88:131–142
that within an ongoing bullying case, the reactions of tar-
gets may fuel back and lead to more bullying or at least to a
stronger perception of being bullied. Hence, further vic-
timization may be prevented by addressing this among both
targets and potential perpetrators.
Acknowledgments The present study was based on data from a
collaborative project between the University of Bergen and Statistics
Norway (Statistisk Sentralbyrå), where the latter institution drew the
sample and collected the data. The project was made possible by
grants from two Norwegian Employer Associations (Næringslivets
Hovedorganisasjon and Kommunenes Sentralforbud) and the Nor-
wegian Government (Rikstrygdeverket/NAV Farve). Thanks to Bengt
Oscar Lagerstrøm, Maria Høstmark and Aina Holmøy in Statistics
Norway, and Stig Berge Matthiesen and Anders Skogstad at the
Department of Psychosocial Science at the University of Bergen for
their contribution. We thank the anonymous reviewers for their
valuable comments on earlier drafts of this article.
Conflict of interest Ståle Einarsen runs a part-time business
delivering anti-bullying training for managers and health and safety
personnel. Morten B. Nielsen declares no conflict of interest.
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