"Poor management is a major cause of stress."
Dr Peter Graham, Head of Health Directorate, UK Health & Safety Executive, 24 September 1998
Stress is not the employee's inability to cope with excessive workloads and the unreasonable demands of incompetent and bullying managers; stress is a consequence of the employer's failure to provide a safe system of work as required by the UK Health & Safety at Work Act 1974. Blaming the sufferer of stress for suffering stress is an admission of failure to fulfil this obligation of duty of care.
The HSE publication Working on Stress describes the view that "All you need to do is go for counselling to stop work-related stress" as "wrong" and as being "unlikely to tackle the source of the problem".
HSE Stress Management Standards
Stress comes in two forms: positive and negative:
Positive stress (or eustress) is the result of competent management and mature leadership where everyone works together and everyone is valued and supported. Positive stress enhances well-being and can be harnessed to enhance performance and fuel achievement.
Negative stress (or distress) is the result of a bullying climate where threat, coercion and fear substitute for non-existent management skills. Employees have to work twice as hard to achieve half as much to compensate for the dysfunctional and inefficient management. Negative stress diminishes quality of life and causes injury to health resulting in the symptoms of ill-health described on this page. When people use the word "stress" on its own, they usually mean "negative stress". The CBI estimates stress and stress-related illness cost UK industry and taxpayers £12 BILLION each year. The UK Department of Health state that 3.6% of national average salary budget is paid to employees off sick with stress. Stress is now officially the Number One cause of sickness absence although 20% of employers still do not regard stress as a health and safety issue.
Stress plays havoc with the body's immune system.
The symptoms of stress seem to cover more pages of every book published on the subject.
Stress caused by bullying results in these symptoms (and more):
- main symptoms - stress, anxiety, sleeplessness, fatigue (including Chronic Fatigue Syndrome - see below), trauma
- physical symptoms - reduced immunity to infection leading to frequent colds, coughs, flu, glandular fever, etc (especially on days off, eg weekends and holidays), aches & pains (with no clear cause - this lack of attributability suggests stress as the cause - sometimes diagnosed as fibromyalgia), back pain, chest pains and angina, high blood pressure, headaches and migraines, sweating, palpitations, trembling, hormonal problems (disturbed menstrual cycle, dysmenorrhoea, loss of libido, impotence), physical numbness (especially in toes, fingers, and lips), emotional numbness (including anhedonia, an inability to feel joy and love), irritable bowel syndrome or IBS, paruresis (shy bladder syndrome), thyroid problems, petit mal seizures, skin irritations and skin disorders (eg athlete's foot, eczema, psoriasis, shingles, internal and external ulcers, urticaria), loss of appetite (although a few people react by overeating), excessive or abnormal thirst, waking up more tired than when you went to bed, etc
- psychological symptoms - panic attacks, reactive depression (which some people describe as Adjustment Disorder with depressed mood), thoughts of suicide, stress breakdown (this is a psychiatric injury, not a mental illness), forgetfulness, impoverished or intermittently functioning memory, poor concentration, flashbacks and replays, excessive guilt, disbelief and confusion and bewilderment ("why me?" - click here for the answer), an unusual degree of fear, sense of isolation, insecurity, desperation, etc; one experiences acute anxiety at the prospect of meeting the bully or visiting the location where the bullying took place, or at the thought of touching the paperwork associated with the case; one is unable to attend disciplinary meetings and may vomit before, during or after the meeting, sometimes at the thought of the meeting or on receiving a threatening letter insisting one attends (these are PTSD diagnostic criteria B4 and B5)
- behavioural symptoms - tearfulness, irritability, angry outbursts, obsessiveness (the experience takes over your life), hypervigilance (feels like but is not paranoia), hypersensitivity (almost every remark or action is perceived as critical even when it is not), sullenness (a sign the inner psyche has been damaged), mood swings, withdrawal, indecision, loss of humour, hyperawareness (acute awareness of time, seasons, distance travelled), excessive biting, teeth grinding, picking, scratching or tics, increased reliance on drugs (tannin, caffeine, nicotine, alcohol, sleeping tablets, tranquillisers, antidepressants, other substances), comfort spending (and consequent financial problems), phobias (especially agoraphobia), etc
- effects on personality - shattered self-confidence and self-esteem, low self-image, loss of self-worth and self-love
Other symptoms and disorders reported include sleep disorder, bipolar disorder, mood disorder, eating disorder, anxiety disorder, panic disorder, skin disorder.
Increasingly researchers are suggesting that diabetes, asthma, allergies, fibromyalgia, multiple sclerosis (MS), chronic fatigue syndrome (ME) and even some forms of cancer are caused or aggravated by stress. An article in Biologist (T cells divide and rule in Gulf War syndrome (and asthma, TB, cancer, ME), Jenny Bryan, Immunology section in The Biologist, (1997) 44 (5)) suggests that a shared immunological defect may link many disorders. Others suggest that the inappropriateness of the stress response in dealing with modern threats - which are largely psychological rather than physical - is to blame.
The traumatising effect of bullying results in the target being unable to state clearly what is happening to them and who is responsible; the target may be so traumatised that they are unable to articulate their experience for a year or more after the event. This often frustrates or prevents legal action: see 12-week tribunal application limit and psychological reactivity of PTSD.
Another frustration is incorrect diagnosis by a medical or mental health professional who doesn't understand Complex PTSD or who is antagonistic towards the concept of psychiatric injury. If you're under one of these characters, ditch them immediately as they will sabotage both your legal case and your efforts to recover. False diagnoses commonly given include schizophrenia, paranoia, work phobia, school phobia, borderline personality disorder (as a cause rather than a symptom), etc.
Bullying results in strong feelings of fear, shame, embarrassment, and guilt, which are encouraged by the bully to keep their target quiet. This is how all abusers (including child sex abusers) silence their targets. For detailed reasons why targets of abuse don't or can't report their abuse, click here.
Work colleagues often withdraw their support and then join in with the bullying, which increases the stress and consequent psychiatric injury; to see why mobbing breaks out, click here.
Poor concentration, impaired memory, and fatigue are common and early signs of excessive stress. These have significant Health & Safety implications if the employee drives a vehicle, operates machinery, or is responsible for the care or welfare of others as part of their duties. RoSPA estimate that in the UK at least 1000 road deaths each year involve people for whom driving is part of their job. Fatigue is a major factor.
Fight or flight: the stress response
The fight or flight mechanism, or stress response, is designed for responding to physical danger (eg being about to be attacked by a sabre-toothed tiger) but today is more likely to be activated by a psychological danger (eg bullying at work, harassment, stalking, abuse) for which it was not designed. The stress response can also be activated by anticipation of low-probability or long-term or non-life-threatening events such as financial problems (clinching the next big deal, how to pay the mortgage next month, wondering when the next benefit cheque will arrive), motorway traffic jams, job security, picking up a parking ticket for a car park overstay, etc.
Different people respond with different degrees of stress to different stressors, a fact which has dogged research. However, there are at least four factors which determine the degree to which one will feel stressed:
- control: a person feels stressed to the extent to which they perceive they are not in control of the stressor; at work, employees have no control over their management
- predictability: a person feels stressed to the extent to which they are unable to predict the behaviour or occurrence of the stressor (bullies are notoriously unpredictable in their behaviour)
- expectation: a person feels stressed to the extent to which they perceive their circumstances are not improving and will not improve (a bullying situation almost always gets worse, especially as one gains insight into the cause)
- support: a person feels stressed to the extent to which they lack support systems, including work colleagues, management, personnel, union, partner, family, friends, colleagues, persons in authority, official bodies, professionals, and the law
Once the stress response is activated, the body's energy is diverted to where it is needed, thus heart rate, blood pressure and breathing rate increase. All non-essential body functions are temporarily shut down or operate at reduced level; these include digestion, growth, sexual systems (menstrual cycle, libido, testosterone production), immune system, storage of energy as fat, etc. In response to threat, glucose, proteins and fats are rapidly released from storage (in muscles, fat cells and liver) and energy becomes abundantly available to those muscles which will help you fight the danger or run away from it. In extreme cases bowels and bladder will spontaneously evacuate to lighten the load; the smell may also help to deter the attacker. There is no point in digestion, reproduction and immune system etc continuing to operate if you're likely to be the sabre-toothed tiger's dinner in the next ten minutes - better divert that energy into avoiding being on the menu.
Therefore, the prospect of going to work, or the thought or sound of the bully approaching immediately activates the stress response, but fighting or flight are both inappropriate. In repeated bullying, the stress response prepares the body to respond physically when what is required is an employer-wide anti-bullying policy, knowledge of bullying motivations and tactics, assertive responses to defend ourselves against unwarranted verbal and physical harassment, and effective laws against bullying as an ultimate deterrent or arbiter when all else fails.
The fatigue caused by bullying is understandable when you realise that the body's fight or flight mechanism ultimately becomes activated for long periods, sometimes semi-permanently. For a person with a regular daytime job, the activation can last from Sunday evening - at the prospect of having to go to work the following day - through to the following Saturday morning - at the prospect of two days relief.
The fight or flight mechanism is designed to operate briefly and intermittently, but when activated for abnormally long periods, causes the body's physical, mental and emotional batteries to drain dry. Energy stored in the body as protein, glycogen and triglycerides is rapidly converted back to amino acids, glucose and fatty acids etc to help the body deal with the perceived threat. The process of conversion, achieved via the release of stress hormones such as glucocorticoids, glucagon, epinephrine (adrenaline) and norepinephrine (noradrenaline), itself consumes energy. The stress hormones also trigger the conversion of protein in those muscles not required for flight or fright into amino acids.
Whilst the human body is capable of withstanding considerable levels and periods of stress, when the stress response is turned on for long periods, the body inevitably sustains damage through prolonged raised levels of glucocorticoids (which are toxic to brain cells), excessive depletion of energy reserves, resulting in fatigue, loss of strength and stamina, muscle wastage (as in steroid myopathy when patients receive large doses of glucocorticoids to treat various illnesses), and adult-onset diabetes.
At the weekend and days off, the weakened immune system cannot fight off viruses (eg colds, flu, glandular fever etc) and the person suffers constant illnesses during which the batteries do not recharge. Even without viral infection, the obsessiveness and disturbed sleeping patterns prevent the body from replenishing stored energy. Reactivation of the fight or flight mechanism prior to returning to work produces a flow of stress hormones which appear to temporarily suppress the effects of illness.
For suggested reading click here.
Chronic Fatigue Syndrome
Many people who are bullied experience and report symptoms similar to Chronic Fatigue Syndrome (formerly ME, myalgic encephalomyelitis, also called Chronic Fatigue Immune Deficiency Syndrome [CFIDS] and Post Viral Fatigue Syndrome). The main symptoms are:
- overwhelming fatigue
- pains in the joints and muscles with no obvious cause
- occasional bursts of energy, followed by exhaustion and joint/muscle pain
- inability to concentrate
- poor recall, eg words, sentence construction, etc
- mood swings, including anger and depression
- difficulty in learning new information
- sense imbalances, eg in smell, taste and appetite
- dislike of loud noises and bright lights
- inability to control body temperature
- sleep disturbance (eg sleeping by day and waking at night)
- disturbance of balance
- clumsiness, eg unable to grasp small objects, inability to separate sheets of paper
Chronic Fatigue Syndrome achieved official recognition from the UK's Chief Medical Officer Sir Kenneth Calman on 15 July 1998. This view was endorsed by a report published in January 2002 which was compiled for Chief Medical Officer for England. Professor Sir Liam Donaldson called for the recognition of Chronic Fatigue Syndrome (CFS or CFIDS, also known as myalgic encephalomyelitis or ME) as a chronic condition with long term effects on health on a par with illnesses such as multiple sclerosis and motor neurone disease. The report also recommends early diagnosis, better access to treatment, and that CFS/ME should be included in the education and training of doctors, nurses and other healthcare professionals. The only omission from the report seems to be that one of the causes of CFS can be long-term bullying, harassment and abuse, which compromise the body's immune system and drain the body's energy reserves.
The syndrome is not well understood, but a virus in the same family of enteroviruses as multiple sclerosis (MS) and polio is thought to be implicated. The only cure is complete rest. Exercise, which in people without CFS strengthens the body and aids good health, makes the condition worse. CFS is often linked to stress and trauma, although the stressors may not always be obvious.
Action for ME: What is ME? What is CFS? Information for clinicians and lawyers
News item, May 2003: chronic fatigue costs UK £3.5 billion a year says charity Action for ME.
Irritable Bowel Syndrome (IBS)
Irritable Bowel Syndrome, or IBS, is a classic symptom of stress. It's not a disease but a functional disorder (ie a malfunction) of the digestive system, hence it's other name of spastic colon. Certain foods, especially wholewheat and fat, cause a violent spasm of the intestine resulting in abdominal pain (often excruciating), stomach cramps, bloating, endless tummy rumbling, gas, belching, nausea and sometimes vomiting, constipation or diarrhoea (or both alternating) and a general debilitating feeling of great unwellness. Attacks are triggered by certain foods and can last a day. The cause is unknown and IBS can start at any age with no apparent reason, although long-term stress is often, if unscientifically, implicated. Up to 20% of the population may experience IBS to some degree, but sufferers may find diagnosis can be difficult to obtain. There's no "cure" but strict attention to diet can reduce or even eliminate the symptoms. Many people suffer for years before obtaining diagnosis, after which their life is transformed with a new diet. More at Help For IBS.com.
Over time, the symptoms described above result in psychiatric injury, which is not a mental illness. Despite superficial similarity, and comments (both direct and implied) from those around you, there are many distinct differences between psychiatric injury and mental illness including
a) mental illness is assumed to be inherent (internal) whereas psychiatric injury is caused by something or someone else (external) - who is liable;
b) an injury is likely to get better;
c) the person suffering mental illness exhibits a range of symptoms associated with mental illness (paranoia, schizophrenia, delusions, etc) but not with psychiatric injury, whereas the person suffering psychiatric injury will typically exhibit a range of symptoms (eg hypervigilance, hypersensitivity, obsessiveness, irritability, fatigue, sleeplessness) associated with psychiatric injury but not with mental illness.
A table showing the differences between psychiatric injury and mental illness is on the PTSD page - click here.
One of the symptoms of psychiatric injury is reactive depression - it is a reaction to an external event. My understanding is that the chemistry of reactive depression is different to clinical or endogenous depression (which is associated with mental illness).
If you are diagnosed as suffering depression as a result of bullying at work, make sure it is diagnosed (eg on your sick note) as reactive depression. The word "depression" on its own is usually (mis)interpreted (especially by the bully) as "endogenous depression".
In April 2005 researchers from King's College Hospital identified depression as the main reason of sickness absence, although they made no mention of a primary cause of depression, ie cumulative negative stress caused by bullying. [More]
The mental health trap
In every workplace bullying relationship the symptoms suffered by the target eventually become sufficiently noticeable that people start to ask questions. At this moment, the bully will try and portray their target as mentally ill as a way of abdicating and denying their responsibility for the injury which they have caused. I call this the mental health trap.
To handle the mental health trap, on every occasion that the bully implies you are "mentally ill" or "mentally unstable" or are a person with a "mental health problem", look the bully in the eye and (preferably with a witness present) say:
The state of my physical and mental wellbeing today is a direct consequence of your behaviour towards me over the last xx months/years.
Put this in writing, with support from your union or other representative. You may need to repeat it. If you are coerced into reporting to occupational health, use this phrase to identify the cause of your injury. Do not have any qualms about naming the individual whose behaviour is the cause of your psychiatric injury. Bullies are skilled at finding and exploiting your forgiving streak in order to get you to retract allegations. This is a deliberate tactic - so don't be fooled.
If the bully or your employer insist on labelling you as mentally ill, consider including libel (written), slander (spoken) and defamation of character in your legal proceedings. If you are being bullied by the medical profession, or the employer's doctor insists on labelling you as mentally ill, question the competence of a medical practitioner who is unable to tell the difference between mental illness and psychiatric injury. If you're fighting this battle, see the page on PTSD for further insight.
Post Traumatic Stress Disorder (PTSD)
Whilst there is no official diagnosis yet, the symptoms of being bullied are congruent with those of Post Traumatic Stress Disorder (PTSD). I estimate half the UK workforce are exhibiting many of the symptoms of PTSD, albeit diagnosed as "stress" or "anxiety" or "fatigue"..
The diagnostic criteria for PTSD are defined in DSM-IV, the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual. This is covered in detail on a separate page; click here to display.
With bullying, the injury is caused by an accumulation of small events rather than one major event. The related diagnosis of Prolonged Duress Stress Disorder (PDSD, which is PTSD over time) may be more appropriate. However, whereas PTSD is in DSM-IV, PDSD is not - yet. PDSD, or Complex PTSD as it is now becoming known, is a more appropriate diagnosis for people who experience distressing events every day, such as the emergency services (eg fire, ambulance and police officers etc), as well as those in abuse situations.
As well as PTSD caused by accident, disaster, violence and rape, David Kinchin's book Post Traumatic Stress Disorder: the invisible injury includes chapters on PTSD resulting from terrorism, physical and sexual abuse, and bullying. The official estimate of 850,000 cases of PTSD in the UK may swell dramatically as a result of this new research (it's estimated for instance that as many as 14 million people are bullied at work in the UK). This book contains insight that only someone who has experienced PTSD can impart; as David Kinchin says in the introduction, "This is the book I so badly wanted to read when I was traumatised". For an overview, click here; to order a copy click here.
We know that at least sixteen children in the UK kill themselves each year because of bullying at school. Each of these deaths is foreseeable, preventable and unnecessary. The true total could be as high as 80 or more. These estimates, which are published in the book Bullycide: death at playtime by Neil Marr and Tim Field, are endorsed by leading childcare charities.
People who are bullied have many common characteristics including an unwillingness to resort to violence (or legal action) to resolve conflict, and a tendency to internalise anger rather than express it outwardly. Focusing anger inward is a recognised cause of depression. Bullying is perpetrated over a long period of time, perhaps measured in years, and the internalised anger builds to the point where one of these three occur:
- the target starts to exhibit all the symptoms of stress as the internal pressure causes the body to go out of stasis (this happens in every case)
- the target focuses the anger onto themselves and self-harms, either by using drugs (usually alcohol), or by attempting or committing suicide (the UK has the highest suicide rate in Europe)
- in rare cases, and the target "flips" and starts to exhibit the same behaviours as the bully; in extremely rare but well-publicised cases, the target returns to the workplace to carry out a spree killing
How many adult suicides are caused by bullying? Consider the following:
bullying (an abdication and denial for the effect of one's behaviour on others)
prolonged negative stress (psychiatric injury)
reactive depression (the cause is external - someone is responsible and liable)
...which results in...
fluctuating baseline of one's objectivity (balance of the mind disturbed)
...which leads to...
contemplated suicide (being viewed as suffering mental illness)
attempted suicide (cry for help)
...which may end in...
suicide (manslaughter - causation)
It's likely that many suicides are the result of bullying, but the target's lack of awareness of what is going on, their unwillingness to confide what is happening, the traumatization, and the inability to articulate, everyone else's denial, the bully's accomplished lying and Jekyll and Hyde nature, plus the general lack of knowledge and awareness of society, prevent the real cause from being identified.
For insight into the stress response and the effects of prolonged stress on the body I recommend the book Why zebras don't get ulcers: an updated guide to stress, stress-related diseases, and coping by Robert M Sapolsky (Freeman, 1998, ISBN 0-7167-3210-6). Click here for suggested reading.
Job stress can result in reactive depression: see Donald J Franklin's page on reactive depression.
For information on depression see the page by Irish charity Aware
Depression - a common symptom of Complex Post Traumatic Stress Disorder resulting from long-term bullying and abuse - takes a huge toll on productivity: http://www.psychologytoday.com/htdocs/prod/PTOArticle/PTO-20030722-000001.asp
West Dorset Hospitals NHS Trust becomes first employer to be given official stress warning: the UK Health and Safety Executive (HSE) becomes proactive in the fight against stress and bullying: http://news.independent.co.uk/uk/health/story.jsp?story=430762 and http://news.bbc.co.uk/1/hi/health/3124783.stm
The UK Health and Safety Executive (HSE) Stress Management Standards
Action strategies for combating depression by building self-esteem: http://www.psychologytoday.com/htdocs/prod/PTOArticle/PTO-20031001-000001.asp and http://www.psychologytoday.com/htdocs/prod/PTOArticle/PTO-20031224-000003.asp
Beyond Blue is an Australian resource on depression.
Depression Anxiety disorders- Panic, Phobic and other social anxiety disorder: this easy-to-understand, sympathetic guide deals with the entire range of mental health disorder and shows that anxiety disorder has many different forms as well as degree of severity with treatment options.
November 2001: more than half of British workers are suffering from stress and the problem is getting worse, a survey has suggested.
DEPRESSION AMONG WORKERS IS A PREVALENT AND COSTLY PROBLEM
One in 10 office workers in Britain, the United States, Germany, Finland and Poland suffers from depression, anxiety, stress or burnout, the results of an International Labor Organization (ILO) survey show. See: http://www.ilo.org/public/english/bureau/inf/pr/2000/37.htm
UK Eating Disorders Association.
February 2005: Stress link to type 2 (adult onset) diabetes in women: http://www.theaustralian.news.com.au/common/story_page/0,5744,12265708%5E23289,00.html
July 2002: Longs hours and heart attacks
August 2002: Mental Stress lead to Physical Illness: High Stress Levels Raise Risk of Heart Attack, Stroke
September 2002: What is stress really doing to your body? Rosalind Ryan writes at femail.co.uk on how stress may be linked to Alzheimer's Disease, cancer, infertility, hair loss and bad skin and more.
Reverse Therapy is the radical new treatment for ME, Chronic Fatigue Syndrome, Fibromyalgia etc.
Connect Medical Services give patients a fuller understanding of the conditions that their Doctors are treating them for and to help them to exercise choice and responsibility when making decisions about healthcare.