Prevalence and Correlates of Work-Phobic Anxiety in a National Representative Sample
Abstract
Abstract. Work anxiety is a common mental health problem that is often overlooked and often causes long periods of sick leave. This is the first representative survey on the distribution of work-phobic anxiety in Germany. Of the 2,030 working-age participants (18 – 67 years), 7 % had increased work-phobic anxiety of a moderate (5 % with scores >1.5 – 2.5 on a scale from 0 – 4) or high (2 % with scores >2.5 – 4) degree. People with high levels of work-phobic anxiety reported the longest sick leave durations during the past 12 months (8 weeks) and the most periods of unemployment in their professional lives. The three groups were similar in age, sex, and partnership status. People with high work-phobic anxiety perceived themselves least competent in almost all dimensions of psychological capacity. Occupational health must consider work-phobic anxiety as a specific mental health problem closely linked to work-ability problems.
Zusammenfassung. Arbeitsängste gehen oft mit langen Krankheitszeiten einher. Dies ist die erste repräsentative Erhebung zur Verbreitung von arbeitsphobischen Ängsten bei Personen im Erwerbsalter in Deutschland. Von den 2 030 Teilnehmern im erwerbsfähigen Alter (18 – 67 Jahre) hatten 7 % eine erhöhte arbeitsphobische Angst mittleren (5 % mit Werten >1.5 – 2.5 auf einer Skala von 0 – 4) oder hohen Ausmaßes (2 % mit Werten >2.5 – 4). Personen mit einem hohen Grad an arbeitsphobischer Angst hatten in den letzten 12 Monaten die längste Arbeitsunfähigkeitsdauer (8 Wochen) und die meisten Arbeitslosigkeitsperioden in ihrem Berufsleben. Die drei Gruppen waren ähnlich hinsichtlich der Verteilung von Alter, Geschlecht und Partnerschaftsstatus. Personen mit hoher arbeitsphobischer Angst nahmen sich in fast allen Dimensionen der psychischen Leistungsfähigkeit als am wenigsten kompetent wahr. Die Arbeitspsychologie und -medizin muss sich arbeitsbezogenen Ängsten als einem spezifischen psychischen Gesundheitsproblem bewusst sein, das in engem Zusammenhang mit Problemen der Arbeitsfähigkeit steht.
Work-Phobic Anxiety Endangers Work Ability
All workplaces contain some characteristics that may trigger anxiety in some persons. These stressors are, among others, rivalries between colleagues, control and sanctioning by supervisors, the possibility of failure, aggressive third parties, or physical dangers (Muschalla & Linden, 2013).
Work anxiety is a specific mental health phenomenon that is directly associated with negative social-medicine consequences, i. e., increased sick leave and problems in work ability. Work anxiety has many facets that can be distinguished psychopathologically, such as anxiety of insufficiency, hypochondriac anxiety, social anxiety toward colleagues or supervisors, work-related worrying, and work(place)-phobic anxiety (Muschalla et al., 2010). Problems become relevant to the person′s professional career when the specific work anxiety leads to work-ability problems, work-avoidance tendencies, and, finally, sick leave (Köllner & Gillmann, 2015).
Work-phobic anxiety is the form of work anxiety that is most impairing and accompanied by the longest sick leaves. Like other specific phobias, it is composed of two main symptoms, a work-related feeling of panic and avoidance of the workplace (Muschalla & Linden, 2009).
About 60 % of patients in psychotherapy treatment suffer from some type of work anxiety, and 10 – 17 % specifically from work-phobic anxiety (Muschalla & Linden, 2009, 2014). Thus, work anxieties are even more common than other non-work-related anxiety disorders. Existing empirical research has shown that work anxiety can be distinguished from other non-work-related anxieties and general mental disorders: In about one-quarter of patients with clinically relevant work anxiety, it is the only mental health problem (Linden & Muschalla, 2007).
Work anxiety has been investigated in various professional groups as well as transnationally (Allam, 2007; Chen et al., 2017; Dhurup et al., 2015; Haines et al., 2002; Macovei, 2016; Mannor et al., 2016; Muschalla et al., 2013; Payne et al., 1982; Smith, 2009; Srivastava et al., 1995; Vignoli et al., 2017). Work-phobic anxiety, in particular, is associated with long-term sick leave, job loss, and impairment of the psychological capacities relevant to the ability to work (Muschalla & Linden, 2009, 2014). Work-ability problems and high rates of sick leave tend to occur quite often in employees in public-service jobs (Linden et al., 2014). Some preventive and therapeutic interventions have been evaluated in people with work anxieties (Muschalla, 2017).
Although work anxiety has been a topic of interest in different studies, to date there have been few reports on the frequency of its occurrence in different clinical and professional samples. In a sample of Italian blue-collar workers, about 4 % were affected by high levels of work-phobic anxiety (Vignoli et al., 2017). In a sample of workers from different professions in Germany (which excluded people with mental disorders), about 5 % were affected (Muschalla et al., 2013). However, presently no data exist on the distribution of work-phobic anxiety in a representative, national cohort. Therefore, this study provides evidence to close the gap in the research and investigate the prevalence and correlates of work-phobic anxiety in a representative sample in Germany.
Accompanying Explanations for Work Ability: Embitterment and Capacities
An additional phenomenon that may contribute to work avoidance, and one that is often discussed in the context of injustice at work, is that of embitterment reactions (Michailidis & Cropley, 2018). Empirical research showed that 25 % of those affected by work problems, such as unemployment, are accompanied by an embitterment effect (Linden & Rotter, 2019). Similarly, many embittered people report an embittered reaction to a work situation or work event they perceived as being grossly unjust or unfair, such as an unfair termination from a job, the absence of a promotion, or an unfair allocation of resources. Because of this finding, and because this aspect is relevant to both occupational health prevention and therapy, it would be interesting to determine how frequently embitterment occurs together with work-phobic anxiety.
According to the internationally established biopsychosocial model of (work) health of the ICF (WHO, 2001), not only symptoms but also capacities are relevant for (work) participation. Thus, besides symptoms such as work-phobic anxiety, capacities play an important role in work ability. Not only that someone has a mental health problem, be it anxiety or mood problems, is relevant to work ability, also their capacity level, i. e., the activity spectrum and what they can do, plays a role. Psychological capacities such as adherence to rules, flexibility, interactional capacities, mobility, proactivity, and endurance are increasingly necessary in our modern working world (Linden et al., 2014; Muschalla, 2017). People with capacity problems are more likely to have more observable problems at work, which in turn may generate negative feedback and lead to their developing anxiety. On the other hand, people with anxiety may be impaired in applying their capacities to do their best at work. Previous studies found that persons with work-phobic anxiety have a reduced capacity level (Muschalla & Linden, 2014).
Research Questions
Here are the research questions addressed in this representative study:
- 1.How is work-phobic anxiety distributed in a representative sample of working people? How many people suffer from moderate or high work-phobic anxiety?
- 2.Are there differences between people with low work-phobic anxiety and people with moderate or high work-phobic anxiety in terms of their sociodemographic and work-related characteristics?
- 3.Are there differences between people with low work-phobic anxiety and people with moderate or high work-phobic anxiety in terms of their work-relevant psychological capacities and the occurrence of embitterment reactions?
Materials and Method
A representative survey was carried out throughout all of Germany in 2019, conducted by a professional organization that undertakes representative surveys throughout Europe (USUMA). The sampling procedure comprised three stages as follows: First, areas were selected (sample-point selection) by random sampling. USUMA works with approx. 250 sample points throughout Germany, so that approx. 10 interviews are to be realized per point. The second stage (random route procedure for household selection) involved the random selection of households within these areas on the basis of an on-site inspection. In the third stage (selection of persons), the interviewer identifed all persons in the selected households who corresponded to the population of the sample and selected a target person with whom the interview was to be conducted using a predetermined random procedure using the “Swedish key.”
Ethics approval was obtained from the Technische Universität Braunschweig (D-2019 – 03). A total of 2,531 participants contributed to the survey with full data, 2,030 of whom were of employable age, i. e., between 18 and 67 years old. A detailed sample description can be found in Table 1 (right column for total sample).
Procedure
First, the participants were asked basic sociodemographic and profession-related questions in an interview, after which they completed self-rating questionnaires as an additional self-rating.
Workplace Phobia Scale (WPS, Muschalla & Linden, 2009). The WPS (Muschalla & Linden, 2009) is a self-rating scale consisting of 13 items for measuring work-phobic anxiety, i. e., anxiety with work-related panic and work-related avoidance behavior. The WPS was derived from the Job Anxiety Scale (JAS; Muschalla et al., 2010), which covers different dimensions of work-related anxiety. The WPS’s psychometric properties have been tested using a psychosomatic inpatient sample, providing split-half reliability of 0.97 and Cronbach’s alpha of 0.96. The items are rated on a Likert scale, whereby 0 = No agreement and 4 = Full agreement. The mean score is relevant for data analysis. The WPS has been validated using structured diagnostic interviews as criteria (Muschalla & Linden, 2009; Sheehan et al., 1994). The WPS is given to the participants under the title of Questionnaire on Workplace Problems and examines “behavior, thoughts, and feelings that can occur in relation to the workplace.”
Self-Rating for Psychological Capacities (Mini-ICF-APP-S, Linden et al., 2018). The assessment of capacities and capacity limitations in occupational medicine should be based on expert ratings. However, given that self-perceived work ability is a strong predictor of future real work ability (de Vries et al., 2018), we can also obtain important information from capacity self-ratings. A self-rated capacity profile reflects the patient’s self-image and may provide information that could prove useful for planning further therapy, capacity training, or work adjustment. The Mini-ICF-APP-S is such a self-rating test of psychomental capacities (Linden et al., 2018) covering the same 13 capacity dimensions (Table 2) as the original, internationally validated and established observer-rated Mini-ICF-APP (AWMF, 2019; Balestrieri et al., 2013; Molodynski et al., 2013; Pinna et al., 2015). Like the observer-rating, the Mini-ICF-APP-S self-rating includes 13 items, each of which represents a capacity dimension. Descriptions of each capacity dimension are provided. The rating points are described at a behavioral level, i.e., the extent to which the person easily can (or finds it difficult to) perform capacity-related activities. The self-rating therefore enables a bipolar rating from 0 = This is definitely one of my strengths to 3 = This is somehow possible, 4 = This does not always work to 7 = I am completely unable to do this. This bipolar rating with 8 scale points makes it possible to describe capacities as relative strengths or weaknesses.
Posttraumatic Embitterment Scale (PTED, Linden, 2009). Preceding the Posttraumatic Embitterment Scale (Linden, 2009), participants were asked whether and which private, social, or occupational injustice event they had perceived which triggered a long-lasting feeling of injustice and being hurt. Embitterment was assessed using the 19-item PTED (Linden et al., 2009). It starts with the statement “During recent years, there was a severe and negative life event …,” which is followed by answers such as “… that hurt my feelings and caused considerable embitterment,” “… that triggers feelings of satisfaction when I think that the party responsible has to live through a similar situation,” or “… that caused me to withdraw from friends and social activities.” Ratings are made on a 5-point Likert scale, ranging from 1 = Not true at all to 5 = Extremely true. The mean score from the PTED scale is used to measure the degree of embitterment. The PTED scale measures dimensional embitterment, i. e., it can be used, independent of one specific event, as a screening for the general embitterment load that the person perceives to be because of any life events (independent of how many and which life events). The PTED scale can be used in any population (including the general population and among healthy people, e. g., Kühn et al., 2018). The scores reflects the level of embitterment perception. Therefore, it can be used for sample description, which aims to ascertain the level of embitterment of people in general. In this investigation, we included people with and without reported events. The PTED scale can be used for measuring embitterment as a dimensional phenomenon, but not as a tool for the categorical diagnosis of an embitterment disorder. Other studies have also used the PTED scale for measuring the level of embitterment, e. g., in general population samples or general clinical samples (Kühn et al., 2018; Linden & Rotter, 2019).
Results
About 7 % of the representative population who are of working age report moderate or high work-phobic anxiety (Table 1). There are no differences between the three work-phobic anxiety level groups in terms of the sociodemographic characteristics age, sex, partnership status, and distribution of school education (Table 1). However, there are differences in professional characteristics: Those with the highest work-phobic anxiety have been unemployed more often and are more often state employees or blue-collar workers. Nearly all (96 – 98 %) of those with work-phobic anxiety have been on sick leave at some time during the past 12 months, compared to only 5 % of those without work-phobic anxiety. Persons with high work-phobic anxiety also had the longest sick leave durations (8 weeks) during the past year, compared to 1 or 3 weeks of sick leave in persons with low and moderate work-phobic anxiety, respectively. Interestingly, the highest proportion of people without a religious denomination (39 %) is in the group with high work-phobic anxiety.
The work-phobic anxiety level groups show systemic differences in their capacity levels: People with high work-phobic anxiety and, in part, moderate work-phobic anxiety perceive their psychological capacities to be lower than those who have low work-phobic anxiety (Table 2). At least 42 % of those with high work-phobic anxiety have a relevant capacity impairment. Endurance, teamwork capacity, and proactivity are the most frequently impaired capacities (42 %, 37 %, and 36 %, respectively).
In addition to the work-phobic anxiety problem, some members of the two groups with moderate and high work-phobic anxiety experience embitterment as an additional mental health problem: 21 % of those with moderate work-phobic anxiety and 39 % of those with high work-phobic anxiety report being embittered by at least one critical life event. 28 % of these embitterment cases were because of perceived professional injustice. As many as 43 – 50 % of people with moderate or high work-phobic anxiety and accompanying embitterment say that their embitterment stems from an unjust event at work.
Discussion
Prevalence of Work-Phobic Anxiety
The main result of this descriptive representative study is that a considerable proportion of the general working population (7 %) is affected by moderate to high work-phobic anxiety. Work-phobic anxiety is denoted by long periods of sick leave (on average 8 weeks per year, compared to 1 week in people without work-phobic anxiety), and capacity impairments, for example, in 42 % impaired endurance. One-third of those with work-phobic anxiety have an additional problem with embitterment, and half of them report that this stems from an occupational injustice.
The rate of work-phobic anxiety varies from that found in other studies, e. g., 4 % in a convenience sample in an Italian retail company (Vignoli et al., 2017) and 5 % in a German convenience sample of employees from different occupational fields (Muschalla et al., 2013). Other studies use different concepts and operationalizations of work anxiety and have reported rates of higher work anxiety of about 3 % (orderlies), 16 – 23 % (physicians and nurses; Mikkola et al., 2017), and a “few instances of very high job anxiety level” in CEOs (Mannor et al., 2016, p. 1985). In an Indian sample, 18 % of 60 secondary school teachers reported high work anxiety (Mishra et al., 2013). To a certain extent, our findings show parallels to the characteristics also found with other mental disorders, e. g., the higher rate of people without a religious denomination in the group of those with high work-phobic anxiety. People with lower anxiety more often have a religious affiliation (Kugelmass & Garcia, 2015). One possible explanation may be that religion, or a stable set of basic beliefs, can make it easier to endure hardships. Thus, the findings from our representative study agree with what is known from other independent studies, in different work contexts, and in other countries throughout the world. Work(–phobic) anxiety is not a nationally bound phenomenon. It may occur in any profession, so that, conservatively said, at least 5 % of the working population may be affected. Attention should be paid to applying prevention of work(–phobic) anxiety in occupational settings as well as offering treatment and occupational reintegration of those who are already on sick leave in clinical settings.
Capacities and Work-Phobic Anxiety
We studied the differences between people with low work-phobic anxiety and those with higher work-phobic anxiety and found differences in their work-relevant characteristics, such as their capacity levels. Those with high work-phobic anxiety often have problems regarding work-relevant capacities (especially endurance, teamwork, and proactivity) to an extent that makes third-party assistance necessary.
Patients in primary care with work-phobic anxiety had significantly higher capacity problems in flexibility, judgment, decision-making capacities, interactional capacities (contacting others), and planning and structuring of tasks, compared to patients with other mental disorders (Muschalla & Linden, 2014). This resembles the findings of this representative survey, where at least 42 % of the highly work-phobic reported being severely impaired and having greater impairments than others across all capacity domains. These capacity impairments represent serious problems; they are visible in the form of failures, insufficient work processes, and poor outcomes, and therefore provoke negative reactions from colleagues and supervisors. Employees are normally expected to do their work on their own, without the support of others. This finding on capacity impairments adds to what was already known from clinical observations (Köllner & Gillmann, 2015; Muschalla & Linden, 2009). Specific action (e. g., Muschalla, 2017; van Vilsteren et al., 2015) is required to prevent these people from becoming unable to work because of sick leave or even job loss.
Another salient finding is the relatively high proportion of blue-collar workers in the group with high work-phobic anxiety. Another representative study found that blue-collar workers tend to be affected by high job stress (Wieclaw et al., 2008). Workers with low qualifications are also relatively often affected by mental disorders (Stansfeld et al., 2008). According to this study, state employees were relatively often found in the group with high work-phobic anxiety and are known to have high sick-leave rates of about 10 % (e. g., Linden et al., 2014).
Embitterment and Work Anxiety
Phenomenologically, workplaces have several characteristics that could trigger unpleasant feelings of anxiety or embitterment (Linden & Maerker, 2010). Furthermore, in the past work-related mental-health problems have often been discussed concerning work conditions. The perception of injustice is a condition that has often been found to be associated with reduced mental well-being (Linden et al., 2020) and counterproductive employee behavior, which may occur as a reaction to it (Lavelle et al., 2016; Saleem & Gopinath, 2015). Work problems and embitterment reactions because of work events, conflicts, or bullying can also be accompanied by work-phobic anxiety if the person affected can no longer tolerate being in the work environment and meeting colleagues or supervisors who might be associated with an unjust work event. Physiological arousal and avoidance tendencies might consequently arise, potentially resulting in extended sick leave or even disability retirement (Lang & Hellweg, 2006). People with embitterment are, like those with work-phobic anxiety, more frequently prone to sick leave and early retirement. A comorbid problem of embitterment and work-phobic anxiety might have an even more severe negative impact on their participation in professional life. Thus, these two specific phenomena and the potential combination thereof should be considered in future research and practice in the context of questions concerning sick leave and work-related mental-health problems.
Limitations, Strengths, and Conclusion
This is a representative investigation using a large national sample and is therefore representative of this specific population. As shown by comparison data from other countries (even if unrepresentative), the frequency of people having high work anxiety ranges from about 5 – 10 % in different professional groups and nations. This indicates the content validity of the work-phobic anxiety concept and shows that it is relevant not only in so-called Western industrial societies. One limitation is that the data are national (from Germany), and that no longitudinal data are available. Data from this study are descriptive and do not allow for a causal interpretation.
Future research should investigate the impact of work-phobic anxiety on the economic conditions and life-long participation of those affected and the potential differences in international comparisons. Clinicians as well as work and organizational psychologists, managers, and occupational physicians should all be aware of work-phobic anxiety and should be informed about possible preventive and intervention measures (Muschalla, 2017). Work-phobic anxiety is not an uncommon phenomenon in the general working population but potentially one that is not always adequately recognized.
We thank Prof. Elmar Brähler and the USUMA GmbH for organizing and conducting the representative survey.
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