Occupational Medicine
A Basic Guide

07: Psychological Factors and Workforce Health

Workplace Violence and Occupational Posttraumatic Stress Disorder
Mason Harrell, MD, MPH

Workplace violence is a major source of occupational stress and is now a common cause of posttraumatic stress disorder (PTSD). Such violence can include any act or threat against a person or property that occurs within the confines of the workplace or related to the workplace environment. It includes threats, intimidation, disrespect, insults, coercion, frightening, harassment, stalking, assaults, homicide, or any unacceptable disruptive behavior that results in fear for personal safety. On the more severe end of the spectrum, stress caused by violence can have an impact on vital signs, cause a panic attack, or cause psychiatric disease. Less severe forms of violence—such as an intimidating boss publicly insulting his or her employees—can cause subtle stress and often goes undetectable.


Workplace violence can be inflicted by an employee, manager, supervisor, coworker, customer, patient, relative, domestic partner, personal acquaintance, or stranger. A large variety of circumstances in the work environment are associated with workplace violence. Some examples include disciplinary actions, job loss, abusive authority, and interpersonal conflict. Workplace violence can also be a product of bigotry and extremism, which can lead to hate crimes and terrorism. Workers who are at higher risk for experiencing workplace violence include convenience store employees, taxi drivers, bus drivers, health care workers, law enforcement personnel, military personnel, security guards, bartenders, sales employees, and teachers.


Preventing Violence Is the Goal



Workplace violence can and does happen anywhere, although certain workplaces are at higher-than-average risk for coworker violence: their characteristics include job insecurity, perceived injustice, and a harsh management style. Prevention starts with instilling a climate of safety and communication transparency, with top leadership setting the tone. Employees’ reports must not lead to retaliative action against the reporter. Policies and procedures must serve as the legal backbone for enforcing disciplinary actions, and employees should be well aware of policies regarding harassment, intimidation, violent threats, and violence. Employees should also know how to identify warning behaviors, take them seriously, and to whom they should be reported. Prevention controls that employers may use include video surveillance, alarm systems, metal detectors, lighting, physical barriers, secured access, panic buttons, accessible exits, and security staffing.



As with any occupational hazard, the first goal should be to prevent violence from occurring. As in any other workplace injury–mitigation program, a hierarchy of hazard controls should be applied through the hierarchy of elimination, substitution, engineering controls, administrative controls, and lastly personal protective equipment.



Violence between coworkers is often preventable because it is usually preceded by multiple warning signs. They include :

  • direct or indirect threats
  • mood or behavior changes
  • controlling behaviors
  • paranoia
  • weapon possession/acquisition
  • stalking
  • taking extreme positions on beliefs
  • fixation
  • financial hardship
  • loss of an intimate relationship
  • isolation
  • anger outbursts
  • absenteeism
  • presenteeism
  • similar extraordinary behaviors.


It is important for all parties involved to identify these circumstances early and take appropriate mitigative actions, such as approaching the coworker, notifying the police, or bringing these concerns to the attention of supervisors. When providers get involved, they play an intimate role in preventing workplace violence by picking up on clues during patient interviews and exams.


To screen persons at high risk for acts of violence, providers can ask probing questions regarding social history, mental health, stress, and relationships. Depending on the circumstances and purposes of the patient encounter, the following questions can be used:


  • When was the last time you used an illegal controlled substance?
  • Have you ever been in police custody or arrested or charged with a crime?
  • Have you ever thought of harming yourself?
  • Have you ever resorted to physical violence or verbal abuse to resolve a conflict?
  • In the past year have you experienced an extreme change in your beliefs?
  • How do you deal with people whose beliefs are contrary to yours?
  • Do you have any strong beliefs that could justify violence?
  • How does it make you feel when people tell you what to do?
  • What is the worst bullying or humiliation that you ever had to endure?
  • Do you have any debt collectors calling you?
  • Have you ever been the subject of a restraining order?[i]


If a provider suspects an imminent act of violence, the provider should consider his or her plan, which can include notifying the appropriate authorities, consulting with legal counsel, and convening a committee or task force with the employer.


When screening for potential violence, providers should always be alert to indicators that the interviewee is lying, usually detectable through a change in baseline behavioral and communication patterns. Deception indicators include increases in leg movements or fidgeting, pupil dilation, staring at the provider, and speech abnormalities.


The most effective method for detecting deception in an interview may be through subjecting the interviewee to cognitive overload. Asking a series of questions that do not require much effort to answer, in quick succession, will cause a deceptive person to have to slow down to calculate responses.


The following reactions are fairly reliable signs of deception:


  • Repeating the question, delaying, or using other stalling techniques such as saying “that’s a good question”
  • Asking for the question to be repeated
  • Redirecting to another topic


When providers are part of a committee dedicated to addressing threats in the workplace, they serve as the behavioral experts trained to identify and assess aberrant behaviors and can advise management, human resources, legal, and/or insurance professionals to assess a worker’s changing behavior.


The Provider’s Role After an Incident


After a workplace violence incident has occurred, early interventions can significantly expedite the victim’s physical and emotional recovery and decrease his or her risk for chronic physical and psychological conditions. Assuring timely help and support may prevent normal stress reactions from worsening and developing into PTSD. A post-incident plan is a vital component to an effective violence-prevention program. All workplaces should have and use violence incident report forms; NIOSH and OSHA provide free online examples . The plan should include immediate notification to a supervisor or management, who should refer the employee to the employee assistance program if the workplace offers one. Coordinated services for counseling, legal advice, medical treatment, and thorough information about workers’ compensation should be provided. Medical professionals should be made easily accessible, free of charge, to all those involved, victims and witnesses alike.


The victims of violence can suffer from short- and long-term mental health conditions, fear of returning to work, changes in their relationships at work and at home, feelings of guilt, and fear of backlash from supervisors. In addition to the provider, professionals who can provide care include certified employee assistance professionals, psychologists, psychiatrists, clinical nurse specialists, and licensed clinical social workers. In addition to rendering appropriate treatment, providers should also identify the cause of the incident in order to make recommendations to the workplace to prevent a similar event from occurring in the future.



Most workers who experience workplace violence or other forms of trauma experience only temporary difficulties with coping and dysfunction. PTSD screening should include psychological/psychiatric evaluation and psychometric testing. When symptoms worsen, last longer than one month, and are accompanied by functional impairment, the worker may have occupational PTSD. Common signs and symptoms of PTSD include intrusive recollections, disturbing dreams, hypervigilance, startle responses, difficulty sleeping, avoidance of external reminders of trauma, persistent and exaggerated negative beliefs and emotions, and social withdrawal.


Diagnostic criteria for PTSD include symptoms that create distress or functional impairment that are not due to medication, substance use, or other illness, and all of the following must be present for more than one month: at least one re-experiencing symptom, at least one avoidance symptom, at least two arousal and reactivity symptoms, and at least two cognition and mood symptoms.[i] Acute stress disorder is a condition which meets the same criteria as Post Traumatic Stress Disorder, but has been of less than 30 days duration. Treatment plans may include education, exercise, yoga, cognitive behavioral therapy, mind/body interventions, deep breathing exercises, meditation, exposure therapy, virtual reality, and medications. Providers should consider early referral for a mental/behavioral health evaluation .


Risk factors for developing PTSD include prior psychiatric disorder, prior trauma exposure, genetic predisposition, history of chronic stress, personality factors, low IQ, and history of substance misuse. Women are also at greater risk than men of developing PTSD.


PTSD has become a major health and safety issue over recent years. Individuals with occupations that are at higher risk of workplace violence than others are also at higher risk of developing PTSD. They specifically include law enforcement officers, military personnel, security guards, bartenders, professional drivers, gas station attendants, nurses, and managers of food service and lodging establishments. PTSD diagnoses are increasing in the U.S. population, and they are increasingly being attributed to workplace trauma in which the worker was the victim of or witnessed the severe traumatizing event. Such exposures can include but are not limited to life-threatening events, homicide, suicide, death, hostage events, terrorist attacks, assault, sexual assault, battery, and natural or man-made disasters.