Post-traumatic Embitterment disorder
SpecialtyPsychiatry, Clinical psychology
SymptomsSevere emotional symptoms and behavioral problems in direct temporal connection to the triggering event; recurring intrusive thoughts; avolition; dysphoric-aggressive-depressive mood; unspecific somatic symptoms; phobic avoidance of persons or places related to the triggering event; fantasies of aggression and revenge towards the stressor
Usual onsetimmediately at the moment of the triggering event
Durationat least 6 months
Causesone singular traumatic event experienced as insulting, humiliating or unjust
Diagnostic methodBased on symptoms
Differential diagnosisPost-traumatic stress disorder, Major depressive disorder, Adjustment disorder, Phobia, Personality disorders, Paranoia, Delusions, Schizotypal disorder, Schizophrenia, Querulant delusion, Moral injury
TreatmentCounseling, wisdom therapy
Prognosisgood if treated in time, poor if untreated

Post-traumatic embitterment disorder (PTED) is defined as a pathological reaction to a negative life event, which those affected experienced as a grave insult, humiliation, betrayal, or injustice. Prevalent emotions of PTED are embitterment, anger, fury, and hatred, especially against the triggering stressor, often accompanied by fantasies of revenge. The disorder commences immediately and without time delay at the moment of the triggering event. If left untreated, the prognosis of PTED presents as rather unfavorable, with those who have the disorder trapped in a vicious circle of strong negative emotions constantly intensifying one another and eventually leading into a self-destructive downward spiral. People affected by PTED are more likely to put fantasies of revenge into action, making them a serious threat to the stressor.

The concept of PTED as a distinct clinical disorder has been first described by the German psychiatrist and psychologist Michael Linden in 2003,[1] who remains its most involved researcher. Even though it has been backed up by empirical research in the past years, it remains disputed as to whether embitterment should be included among psychological disorders.[2][3][4][5][6][7][8] Therefore, PTED currently does not hold its own category in the ICD-10 but is categorized under F43.8 “Other reactions to severe stress”. It cannot be categorized as an adjustment disorder under F43.2, since “ordinary” adjustment disorders normally subside within six months, while PTED is much more likely to become chronic. A condition similar to PTED has already been described by Emil Kraepelin as early as 1915 by the name querulous paranoia as a form of traumatic neuroses, explicitly demarcating it from personality disorders.[9]

Bitterness and embitterment

Bitterness (also called resentment) is defined as a basic human reaction in response to experiences of injustice, betrayal, or humiliation, consisting of emotions such as anger, wrath, hostility, disappointment, disgust, and shame. However, while “ordinary” bitterness is just a transient emotion, which will eventually fade away, embitterment is described as a much more prolonged state of bitterness, which will not easily subside and can severely impair the quality of life of those affected and of their environment. Typically, embitterment will flare up time and time again upon recalling the triggering incident.[10][11][4]

Prevalance

Preliminary data suggest a prevalence of about 2–3% in the general population. Increased prevalence rates are observed when larger groups of people are subject to social upheaval. Accordingly, Linden described this condition for the first time after the German reunification.[12]

Causes

Severe reactions of embitterment can be triggered if someone’s core beliefs are being heavily violated. In psychology, core beliefs are defined as mindsets, opinions, and values, which define an individual. They function as a cognitive reference system which structures the perception of the world, of oneself, of others, of what is important or not, what is right or wrong, and what is necessary to be done, and can involve both negative and positive feelings. They are of great individual and social importance and can be handed down transgenerationally, thereby shaping entire cultures. Core beliefs are not necessarily true in view of reality, but they feel true to an individual, no matter what they consist of. Therefore, information contradicting them is commonly ignored, making them difficult to change or challenge.[13]

Since core beliefs are a central aspect of an individual's identity, they are especially vulnerable to insults, humiliations, betrayal, and injustice, which are psychologically perceived as aggressions. PTED can be triggered if a violation of a core belief, especially a positive one, is too severe to be ignored and to be properly processed, and if there is no way for those affected to fight back and defend their beliefs, leaving them in a state of helplessness, resignation and eventually embitterment. As core beliefs are unique for every individual, what might seem like a triviality or just a minor nuisance to one person, can cause an existential crisis in another one, especially if they lack the psychological resilience to overcome the crisis.

Symptoms and diagnostic criteria

A. Essential criteria:[14][15]

  1. clinically significant emotional symptoms or behavioral problems, starting immediately after exactly one singular negative, stressful life event, which – from the outside – appears to be no more than an everyday occurrence (i.e., nothing out of the ordinary like road accidents, robberies, or war)
  2. patient is aware of the triggering event and has identified it as the cause of the disorder
  3. triggering event is experienced as unjust, humiliating or insulting
  4. recurring intrusive thoughts of the triggering event
  5. patients reacts with emotional arousal upon recalling the triggering event

B. Additional symptoms:

  1. dysphoric-aggressive-depressive mood; mood appears similar to Major depressive disorder with Somatic symptom disorder
  2. unimpaired affect regulation when distracted
  3. Avolition
  4. patient sees their self as victim
  5. patient sees their self as helpless and unable to overcome the triggering event or its cause
  6. self-blame for not having prevented the triggering event or for being unable to cope with it
  7. indifference in view of own health
  8. unspecific somatic symptoms (e.g., insomnia, loss of appetite, pain)
  9. phobic avoidance of persons or places related to the triggering event
  10. weariness of life and suicidal ideation
  11. recurring fantasies of revenge and aggressive thoughts towards the stressor, sometimes including fantasies of murder or murder-suicide
  12. querulous persistence in the fight for the restoration of justice

C. no signs of a psychological disorder in the year prior to the triggering event, which could explain the abnormal reaction; no recrudescence into previous psychological disorder

D. clinically significant impairment or strain on own condition, and social, occupational, or other important spheres of life

E. symptoms have been persisting for at least six months since the moment of the triggering event

PTED does not present as “traumatic” in view of its preceding trigger, but because of its chronological course of events: Minutes prior to the triggering event, those affected were perfectly healthy, minutes later they are ill and severely impaired. In this regard PTED resembles PTSD. However, the nature of the triggering event in PTED has little influence on the nature of the ensuing symptoms.

PTED will not subside on its own but rather intensify over time, leading patients into a self-destructive downward spiral of negative emotions constantly reinforcing one another. If left untreated, PTED is very likely to eventually lead those affected into implementing their aggressions towards the stressor, thereby committing the most serious felonies.[16]

Diagnosis

BEI

The Berner Embitterment-Inventory (BEI) (Znoj, 2008; 2011) measures emotional embitterment, performance-related embitterment, pessimism/hopelessness, and misanthropy/aggression.

PTED scale

The PTED scale is a 19 item self-rating questionnaire and can be used to identify reactive embitterment and assess the severity of PTED.[17] Answers are given on a five-point Likert scale. An average score of 2.5 identifies with a clinically relevant degree of embitterment response, though it does not officially confirm a diagnosis. Higher values are only indications of critical embitterment. The diagnosis of PTED is only possible through a detailed clinical assessment or standardized diagnostic interview.

Standardized diagnostic interview

The standardized diagnostic interview of PTED[15] asks for core criteria of PTED. In the diagnostic interview, it must be clarified what the patient means when they describe their experiences and feelings.

Differential diagnoses

  • Post-traumatic stress disorder:
    • triggered by one singular or several potentially life-threatening, uncommon events causing extreme fear and panic (e.g., road accidents, robberies, war)
    • cardinal emotion is recurring or persisting fear; embitterment does not occur
  • Major depressive disorder:
    • very common misdiagnosis due to several symptomatic similarities (e.g., depressed mood, avolition, suicidality, absent-mindedness)
    • contrary to PTED no direct temporal connection to debilitating events, no singular stressor
    • no anhedonia in PTED patients
  • Adjustment disorder:
    • normally subsides within six months after the triggering event
    • can be caused by a number of events, not necessarily by insults, betrayal, humiliation or injustice
  • Phobia:
    • Avoidance behavior caused by fear, not by embitterment
  • Personality disorders:
    • Lifelong development, no immediate connection to a singular event
    • PTED completely reversible by therapy, effects of PDs only mitigable
    • Development of PTED might be facilitated by existing PDs[10]
  • Paranoia, delusions, schizotypal disorder, schizophrenia, querulant delusion, moral injury

Psychotherapy

The treatment of posttraumatic bitterness is complicated by the typical resignative-aggressive-defensive attitude of the patient, which is also directed against therapeutic offers. One approach of treatment is wisdom therapy developed by Linden, a form of cognitive-behavioral therapy that aims to empower the patient to distance themselves from the critical life event and build up new life perspectives.[18][19] One uses the usual cognitive strategies of attitude change and problem-solving are used, such as:

  • behavior therapeutic methods like behavioral analysis and cognitive rehearsal
  • analysis of automatic thoughts and schemata
  • reframing or cognitive reattribution
  • exposure treatments
  • increase of activities
  • rebuilding of social contacts
  • promotion of self-effectiveness

A special treatment module aims at the training of wisdom competencies, which means promoting the following abilities:

  • changing perspectives
  • empathy
  • perception and acceptance of emotions
  • emotional balance and sense of humour
  • contextualism
  • long-term orientation
  • value relativism
  • tolerance of uncertainty
  • self-distance and self-relativization

Methodically, the method of "insolvable problems" is used. In this procedure, fictitious serious and insolvable conflict situations are presented, which allow the patients to train wisdom capacities and transfer them to their own situation (so-called "learning transfer.")[18][20]

Criticism

The problem of embitterment reactions and also the post-traumatic embitterment disorder increasingly gain international attention.[21][22][23][24][25][26][27][28][29][30] Nevertheless, there are some unsolved problems. Further research is needed to differentiate between PTED and other mental disorders.[31] In 2014 science journalist Jörg Blech mentioned this disorder in his book Die Psychofalle - Wie die Seelenindustrie uns zu Patienten macht ("The Psycho Trap: How the Mental Health Industry Makes Us Patients").[32] It is discussed whether the introduction of PTED may make a problem out of everyday problems.

Bibliography

References

  1. ↑ Linden, M. (2003). "Posttraumatic embitterment disorder". Psychother Psychosom. 72 (4): 195–202. doi:10.1159/000070783. PMID 12792124. S2CID 19723598.
  2. ↑ Linden, Michael (2017). Verbitterung und Posttraumatische Verbitterungsstörung. Hogrefe Verlag (1. Auflage ed.). Göttingen. ISBN 978-3-8017-2822-9. OCLC 971201601.{{cite book}}: CS1 maint: location missing publisher (link)
  3. ↑ Linden, Michael; Rotter, Max; Lieberei, Barbara; Baumann, Kai (2007). Posttraumatic Embitterment Disorder: Definition, Evidence, Diagnosis, Treatment. MA. ISBN 978-0-88937-344-0.
  4. 1 2 Linden, M.; Maercker, A. "Embitterment. Societal, psychological, and clinical perspectives". Springer. {{cite journal}}: Cite journal requires |journal= (help)
  5. ↑ Linden, M.; Baumann, K.; Lieberei, B.; Lorenz, C.; Rotter, M. (2011). "Treatment of posttraumatic embitterment disorder with cognitive behaviour therapy based on wisdom psychology and hedonia strategies". Psychotherapy and Psychosomatics. 80 (4): 199–205. doi:10.1159/000321580. PMID 21494061. S2CID 24773913.
  6. ↑ Linden, M.; Rutkowsky, K. (2013-01-29). Hurting memories and beneficial forgetting. Posttraumatic stress disorders, biographical developments, and social conflicts. Elsevier. ISBN 978-0-12-398393-0.
  7. ↑ Znoj, H.J.; Abegglen, S.; Buchkremer, U.; Linden, M. "The embittered mind: Dimensions of embitterment and validation of the concept". Journal of Individual Differences. 37 (4): 213–222. doi:10.1027/1614-0001/a000208.
  8. ↑ Sartorius, Norman (2011). "Should embitterment be included among mental disorders?". Embitterment. pp. 248–254. doi:10.1007/978-3-211-99741-3_21. ISBN 978-3-211-99740-6.
  9. ↑ Kraepelin, Emil; Mayer-Gross, Willy; King's College London (1909). Psychiatrie [electronic resource] : ein Lehrbuch für Studierende und Ärzte. Foyle Special Collections Library King's College London. Leipzig : Johann Ambrosius Barth.
  10. 1 2 Rotter, Max (2011). "Embitterment and personality disorder". Embitterment. pp. 177–186. doi:10.1007/978-3-211-99741-3_14. ISBN 978-3-211-99740-6.
  11. ↑ Alexander, J. (1960). "The psychology of bitterness". International Journal of Psycho-Analysis. 41: 514–520. PMID 13682342.
  12. ↑ Linden, Michael (2017). Verbitterung und Posttraumatische Verbitterungsstörung (1. Auflage ed.). Göttingen: Hogrefe. pp. 19–21. ISBN 978-3-8017-2822-9. OCLC 999757230.
  13. ↑ "Core Beliefs Info Sheet (Worksheet)". Therapist Aid. Retrieved 2022-05-25.
  14. ↑ Michael Linden: Verbitterung und Posttraumatische Verbitterungsstörung. In: Fortschritte der Psychotherapie. 1. Auflage. Band 65, 2017, S. 5f.
  15. 1 2 Linden, M.; Baumann, K.; Rotter, M.; Lieberei, B. (2008). "Diagnostic Criteria and the Standardized Diagnostic Interview for Posttraumatic Embitterment Disorder (PTED)". International Journal of Psychiatry in Clinical Practice. 12 (2): 93–96. doi:10.1080/13651500701580478. PMID 24916618. S2CID 43218399.
  16. ↑ Michael Linden: Verbitterung und Posttraumatische Verbitterungsstörung. In: Fortschritte der Psychotherapie. 1. Auflage. Band 65, 2017, S. 18f.
  17. ↑ Linden, M.; Rotter, M.; Baumann, K.; Schippan, B. (2009). "The Posttraumatic Embitterment Disorder Self-Rating Scale (PTED Scale)". Clinical Psychology and Psychotherapy. 16 (2): 139–147. doi:10.1002/cpp.610. PMID 19229838. S2CID 21479673.
  18. 1 2 Baumann, K.; Linden, M. "Weisheitstherapie". Verhaltenstherapiemanual (Springer): 416–422.
  19. ↑ Linden, M. "Psychotherapie der Verbitterung: Weisheitstherapie". Fachtagung: Verletzung, Verbitterung, Vergebung.
  20. ↑ Linden, M. "Verbitterung und Posttraumatische Verbitterungsstörung". Hogrefe Verlag.
  21. ↑ Hasanoglu, A. "Yeni Bir Tanı Kategorisi Önerisi: Travma Sonrası Hayata Küsme Bozukluğu". Türk Psikiyatri Dergisi. 19 (1): 94–100.
  22. ↑ Sensky, T. (2010). "Chronic Embitterment and Organisational Justice". Psychother Psychosom. 79 (2): 65–72. doi:10.1159/000270914. PMID 20051704. S2CID 33399909.
  23. ↑ Dobricki, M.; Maercker, A. (2010). "(Post-traumatic) embitterment disorder: Critical evaluation of its stressor criterion and a proposed revised classification". Nord J Psychiatry. 64 (3): 1–26. doi:10.3109/08039480903398185. PMID 20148750. S2CID 20643288.
  24. ↑ Karatuna, I.; Gök, S. (2014). "A Study Analyzing the Association between Post-Traumatic Embitterment Disorder and Workplace Bullying". Journal of Workplace Behavioral Health. 29 (2): 127–142. doi:10.1080/15555240.2014.898569. hdl:20.500.11857/428. S2CID 145093175.
  25. ↑ Joel, S.; Lee, J.S.; Kim, S.Y.; Won, S.; Lim, J.S.; Ha, K.S. (2017). "Posttraumatic Embitterment Disorder and Hwa-byung in the General Korean Population". Psychiatry Investig. 14 (4): 392–12792124. doi:10.4306/pi.2017.14.4.392. PMC 5561395. PMID 28845164.
  26. ↑ Blom, D.; Thomaes, S.; Kool, M.B.; van Middendorp, H.; Lumley, M.A.; Bijlsma, J.W.J.; Geenen, R. (2012). "A combination of illness invalidation from the work environment and helplessness is associated with embitterment in patients with FM". Rheumatology. 51 (2): 347–353. doi:10.1093/rheumatology/ker342. PMID 22096009.
  27. ↑ Belaise, C.; Bernhard, L.M.; Linden, M. "L'embitterment: caratteristiche cliniche". Rivista di Psichiatria. 47 (5): 376–387.
  28. ↑ Michailidis, Evie; Cropley, Mark (2 September 2017). "Exploring predictors and consequences of embitterment in the workplace". Ergonomics. 60 (9): 1197–1206. doi:10.1080/00140139.2016.1255783. PMID 27801614. S2CID 5003336.
  29. ↑ Shin, C.; Han, C.; Linden, M.; Chae, J.H.; Ko, Y.H.; Kim, Y.K.; Kim, S.H.; Joe, S.H.; In-Kwa Jung, I.K. (2012). "Standardization of the Korean Version of the Posttraumatic Embitterment Disorder Self-Rating Scale". Psychiatry Investigation. 9 (4): 368–372. doi:10.4306/pi.2012.9.4.368. PMC 3521113. PMID 23251201.
  30. ↑ Linden, M.; Rotter, M.; Baumann, K.; Lieberei, B. "Posttraumatic Embitterment Disorder – Japanese Translation". Okayama-shi, Japan: Okayama University Press.
  31. ↑ Dvir, Y. (2007). "Posttraumatic Embitterment Disorder: Definition, Evidence, Diagnosis, Treatment". Psychiatric Services. 58 (11): 1507–1508. doi:10.1176/appi.ps.58.11.1507-a.
  32. ↑ Blech, Jörg (2014-03-27). Die Psychofalle - Wie die Seelenindustrie uns zu Patienten macht (in German). Frankfurt am Main: S. Fischer. ISBN 978-3-10-004419-8.
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