Posttraumatic embitterment disorder
The Posttraumatic Embitterment Disorder (PTED) is a pathological reaction to drastic life events and has the tendency not to stop. The trigger is an extraordinary although common negative life event as for example divorce, dismissal, personal insult or vilification. The consequence is severe and long lasting embitterment. This disorder is not “traumatic” because of the content of the triggering event but because of the temporal connection to the critical incident. Minutes before the person was healthy, minutes later he or she is chronically ill and severely affected. This type of disorder has been discussed in psychiatry or in the judiciary under acts of querulatory delusion. Thus, for example, in the textbook of psychiatry Kraepelin (Kraepelin, 1915) among the "psychogenic disorders" the description of acts of querulatory delusion are described as a form of "traumatic neurosis", which is also explicitly distinguished from personality disorders. The German psychiatrist Michael Linden (Linden, 2003) and others have emphasized the importance of embitterment (Linden, 2017) (Linden et al., 2007) (Linden & Maercker, 2011) (Linden et al., 2011) (Linden & Rutkowsky, 2013) (Znoj et al., 2016)
Forms of embitterment
Embitterment is an emotion which is known to everybody as a negative feeling in reaction to negative life events. People understand what is meant by “embitterment” without professional knowledge, just as everyone knows what is fear or anger. (Linden & Maercker, 2011) (Alexander, 1966). Embitterment is like anxiety a reactive emotion towards injustice, insult or breach of trust. Embitterment is gnawing and has the tendency not to stop. In many cases, embitterment fades away, but in others it comes up again and again when the occasion is recalled. With greater intensity, it can limit the whole life and their environment with severe impairment. There are indications that there are also bitterness-prone personalities or that some personality disorders also go hand in hand with mild vulnerability and thus an increased tendency to embitterment. Posttraumatic embitterment is a special form of an embitterment reaction.
Symptoms of Posttraumatic Embitterment Disorder
The following diagnostic criteria characterize a Posttraumatic embitterment disorder (Linden et al., 2008):
- clinical significant emotional symptoms or behavioural problems, which appear after a unique although common stressful life event
- traumatic stress is experienced in the following way:
- the patient knows the stressor and considers it as the cause of the disorder,
- the event is experienced as unfair, insulting or as breach of trust,
- the reaction of the patient regarding the event include feeling of embitterment, anger and helplessness,
- the patient reacts with emotional arousal when he is reminded of the event,
- symptoms are recurrent intrusions concerning the event, a dysphoric-aggressive-depressive mood, reduced drive, unspecific psychosomatic symptoms, phobic avoidance of persons or places related to the event, thoughts of revenge and fantasies of murder suicide, suicidal ideation or fantasies of extended suicide.
- there were no mental disorders prior to the event, which could explain this abnormal reaction,
- daily activities and tasks are impaired,
- the symptoms last longer than 6 month.
The „Berner Embitterment-Inventory (BEI)“ (Znoj, 2008; 2011) measures (1) „emotional embitterment“, (2) „performance-related embitterment“, (3) „pessimism/hopelessness“, (4) „misanthropy/aggression“.
The „PTED scale“ is a 19 Items self rating questionnaire and can be used to identify reactive embitterment and assess the severity of PTED (Linden et al., 2009).. Answers are given on a 5 point Likert scale. An average score 2,5 speaks for a clinical relevant degree of embitterment response. The interpretation of self rating scales must bear in mind that they are not able to make 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 (Linden et al., 2008) asks for core criteria of PTED. In the diagnostic interview it must be clarified what the patient means when he describes his experiences and feelings, so that an experienced clinician is needed.
Differential diagnosis of PTED
The Posttraumatic Embitterment Disorder (PTED) has to be differentiated from the Posttraumatic Stress Disorder (PTSD). PTSD is defined through intrusions referring to a specific „traumatic“ event, which was experienced as “extraordinary threat” and acted as an “unconditional” fear and panic triggering stimulus. When re-exposed or reminding it comes to a “cognitive rehearsal” and a revival of fear and hyperarousal and at the same time the attempt to suppress the overwhelming pictures up to a state of numbing. PTSD is an anxiety disorder. In PTED there are similarly intrusions and the avoidance of situations or objects. The major difference is the quality of the prevailing emotion. In PTED this is embitterment, the feeling of vilification, injustice, and aggression towards the perpetrator. Patients often want to think about what has happened so that the world can see what one did to them. Many cases that look like PTSD are PTED cases because the problem did not start after an anxiety-triggering situation, but later in the context of injustice, humiliation by the company, insurance, police and courts.
Preliminary data suggest a prevalence of about 2-3% in the general population. Any therapists, experts in social law or lawyers know such cases. 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.
Cause and trigger
Embitterment occurs in reaction to extraordinary but nevertheless everyday negative life events like divorce or dismissal. The question is why and under which conditions this results in a pathological reaction. Critical life events always trigger negative emotions like fear, uncertainty, disorientation, anger, or impairment in mood. There are traumatic events, which lead to pathological emotions i.e. states which are no longer under control of the affected person and develop into dysfunctional behavior with strong suffering for the affected person and his or her environment. This is the case after strong spells of panic, which can lead to a “posttraumatic stress disorder”. Another form of “traumatic” events are those that violate “basic beliefs”(Hafer & Sutton, 2016 ). „Basic beliefs“ or cognitive schemata are a cognitive reference system which structures the perception of the world, what is seen as important or not, and what is necessary to be done. They enable us to develop a trust in ourselves, other persons and the world. They are usually not put in question and associated with positive feelings as long as the world complies with our cognitive schemata. These "basic beliefs", "cognitive schemata" or "ideology" are of great individual and social importance. (Linden, 2007). Therefore it is also understandable, that people defend their basic beliefs if they are questioned through life events, i.e. an event which is in conflict with one´s own values and self concept. If an event is too important to be ignored and an “assimilation” of the event in existing schemata or basic beliefs is not possible, or a change/adaptation of these schemata (“accommodation”) is unthinkable, this can lead to an “adaptation disorder”. Embitterment arises when basic beliefs are questioned, attacked, disproved or degraded through a life event or the behaviour of others. The theory of “violation of basic beliefs” explains why events, which seem to be trivial for some people, can be of importance to others. What is seen as injustice, insult or humiliation depends on personal beliefs and values.
The treatment of post-traumatic 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 himself from the critical life event and build up new life perspectives (Baumann & Linden, 2008) (Linden, 2009). 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 and
- promotion of self-effectiveness.
As special treatment module aims at the training of wisdom competencies, which means the promotion of the following abilities
- changing perspectives,
- perception and acceptance of emotions,
- emotional balance and sense of humour,
- 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") (Baumann & Linden, 2008) (Linden, 2017).
The problem of embitterment reactions and also the post-traumatic embitterment disorder increasingly gain international attention (Hasanoglu, 2008), (Sensky, 2010), (Dobricki & Maercker, 2009), (Karatuna & Gök, 2014), (Joel et al., 2017), (Blom et al., 2012), (Ege, 2010), (Belaise et al., 2012), (Michailidis & Cropley, 2016), (Shin et al., 2012), (Linden et al., 2014). Nevertheless there are some unsolved problems. Further research is needed to differentiate between PTED and other mental disorders (Dvir, 2007). The science journalist Jörg Blech mentioned 2014 in his book „Die Psychofalle - Wie die Seelenindustrie uns zu Patienten macht“ this disorder (Blech, 2014). It is discussed whether the introduction of PTED may make a problem out of everyday problems. However, according to the available studies, the primary problem is not the differentiation between healthy and ill persons, since patients with PTED have regularly been given a variety of diagnoses. It is about the differential diagnostic differentiation of a special type of disorder, as a precondition for a goal-oriented therapy.
- Kraepelin, E. "Psychiatrie". Barth Verlag.
- Linden, M. (2003). "Posttraumatic embitterment disorder". Psychother Psychosom. 72 (4): 195–202. doi:10.1159/000070783. PMID 12792124.
- Linden, M. "Verbitterung und Posttraumatische Verbitterungsstörung. Fortschritte der Psychotherapie". Hogrefe Verlag.
- Linden, M.; Rotter, M.; Baumann, K.; Lieberei, B. "Posttraumatic embitterment disorder. Definition, Evidence, Diagnosis, Treatment". Hogrefe & Huber.
- Linden, M.; Maercker, A. "Embitterment. Societal, psychological, and clinical perspectives". Springer.
- 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.
- 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.
- 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.
- Alexander, J. "The psychology of bitterness". International Journal of Psycho-Analysis. 41: 514–520.
- Linden, M.; Baumann, K.; Rotter, M.; Lieberei, B. "Diagnostic Criteria and the Standardized Diagnostic Interview for Posttraumatic Embitterment Disorder (PTED)". International Journal of Psychiatry in Clinical Practice. 12: 93–96.
- Linden, M.; Rotter, M.; Baumann, K.; Schippan, B. "The Posttraumatic Embitterment Disorder Self-Rating Scale (PTED Scale)". Clinical Psychology and Psychotherapy. 16: 139–147.
- Hafer, C.L.; Sutton, R. "Belief in a just world". Handbook of Social Justice Theory and Research: 145–160.
- Linden, M. "Posttraumatische Verbitterungsstörung. Befreite Psyche durch "Weisheitstherapie"". NeuroTransmitter. 3: 63.
- Baumann, K.; Linden, M. "Weisheitstherapie". Verhaltenstherapiemanual (Springer): 416–422.
- Linden, M. "Psychotherapie der Verbitterung: Weisheitstherapie". Fachtagung: Verletzung, Verbitterung, Vergebung.
- Linden, M. "Verbitterung und Posttraumatische Verbitterungsstörung". Hogrefe Verlag.
- Hasanoglu, A. "Yeni Bir Tanı Kategorisi Önerisi: Travma Sonrası Hayata Küsme Bozukluğu". Türk Psikiyatri Dergisi. 19 (1): 94–100.
- Sensky, T. (2010). "Chronic Embitterment and Organisational Justice". Psychother Psychosom. 79 (2): 65–72. doi:10.1159/000270914. PMID 20051704.
- Dobricki, M.; Maercker, A. "(Post-traumatic) embitterment disorder: Critical evaluation of its stressor criterion and a proposed revised classification". Nord J Psychiatry: 1–26.
- 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.
- Joel, S.; Lee, J.S.; Kim, S.Y.; Won, S.; Lim, J.S.; Ha, K.S. "Posttraumatic Embitterment Disorder and Hwa-byung in the General Korean Population". Psychiatry Investig. 14 (4): 392–12792124.
- Blom, D.; Thomaes, S.; Kool, M.B.; van Middendorp, H.; Lumley, M.A.; Bijlsma, J.W.J.; Geenen, R. "A combination of illness invalidation from the work environment and helplessness is associated with embitterment in patients with FM". Rheumatology. 51: 347–353.
- Ege, H. "Different typologies of workplace conflict and their connections with post traumatic embitterment disorder (PTED)". HEALTH. 2: 234–236.
- Belaise, C.; Bernhard, L.M.; Linden, M. "L'embitterment: caratteristiche cliniche". Rivista di Psichiatria. 47 (5): 376–387.
- Michailidis, E.; Cropley, M. (2016). "Exploring predictors and consequences of embitterment in the workplace". Ergonomics. 60 (9): 1197–1206. doi:10.1080/00140139.2016.1255783. PMID 27801614.
- 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. "Standardization of the Korean Version of the Posttraumatic Embitterment Disorder Self-Rating Scale". Psychiatry Investigation. 9: 368–372.
- Linden, M.; Rotter, M.; Baumann, K.; Lieberei, B. "Posttraumatic Embitterment Disorder – Japanese Translation". Okayama-shi, Japan: Okayama University Press.
- 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.
- Blech, J. "Die Psychofalle - Wie die Seelenindustrie uns zu Patienten macht". Fischer Verlag.