Posttraumatic Embitterment Disorder

Post traumatic Embitterment Disorder (PTED) is a newly described reactive disorder. It is a special form of maladjustment reaction proposed by the German Psychiatrist Dr. Michael Linden of the University of Berlin in 2003.  PTED was introduced as a new concept for a subgroup of Adjustment Disorders. It can also be described as an Adaptation disorder.

Embitterment is a persistent feeling of being let down or insulted, or feeling revengeful but helpless. The feeling of bitterness is always associated with a burning sense of unfairness or injustice, a protesting feeling of having been wronged without cause. It signifies an aggressive protest against a felt and perceived injustice, and is a goad to desperate, sometimes reckless, efforts to gain redress.

Dr.  Linden recognized embitterment as a unique human emotional experience. Feeling embittered is a prolonged emotional state of hate and anger caused by the belief that one has been treated unfairly. Dr.  Linden states that similar to anxiety or depression, embitterment must be understood as a dimensional phenomenon, which becomes pathological when reaching greater intensities, when it is associated with additional symptoms, and when daily role performance is impaired

PTED is a reaction to unjust or humiliating life events, including embitterment and impairment of mood, somatoform complaints, and reduction in drive, withdrawal from social contacts, and even suicide and murder suicide.

PTED is frequently seen in patients who have had to cope with events of personal injustice, humiliation, frustration, and helplessness. Emotional embitterment exists in a dimension similar to depression and anxiety, and therefore, when it is most intense, it can become pathological and lead to devastating personal, social, and occupational impairment.

This clinical syndrome is described as ‘post-traumatic’, because its onset must follow a single precipitating life stressor, which inevitably causes the patients to feel they have been treated unfairly. Unlike the life-threatening events leading to PTSD (Posttraumatic stress disorder) the events leading to Post traumatic Embitterment Disorder are exceptional but usual life events that do not cause a threat to one’s physical integrity but instead cause a violation of basic beliefs, which can be experienced as traumatic.

Dr. Linden states that PTSD is caused by a physical threat to one’s life; in PTED it is hypothesized to come from a threat to one's basic belief system. PTED is thus, like PTSD, not characterized by a particular type of stressful events, but by a distinct psychological process (experiences of injustice and humiliation) and by a highly specific psychopathological profile (embitterment). Elevated rates of PTED may occur in times of major social changes that force people to reorganize their personal biographies.

The PTED patients are suffering from severe, multiform, and disabling symptoms. The trigger event in PTED is an exceptional, though normal negative life event that is experienced as a violation of basic beliefs and values. The predominant emotion in PTED is embitterment.

Core criteria of Post traumatic Embitterment Disorder are: (1) a single exceptional negative life event precipitates the onset of the illness; (2) the present negative state developed in the direct context of this event; (3) the emotional response is embitterment and feelings of injustice; (4) repeated intrusive memories of the event; (5) emotional modulation is unimpaired, patients can even smile when engaged in thoughts of revenge, and (6) no obvious other mental disorder that can explain the reaction. Additional symptoms are feelings of helplessness, self-blame, rejection of help, suicidal ideation, dysphoria, aggression, down-heartedness, seemingly melancholic depression, unspecific somatic complaints, loss of appetite, sleep disturbances, reduced drive pain, phobic symptoms in respect to the place or to persons related to the event.

The diagnosis of PTED can lead to specific therapeutic interventions. PTED can be discriminated from PTSD, depression, anxiety disorders, and other adjustment disorders. In contrast to other adjustment disorders the symptomatology found in PTED does not show a tendency of spontaneous remission. On the contrary, patients tend to actively keep memories of the event alive. In Depression, the specific causal connection between the trigger event and symptomatology in Posttraumatic Embitterment Disorder cannot be found. Although PTED is similar to Post-traumatic Stress Disorder (PTSD) the trigger event is not life threatening.

This disorder was initially described in immigrants from East Germany following the fall of the Berlin Wall and which does not exactly match the diagnostic criteria of adjustment disorder or PTSD.  Immigrants frequently report a depressive state in which physical symptoms are in the foreground accompanied by social withdrawal and diminished energy. Negative life events, which are not life threatening and are not experienced every day, can impair mental health so that the above state may worsen and an immigrant may have a reduction in his performance at work. This state, which is accompanied by such symptoms as embitterment, feelings of injustice, repeated intrusive memories of critical events (injustice at work place, loss of a job, discrimination in a public office, etc.), phobic symptoms, and avoidance behavior towards the place or persons related to the event.

Posttraumatic Embitterment Disorder may occur in times of major social changes that force people to reorganize their personal biographies. According to Professor Harald Ege Post-Traumatic Embitterment Disorder is the most appropriate psychological diagnosis for victims of workplace conflicts, particularly bullying.  

Dr Linden proposes "wisdom therapy" as an approach to treat PTED. Wisdom therapy is a form of cognitive therapy based on recent developments in the field of wisdom psychology. Treatment involves presenting the patient with case vignettes of unsolvable life problems and teaching patients to attain a change of perspective, distance from oneself, empathy with the aggressor, acceptance of unwanted emotions, emotional serenity, contextualism, value relativism, relativism of aspirations, and long-term perspectives.

Although PTED so far has no official status and is not listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) or The International Classification of Diseases (ICD) it deserves more scientific and clinical attention.

Dr. Ruwan M Jayatunge M.D.

References

Ege, H. (2010) Different typologies of workplace conflict and their connections with post traumatic embitterment disorder (PTED). Health, 2, 234-236.

Hasanoğlu, A. (2008).Suggestion of a new diagnostic category: posttraumatic embitterment disorder.Turk Psikiyatri Derg. ;19(1):94-100.

Linden, M. (2003). "Posttraumatic embitterment disorder". Psychother Psychosom 72 (4): 195–202.

Linden, M., Baumann, K., Lieberei, B., Rotter, M. (2009). The Post-Traumatic Embitterment Disorder Self-Rating Scale (PTED Scale). Clinical Psychology & Psychotherapy,16, 139–147.

Linden, M.1., 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. Psychother Psychosom.  ;80(4):199-205.

Rotter, M.(2009). Reactive Embitterment Conceptualization, Relevancy and Differentiation.

Shin, C., Han, C., Linden, M., Chae, J.H., Ko, Y.H., Kim, Y.K., Kim, S.H., Joe, S.H., Jung, I.K. (2012). Standardization of the korean version of the posttraumatic embitterment disorder self-rating scale. Psychiatry Investig.  ;9(4):368-72.

Wong,M. J.S. (2007). Posttraumatic Embitterment Disorder: Definition, Evidence, Diagnosis, Treatment. Hong Kong J Psychiatry; 17:103-4.