Post-traumatic embitterment disorder

Last updated
Post-traumatic Embitterment disorder
Specialty Psychiatry, Clinical psychology
Symptoms Severe 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 method Based on symptoms
Differential diagnosis Post-traumatic stress disorder, Major depressive disorder, Adjustment disorder, Phobia, Personality disorders, Paranoia, Delusions, Schizotypal disorder, Schizophrenia, Querulant delusion, Moral injury
TreatmentCounseling, wisdom therapy
Prognosis good 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.

Contents

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]

Prevalence

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.[ page needed ]

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)[ full citation needed ] 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

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:

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

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

Related Research Articles

A nightmare, also known as a bad dream, is an unpleasant dream that can cause a strong emotional response from the mind, typically fear but also despair, anxiety, disgust or sadness. The dream may contain situations of discomfort, psychological or physical terror, or panic. After a nightmare, a person will often awaken in a state of distress and may be unable to return to sleep for a short period of time. Recurrent nightmares may require medical help, as they can interfere with sleeping patterns and cause insomnia.

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event. Young children are less likely to show distress, but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

<span class="mw-page-title-main">Dialectical behavior therapy</span> Psychotherapy for emotional dysregulation

Dialectical behavior therapy (DBT) is an evidence-based psychotherapy that began with efforts to treat personality disorders and interpersonal conflicts. Evidence suggests that DBT can be useful in treating mood disorders and suicidal ideation as well as for changing behavioral patterns such as self-harm and substance use. DBT evolved into a process in which the therapist and client work with acceptance and change-oriented strategies and ultimately balance and synthesize them—comparable to the philosophical dialectical process of thesis and antithesis, followed by synthesis.

Dissociation is a concept that has been developed over time and which concerns a wide array of experiences, ranging from a mild emotional detachment from the immediate surroundings, to a more severe disconnection from physical and emotional experiences. The major characteristic of all dissociative phenomena involves a detachment from reality, rather than a false perception of reality as in psychosis.

Psychological trauma is an emotional response caused by severe distressing events that are outside the normal range of human experiences. It must be understood by the affected person as directly threatening the affected person or their loved ones with death, severe bodily injury, or sexual violence; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response, but does not produce trauma per se. Examples include violence, rape, or a terrorist attack.

Eye movement desensitization and reprocessing (EMDR) is a form of psychotherapy that is a recommended treatment for post-traumatic stress disorder, but remains controversial within the psychological community. It was devised by Francine Shapiro in 1987 and originally designed to alleviate the distress associated with traumatic memories such as post-traumatic stress disorder (PTSD).

Psychodynamic psychotherapy and psychoanalytic psychotherapy are two categories of psychological therapies. Their main purpose is revealing the unconscious content of a client's psyche in an effort to alleviate psychic tension, which is inner conflict within the mind that was created in a situation of extreme stress or emotional hardship, often in the state of distress. The terms "psychoanalytic psychotherapy" and "psychodynamic psychotherapy" are often used interchangeably, but a distinction can be made in practice: though psychodynamic psychotherapy largely relies on psychoanalytical theory, it employs substantially shorter treatment periods than traditional psychoanalytical therapies. Psychodynamic psychotherapy is evidence-based; the effectiveness of psychoanalysis and its relationship to facts is disputed.

Complex post-traumatic stress disorder is a stress-related mental disorder generally occurring in response to complex traumas, i.e., commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.

Exposure therapy is a technique in behavior therapy to treat anxiety disorders. Exposure therapy involves exposing the patient to the anxiety source or its context. Doing so is thought to help them overcome their anxiety or distress. Numerous studies have demonstrated its effectiveness in the treatment of disorders such as generalized anxiety disorder (GAD), social anxiety disorder (SAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and specific phobias.

Prolonged exposure therapy (PE) is a form of behavior therapy and cognitive behavioral therapy designed to treat post-traumatic stress disorder. It is characterized by two main treatment procedures – imaginal and in vivo exposures. Imaginal exposure is repeated 'on-purpose' retelling of the trauma memory. In vivo exposure is gradually confronting situations, places, and things that are reminders of the trauma or feel dangerous. Additional procedures include processing of the trauma memory and breathing retraining.

Memory and trauma is the deleterious effects that physical or psychological trauma has on memory.

In psychology, posttraumatic growth (PTG) is positive psychological change experienced as a result of struggling with highly challenging, highly stressful life circumstances. These circumstances represent significant challenges to the adaptive resources of the individual, and pose significant challenges to the individual's way of understanding the world and their place in it. Posttraumatic growth involves "life-changing" psychological shifts in thinking and relating to the world and the self, that contribute to a personal process of change, that is deeply meaningful.

<span class="mw-page-title-main">Michael Linden</span>

Michael Linden is a German psychiatrist and professor of psychiatry, psychosomatic medicine and psychotherapy in the Charité University Hospital in Berlin.

Eclectic psychotherapy is a form of psychotherapy in which the clinician uses more than one theoretical approach, or multiple sets of techniques, to help with clients' needs. The use of different therapeutic approaches will be based on the effectiveness in resolving the patient's problems, rather than the theory behind each therapy.

Trauma-sensitive yoga is yoga as exercise, adapted from 2002 onwards for work with individuals affected by psychological trauma. Its goal is to help trauma survivors to develop a greater sense of mind-body connection, to ease their physiological experiences of trauma, to gain a greater sense of ownership over their bodies, and to augment their overall well-being. However, a 2019 systematic review found that the studies to date were not sufficiently robustly designed to provide strong evidence of yoga's effectiveness as a therapy; it called for further research.

<span class="mw-page-title-main">Post-traumatic stress disorder and substance use disorders</span> Association of PTSD and substance dependencies

Post-traumatic stress disorder (PTSD) can affect about 3.6% of the U.S. population each year, and 6.8% of the U.S. population over a lifetime. 8.4% of people in the U.S. are diagnosed with substance use disorders (SUD). Of those with a diagnosis of PTSD, a co-occurring, or comorbid diagnosis of a SUD is present in 20–35% of that clinical population.

MDMA-assisted psychotherapy is the use of prescribed doses of MDMA as an adjunct to psychotherapy sessions. Research suggests that MDMA-assisted psychotherapy for post-traumatic stress disorder (PTSD), including Complex PTSD, might improve treatment effectiveness. In 2017, a Phase II clinical trial led to "breakthrough therapy" designation by the US Food and Drug Administration (FDA) for potential use as a treatment for PTSD.

<span class="mw-page-title-main">Narrative exposure therapy</span> Short-term therapy for trauma-related disorders

Narrative Exposure Therapy (NET) is a short-term psychotherapy used for the treatment of post-traumatic stress disorder and other trauma-related mental disorders. It creates a written account of the traumatic experiences of a patient or group of patients, with the aim of recapturing self-respect and acknowledging the patient's value. NET is an individual treatment, NETfacts is a format for communities.

Psychological trauma in adultswho are older, is the overall prevalence and occurrence of trauma symptoms within the older adult population.. This should not be confused with geriatric trauma. Although there is a 90% likelihood of an older adult experiencing a traumatic event, there is a lack of research on trauma in older adult populations. This makes research trends on the complex interaction between traumatic symptom presentation and considerations specifically related to the older adult population difficult to pinpoint. This article reviews the existing literature and briefly introduces various ways, apart from the occurrence of elder abuse, that psychological trauma impacts the older adult population.

Psychedelic treatments for trauma-related disorders are the use of psychedelic substances, either alone or used in conjunction with psychotherapy, to treat trauma-related disorders. Trauma-related disorders, such as post-traumatic stress disorder (PTSD), have a lifetime prevalence of around 8% in the US population. However, even though trauma-related disorders can hinder the everyday life of individuals with them, less than 50% of patients who meet criteria for PTSD diagnosis receive proper treatment. Psychotherapy is an effective treatment for trauma-related disorders. A meta-analysis of treatment outcomes has shown that 67% of patients who completed treatment for PTSD no longer met diagnostic criteria for PTSD. For those seeking evidence-based psychotherapy treatment, it is estimated that 22-24% will drop out of their treatment. In addition to psychotherapy, pharmacotherapy (medication) is an option for treating PTSD; however, research has found that pharmacotherapy is only effective for about 59% of patients. Although both forms of treatment are effective for many patients, high dropout rates of psychotherapy and treatment-resistant forms of PTSD have led to increased research in other possible forms of treatment. One such form is the use of psychedelics.

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)[ page needed ]
  3. Linden, Michael; Rotter, Max; Lieberei, Barbara; Baumann, Kai (2007). Posttraumatic Embitterment Disorder: Definition, Evidence, Diagnosis, Treatment. MA. ISBN   978-0-88937-344-0.[ page needed ]
  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.[ page needed ]
  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.