Posttraumatic embitterment disorder


The posttraumatic embitterment disorder is a pathological reaction to drastic life events. The trigger is an extraordinary though common negative life event. The consequence is severe and long-lasting embitterment. This disorder is not characterised by the triggering event but by the temporal connection to the critical incident.The German psychiatrist Michael Linden and others have emphasised the importance of embitterment.

Forms of embitterment

Embitterment is a persistent negative feeling in reaction to common negative life events, and is a reactive emotion towards injustice, insult or breach of trust. Embitterment is a gnawing feeling 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 a person's whole life and their environment with severe impairment.

Signs and symptoms

The following diagnostic criteria characterize posttraumatic embitterment disorder:
  1. The patient is aware of the stressor and recognizes it as the cause of the disorder.
  2. The event is experienced as unfair, insulting or as a breach of trust.
  3. The reaction of the patient regarding the event includes feelings of embitterment, anger and helplessness.
  4. The patient reacts with emotional arousal when they are reminded of the event.
Embitterment occurs in reaction to extraordinary but 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 a person's mood. There are traumatic events, which lead to pathological emotionsstates 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”. 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 are usually not questioned and are 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. 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 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 an injustice, insult or humiliation depends on personal beliefs and values.

Diagnosis

BEI

The Berner Embitterment-Inventory 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. 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 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 diagnosis

The posttraumatic embitterment disorder has to be differentiated from the posttraumatic stress disorder. 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 reminded, 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 similar 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.

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.
One uses the usual cognitive strategies of attitude change and problem-solving are used, such as:
As special treatment module aims at the training of wisdom competencies, which means promoting the following abilities:
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

Epidemiology

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.

Criticism

The problem of embitterment reactions and also the posttraumatic embitterment disorder increasingly gain international attention.
Nevertheless, there are some unsolved problems. Further research is needed to differentiate between PTED and other mental disorders. In 2014 science journalist Jörg Blech mentioned this disorder in his book Die Psychofalle - Wie die Seelenindustrie uns zu Patienten macht. 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.