Posttraumatic embitterment disorder

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Posttraumatic embitterment disorder
SpecialtyPsychology

The posttraumatic embitterment disorder (PTED) is a pathological reaction to drastic life events. The trigger is an extraordinary, though common, negative life event (for example, divorce, bereavement, dismissal, personal insult, or vilification). 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[1] and others have emphasised the importance of embitterment.[2][3][4][5][6][7]

Forms of embitterment[]

Embitterment is a persistent negative feeling in reaction to common negative life events,[4][8] 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:[9]

  • Clinically significant emotional symptoms or behavioural problems, which appear after a unique although common stressful life event.
  • Traumatic stress is experienced in the following ways:
  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.
  • 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 that could explain this abnormal reaction.
  • Daily activities and tasks are impaired.
  • The symptoms last longer than six months.

Cause[]

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 emotions—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”.[10] 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.[11] 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 an injustice, insult or humiliation depends on personal beliefs and values.

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.[12] 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[9] 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 (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 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.[13][14] 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

As 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.")[13][15]

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.[16][17][18][19][20][21][22][23][24][25] Nevertheless, there are some unsolved problems. Further research is needed to differentiate between PTED and other mental disorders.[26] 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 Soul Industry Makes Us Patients").[27] 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.

References[]

  1. ^ Linden, M. (2003). "Posttraumatic embitterment disorder". Psychother Psychosom. 72 (4): 195–202. doi:10.1159/000070783. PMID 12792124. S2CID 19723598.
  2. ^ Linden, M. "Verbitterung und Posttraumatische Verbitterungsstörung. Fortschritte der Psychotherapie". Hogrefe Verlag.
  3. ^ Linden, M.; Rotter, M.; Baumann, K.; Lieberei, B. "Posttraumatic embitterment disorder. Definition, Evidence, Diagnosis, Treatment". Hogrefe & Huber.
  4. ^ a b Linden, M.; Maercker, A. "Embitterment. Societal, psychological, and clinical perspectives". Springer. 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. ^ Alexander, J. (1960). "The psychology of bitterness". International Journal of Psycho-Analysis. 41: 514–520. PMID 13682342.
  9. ^ a b 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.
  10. ^ Hafer, C.L.; Sutton, R. "Belief in a just world". Handbook of Social Justice Theory and Research: 145–160.
  11. ^ Linden, M. "Posttraumatische Verbitterungsstörung. Befreite Psyche durch "Weisheitstherapie"". NeuroTransmitter. 3: 63.
  12. ^ 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.
  13. ^ a b Baumann, K.; Linden, M. "Weisheitstherapie". Verhaltenstherapiemanual (Springer): 416–422.
  14. ^ Linden, M. "Psychotherapie der Verbitterung: Weisheitstherapie". Fachtagung: Verletzung, Verbitterung, Vergebung.
  15. ^ Linden, M. "Verbitterung und Posttraumatische Verbitterungsstörung". Hogrefe Verlag.
  16. ^ Hasanoglu, A. "Yeni Bir Tanı Kategorisi Önerisi: Travma Sonrası Hayata Küsme Bozukluğu". Türk Psikiyatri Dergisi. 19 (1): 94–100.
  17. ^ Sensky, T. (2010). "Chronic Embitterment and Organisational Justice". Psychother Psychosom. 79 (2): 65–72. doi:10.1159/000270914. PMID 20051704. S2CID 33399909.
  18. ^ 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.
  19. ^ 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. S2CID 145093175.
  20. ^ 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.
  21. ^ 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.
  22. ^ Belaise, C.; Bernhard, L.M.; Linden, M. "L'embitterment: caratteristiche cliniche". Rivista di Psichiatria. 47 (5): 376–387.
  23. ^ Michailidis, E.; Cropley, M. (2016). "Exploring predictors and consequences of embitterment in the workplace" (PDF). Ergonomics. 60 (9): 1197–1206. doi:10.1080/00140139.2016.1255783. PMID 27801614. S2CID 5003336. Archived (PDF) from the original on 2018-07-19. Retrieved 2019-07-05.
  24. ^ 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.
  25. ^ Linden, M.; Rotter, M.; Baumann, K.; Lieberei, B. "Posttraumatic Embitterment Disorder – Japanese Translation". Okayama-shi, Japan: Okayama University Press.
  26. ^ 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.
  27. ^ Blech, J. "Die Psychofalle - Wie die Seelenindustrie uns zu Patienten macht". Fischer Verlag.
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