Post-traumatic embitterment disorder
Encyclopedia
Post-traumatic embitterment disorder (PTED) is a proposed disorder modeled after post-traumatic stress disorder
. Some psychiatrists are proposing this as a mental disorder because they believe there are people who have become so bitter they can barely function.
Michael Linden
in his seminal (2003) paper and modeled after PTSD since many of his patients did not fit the PTSD label.
Linden, who has conducted research on the proposed disorder, describes its effect on people: “They feel the world has treated them unfairly. It’s one step more complex than anger. They’re angry plus helpless.” He says that people with the disorder are almost treatment resistant and that; “These people usually don’t come to treatment because ‘the world has to change, not me.’” He believes that 1 to 2 percent of people are affected at any given time, and explains that, although sufferers of the disorder tend to have a desire for vengeance, “…Revenge is not a treatment.” (“Experts say embitterment should be a mental illness,” The Oregonian, pg. B3, 5/27/09)
Strictly speaking these PTED patients do not fit the formal criteria for PTSD prompting the description of a new and separate disorder and can be clinically distinguished from it.
's Nicomachean ethics
describing PTED in a similar form.
No Official Status and Medical Recognition in DSM
PTED is not listed in the DSM-IV-TR or ICD-10-CM.
.)
The revised 2009 description of PTED follows below (Reference: Max Rotter's Thesis)
(The below is slightly different clinically than the original PTED description; in Linden's seminal 2003 Paper))
Affect modulation is unimpaired and normal affect can be observed if the person is distracted.
The trigger event is a single negative life event that can occur in every life domain. The event is experienced as traumatic due to a violation of basic beliefs. Traumatic events of this type include, but are not limited to, conflict at the workplace, unemployment, the death of a relative, divorce, severe illness, or experience of loss or separation. The illness develops in the direct context of the event. The person must not have had any obvious mental disorder prior to the event that could explain the abnormal reaction.
Individuals may blame themselves for the event, for not having prevented it, or for not being able to cope with it.
Patients may show a variety of unspecific somatic complaints, such as loss of appetite, sleep disturbance, pain and anhedonia
.
In contrast to Adjustment Disorder the symptomatology of Posttraumatic Embitterment Disorder does not show the tendency of spontaneous remission.
In contrast to Depression affect modulation is unimpaired in Posttraumatic Embitterment Disorder. In Depression, the specific causal connection between the trigger event and symptomatology in Posttraumatic Embitterment Disorder cannot be found.
While in Posttraumatic Stress Disorder anxiety is the predominant emotion, in Posttraumatic Embitterment Disorder it is embitterment.
In Posttraumatic Stress Disorder there must be a critical event that has to be exceptional, life-threatening and, most important, is invariably leading to acute panic and extreme anxiety.
In Posttraumatic Embitterment Disorder there is always an acute event that can be called normal as it can happen to many persons in a life course. Still it is also an exceptional event as it is not an everyday event.
B. The traumatic event is experienced in the following ways:
B1. The person knows about the event and sees it as the cause of illness.
B2. The event is perceived as unjust, as an insult, and as a humiliation.
B3. The person’s response to the event involves feelings of embitterment, rage, and helplessness.
B4. The person reacts with emotional arousal when reminded of the event.
C. Characteristic symptoms resulting from the event are repeated intrusive memories and a persistent negative change in mental well being.
D. No obvious mental disorder was present prior to the event that could explain the abnormal reaction.
E. Performance in daily activities and roles is impaired.
F. Symptoms persist for more than 6 months.
) as follows: PTED is conceptualized as a special form of adjustment disorder, which develops in the direct context of a casual negative life event. It is explained by a mismatch between basic beliefs and negative life events, which violates this cognitive schema.
There is no published work at this time on different underlying neurological, endocrinology, and physiological changes in PTED patients as an analog to the PTSD Treatment book. This research has not yet been done or started for the most part. PTED research is 40 years behind PTSD research.
Cognitive Psychology has documented led personal metaphysical-existential worldview belief system and conceptual schema system for decades.
PTED is caused by a not-necessarily physical but mental, social, psychological, or event shattering of such a schema and belief system.
Linden 2003 writes that embitterment is the driving emotion in PTED in contrast to anger in PTSD.
In trauma, 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 -- which may be just as life-threatening as physical trauma i.e. an existentialist, metaphysical, value-systems attack.
"From our own clinical observation comes a more specific model, which stipulates a violation of strong ‘basic beliefs’ as the cause for a pervasive mood not of ‘depression’ or ‘anxiety’, but of feelings of injustice and ‘embitterment’. Basic beliefs can be conceptualized as value systems that are learned in childhood and adolescence. They encompass religious or political beliefs and values as well as basic definitions of oneself and one’s personal goals in life. They are needed to guide coherent behavior over the life cycle of an individual, and even over generations for groups and whole nations. This makes them resistant to change, even when confronted with opposing evidence. If these basic beliefs are threatened or violated, it can come either to martyrdom, i.e. an active opposition, or to embitterment, or possibly both. In this context it is of great interest that, for instance, political activists show less psychopathology after torture than non-activists, even when the former experienced more severe torture. It is hypothesized that the core pathogenic mechanism in PTED is a characteristic mismatch between basic beliefs and critical event, so that the event activates this particular, deeply held belief and the associated emotions."
The Dimensions of Wisdom targeted in Wisdom Therapy are: 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.
It is demonstrated that Wisdom Activation in PTED patients is inhibited in the specific areas of of their embitterment dysfunction.
Wisdom Therapy involves presenting the patient with case vignettes of unrelated-teaching problems in the guise of unsolvable life problems.
This will indirectly reactivate underutilized wisdom to carry over to their embittered problems later on after Therapy.
Also see the following article:
Article: Posttraumatic Embitterment Disorder and Wisdom Therapy
Journal: Journal of Cognitive Psychotherapy Article
Date: April 1, 2008
The latest scientific survey analysis of the medical literature on drug treatments for PTSD is in Mathew Friedman's chapter in the book on PTSD treatments.
Selective Serotonin Reuptake Inhibitors (SSRI's) are antidepressants like: Prozac, Paxil, Lexapro, Zoloft, Celexa, and Luvox. They have some benefit in PTED due to their antiobsessional properties. Anafranil, a TCA, is also used extensively.
The related concepts are discussed and distinguished: (ordinary) embitterment, reactive embitterment, versus PTED. Reactive Embitterment may be: specific, diffuse or non-PTED. Various rating, assessment scales, and distinctions are studied and investigated.
See the thesis:
Thesis Title: Reactive Embitterment: Conceptualization, Relevancy, Differentiation
Author: Max Rotter
Date: March 4, 2009
The first published and seminal book comprehensively explaining and focusing completely narrow-angle on the syndrome and all related information up to 2006 which includes most if not all of the essential information in Michael Linden’s 2003 through 2008 scholarly publications.
The cited references in the above book and the following book give as complete a survey of all related PTED published articles for those looking for a complete published scientific literature account.
The second book is an unofficial "sequel" and companion to the first book; it is topically a wide-angle view of embitterment and PTED in a broad aspects of embitterment throughout the social sciences to 2010.
Linden M. (2003). The Posttraumatic Embitterment Disorder. Psychotherapy and Psychosomatics, 72, 195 – 202.
The other primary foundational scientific articles (exluding the books by Linden et all) are:
Linden M., Baumann K., Rotter M., & Schippan B. (2007). The psychopathology of posttraumatic embitterment disorders (PTED). Psychopathology, 40, 159-165.
Linden M., Baumann K., Rotter M., Schippan 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.
Linden M., Baumann K., Rotter M., Schippan B. (2008). Posttraumatic embitterment disorder in comparison to other mental disorders. Psychotherapy and Psychosomatics, 77, 50-56.
The above articles highly overlap with Linden's 2006 book.
Post-traumatic stress disorder
Posttraumaticstress disorder is a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity,...
. Some psychiatrists are proposing this as a mental disorder because they believe there are people who have become so bitter they can barely function.
Scientific History: First Described in 2003
PTED was named by German psychiatristPsychiatrist
A psychiatrist is a physician who specializes in the diagnosis and treatment of mental disorders. All psychiatrists are trained in diagnostic evaluation and in psychotherapy...
Michael Linden
Michael Linden
Michael Linden is a German psychiatrist and professor of psychiatry, psychosomatic medicine and psychotherapy in the Charité University Hospital in Berlin....
in his seminal (2003) paper and modeled after PTSD since many of his patients did not fit the PTSD label.
Linden, who has conducted research on the proposed disorder, describes its effect on people: “They feel the world has treated them unfairly. It’s one step more complex than anger. They’re angry plus helpless.” He says that people with the disorder are almost treatment resistant and that; “These people usually don’t come to treatment because ‘the world has to change, not me.’” He believes that 1 to 2 percent of people are affected at any given time, and explains that, although sufferers of the disorder tend to have a desire for vengeance, “…Revenge is not a treatment.” (“Experts say embitterment should be a mental illness,” The Oregonian, pg. B3, 5/27/09)
Strictly speaking these PTED patients do not fit the formal criteria for PTSD prompting the description of a new and separate disorder and can be clinically distinguished from it.
Philosophical History
Non-medically scientific discussions of paralyzing embitterment run continually to today to pre-history. Linden often cites a paragraph by from AristotleAristotle
Aristotle was a Greek philosopher and polymath, a student of Plato and teacher of Alexander the Great. His writings cover many subjects, including physics, metaphysics, poetry, theater, music, logic, rhetoric, linguistics, politics, government, ethics, biology, and zoology...
's Nicomachean ethics
Nicomachean Ethics
The Nicomachean Ethics is the name normally given to Aristotle's best known work on ethics. The English version of the title derives from Greek Ἠθικὰ Νικομάχεια, transliterated Ethika Nikomacheia, which is sometimes also given in the genitive form as Ἠθικῶν Νικομαχείων, Ethikōn Nikomacheiōn...
describing PTED in a similar form.
No Official Status and Medical Recognition in DSMDSM-Business:* DSM , an international life science and performance materials company from the Netherlands* Delhi school of music, a music school in India...
or ICDICDThe International Statistical Classification of Diseases and Related Health Problems is a medical classification that provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease...
PTED is not listed in the DSM-IV-TR or ICD-10-CM.Complete and Comprehensive DSM-IV-style description - Specification of Diagnostic Criteria of Posttraumatic Embitterment Disorder (PTED)
(MEDICAL NOTE PTED IS NOT INCLUDED AT THIS TIME OR OFFICIALLY ENDORSED BY THE DSM; BUT AN ENTRY ONLY WRITTEN IN THE STYLE OF SUCH AN ENTRY BY THE LEADING RESEARCHERS. PTED is only under potential consideration for the DSM-5DSM-5
The next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders , commonly called DSM-5 , is currently in consultation, planning and preparation...
.)
The revised 2009 description of PTED follows below (Reference: Max Rotter's Thesis)
(The below is slightly different clinically than the original PTED description; in Linden's seminal 2003 Paper))
Diagnostic Features
The essential feature of Posttraumatic Embitterment Disorder is the development of clinically significant emotional or behavioral symptoms following a single exceptional, though normal negative life event. The person knows about the event and perceives it as the cause of illness. The event is experienced as unjust, as an insult, and as a humiliation. The person’s response to the event must involve feelings of embitterment, rage, and helplessness. The person reacts with emotional arousal when reminded of the event. The characteristic symptoms resulting from the event are repeated intrusive memories and a persistent negative change in mental well-being.Affect modulation is unimpaired and normal affect can be observed if the person is distracted.
The trigger event is a single negative life event that can occur in every life domain. The event is experienced as traumatic due to a violation of basic beliefs. Traumatic events of this type include, but are not limited to, conflict at the workplace, unemployment, the death of a relative, divorce, severe illness, or experience of loss or separation. The illness develops in the direct context of the event. The person must not have had any obvious mental disorder prior to the event that could explain the abnormal reaction.
Associated Features
Individuals with Posttraumatic Embitterment Disorder frequently manifest decreased performance in daily activities and roles. Posttraumatic Embitterment Disorder is associated with impaired affectivity. Besides prolonged embitterment individuals may display negative mood, irritability, restlessness, and resignation.Individuals may blame themselves for the event, for not having prevented it, or for not being able to cope with it.
Patients may show a variety of unspecific somatic complaints, such as loss of appetite, sleep disturbance, pain and anhedonia
Anhedonia
In psychology and psychiatry, anhedonia is defined as the inability to experience pleasure from activities usually found enjoyable, e.g. hobbies, exercise, social interaction or sexual activity....
.
Specific Culture Features
Elevated rates of Posttraumatic Embitterment Disorder may occur in times of major social change.Differential Diagnosis
Despite partial overlaps in symptomatology, the Posttraumatic Embitterment Disorder can be differentiated from other Affective Disorders, Posttraumatic Stress Disorder, or Anxiety Disorders.In contrast to Adjustment Disorder the symptomatology of Posttraumatic Embitterment Disorder does not show the tendency of spontaneous remission.
In contrast to Depression affect modulation is unimpaired in Posttraumatic Embitterment Disorder. In Depression, the specific causal connection between the trigger event and symptomatology in Posttraumatic Embitterment Disorder cannot be found.
While in Posttraumatic Stress Disorder anxiety is the predominant emotion, in Posttraumatic Embitterment Disorder it is embitterment.
In Posttraumatic Stress Disorder there must be a critical event that has to be exceptional, life-threatening and, most important, is invariably leading to acute panic and extreme anxiety.
In Posttraumatic Embitterment Disorder there is always an acute event that can be called normal as it can happen to many persons in a life course. Still it is also an exceptional event as it is not an everyday event.
Diagnostic criteria for Posttraumatic Embitterment Disorder
A. Development of clinically significant emotional or behavioral symptoms following a single exceptional, though normal negative life event.B. The traumatic event is experienced in the following ways:
B1. The person knows about the event and sees it as the cause of illness.
B2. The event is perceived as unjust, as an insult, and as a humiliation.
B3. The person’s response to the event involves feelings of embitterment, rage, and helplessness.
B4. The person reacts with emotional arousal when reminded of the event.
C. Characteristic symptoms resulting from the event are repeated intrusive memories and a persistent negative change in mental well being.
D. No obvious mental disorder was present prior to the event that could explain the abnormal reaction.
E. Performance in daily activities and roles is impaired.
F. Symptoms persist for more than 6 months.
Severity Measurement
Patient self-assessment of the severity is made with: The Post-Traumatic Embitterment Disorder Self-Rating Scale (PTED Scale).Descriptive Definition
Max Rotter's Thesis clarifies the primary hypothetical cause and mechanism from the standpoint of Schema Theories in Psychology (see Schema (psychology)Schema (psychology)
A schema , in psychology and cognitive science, describes any of several concepts including:* An organized pattern of thought or behavior.* A structured cluster of pre-conceived ideas....
) as follows: PTED is conceptualized as a special form of adjustment disorder, which develops in the direct context of a casual negative life event. It is explained by a mismatch between basic beliefs and negative life events, which violates this cognitive schema.
PTSD Considerations for Potential Analogy
PTSD has a significant arousal and effect on a variety of physiological, endocrine system, HPA axis, brain centers, and neurological systems. These suggest and have been the bases of treatments which have been well known and studied for decades via both theoretical and practical descriptions of illness, rationales of treatment modalities, and mechanisms of therapeutic actions.PTED Considerations
PTED may arouse or influence PTSD-affected systems differently or arouse different systems. Thus PTED, although modeled on PTSD, may have slightly through great different disordering, mechanisms, and treatments.There is no published work at this time on different underlying neurological, endocrinology, and physiological changes in PTED patients as an analog to the PTSD Treatment book. This research has not yet been done or started for the most part. PTED research is 40 years behind PTSD research.
PTSD versus PTED Causation Differences
PTSD often is caused by a physical, anxiety attack on a person’s life.Cognitive Psychology has documented led personal metaphysical-existential worldview belief system and conceptual schema system for decades.
PTED is caused by a not-necessarily physical but mental, social, psychological, or event shattering of such a schema and belief system.
Linden 2003 writes that embitterment is the driving emotion in PTED in contrast to anger in PTSD.
In trauma, 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 -- which may be just as life-threatening as physical trauma i.e. an existentialist, metaphysical, value-systems attack.
"From our own clinical observation comes a more specific model, which stipulates a violation of strong ‘basic beliefs’ as the cause for a pervasive mood not of ‘depression’ or ‘anxiety’, but of feelings of injustice and ‘embitterment’. Basic beliefs can be conceptualized as value systems that are learned in childhood and adolescence. They encompass religious or political beliefs and values as well as basic definitions of oneself and one’s personal goals in life. They are needed to guide coherent behavior over the life cycle of an individual, and even over generations for groups and whole nations. This makes them resistant to change, even when confronted with opposing evidence. If these basic beliefs are threatened or violated, it can come either to martyrdom, i.e. an active opposition, or to embitterment, or possibly both. In this context it is of great interest that, for instance, political activists show less psychopathology after torture than non-activists, even when the former experienced more severe torture. It is hypothesized that the core pathogenic mechanism in PTED is a characteristic mismatch between basic beliefs and critical event, so that the event activates this particular, deeply held belief and the associated emotions."
First Line talk therapy treatment is Wisdom Therapy
Michael Linden proposes Wisdom Therapy as a provisional and studied treatment in his books.The Dimensions of Wisdom targeted in Wisdom Therapy are: 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.
It is demonstrated that Wisdom Activation in PTED patients is inhibited in the specific areas of of their embitterment dysfunction.
Wisdom Therapy involves presenting the patient with case vignettes of unrelated-teaching problems in the guise of unsolvable life problems.
This will indirectly reactivate underutilized wisdom to carry over to their embittered problems later on after Therapy.
Also see the following article:
Article: Posttraumatic Embitterment Disorder and Wisdom Therapy
Journal: Journal of Cognitive Psychotherapy Article
Date: April 1, 2008
Psychopharmacology of PTED
There are no published or suggested studies on drug treatments for PTED.The latest scientific survey analysis of the medical literature on drug treatments for PTSD is in Mathew Friedman's chapter in the book on PTSD treatments.
Selective Serotonin Reuptake Inhibitors (SSRI's) are antidepressants like: Prozac, Paxil, Lexapro, Zoloft, Celexa, and Luvox. They have some benefit in PTED due to their antiobsessional properties. Anafranil, a TCA, is also used extensively.
PTED versus the emotions of "regular" Embitterment and versus Reactive Embitterment
PTED is a psychological adjustment-reactive disorder more severe than just being embittered in colloquial language. It can be qualitatively measured with high scientific reliability and repeatability.The related concepts are discussed and distinguished: (ordinary) embitterment, reactive embitterment, versus PTED. Reactive Embitterment may be: specific, diffuse or non-PTED. Various rating, assessment scales, and distinctions are studied and investigated.
See the thesis:
Thesis Title: Reactive Embitterment: Conceptualization, Relevancy, Differentiation
Author: Max Rotter
Date: March 4, 2009
Primary Source Seminal Books on PTED
There are only two books ever published on PTED; both are by or edited by Michael Linden. These books are the primary sources on this syndrome and the best starting place instead of the scattered academic literature.The first published and seminal book comprehensively explaining and focusing completely narrow-angle on the syndrome and all related information up to 2006 which includes most if not all of the essential information in Michael Linden’s 2003 through 2008 scholarly publications.
The cited references in the above book and the following book give as complete a survey of all related PTED published articles for those looking for a complete published scientific literature account.
The second book is an unofficial "sequel" and companion to the first book; it is topically a wide-angle view of embitterment and PTED in a broad aspects of embitterment throughout the social sciences to 2010.
Primary Source Articles (not books) Seminal Publications on PTED
The syndrome was first described in:Linden M. (2003). The Posttraumatic Embitterment Disorder. Psychotherapy and Psychosomatics, 72, 195 – 202.
The other primary foundational scientific articles (exluding the books by Linden et all) are:
Linden M., Baumann K., Rotter M., & Schippan B. (2007). The psychopathology of posttraumatic embitterment disorders (PTED). Psychopathology, 40, 159-165.
Linden M., Baumann K., Rotter M., Schippan 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.
Linden M., Baumann K., Rotter M., Schippan B. (2008). Posttraumatic embitterment disorder in comparison to other mental disorders. Psychotherapy and Psychosomatics, 77, 50-56.
The above articles highly overlap with Linden's 2006 book.