Posttraumatic embitterment disorder

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.

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.

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.

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]

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.

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.