Post-traumatic embitterment disorder

In addition to the classic form of PTED triggered by a single event, a 2018 study identified three additional forms of pathological embitterment: non-reactive embitterment, or embitterment-prone personality, where no specific trigger can be identified; secondary embitterment, which occurs in the context of other mental disorders; and complex embitterment, which—analogous to complex PTSD—develops over time in response to repeated stressors. The clinical significance of these forms remains debated. However, more recent studies suggest that complex post-traumatic embitterment may be both more common and more severe than classic PTED.

PTED is not yet recognized as a distinct clinical disorder in the current medical classification systems ICD-11 and DSM-5. In both systems, PTED may be classified as an adjustment disorder. In ICD-11, however, an embitterment reaction is for the first time explicitly named under adjustment disorders.

In psychiatry and clinical psychology, as well as the legal system, individuals affected by embitterment disorders have long been referred to as querulants. As early as 1915, German psychiatrist Emil Kraepelin described “querulous delusions” (German: Querulantenwahn) in his textbook of psychiatry, characterizing them as a form of “traumatic neurosis” (German: traumatische Neurosen) distinct from personality disorders. PTED as a separate disorder was first proposed by German psychiatrist and psychologist Michael Linden in 2003. Although a growing body of research has added to the construct in recent years, the nosological validity of PTED remains disputed.

Bitterness and embitterment

Bitterness (also known as resentment) is a basic human emotional response to experiences of injustice, betrayal, or humiliation, involving feelings such as anger, wrath, hostility, disappointment, disgust, and shame. However, while bitterness is considered a transient emotion that eventually fades, embitterment is defined as a prolonged state of bitterness that does not easily subside and may severely impair quality of life. Typically, emotions associated with embitterment will recur every time the triggering event is recalled.

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Prevalence

There is little empirical evidence as to the prevalence of embitterment and PTED in the general population. In a nationally representative prevalence study conducted in Germany, 11.7% of respondents reported moderate levels of embitterment, while 3.8% reported high levels. Among those with high levels of embitterment, at least 7.2% were so severely affected that they required support in their everyday lives. Respondents with the highest levels of embitterment were less likely to have completed secondary education, more likely to be unemployed, more often on sick leave, and had on average lower incomes. The proportion of Muslims was considerably higher among those with severe embitterment than among those with low levels of embitterment (11.6% vs. 2.8%), whereas the proportion of people with no religious affiliation was significantly lower (20% vs. 27.3%). There were no significant differences between the groups in terms of age, sex, household size, or occupation. By far the most commonly reported cause of embitterment was an injustice committed by someone close to the affected person in their personal life, followed by injustices at work or in personal life more generally, injustices caused by an institution, and, lastly, injustices attributed to society.

Pathogenesis

Persistent states of embitterment may arise when an individual’s core beliefs are profoundly violated. In psychology, core beliefs refer to convictions, attitudes, and values shaping a person’s understanding of themselves and the world. They provide a cognitive framework for how someone sees the world, themselves, and others, what they regard as important, how to act in a given situation, and serve as a moral compass. Core beliefs may be either positive or negative. They are important both to individuals and to society and can be passed down through generations, in some cases shaping entire cultures. They do not necessarily reflect reality, but are experienced as real by the individual, regardless of their content. Information that conflicts with these beliefs is therefore often disregarded, making it difficult to change them (confirmation bias). One of the most fundamental core beliefs is the belief in a just world.

Because core beliefs are a crucial part of an individual’s identity, they are particularly susceptible to insult, humiliation, betrayal, and injustice. If a core belief is violated so severely that the experience cannot be ignored or adequately processed, and if the affected individual was not able to defend themselves and their beliefs in that situation, this may lead to PTED, turning initial feelings of helplessness and resignation into embitterment. Since core beliefs differ from person to person, an event one person might dismiss as trivial or a minor annoyance may constitute an existential crisis for another.

Symptoms and diagnostic criteria

PTED is triggered by a single adverse life event perceived as unjust, humiliating, or insulting. This is generally an ordinary, everyday event, such as losing one’s job, bullying, or a conflict with authorities, rather than an extreme event outside the range of usual human experience, such as robbery, a traffic accident, or war. Thus, in PTED, the event is not traumatic because of its objective severity, but because of how the event is subjectively appraised by the affected person (see Transactional model of stress and coping). The precise nature of the event, whether it involves degradation, humiliation, or a breach of trust, does not affect the type of symptoms that result, but may affect their severity.

Because PTED is not currently recognized as a distinct disorder, its diagnostic criteria vary between sources.

A. Essential criteria:

A single adverse life event followed by an immediate onset of the disorder.
The patient is aware of the trigger and identifies it as the cause of their condition.
The triggering event is perceived as unjust, humiliating, and/or insulting.
Recurrent emotional distress and feelings of embitterment when the event is discussed.
Recurrent intrusive memories; great importance may be placed on not forgetting the event.
Emotional responsiveness remains intact; unimpaired emotional regulation when distracted; thoughts of revenge may elicit joy.
No manifest mental disorder in the year preceding the trigger; current condition is not a recurrence of a pre-existing mental disorder.

B. Additional symptoms:

The patient perceives themselves as a victim, feels helpless and unable to cope with the event or its cause.
Self-blame for having failed to prevent the event and for being unable to cope with it.
Indifference toward their own well-being; uncertainty whether the emotional wound should even be allowed to heal.
Suicidal ideation.
Dysphoric-aggressive-depressive mood, resembling depression with somatic syndrome at first glance.
Nonspecific somatic complaints (e.g., sleep disturbances, loss of appetite, pain).
Phobic avoidance of places or people associated with the triggering event.
Reduced or inhibited drive, more in the sense of feeling stuck rather than unwilling.

Additional criteria proposed in different sources include: a querulous persistence in the fight for justice; recurrent thoughts of aggression, revenge, and murder-suicide directed toward the stressor; clinically significant distress or impairment in social, occupational, or other important areas of functioning, as well as subjective well-being; a duration of at least six months.

PTED tends to become chronic, as affected individuals may become caught in a vicious cycle of mutually reinforcing negative emotions and thoughts, which can turn into a self-destructive downward spiral. The disorder is rarely overcome without psychotherapeutic intervention. Without timely and appropriate treatment, there is a substantially increased risk that fantasies of revenge will be acted upon, potentially leading to serious crimes.

Diagnostic tools

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. 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 diagnoses

Post-traumatic stress disorder:
- triggered by one singular or several potentially life-threatening, uncommon events causing extreme fear and panic (e.g., road accidents, robberies, war)
- cardinal emotion is recurring or persisting fear; embitterment does not occur
Major depressive disorder:
- very common misdiagnosis due to several symptomatic similarities (e.g., depressed mood, avolition, suicidality, absent-mindedness)
- contrary to PTED no direct temporal connection to debilitating events, no singular stressor
- no anhedonia in PTED patients
Adjustment disorder:
- normally subsides within six months after the triggering event
- can be caused by a number of events, not necessarily by insults, betrayal, humiliation or injustice
Phobia:
- Avoidance behavior caused by fear, not by embitterment
Personality disorders:
- Lifelong development, no immediate connection to a singular event
- PTED completely reversible by therapy, effects of PDs only mitigable
- Development of PTED might be facilitated by existing PDs
Paranoia, delusions, schizotypal disorder, schizophrenia, querulant delusion, moral injury

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:

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

A 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.")

Criticism

The problem of embitterment reactions and also the post-traumatic 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 writer 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 Into Patients"), which discussed whether the introduction of PTED might make a problem out of everyday problems.