Post-traumatic bitterness disorder

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Classification according to ICD-10
F43 Reactions to severe stress and adjustment disorders
F43.8 other reaction to severe stress
ICD-10 online (WHO version 2019)

The posttraumatic embitterment disorder ( Posttraumatic embitterment disorder , PTED) is a mental disorder from the group of adjustment disorders in response to experiences of humiliation, injustice or breach of trust. The leading emotion is bitterness, accompanied by a host of other psychological complaints up to self or external aggression, whereby the PTED also takes a chronic course in many cases.

In psychiatry and clinical psychology resp. In psychotherapy and in the judiciary , this type of disorder has long been discussed under the term “troublemaker” . For example, in Emil Kraepelin's textbook on psychiatry from 1915, under the heading of “psychogenic diseases”, the description of the “troublemaker delusion” as a form of “traumatic neuroses” is explicitly differentiated from personality disorders by Kraepelin . In contrast, PTED was first described in 2003 by the German psychiatrist and psychologist Michael Linden as an independent clinical syndrome .

It is currently unclear whether, in addition to post-traumatic bitterness in the narrower sense, there is also a “complex PTED” as a result of repeated and cumulative experiences of insult.

Triggers and Symptoms

Bitterness is a general human emotion known to everyone from their own experience, just as this also applies to fear: Similar to the latter, bitterness is a reactive emotion to injustice, insult, degradation or breach of trust, whereby the bitterness subsides again in many cases.

As a special form of such a bitterness reaction, however, bitterness in PTED tends to be long-lasting and, as soon as its cause is remembered, to be reactivated again and again. With greater intensity, it can seriously affect the whole life of those affected and their environment.

distribution

Preliminary data suggest a prevalence of around 2–3% in the population. Increased prevalence figures are observed when larger groups of people are subject to social upheaval. Linden therefore described this clinical picture in his patient for the first time after German reunification.

causes

Serious bitterness reactions occur when important “basic assumptions” are grossly violated by an event or other people. Basic assumptions (in English: basic beliefs ) are psychological attitudes and value orientations by which a person defines himself and which serve to be able to behave coherently over his life span (for example “The family is the most important thing in life!” “The job is the most important thing in life! ”“ Material security or wealth is the most important thing in life! ”“ Reliability and honesty are the most important thing in life! ”etc.). Basic assumptions are often passed on transgenerationally from parents to children over centuries and thus significantly shape the culture of groups of people. One of the most important basic assumptions is z. B. the belief in a just world (in English: belief in a just world psychology ).

Basic assumptions help determine what people consider important and what they stand up for. It is therefore true that people are particularly vulnerable, especially in those areas in which they are particularly productive. Insults and injustice are psychologically to be understood as aggression, and if these cannot be responded to with effective defense, helplessness, resignation and bitterness can result, the latter in turn also having the character of aggression, in this case admittedly at the risk of self-destruction what the z. T. dysfunctional actions up to extended suicides explained.

Factors that can protect against bitterness and that are also used therapeutically are “wisdom” in the sense of modern “wisdom psychology” (expertise in dealing with difficult and insoluble life questions) or the ability to forgive in the sense of “forgiveness psychology”. After successfully coping with bitterness reactions, post-traumatic growth can take place again.

Characteristics

The following criteria characterize a post-traumatic bitterness disorder:

  • Clinically significant emotional symptoms or behavioral abnormalities that occur after a one-off extraordinary, even if - seen from the outside - often “only” life-standard stress.
  • The patient knows the stressful event and sees it as the cause of his illness.
  • The traumatic stress is experienced in the following ways:
  1. the stressful event is experienced as unfair, insulting or a breach of trust;
  2. the patient, when reminded of the event, reacts again with emotional excitement;
  3. the patient's reaction to the event includes feelings of bitterness, anger, and helplessness.
  • Symptoms include regular, obtrusive memories, dysphoric depression, drive reduction or blockade, unspecific psychosomatic symptoms, phobic avoidance of event-related places and people, revenge fantasies and aggressive feelings towards the aggressor, querulatory tenacity in the struggle to restore justice, Weariness with life up to fantasies of an extended suicide .
  • There was no mental illness prior to the event that could explain the abnormal response.
  • Daily activities and tasks are restricted.
  • The symptoms have existed for more than six months.

The disorder is not "traumatic" with regard to the previous triggering event, but because of its temporal course: Minutes before the stressful event, people were healthy, but minutes later they are sick and severely impaired (but this also applies to the Post Traumatic Stress Disorder (PTSD) applies).

Differential diagnostics

Post-traumatic bitterness must be differentiated from other psychiatric illnesses:

  • From post-traumatic stress disorder (PTSD), with which it has some structural aspects in common: In PTSD, there is a life-threatening , unusual and unconditionally panic-inducing stimulus at the beginning , which accordingly leads to fear as a leading symptom, while at the beginning of a PTED there is only one There is an experience of hurt or injustice and bitterness is the predominant emotion it triggers.
  • Some symptoms of PTED can be reminiscent of depression , but for which there is no specific triggering event and for which the affective ability to vibrate is also impaired.
  • Simple adjustment disorders do not have as pronounced symptoms as PTED and should subside again after a short time.
  • With the exception of the “ongoing personality change after extreme experience”, which, however, requires a catastrophic burden, there is no event-related development in personality disorders from which PTED is to be distinguished. Instead, unlike PTED, the latter has a steady development of the disorder over the life span. (In the meantime, however, there are also indications that there are “bitterness-prone” personalities or that some personality disorders are also associated with being easily offended and thus an increased tendency to bitterness.)

Measuring instruments

Bernese bitterness

The Bernese Bitterness Sheet (BVB) (Znoj, 2008; 2011) records:

  1. emotional bitterness
  2. performance-related bitterness
  3. Pessimism / hopelessness
  4. Misanthropy / aggression .

PTED scale

The PTED scale is a 19-point self-rating questionnaire that is used as a screening tool to record reactive bitterness (Linden et al., 2009) and is now available in Bosnian, Chinese, German, English, French, Dutch, Italian, and Korean , Croatian, Portuguese, Turkish, and Pakistani is available. An averaged total value ≥ 2.5 can be viewed as an indication of the presence of a clinically relevant bitterness reaction.

Standardized diagnostic interview for PTED

The standardized diagnostic interview for PTED asks about the central criteria of PTED, whereby the examiner has to assess what the patient means and in particular whether there is a bitterness reaction.

psychotherapy

The treatment of the post-traumatic bitterness is made more difficult by the resigned-aggressive-defensive attitude of the patients, which can also be directed against offers of therapeutic help. One approach to treatment is the "wisdom therapy" developed by Linden, a form of cognitive behavioral therapy that aims to enable the patient to work through the critical life event and, in particular, the insults and degradations associated with it, to distance themselves from them and to build new life perspectives. For this purpose, on the one hand, common cognitive strategies of attitude change and problem solving are used, such as

  • behavioral methods of behavior analysis and cognitive rehabilitation;
  • Analysis of automatic thoughts and schemes;
  • Reframing or cognitive renaming;
  • Exposure method;
  • Activity building;
  • Rebuilding social contacts and
  • Promotion of self-efficacy experiences.

A special therapy module is the targeted training of “wisdom competencies”, in particular the promotion of skills

  • to change perspective,
  • to empathy,
  • on emotion perception and emotion acceptance,
  • to emotional balance and to humor (serenity) or serenity,
  • to contextualism ,
  • to a sustainability orientation,
  • to value relativism,
  • to an uncertainty tolerance as well
  • on self-distance and the relativization of aspirations (self-relativization).

Methodically, the procedure of "unsolvable problems" is used, in which one specifies fictitious serious and unsolvable conflict situations, on the basis of which the patients can / should practice the abovementioned skills in order to then transfer them to their own situation (so-called "learning transfer") .

criticism

The problem of bitterness reactions and also the post-traumatic bitterness disorder have recently been gaining increasing international attention. However, there are still a number of unresolved problems. For example, further investigations are required to differentiate from other mental disorders and to clarify when an observed disorder can actually be assumed to be a (new) independent illness.

The science journalist Jörg Blech , for example, mentioned the disorder discussed here several times in his book "Die Psychofalle - How the soul industry turns us into patients" in 2014 as an example of numerous new diagnoses in the field of mental disorders that only relate to life crises, i. H. individually and / or socially disturbed living conditions and do not fit into the diagnostic schemes commonly used up to now, which ultimately pathologizes more and more problems such as unemployment, grief or disappointments and thus shifts societal and / or social problems to the field of psychiatry - a development that ultimately only of benefit to the pharmaceutical and health industry, but not to the patient (see also the stigmatization of the mentally ill) themselves.

Another effect of this trend would be that it would shift the borderline between “healthy” and “sick” more and more to the disadvantage of the patient, and that also in the statistics.

In the case of PTED, however, since patients with this disorder were regularly given a wide variety of diagnoses, the primary problem is not the distinction between “healthy” and “sick”, but that of a differential diagnostic differentiation of this special disorder from others as a prerequisite for it targeted treatment.

supporting documents

  1. ↑ Bitterness: New Scientific Development . In: Deutsches Ärzteblatt . 6, August, p. 258.
  2. ^ E. Kraepelin: Psychiatry . In: Barth Verlag . 1915.
  3. ↑ a b Michael Linden: Bitterness and Post-Traumatic Bitterness Disorder . In: Advances in Psychotherapy . tape 65 . Hogrefe, 2017, ISBN 978-3-8444-2822-3 , 1.5.1 Epidemiology.
  4. ↑ M. Linden: Posttraumatic embitterment disorder. . In: Psychother Psychosom . 72, No. 4, August, pp. 195-202. doi : 10.1159 / 000070783 . PMID 12792124 .
  5. ↑ M. Linden: Bitterness and Post-Traumatic Bitterness Disorder. Advances in psychotherapy. . In: Hogrefe Verlag . August.
  6. ↑ M. Linden, M. Rotter, K. Baumann, B. Lieberei: Posttraumatic embitterment disorder. Definition, evidence, diagnosis, treatment. . In: Hogrefe & Huber . August.
  7. ↑ a b M. Linden, A. Maercker: Embitterment. Societal, psychological, and clinical perspectives . In: Springer . August.
  8. ↑ M. Linden, K. Baumann, B. Lieberei, C. Lorenz, M. Rotter: Treatment of posttraumatic embitterment disorder with cognitive behavior therapy based on wisdom psychology and hedonia strategies . In: Psychotherapy and Psychosomatics . 80, August, pp. 199-205.
  9. ↑ M. Linden, K. Rutkowsky: Hurting memories and beneficial forgetting. Posttraumatic stress disorders, biographical developments, and social conflicts. . In: Elsevier . August.
  10. ↑ HJ Znoj, S. Abegglen, U. Buchkremer, M. Linden: The embittered mind: Dimensions of embitterment and validation of the concept. . In: Journal of Individual Differences . 37, No. 4, August, pp. 213-222.
  11. ↑ J. Alexander: The psychology of bitterness. . In: International Journal of Psycho-Analysis . 41, August, pp. 514-520.
  12. ^ CL Hafer, R. Sutton: Belief in a just world. . In: Handbook of social justice theory and research . August, pp. 145-160.
  13. ↑ M. Linden: Post-traumatic bitterness disorder. Liberate the psyche through "wisdom therapy". . In: NeuroTransmitter . 3, August, p. 63.
  14. ↑ a b M. Linden, K. Baumann, M. Rotter, B. Lieberei: Diagnostic Criteria and the Standardized Diagnostic Interview for Posttraumatic Embitterment Disorder (PTED). . In: International Journal of Psychiatry in Clinical Practice . August 12, pp. 93-96.
  15. ↑ M. Linden, M. Rotter, K. Baumann, B. Schippan: The Posttraumatic Embitterment Disorder Self-Rating Scale (PTED Scale). . In: Clinical Psychology and Psychotherapy . August 16, pp. 139-147.
  16. ↑ a b K. Baumann, M. Linden: Wisdom Therapy . In: Behavioral Therapy Manual (Springer) . August, pp. 416-422.
  17. ↑ M. Linden: Psychotherapy of bitterness: Wisdom therapy . In: Symposium: Injury, bitterness, forgiveness . August.
  18. ↑ M. Linden: Bitterness and Post-Traumatic Bitterness Disorder . In: Hogrefe Verlag . August.
  19. ↑ A. Hasanoglu: Yeni Bir Tani Kategorisi Önerisi: Travma sonrasi Hayata Küsme Bozukluğu. . In: Türk Psikiyatri Dergisi . 19, No. 1, August, pp. 94-100.
  20. ↑ T. Sensky: Chronic embitterment and Organizational Justice. . In: Psychother Psychosom . 79, August, pp. 65-72.
  21. ↑ M. Dobricki, A. Maercker: (post-traumatic) embitterment disorder: Critical evaluation of its stressor criterion and a Proposed revised classification. . In: Nord J Psychiatry . August, pp. 1–26.
  22. Jump up ↑ S. Joel, JS Lee, SY Kim, S. Won, JS Lim, KS Ha: Posttraumatic Embitterment Disorder and Hwa-byung in the General Korean Population. . In: Psychiatry Investig . 14, No. 4, August, pp. 392-12792124.
  23. ↑ D. Blom, S. Thomaes, MB Kool, H. van Middendorp, MA Lumley, JWJ Bijlsma, R. Geenen: A combination of illness invalidation from the work environment and helplessness is associated with embitterment in patients with FM. . In: Rheumatology . 51, August, pp. 347-353.
  24. ^ H. Ege: Different typologies of workplace conflict and their connections with post traumatic embitterment disorder (PTED). . In: HEALTH . 2, August, pp. 234-236.
  25. ↑ C. Belaise, LM Bernhard, M. Linden: L'embitterment: caratteristiche cliniche. . In: Rivista di psichiatria . 47, No. 5, August, pp. 376-387.
  26. ↑ E. Michailidis, M. Cropley: Exploring predictors and consequences of embitterment in the workplace. . In: Ergonomics . August. doi : 10.1080 / 00140139.2016.1255783 .
  27. ↑ C. Shin, C. Han, M. Linden, JH Chae, YH Ko, YK Kim, SH. Kim, SH. Joe, IK In-Kwa Jung: Standardization of the Korean Version of the Posttraumatic Embitterment Disorder Self-Rating Scale. . In: Psychiatry Investigation . August 9, pp. 368-372.
  28. ↑ M. Linden, M. Rotter, K. Baumann, B. Lieberei: Posttraumatic Embitterment Disorder - Japanese Translation . In: Okayama-shi, Japan: Okayama University Press . August.
  29. ^ Y. Dvir: Posttraumatic Embitterment Disorder: Definition, Evidence, Diagnosis, Treatment. . In: Psychiatric Services . 58, No. 11, August, pp. 1507-1508. doi : 10.1176 / appi.ps.58.11.1507-a .
  30. ↑ Jörg Blech: The Psychofalle - How the soul industry makes us patients. . In: Fischer Verlag . August.