Posttraumatic embitterment disorder

Posttraumatic embitterment disorder (PTED) is a proposed disorder modeled after posttraumatic stress disorder. Some psychiatrists are proposing this as a mental disorder because they believe that there are people who have become so bitter, they can barely function.^[1] PTED patients do not fit the formal criteria for PTSD and can be clinically distinguished from it, prompting the description of a new and separate disorder.^[2][3]

German psychiatrist Michael Linden, who has conducted research on the proposed disorder,^[4] 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."^[3]

PTED so far has no official status and is not listed in the DSM-IV-TR or ICD-10-CM.

History

Non-medical discussions of paralyzing embitterment is a long running theme in literature. A paragraph from Aristotle's Nicomachean ethics describes PTED.

PTED was named by Linden in his seminal (2003) paper and modeled after PTSD since many of his patients did not fit the PTSD label.

Mechanisms of disorder and treatment implications

PTSD as potential analogy

PTSD has significant arousal and other effects on physiological, endocrine, HPA axis, brain centers, and neurological systems. These have been the bases of treatments well known and studied for decades via both theoretical and practical descriptions of illness, rationales of treatment modalities, and mechanisms of therapeutic actions.

PTED may arouse or influence PTSD-affected systems differently or arouse different systems. Thus PTED, although modeled on PTSD, may differ to various degrees and in various ways.

There is no published work at this time on different underlying neurological, endocrinology, and physiological changes in PTED patients as an analog to PTSD.

Causes

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."

— Linden (2003)

Wisdom therapy

Michael Linden proposes "wisdom therapy" as a provisional treatment in his books. He demonstrated that wisdom activation in PTED patients is inhibited in the specific areas 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 indirectly reactivates underutilized wisdom to carry over to the patient's embittered problems later on after therapy. The components of wisdom therapy are to 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.^[5]

Psychopharmacology

There are no published or suggested studies on drug treatments for PTED. 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.^[6]

"Ordinary" embitterment and reactive embitterment

PTED is a psychological adjustment-reactive disorder more severe than just being embittered in the colloquial sense. It can be qualitatively measured with high scientific reliability and repeatability. Related concepts include (ordinary) embitterment and reactive embitterment. Reactive embitterment may be specific, diffuse or non-PTED. Various ratings, assessment scales, and distinctions have been investigated.^[7]

References