Posttraumatic Embitterment Disorder: Definition, Evidence, Diagnosis, Treatment

The special form of maladjustment reaction called the ‘post traumatic embitterment disorder’ (PTED) first came to light after the observation in Germany of an increase in pathological reactions to critical life events in the aftermath of German reunification. Patients with this disorder showed distinct and characteristic psychopathological features. This type of reaction is thought to be universal and frequently seen in patients who have had to cope with events of personal injustice, humiliation, frustration, and helplessness. Being the first monograph on the subject, this book was written by leading researchers who intend to give a comprehensive overview of both the conceptual background and recent developments in PTED research.

The book is divided into 3 parts. The first part gives an overview of the theoretical background of stress and stress reactions, discussing different conceptualisations of stress and life events. Aetiological agents are discussed, and the methodological aspects and findings of life events research presented. The definition, epidemiology, aetiology, and treatment of adjustment disorders under the ICD-10 and DSM-IV diagnostic categories are discussed and post- traumatic stress disorder (PTSD) is introduced as a well- defined reactive disorder. It then presents the theoretical concept of PTED as a special form of adjustment disorder. The authors recognise embitterment as a unique human emotional experience. Feeling embittered is a prolonged emotional state of hate and anger caused by the belief that one has been treated unfairly. Emotional embitterment exists in a dimension similar to depression and anxiety, and therefore, when it is most intense, it can become pathological and lead to devastating personal, social, and occupational impairment. This clinical syndrome is described as ‘post-traumatic’, because its onset must follow a single precipitating life stressor, which inevitably causes the patients to feel they have been treated unfairly. Unlike the life-threatening events leading to PTSD, the events leading to PTED are exceptional but usual life events that do not cause a threat to one’s physical integrity but instead cause a violation of basic beliefs, which can be experienced as ‘traumatic’. The book discusses the possible aetiological factors for PTED, in particular ‘violation of basic belief’ and ‘lack of wisdom’. It presents the most recent advances in wisdom psychology research and illustrates how wisdom can be conceptualised not as a personality characteristic but as a cultural and collective product and as an expertise. This can be divided into various wisdom-related performances that can be operationalised and measured.

The second part of the book summarises the empirical evidence for PTED. Data from research conducted by the Department of Behavioural Medicine and Psychosomatics of the Rehabilitation Centre Seehof of Germany are presented. The research-derived diagnostic criteria for PTED according to the rules of DSM-IV and the clinical course and characteristic psychopathologies seen in PTED are outlined and compared with other mental disorders. A diagnostic interview for PTED, along with a self-rating scale for PTED, is also described, together with data on its principal component analysis, internal consistency, test- retest reliability, and convergent and discriminant validity. Features of the epidemiology of PTED in clinical and non- clinical populations in Germany are also described. Lastly, in the second part, aetiological concepts and vulnerability factors in relation to wisdom psychology are discussed.

The third part of the book deals with psychological treatment for PTED. Firstly it presents treatment concepts based on the cognitive-behavioural model, and then introduces an evolving specific treatment for PTED called ‘wisdom therapy’, a new psychotherapeutic approach that aims to activate patients’ wisdom-related knowledge.

This book is easy to read, clear, and well-organised with case vignettes throughout the book. The full version of the research-derived semi-standardised diagnostic interview for PTED, its self-rating scale, as well as the wisdom rating scale and the wisdom-training outline are included. The book effectively presents the pioneering work being done in PTED. Further research in this field is needed to assess the epidemiology, and the validity and reliability of the proposed diagnostic criteria in different populations. The specific psychological treatment for PTED, ‘wisdom therapy’, is still in the early stages of development, and pharmacological treatment for PTED is not discussed at all in the book. Further research is required to improve outcomes in patients suffering from this disorder and to reduce any disability it may cause.

While the incidence of PTSD rises during times of adversity, such as war, PTED is seen more frequently when there are societal changes that force people to cope with reorganisation of their lives and prospects. Hong Kong and China have recently undergone rapid economic change, something likely to affect the lives of many. It is foreseeable that clinicians will encounter more patients suffering from adjustment disorders caused by these major societal changes. While introducing PTED as a unique adjustment disorder, this book also illuminates the specific psychopathologies many people living today may be experiencing and is useful for clinicians who regularly encounter patients with adjustment disorders, particularly those who have a specific interest in this field.

Dr Mark JS Wong
Department of Psychiatry
Tai Po Hospital
Tai Po
Hong Kong
China

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