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Posttraumatic embitterment disorder

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Post-traumatic embitterment disorder (PTED) is a proposed disorder modeled after post-traumatic stress disorder (WP). Some psychiatrists are proposing this as a mental disorder because they believe there are people who have become so bitter they can barely function. [1][2]


Scientific History: First Described in 2003Edit

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

Linden, who has conducted research on the proposed disorder, 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.” (“Experts say embitterment should be a mental illness,” The Oregonian, pg. B3, 5/27/09)

Strictly speaking these PTED patients do not fit the formal criteria for Wikipedia:PTSD prompting the description of a new and separate disorder and can be clinically distinguished from it.

The disorder as portrayed in fictionEdit

Non-medical discussions of paralyzing embitterment is a long running theme in literature. A paragraph from Wikipedia:Aristotle's Wikipedia:Nicomachean ethics describes PTED. Fictional PTED patients might include the characters: Wikipedia:Captain Ahab from Wikipedia:Moby-Dick, Wikipedia:Edmond Dantes from Wikipedia:The Count of Monte Cristo, Wikipedia:Captain Nemo from Wikipedia:20,000 Leagues Under the Sea, Wikipedia:Miss Havisham from Wikipedia:Great Expectations by Wikipedia:Charles Dickens, Severus Snape from the "Harry Potter series", by JK Rowling, Wikipedia:Achilles from the Wikipedia:Iliad by Wikipedia:Homer, and Wikipedia:Khan Noonien Singh in Star Trek II: The Wrath of Khan.

This is not an official medically diagnosed list and indeed a scientific study and diagnosis should be made by psychologists and literary critics of these and others to sharpen, clarify, and extend this list via literary-medical publications.

PTED is not in the latest Wikipedia:DSM-IV-TR. It might be included the Wikipedia:DSM-5. There is no hard information on this nor if it would be a provisional diagnosis.

PTED is not in the latest Wikipedia:ICD-10-CM. It might be included the Wikipedia:ICD-11. There is no hard information on this nor if it would be a provisional diagnosis.

This article has no other information about official recognition of PTED at this time by these two leading bodies.

Philosophical HistoryEdit

Non-medically scientific discussions of paralyzing embitterment run continually to today to pre-history. Linden often cites a paragraph by from Wikipedia:Aristotle's Wikipedia:Nicomachean ethics describing PTED in a similar form.

No Official Status and Medical Recognition in Wikipedia:DSM or Wikipedia:ICDEdit

PTED is not listed in the Wikipedia:DSM-IV-TR or Wikipedia:ICD-10-CM.

Description, Diagnosis, and AssessmentEdit

Complete and Comprehensive Wikipedia:DSM-IV-style description - Specification of Diagnostic Criteria of Posttraumatic Embitterment Disorder (PTED)Edit


The revised 2009 description of PTED follows below (Reference: Max Rotter's Thesis) (The below is slightly different clinically than the original PTED description; in Linden's seminal 2003 Paper))

Diagnostic FeaturesEdit

The essential feature of Posttraumatic Embitterment Disorder is the development of clinically significant emotional or behavioral symptoms following a single exceptional, though normal negative life event. The person knows about the event and perceives it as the cause of illness. The event is experienced as unjust, as an insult, and as a humiliation. The person’s response to the event must involve feelings of embitterment, rage, and helplessness. The person reacts with emotional arousal when reminded of the event. The characteristic symptoms resulting from the event are repeated intrusive memories and a persistent negative change in mental well-being.

Affect modulation is unimpaired and normal affect can be observed if the person is distracted. The trigger event is a single negative life event that can occur in every life domain. The event is experienced as traumatic due to a violation of basic beliefs. Traumatic events of this type include, but are not limited to, conflict at the workplace, unemployment, the death of a relative, divorce, severe illness, or experience of loss or separation. The illness develops in the direct context of the event. The person must not have had any obvious mental disorder prior to the event that could explain the abnormal reaction.

Associated FeaturesEdit

Individuals with Posttraumatic Embitterment Disorder frequently manifest decreased performance in daily activities and roles. Posttraumatic Embitterment Disorder is associated with impaired affectivity. Besides prolonged embitterment individuals may display negative mood, irritability, restlessness, and resignation. Individuals may blame themselves for the event, for not having prevented it, or for not being able to cope with it. Patients may show a variety of unspecific somatic complaints, such as loss of appetite, sleep disturbance, pain and Wikipedia:anhedonia.

Specific Culture FeaturesEdit

Elevated rates of Posttraumatic Embitterment Disorder may occur in times of major social change.

Differential DiagnosisEdit

Despite partial overlaps in symptomatology, the Posttraumatic Embitterment Disorder can be differentiated from other Affective Disorders, Posttraumatic Stress Disorder, or Anxiety Disorders.

In contrast to Adjustment Disorder the symptomatology of Posttraumatic Embitterment Disorder does not show the tendency of spontaneous remission.

In contrast to Depression affect modulation is unimpaired in Posttraumatic Embitterment Disorder. In Depression, the specific causal connection between the trigger event and symptomatology in Posttraumatic Embitterment Disorder cannot be found.

While in Posttraumatic Stress Disorder anxiety is the predominant emotion, in Posttraumatic Embitterment Disorder it is embitterment. In Posttraumatic Stress Disorder there must be a critical event that has to be exceptional, life-threatening and, most important, is invariably leading to acute panic and extreme anxiety. In Posttraumatic Embitterment Disorder there is always an acute event that can be called normal as it can happen to many persons in a life course. Still it is also an exceptional event as it is not an everyday event.

Diagnostic criteria for Posttraumatic Embitterment DisorderEdit

A. Development of clinically significant emotional or behavioral symptoms following a single exceptional, though normal negative life event.

B. The traumatic event is experienced in the following ways:

B1. The person knows about the event and sees it as the cause of illness.

B2. The event is perceived as unjust, as an insult, and as a humiliation.

B3. The person’s response to the event involves feelings of embitterment, rage, and helplessness.

B4. The person reacts with emotional arousal when reminded of the event.

C. Characteristic symptoms resulting from the event are repeated intrusive memories and a persistent negative change in mental well being.

D. No obvious mental disorder was present prior to the event that could explain the abnormal reaction.

E. Performance in daily activities and roles is impaired.

F. Symptoms persist for more than 6 months.


Clinician diagnosis is made with the: Standardized Diagnostic Interview for PTED.

Severity MeasurementEdit

Patient self-assessment of the severity is made with: The Post-Traumatic Embitterment Disorder Self-Rating Scale (PTED Scale).

Descriptive DefinitionEdit

Max Rotter's Thesis clarifies the primary hypothetical cause and mechanism from the standpoint of Schema Theories in Psychology (see Wikipedia:Schema (psychology)) as follows: PTED is conceptualized as a special form of adjustment disorder, which develops in the direct context of a casual negative life event. It is explained by a mismatch between basic beliefs and negative life events, which violates this cognitive schema.

PTED, PTSD, Versus Non-traumatized Persons - Mechanisms of Disorder and Treatment ImplicationsEdit

PTSD Considerations for Potential AnalogyEdit

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

PTED ConsiderationsEdit

PTED may arouse or influence PTSD-affected systems differently or arouse different systems. Thus PTED, although modeled on PTSD, may have slightly through great different disordering, mechanisms, and treatments.

There is no published work at this time on different underlying neurological, endocrinology, and physiological changes in PTED patients as an analog to the PTSD Treatment book. This research has not yet been done or started for the most part. PTED research is 40 years behind PTSD research.

Wikipedia:PTSD versus Wikipedia:PTED Causation DifferencesEdit

Wikipedia:PTSD often is caused by a physical, anxiety attack on a person’s life.

Cognitive Psychology has documented led personal metaphysical-existential worldview belief system and conceptual schema system for decades.

Wikipedia:PTED is caused by a not-necessarily physical but mental, social, psychological, or event shattering of such a schema and belief system.

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."

First Line talk therapy treatment is Wisdom TherapyEdit

Michael Linden proposes Wisdom Therapy as a provisional and studied treatment in his books.

The Dimensions of Wisdom targeted in Wisdom Therapy are: 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.

It is demonstrated that Wisdom Activation in PTED patients is inhibited in the specific areas of 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 will indirectly reactivate underutilized wisdom to carry over to their embittered problems later on after Therapy.

Also see the following article:

Article: Posttraumatic Embitterment Disorder and Wisdom Therapy

Journal: Journal of Cognitive Psychotherapy Article

Date: April 1, 2008

Psychopharmacology of PTEDEdit

There are no published or suggested studies on drug treatments for PTED.

The latest scientific survey analysis of the medical literature on drug treatments for PTSD is in Mathew Friedman's chapter in the book on PTSD treatments. 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.

PTED versus the emotions of "regular" Embitterment and versus Reactive EmbittermentEdit

PTED is a psychological adjustment-reactive disorder more severe than just being embittered in colloquial language. It can be qualitatively measured with high scientific reliability and repeatability.

The related concepts are discussed and distinguished: (ordinary) embitterment, reactive embitterment, versus PTED. Reactive Embitterment may be: specific, diffuse or non-PTED. Various rating, assessment scales, and distinctions are studied and investigated.

See the thesis: Thesis Title: Reactive Embitterment: Conceptualization, Relevancy, Differentiation. Author: Max Rotter. Date: March 4, 2009

Primary Source Seminal Books on PTEDEdit

The first two books ever published on PTED are by or edited by Michael Linden. These books are the primary sources on this syndrome; the academic literature is scattered.

The first published and seminal book comprehensively explaining and focusing completely narrow-angle on the syndrome and all related information up to 2006 which includes most if not all of the essential information in Michael Linden’s 2003 through 2008 scholarly publications.

The cited references in the above book and the following book give as complete a survey of all related PTED published articles for those looking for a complete published scientific literature account.

The second book is an unofficial "sequel" and companion to the first book; it is topically a wide-angle view of embitterment and PTED in a broad aspects of embitterment throughout the social sciences to 2010.

Primary Source Articles (not books) Seminal Publications on PTEDEdit

The syndrome was first described in:

  • Linden M. (2003). The Posttraumatic Embitterment Disorder. Psychotherapy and Psychosomatics, 72, 195 – 202.

The other primary foundational scientific articles (exluding the books by Linden et all) are:

  • Linden M., Baumann K., Rotter M., & Schippan B. (2007). The psychopathology of posttraumatic embitterment disorders (PTED). Psychopathology, 40, 159-165.
  • Linden M., Baumann K., Rotter M., Schippan B. (2008). Diagnostic criteria and the standardized diagnostic interview for posttraumatic embitterment disorder (PTED). International Journal of Psychiatry in Clinical Practice, 12(2), 93-96.
  • Linden M., Baumann K., Rotter M., Schippan B. (2008). Posttraumatic embitterment disorder in comparison to other mental disorders. Psychotherapy and Psychosomatics, 77, 50-56.

The above articles highly overlap with Linden's 2006 book.


  • Effective Treatments for PTSD, Second Edition: Practice Guidelines from the International Society for Traumatic Stress Studies.Editors: Edna B. Foa, Terence M. Keane, Matthew J. Friedman, Judith A. Cohen
  • Shattered Assumptions, by Ronnie Janoff-Bulman
  • Posttraumatic Embitterment Disorder: Definition, Evidence, Diagnosis, Treatment, Michael Linden, Max Rotter, Kai Baumann, Barbara Lieberei, ISBN 0889373442


Wikipedia:Template:Mental illness (alphabetical list)

de:Posttraumatische Verbitterungsstörung

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