What is post-traumatic embitterment disorder (PTED)?

Post-traumatic embitterment disorder (PTED) was first introduced as a new subgroup in adjustment disorders by psychiatrist Dr Michael Linden in 2003. Nearly 20 years on, while healthcare professionals are diagnosing and treating people with PTED in the USA and wider Europe, it remains an under-recognised problem in the UK.

What is PTED?

In essence, PTED is an extreme, enduring reaction to a negative life event. This event need not be extraordinary, or usually even trigger a big negative reaction in most people. Instead, what is important is the extreme reaction it can elicit in someone and how the leading emotion of embitterment ensnares that person's life.

As Linden points out in his 2009 study, embitterment is an emotion that is familiar to all of us. It is that feeling of bitterness and anger at a certain event, and the strong sense of injustice at what happened. Linden’s data from 2009 suggest that one third of the population remember feelings of embitterment and one quarter do so in an intense way.

This does not mean that one quarter of us walk around with undiagnosed PTED. Linden distinguishes 2-3% of this population as having the "clinically relevant intensity" to diagnose this disorder. But in the UK, these people are often either undiagnosed or misdiagnosed, and as a result are not getting the treatment they need.

Causes, symptoms, and effects of PTED

In a 2020 publication, Linden describes PTED as "a response to injustice, humiliation, and breach of trust".

The causes, or 'social stressors', can seem trivial to others but they lead to a severe and lasting reaction because they have a huge impact on the person's self-esteem. Some causes could be:

• Legal disputes.

• Conflicts with family, friends, neighbours, or public authorities.

• Divorce.

• Dismissal from work.

• Breaches of trust, like infidelity by your partner.

• Vilification by others, like workplace gaslighting and bullying.

What are the symptoms of PTED?

People with PTED become so obsessed with what has happened and the injustice of it, that they neglect all other areas of their lives. Christine Pratt, founder of the National Bullying Helpline, explains: "embitterment embraces a cocktail of emotions, including hopelessness, feeling trapped, suicidal, angry and stressed."

A person with an embittered mind will experience a range of emotions, including:

• Bitterness.

• Anger and aggression.

• Frustration.

• Remorse.

• Helplessness.

• Depression.

• Stress and anxiety.

• Self-blame.

• Rejection.

• Feeling trapped.

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Constantly feeling these emotions has a serious impact on a person’s mental health and overall well-being. In turn, this leads to other mental and physical symptoms such as:

• Suicidal thoughts.

• Repeated and intrusive memories of the event.

• Sleep disturbances.

• Loss of appetite.

• Developed phobias resulting in sweating, shakes and heart palpitations.

• Lack of motivation in all areas of life.

• Symptoms relating to anxiety and stress, like panic attacks.

• Pain.

In his original 2003 study, Linden determined that these symptoms resulting from a life event could be classified as post-traumatic embitterment disorder when it has been established that no other mental disorder can explain the reaction, and the symptoms last longer than three months.

What can happen if PTED is untreated?

As a result, people experiencing PTED find it hard to function normally. They can socially withdraw from others and destroy their relationships, develop phobias that limit their ability to live normally and, in the worst cases, may consider and commit suicide.

More commonly, their careers pay the price. Pratt believes that a high percentage of people who call the National Bullying Helpline have post-traumatic embitterment disorder without realising it. Many have been signed off work by their doctors with 'work-related stress', but Pratt describes this as a vague, unhelpful term that's not a sufficient description of what's really going on.

Diagnosis and misdiagnosis of PTED

Work-related stress is just one of many incorrect or insufficient common diagnoses for people with post-traumatic embitterment disorder. Others include:

• Depressive disorders, like depression and 'burnout'.

• Anxiety disorders, like stress and phobias.

• Personality disorders, including narcissistic personality disorder.

• Severe enduring mental health disorders such as schizophrenia.

• Other adjustment disorders, like PTSD.

According to Linden, PTED can be distinguished from other adjustment disorders by looking at the cause, duration, severity and type of the syndrome. The PTED Self-Rating Scale has been developed by Linden to correctly diagnose PTED, and also measure its severity in individuals in a similar way that anxiety and depression can be measured.

Based on the PTED Scale results in 2009, Linden believes that there are many people diagnosed with depression or anxiety who should instead have a PTED diagnosis.

The right PTED treatment

Pratt calls for a better understanding of PTED by healthcare professionals in the UK: "An understanding of how many diagnosed with 'stress' might be better diagnosed with PTED is important as this will affect the treatment they receive. In the workplace, mediation is a waste of time and money and will not work.

"This is because the embittered mind does not compromise. The embittered mind blames others for causing their ill health. Effective PTED therapy is about coaching and retraining the mind."

Linden also argues that 'embittered patients' are treatment-resistant to routine psychotherapeutic approaches like mediation. Mediation sessions involve a 'mediator' - often a therapist - who facilitates a session with a patient and the individual/party who is causing them stress, in an attempt to talk through and resolve a conflict.

A pilot study found that PTED patients treated with cognitive behavioural therapy based on wisdom psychology showed "significant and clinically meaningful" improvements to their condition, compared to those who received routine treatment. Pratt believes that a focused, validated coaching programme will work in some cases.

Wisdom therapy (or coaching) is therefore currently considered to be the most effective way to treat people with PTED. It is a way of coaching the mind by enhancing the wisdom competencies of an individual. This includes their view of the world, of themselves, of others, and of the future. The therapy works to change a person's perspective of the event that caused their embitterment and allows them to develop coping tools like empathy, forgiveness, and tolerance.

The ultimate goal is to provide the person with a new perspective that frees them from a mindset that is keeping them trapped. Pratt believes that the effects of this treatment can't be underestimated:

"When this syndrome is fully recognised and understood by healthcare professionals in the UK, I believe that we can save lives."