THE OTHER RAGE: POSTTRAUMATIC EMBITTERMENT DISORDER

Interview with Michael Linden

[This interview originally published in the Berlin Freitag 52, 12/17/2004 is translated from the German on the World Wide Web, www.freitag.de/2004/52/04521801.php.]

[Everyone knows the feeling of embitterment. However this is growing to a serious sickness for some people. Several years after the turn, professor Michael Linden, physician at the psychosomatic Seehof rehabilitation clinic in Tellow/ Berlin increasingly saw patients with symptoms that he described with a new term: posttraumatic embitterment disorder.]


Freitag: You invented a new sickness…

Michael Linden: “Inventing” is relative. Aristotle already described the phenomenon among the ancient Greeks. We are now trying to improve the diagnostic criteria and develop a treatment.

How did you get the idea of explaining embitterment as a sickness?

In retrospect we are very astonished that this emotion was not considered in the past in psychopathology. The reason is always at hand. Someone is embittered on account of some occasion. One knows why and no longer continues questioning. A self-dynamic develops unseen. If I personally had the choice of having a fear sickness, a depressive sickness or an embitterment disorder, I would certainly not choose embitterment. Embitterment is a much more serious and more negative feeling than fear or depression.

What makes it worse?

Embitterment is a compound emotion that includes despair, aggression against oneself, against another person, hopelessness and mental blocks. Embitterment is a far wider and more comprehensive emotion than depression or fear. Many areas of life are not affected with anxiety. Embitterment seizes everything.

How does embitterment arise?

Take one of my patients as an example. She worked passionately for many years in a small family firm. Economic problems arose and the woman was given a written notice on a Friday afternoon by a messenger. One could long speculate why the owner did this since he saw her every day. In any case, the woman went home, screamed about this over the weekend, was totally depressed and never left her house for a whole year until she came to the clinic. She didn’t meet anyone, accept any new job offers, eat any more and couldn’t sleep.
Wouldn’t that have happened if she received a different kind of notice?

Perhaps.

What are the necessary conditions for a PTED?

Posttraumatic stress disorder (PTSD) is a similar sickness. A life-threatening cause must exist for that diagnosis, for example a bomb attack in war. Approximately a third of the persons affected by such traumatic experiences develop subsequent symptoms that continue and intensify. With PTED, we do not have any extraordinary cause in that sense. A common but not everyday event like a dismissal, separation or sometimes only a quarrel triggers the PTED. Persons can be stricken when they are hurt in areas that are centrally important for them, areas that define their life.

Isn’t the trauma-term a little exaggerated?

Trauma only means that an event leads to a breach. A PTSD does not occur without a life-threatening event. A PTED doesn’t exist without an incisive event that can be identified with a date and time.

Can this be identified from the symptoms?

The embitterment disorder is not a fear sickness. In the PTED there is a sickness experience that violates central cognitive assumptions, becomes independent and leads patients either to kill themselves at least in their minds or to no longer eat or sleep. The patients have intrusions, constantly pressing memories of the event and develop phobias. We have patients who refuse to drive through that part of town where they could meet the aggressor. On first view one could think this is a phobia. I recall a former patient whom I treated unsuccessfully under the diagnosis of a phobia. Today I know why. That was not a phobia.

Isn’t rage, not fear, the basic feeling of embitterment?

Embitterment is different than rage. Rage is directed outwards. Embitterment is a mixture of dejection and inner agitation, a conglomerate of very different bad emotions. The patients cannot manage themselves and seek help. When told of help, they immediately put the helper on the side of the enemy.

Why hasn’t this disturbance been identified up to now?

There are several reasons. Patients offer so many symptoms that any other diagnosis is quickly dismissed, for example phobia or depression. Giving a diagnosis to this patient is not a problem. However it isn’t right. Secondly, an explanation can be quickly offered. Everything is seemingly explained by a separation or termination. Thirdly, we only saw individual patients in the past. Now we see many more persons.

What are the reasons for this?

This is related to the turn. When 17 million people had to reorganize their biography, some came to grief. Certain social conditions increase the incidence of PTSD – wars for example. Obviously certain conditions can lead to more frequent embitterment disorders. We didn’t see this in the first years after the turn but first after a half decade.

How do you explain this?

Many lost their job or had to change immediately after the turn but everyone thought this was a good thing. Time elapsed until the great expectations disappeared in thin air and people ran aground.

Wouldn’t you say that embitterment is an East-phenomenon?

No. I have many patients from the West. Embitterment is a reaction to very individual life risks…

Are these risks culturally conditioned?

They aren’t cultural by nature.

Could PTED appear in Africa or China?

Yes, I recently met a colleague from Korea at a congress who discussed similar phenomena. Basic personal attitudes allow us to act coherently across our lifespan in thousands of individual situations. These attitudes occur in religions, worldviews and overarching values. Pathological reactions appear when the4se attitudes are hurt in a bad way. Everyone knows embitterment as a basic human experience. However a new quality arises upon reaching a certain quantity.

Is embitterment peculiar to one gender?

No, we see embitterment disorder equally with men and women.

Is embitterment related to the level of education?

No. Embitterment has something to do with wisdom but wisdom is independent of intelligence and education. Wisdom could be defined as expert management of ambiguous life problems that in the end cannot be solved. This is an ability we need every day, the ability to change perspective or relativize things. This emotional intelligence has nothing to do with school education. Patients with low scores in these dimensions have a higher risk for embitterment.

What patients do you have in the clinic?

Patients with embitterment disorders are often assigned to us by the health insurance plans or pension insurers after the medical service of the health insurance companies analyzed them because of long incapacity for work and suggested an in-patient treatment. Some have been unable to work for years.

What is the treatment?

We are still testing. We failed with the first patients. Compared to other patients, PTED patients have more mental symptoms when they come and less changed values when they leave. In the past, we weren’t very proud therapeutically of this group.

Do you work in behavioral therapy?

Yes. We have developed procedures for objectively identifying and diagnosing PTED and new therapeutic approaches. We try to name the emotions. The patients often have clear fantasies how they could kill someone but feel inadequate. Nevertheless they think about this without verbalizing since it is too full of shame. This shame threshold must be overcome. Then the exact course of the sickening event can be seen. One must understand the basic assumptions of patients and gradually try to change their interpretation of events. For example, changing perspectives, transporting oneself into other roles and viewing the event retrospectively from a distant point in the future are helpful. Then we systematically attempt to train “wisdom powers.”

What kind of person has an embitterment disorder?

I would say: a powerful person. If you want to play piano in the Philharmonic, you must spend your whole life playing the piano. The family may not be so important for you. You may not still play football etc. This also makes you delicate or susceptible.

There are people who don’t react embittered under the same conditions.

There is a psychic resistance. People have lived under unbearable conditions since time immemorial. Having an argument, being at war and losing children is unfortunately the normal state. Humanity would have died out long ago if people in wartimes did not have babies. We have the ability to handle negative life burdens. There is no one-to-one relation between event and consequence. Therefore a prediction is very difficult.

What is the response to PTED among the experts? Is there a headwind blowing?

Both critical questions and approval occur. We have published our results in several studies. Many clinics and expert doctors say: Yes, I know that. Finally I know what is wrong. Others ask whether a new concept is really necessary and if the diagnosis of PTSD is not sufficient. In the end, further research will have to clarify the relative importance of the PTED diagnosis.

How many persons are embittered?

We did a epidemiological analysis. Approximately half of the people can remember something in the last year that made their blood boil. According to our data, three percent of the analyzed persons are clinically impeded.

Is embitterment an inhibited revenge?

The patients were not improved when they had their revenge.

Isn’t revenge relieved?

Justice would help them but revenge is not justice. Social battles over distribution are involved. The clinical phenomena PTED cannot only be understood socio-economically or politically.