International Journal of Psychiatry in Clinical Practice, 2008; 12(2): 93
96

ORIGINAL ARTICLE

Diagnostic criteria and the standardized diagnostic interview

for posttraumatic embitterment disorder (PTED)

MICHAEL LINDEN, KAI BAUMANN, MAX ROTTER & BARBARA SCHIPPAN

Research Group Psychosomatic Rehabilitation, Charité University Medicine Berlin and Rehabilitation Center Seehof, Teltow/
Berlin, Germany

Abstract
Objective. The posttraumatic embitterment disorder (PTED) is a specific form of adjustment disorder. The purpose of this
study was to specify diagnostic criteria of PTED, and to develop a standardized instrument which allows a standardized
diagnosis. Method. Data were obtained from 50 clinically defined PTED patients and 50 patients with other mental
disorders (N100) using a semi-standardized interview for PTED. Based on the answers of the participants, the description
of PTED was refined and a standardized diagnostic interview for PTED was derived. Results. The diagnostic algorithm
reached satisfying levels of sensitivity (94%) and specificity (92%). Conclusion. The diagnostic interview for PTED allows a
standardized diagnosis of PTED.

Key Words: Adjustment disorder, posttraumatic embitterment disorder, diagnostic criteria

Introduction gered by a single and exceptional negative event.

Negative life events can cause severe impairment in
psychological functioning. Such pathological reac-
tions to stressful events are classified in ICD-10 [1]
and DSM-IV [2] as adjustment disorders. However,
the diagnostic criteria for adjustment disorders are
vague and specify that no diagnosis should be
made, if the criteria for another disorder are met
[3]. The only precisely defined psychiatric disorder
classified as being caused by stress is PTSD. PTSD
develops in response to a life-threatening traumatic
event which provokes intense anxiety, fear, and
panic [2], and is marked by a characteristic pattern
of symptoms such as intrusive thoughts and hyper-
arousal [4]. Recently there has been a tendency
in clinical practice to expand the use of the
diagnostic category of PTSD. It is frequently
applied to patients who suffer from reactive dis-
orders in connection to non-life-threatening nega-
tive events [5]. This expansion of the PTSD
diagnosis indicates a necessity of further subclassi-
fications of adjustment disorders.
With posttraumatic embitterment disorder
(PTED), Linden [6] introduced a new subclass of
adjustment disorders. Similar to PTSD, it is trig-
However, in contrast to PTSD, the trigger event
in PTED is not an anxiety-provoking and life-
threatening stimulus, but an exceptional, though
normal negative life event like unemployment,
occupational problems, divorce, illness, or separa-
tion. The core pathogenic mechanism is not the
provocation of anxiety, but a violation of basic
beliefs [7
9]. This threat to deeply held beliefs,
acts upon the patient as a powerful psychological
shock, which triggers a prolonged feeling of embit-
terment and injustice. The psychopathology in
PTED shows a causal relationship to the event
and cannot be explained by some mental disorder
prior to the event.
Patients who react with prolonged embitterment
to a negative life event can develop impressive
psychopathological symptoms and disability [10].
A population study indicated a prevalence rate
of 2
3% of clinical relevant embitterment in the
general population, suggesting that reactive embit-
terment is an emotion of great social significance
[11].
The present paper specifies diagnostic criteria for
PTED and presents an empirically derived standar-
dized algorithm for the diagnosis of PTED.

Correspondence: Prof. Dr. Michael Linden, Rehabilitation Center Seehof, Lichterfelder Allee 55, D 14513 Teltow/Berlin, Germany. Tel: 49 3328/345678.
Fax: 49 3328/345555. E-mail: michael.linden@charite.de

(Received 21 December 2006; accepted 18 July 2007)

ISSN 1365-1501 print/ISSN 1471-1788 online # 2008 Taylor & Francis
DOI: 10.1080/13651500701580478
94 M. Linden et al.

Method patients (30 women, 20 men) were diagnosed as

Subjects
All Participants (60 females, 40 males) were treated
as inpatients in the Department of Behavioral
Medicine and Psychosomatics of the Rehabilitation
Center Seehof, Teltow/Berlin, which treats prefer-
ably patients from Eastern Germany. The majority
of patients are sent by their physicians or by
insurance companies due to prolonged sick leave.
Distribution of patients in such hospitals is orga-
nized on a national level by insurance companies and
was not subject to special selections. During the
recruitment period (20 months), all therapists from
the department were asked to report patients with
severe reactive disorders. About 1200 patients were
screened throughout this time. The reported pa-
tients were then interviewed and thoroughly exam-
ined by one of the authors (BS). Fifty of 88 reported
suffering from PTED (PTED sample) according to
clinical judgment and in accordance with the clinical
description of the disorders as given by Linden [6].
The reported critical life events in the PTED sample
were work related in 72.9%, related to the family or
partnership in 12.5%, the death of a relative or a
friend in 8.3%, and an illness in 6.3%.
A control group (CG) was set up by selecting
another 50 patients, who were treated for various
mental disorders. Whenever a PTED patient was
admitted, the next incoming patient with the same
gender and age but no indication of PTED was
included. All patients gave their written informed
consent to participate in the study.
Following the matched-pair design, in both groups
60% of patients were female and their average age
was 49 years. There was a significant difference (x2 
11.98, P 0.001) in respect to their occupational

Table I. Specification of diagnostic criteria of PTED.

Posttraumatic embitterment disorder

Diagnostic features
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 features
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.
Specific culture features
Elevated rates of posttraumatic embitterment disorder may occur in times of major social changes that force people to reorganize there
personal biographies.
Differential diagnosis
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 can not 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 disorder
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:
(1) the person knows about the event and sees it as the cause of illness;
(2) the event is perceived as unjust, as an insult, and as a humiliation;
(3) the person’s response to the event involves feelings of embitterment, rage, and helplessness;
(4) 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.
 Diagnostic criteria and diagnostic interview for PTED 95

status, such that 87.5% of CG patients but only
46.9% of PTED patients presently had a permanent
job. No differences in family status were found.
According to the results of the MINI psychiatric
interview [12], both groups fulfilled the criteria
for many disorders with a significantly higher
occurrence of acute major depression (50 vs. 12%;
x2 16.88, P B0.001) and chronic adjustment dis-
order (66 vs. 20%; x2 21.58, P B0.001), but less
generalized anxiety disorder lifetime (4 vs. 22%;
x2 7.16, P 0.007) in PTED patients.
Instrument
Patients were interviewed with a semi-standardized
interview, which had been developed in a pilot study
[5]. The interview asks for the core characteristics
of PTED, the emotional spectrum experienced when
patients are reminded of the event, and psycho-
pathological signs and symptoms.
Procedure
Results of the interview were used to specify the
diagnostic criteria for PTED. Moreover, the discri-
minatory power of the interview and of each item
was analyzed, and a diagnostic algorithm, which
allows the best differentiation of both groups, was
derived. Based on an error analysis of the conflicting
classifications (clinical diagnoses versus diagnoses
based on the diagnostic algorithm) the diagnostic
algorithm was modified and translated into a stan-
dardized diagnostic interview for PTED.
Results
Based on the results of the interview the description
of PTED was refined. The essential features of
the clinical concept as outlined by Linden [6] were
supported by the data. A single exceptional negative
life event precipitates the onset of illness in PTED.
This event is experienced by the patient as the sole
cause of illness. It is perceived as unjust and as an
affront. Patients have repeated intrusive memories
about the event, and they react to the event with
embitterment, rage, and helplessness. Patients with
PTED manifest severe persistent psychopathological
symptoms in the direct context of the critical event,
despite there being no premorbid psychopathology
or functional disorder. Table I summarizes the
features of this disorder according to the standard
structure of the DSM-IV.
The item combination of the semi-standardized
diagnostic interview that allowed the best differen-
tiation (i.e. in reference to sensitivity and specificity)
of both groups was derived from the interview. On
the basis of this diagnostic algorithm, 47 of the
50 PTED patients were correctly classified. Thus,
the sensitivity was 94%. Four of the 50 control
patients, who had been classified as non-PTED

Table II. The standardized diagnostic interview for PTED.

Posttraumatic embitterment disorder

A. Core Criteria
1. During the last years, was there a severe event/experience that led to a noticeable and persistent
0
NO YES
negative change in your mental well-being?
2. Do you experience the critical life-event as unjust or unfair?
0
NO YES
3. Do you feel embitterment, rage, and helplessness when reminded of the event?
0
NO YES
4. Did you suffer from any (substantial/relevant/noticeable) psychological or mental problems NO
0
YES
(depression, anxieties or the like) prior to the event?

EVALUATION BY THE EXAMINER:

EMOTIONAL EMBITTERMENT (MARKED BY EMBITTERMENT, RAGE, AND HELPLESSNESS)?
0
NO YES
CAN ANY PREMORBID MENTAL DISORDER EXPLAIN THE PRESENT PSYCHOPATHOLOGY? NO
0
YES
5. For how long do you suffer already from psychological impairment caused by the event? (Specify in months)

______ Months
0
Less than 6 months
B. Additional Symptoms
1. During the last months, did you have repeatedly intrusive and incriminating thoughts about the event? NO YES
2. Does it still extremely upset you, when you are reminded of the event? NO YES
3. Does the critical event or its originator makes you feel helpless and disempowered? NO YES
4. Is your prevailing mood since the critical event frequently down? NO YES
5. If you are distracted, are you able to experience a normal mood? NO YES
ARE FOUR QUESTIONS IN SECTION B ANSWERED WITH YES?
0
NO YES
POSTTRAUMATIC EMBITTERMENT DISORDER NO YES

Note. The Answers marked with an arrow indicate that one of the essential criteria for the diagnosis of PTED is not met. Thus, the clinician
is asked to directly indicate ‘‘NO’’ in the diagnostic box at the button of the interview.
96 M. Linden et al.
patients, were diagnosed as having PTED. Thus, the
specificity was 92%.
In order to find the reasons for conflicting
classifications (clinical diagnoses versus diagnoses
based on the diagnostic algorithm), the patient files
of the seven wrongly classified patients were re-
viewed. Problems arose because of other premorbid
mental illnesses and because of other negative
emotions that had been mistaken as embitterment
(e.g., bereavement). In order to minimize such
misclassifications, the questions of the interview
and the diagnostic algorithm were refined. The
resulting standardized diagnostic interview for
PTED is presented in Table II. It asks for feelings
of injustice and reactive embitterment as the core
and indispensable psychopathological criterion.
Furthermore, it asks for five additional signs, of
which four must be present to fulfill the diagnostic
criteria for PTED. In addition, the interviewer must
thoroughly ask for a history of other mental dis-
orders and also clarify the specific quality of the
present emotions, so that bereavement or melan-
choly is not mistaken for embitterment.
Discussion
The concept of PTED was originally developed on
the basis of clinical experiences with many such
patients [6]. Since then, several empirical studies on
PTED have been initiated. An indispensable pre-
requisite for further research are instruments which
allow a standardized diagnosis. The diagnostic inter-
view for PTED fulfills the need for a standardized
diagnostic instrument. The sensitivity of 94% and
specificity of 92% are satisfactory and will be
improved if the interviewer makes sure that the
questions are properly understood and the answers
are correctly classified.
The diagnostic interview for PTED was developed
on the grounds of post hoc analyses of empirical
data. Thus, no specifications regarding psychometric
properties can be made, and the details on sensitivity
and specificity of the instrument have to be regarded
as preliminary. Further research is needed to gather
data pertaining to reliability and validity. Moreover,
our findings need confirmation by other researchers.
Key points
. On the basis of an empirical study, a standar-
dized interview and diagnostic algorithm for the
assessment of PTED is presented
. This tool can help other researchers to study
this subject
Statement of interest
This study has been supported by an unrestricted
Research Grant by the Bundesversicherungsanstalt,
Germany (grant number: 8011-106-31/31.51.0).
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