International Journal of Psychiatry in Clinical Practice, 2008; 12(2): 9396
ORIGINAL ARTICLE
Diagnostic criteria and the standardized diagnostic interview for posttraumatic embitterment disorder (PTED)
MICHAEL LINDEN, KAI BAUMANN, MAX ROTTER & BARBARA SCHIPPAN
Int J Psych Clin Pract Downloaded from informahealthcare.com by V U L Periodicals Rec on 12/30/14 For personal use only.
Research Group Psychosomatic Rehabilitation, Charite´ 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 (N 100) 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 Negative life events can cause severe impairment in psychological functioning. Such pathological reactions 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 hyperarousal [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 disorders in connection to non-life-threatening negative events [5]. This expansion of the PTSD diagnosis indicates a necessity of further subclassifications of adjustment disorders. With posttraumatic embitterment disorder (PTED), Linden [6] introduced a new subclass of adjustment disorders. Similar to PTSD, it is trig-
gered by a single and exceptional negative event. However, in contrast to PTSD, the trigger event in PTED is not an anxiety-provoking and lifethreatening stimulus, but an exceptional, though normal negative life event like unemployment, occupational problems, divorce, illness, or separation. The core pathogenic mechanism is not the provocation of anxiety, but a violation of basic beliefs [79]. This threat to deeply held beliefs, acts upon the patient as a powerful psychological shock, which triggers a prolonged feeling of embitterment 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 23% of clinical relevant embitterment in the general population, suggesting that reactive embitterment is an emotion of great social significance [11]. The present paper specifies diagnostic criteria for PTED and presents an empirically derived standardized 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: [email protected]
(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
Int J Psych Clin Pract Downloaded from informahealthcare.com by V U L Periodicals Rec on 12/30/14 For personal use only.
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 preferably 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 organized 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 patients were then interviewed and thoroughly examined by one of the authors (BS). Fifty of 88 reported
patients (30 women, 20 men) were diagnosed as 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 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 disorder (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.
Int J Psych Clin Pract Downloaded from informahealthcare.com by V U L Periodicals Rec on 12/30/14 For personal use only.
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 psychopathological signs and symptoms. Procedure Results of the interview were used to specify the diagnostic criteria for PTED. Moreover, the discriminatory 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
95
based on the diagnostic algorithm) the diagnostic algorithm was modified and translated into a standardized 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 differentiation (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 negative change in your mental well-being? 2. Do you experience the critical life-event as unjust or unfair? 3. Do you feel embitterment, rage, and helplessness when reminded of the event? 4. Did you suffer from any (substantial/relevant/noticeable) psychological or mental problems (depression, anxieties or the like) prior to the event? EVALUATION BY THE EXAMINER:
0 NO 0 NO 0 NO NO
YES YES YES
0 YES
EMOTIONAL EMBITTERMENT (MARKED BY EMBITTERMENT, RAGE, AND HELPLESSNESS)?
0 NO
CAN ANY PREMORBID MENTAL DISORDER EXPLAIN THE PRESENT PSYCHOPATHOLOGY?
NO
0 YES
NO NO NO NO NO
YES YES YES YES YES
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? 2. Does it still extremely upset you, when you are reminded of the event? 3. Does the critical event or its originator makes you feel helpless and disempowered? 4. Is your prevailing mood since the critical event frequently down? 5. If you are distracted, are you able to experience a normal mood? ARE FOUR QUESTIONS IN SECTION B ANSWERED WITH YES?
0 NO
POSTTRAUMATIC EMBITTERMENT DISORDER
NO
YES 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.
Int J Psych Clin Pract Downloaded from informahealthcare.com by V U L Periodicals Rec on 12/30/14 For personal use only.
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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 reviewed. 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 disorders and also clarify the specific quality of the present emotions, so that bereavement or melancholy 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 prerequisite for further research are instruments which allow a standardized diagnosis. The diagnostic interview 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 standardized 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). References [1] WHO. International statistical classification of diseases and related health problems. 10th revision. Geneva: WHO; 1992. [2] APA. Diagnostic and statistical manual of mental disorders. 4th ed. Washington DC: American Psychiatric Association; 1994. [3] Casey P, Dorwick C, Wilkinson G. Adjustment disorders: Fault line in the psychiatric glossary. Br J Psychiatry 2001; 179:47981. [4] Davidson JRT, Foa EB, Blank AS, et al. Posttraumatic stress disorder. In: Widiger TA, Frances AJ, Pincus HA, et al., editors., DSM-IV sourcebook, vol 2. Washington, DC: American Psychiatric Press; 1996. 577 p. [5] Linden M, Schippan B, Baumann K, Spielberg R. Die posttraumatische Verbitterungssto¨ rung (PTED): Abgrenzung einer spezifischen Form der Anpassungssto¨ rungen. Nervenarzt 2004;75:517. [6] Linden M. The posttraumatic embitterment disorder. Psychother Psychosom 2003;72:195202. [7] Beck AT, Rush AJ, Shaw B, Emery G. Cognitive therapy of depression. New York: Guilford Press; 1979. [8] Janoff-Bulman R. Assumptive world and the stress of traumatic events: Applications of the schema construct. Soc Cogn 1989;7:11336. [9] Janoff-Bulman R. Shattered assumptions: Towards a new psychology of trauma. New York: Free Press; 1992. [10] Linden M, Baumann K, Rotter M, Schippan B. The psychopathology of posttraumatic embitterment disorder (PTED). Psychopathology 2007;40:15965. [11] Linden M, Rotter M, Baumann K, Lieberei B. Posttraumatic Embitterment Disorder, Bern, Huber & Hogrefe 2007. [12] Sheehan DV, Lecrubier Y, Sheehan KH, et al. The MiniInternational Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59: 2233. /
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ORIGINAL ARTICLE
Diagnostic criteria and the standardized diagnostic interview for posttraumatic embitterment disorder (PTED)
MICHAEL LINDEN, KAI BAUMANN, MAX ROTTER & BARBARA SCHIPPAN
Int J Psych Clin Pract Downloaded from informahealthcare.com by V U L Periodicals Rec on 12/30/14 For personal use only.
Research Group Psychosomatic Rehabilitation, Charite´ 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 (N 100) 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 Negative life events can cause severe impairment in psychological functioning. Such pathological reactions 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 hyperarousal [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 disorders in connection to non-life-threatening negative events [5]. This expansion of the PTSD diagnosis indicates a necessity of further subclassifications of adjustment disorders. With posttraumatic embitterment disorder (PTED), Linden [6] introduced a new subclass of adjustment disorders. Similar to PTSD, it is trig-
gered by a single and exceptional negative event. However, in contrast to PTSD, the trigger event in PTED is not an anxiety-provoking and lifethreatening stimulus, but an exceptional, though normal negative life event like unemployment, occupational problems, divorce, illness, or separation. The core pathogenic mechanism is not the provocation of anxiety, but a violation of basic beliefs [79]. This threat to deeply held beliefs, acts upon the patient as a powerful psychological shock, which triggers a prolonged feeling of embitterment 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 23% of clinical relevant embitterment in the general population, suggesting that reactive embitterment is an emotion of great social significance [11]. The present paper specifies diagnostic criteria for PTED and presents an empirically derived standardized 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: [email protected]
(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
Int J Psych Clin Pract Downloaded from informahealthcare.com by V U L Periodicals Rec on 12/30/14 For personal use only.
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 preferably 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 organized 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 patients were then interviewed and thoroughly examined by one of the authors (BS). Fifty of 88 reported
patients (30 women, 20 men) were diagnosed as 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 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 disorder (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.
Int J Psych Clin Pract Downloaded from informahealthcare.com by V U L Periodicals Rec on 12/30/14 For personal use only.
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 psychopathological signs and symptoms. Procedure Results of the interview were used to specify the diagnostic criteria for PTED. Moreover, the discriminatory 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
95
based on the diagnostic algorithm) the diagnostic algorithm was modified and translated into a standardized 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 differentiation (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 negative change in your mental well-being? 2. Do you experience the critical life-event as unjust or unfair? 3. Do you feel embitterment, rage, and helplessness when reminded of the event? 4. Did you suffer from any (substantial/relevant/noticeable) psychological or mental problems (depression, anxieties or the like) prior to the event? EVALUATION BY THE EXAMINER:
0 NO 0 NO 0 NO NO
YES YES YES
0 YES
EMOTIONAL EMBITTERMENT (MARKED BY EMBITTERMENT, RAGE, AND HELPLESSNESS)?
0 NO
CAN ANY PREMORBID MENTAL DISORDER EXPLAIN THE PRESENT PSYCHOPATHOLOGY?
NO
0 YES
NO NO NO NO NO
YES YES YES YES YES
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? 2. Does it still extremely upset you, when you are reminded of the event? 3. Does the critical event or its originator makes you feel helpless and disempowered? 4. Is your prevailing mood since the critical event frequently down? 5. If you are distracted, are you able to experience a normal mood? ARE FOUR QUESTIONS IN SECTION B ANSWERED WITH YES?
0 NO
POSTTRAUMATIC EMBITTERMENT DISORDER
NO
YES 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.
Int J Psych Clin Pract Downloaded from informahealthcare.com by V U L Periodicals Rec on 12/30/14 For personal use only.
96
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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 reviewed. 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 disorders and also clarify the specific quality of the present emotions, so that bereavement or melancholy 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 prerequisite for further research are instruments which allow a standardized diagnosis. The diagnostic interview 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 standardized 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). References [1] WHO. International statistical classification of diseases and related health problems. 10th revision. Geneva: WHO; 1992. [2] APA. Diagnostic and statistical manual of mental disorders. 4th ed. Washington DC: American Psychiatric Association; 1994. [3] Casey P, Dorwick C, Wilkinson G. Adjustment disorders: Fault line in the psychiatric glossary. Br J Psychiatry 2001; 179:47981. [4] Davidson JRT, Foa EB, Blank AS, et al. Posttraumatic stress disorder. In: Widiger TA, Frances AJ, Pincus HA, et al., editors., DSM-IV sourcebook, vol 2. Washington, DC: American Psychiatric Press; 1996. 577 p. [5] Linden M, Schippan B, Baumann K, Spielberg R. Die posttraumatische Verbitterungssto¨ rung (PTED): Abgrenzung einer spezifischen Form der Anpassungssto¨ rungen. Nervenarzt 2004;75:517. [6] Linden M. The posttraumatic embitterment disorder. Psychother Psychosom 2003;72:195202. [7] Beck AT, Rush AJ, Shaw B, Emery G. Cognitive therapy of depression. New York: Guilford Press; 1979. [8] Janoff-Bulman R. Assumptive world and the stress of traumatic events: Applications of the schema construct. Soc Cogn 1989;7:11336. [9] Janoff-Bulman R. Shattered assumptions: Towards a new psychology of trauma. New York: Free Press; 1992. [10] Linden M, Baumann K, Rotter M, Schippan B. The psychopathology of posttraumatic embitterment disorder (PTED). Psychopathology 2007;40:15965. [11] Linden M, Rotter M, Baumann K, Lieberei B. Posttraumatic Embitterment Disorder, Bern, Huber & Hogrefe 2007. [12] Sheehan DV, Lecrubier Y, Sheehan KH, et al. The MiniInternational Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59: 2233. /
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