Posttraumatic embitterment disorder (PTED) is characterized by states of “embitterment”, characteristically similar to “Hwa-byung”, which is a Korean culture-bound syndrome. The present study aimed to assess diagnostic relationships between PTED and Hwa-byung.
A total of 290 participants completed our survey. PTED and Hwa-byung were diagnosed using a diagnostic interview and scale. Scales for depression, suicide ideation, and anger were used for evaluation. Fisher's exact tests and Mann-Whitney U tests were performed to evaluate diagnostic overlap between PTED and Hwa-byung, and associations of scale scores for depression, suicide ideation, and anger between the PTED, Hwa-byung, and non-diagnosed groups. Associations of these scales between the depressive and non-depressive groups, and suicidal and non-suicidal groups were also evaluated.
Among the participants, 1.7% of the sample fit the diagnostic criteria for PTED and 2.1% fit the criteria for Hwa-byung. No individual fit the criteria for both. Anger scores were significantly higher in the Hwa-byung group than in the non-diagnostic group. There were not any significant differences in anger scores between the PTED and non-diagnostic groups. Depression scores were significantly higher in the PTED than in the non-diagnostic groups. In contrast, no significant differences were observed between depression scores in the Hwa-byung and non-diagnostic groups.
These results suggest that PTED may be a disorder category that is distinct from Hwa-byung.
Several psychiatric disorders have long been defined as psychological reactions to traumatic or stressful event(s).
PTED, which was first described by Linden in 2003,
Embitterment refers to a persistent, psychological state that includes feeling let down, shamed, or as if one has been a failure. It also includes feelings of injustice and helplessness, along with the urge to fight back and an inability to identify proper goals.
The present study investigated the diagnostic overlap between PTED and Hwa-byung. More specifically, the co-occurrence of PTED and Hwa-byung in the general population was examined. Additionally, depression, perceived stress, suicidality, and state-trait anger expression were compared between each disorder group and a corresponding non-diagnostic group. This study adds to our understanding of the commonalities and differences between these two stress-related diseases that have similar psychopathology.
Participants were recruited from January 2014 to March 2015 via face-to-face interviews, distribution of brochures, print advertisement postings in public places, and direct contact through public speaking engagements. Seventy-one participants were recruited through direct advertisement via brochures handed out in the main street of city center, which is the city's principle commercial area. One hundred and three participants were recruited by direct advertisement through printed postings in the city's only university hospital, which is also its biggest. Sixty-eight participants were recruited through direct advertisement in one middle school and two high schools. Finally, seventy-three participants were recruited at two separate public speaking sessions.
Recruitment was done in one of five metropolitan cities in South Korea. This city contains large manufacturing facilities, many public institutes, and large farming areas and fisheries. This city is highly industrial and many people work in factories. Environmental problems from noise, crowding, and pollution from widespread industrial activity have caused chronic stress to the citizens of this locale. In addition, the recent economic downturn in South Korea may have increased the stress on the populace. All the above situations are considered predispositions for Hwa-byung. Seventy-one participants were recruited through direct advertisement via brochures handed out in the main street of city center, which is the city's principle commercial area. One hundred and three participants were recruited by direct advertisement through printed postings in the city's only university hospital, which is also its biggest. Sixty-eight participants were recruited through direct advertisement in one middle school and two high schools. Finally, seventy-three participants were recruited at two separate public speaking sessions.
Face-to-face interviews and short surveys were carried out to identify participants who met the inclusion and exclusion criteria. Inclusion criteria were as follows: 1) age 12 to 75 years, 2) no report of current psychiatric treatment, no report of history of documented chronic psychiatric disorders, no report of suspected psychiatric disorders, and no history of a psychiatry clinic visit at any time in their lifetime, 3) Korean as a native language, and 4) fluency in Korean. Exclusion criteria were: 1) any lifetime psychiatric history, 2) any cognitive impairment, and 3) any physical or medical condition that would make completing the study protocol difficult (e.g., limb handicap, etc.). Written informed consent was obtained from all participants. The University of Ulsan College of Medicine, Ulsan University Hospital Institutional Review Board approved the protocol, which was conducted in accordance with the Declaration of Helsinki.
The Korean versions of a diagnostic core interview and algorithm for PTED were used to diagnose PTED. Diagnostics consisted of two categories: Criteria A (core criteria) and Criteria B (additional symptoms); the sensitivity and specificity of these criteria are 94% and 92%, respectively.
Core PTED criteria consist of experiencing an event that led to a noticeable and persistent negative change in mental well-being, was unjust or unfair, and caused feelings of embitterment, rage, and helplessness. Core symptoms of any related psychological or mental problem (e.g., depression, anxiety) could not be present prior to the event.
Additional PTED symptoms included 1) repeated intrusive and incriminating thoughts about the event, 2) extremely negative feelings when reminded of the event, 3) the critical event or its originator causing feelings of helplessness and disempowerment, 4) a prevailing depressed mood since the critical event, and 5) the experience of a non-distressing mood when distracted. Four or more of these additional symptoms are needed for a PTED diagnosis, and the stress duration should be more than 6 months.
Participants were also assessed on diagnostic criteria
The Korean version of the State-Trait Anger Expression Inventory (STAXI-K) was used to assess experienced and expressed anger.
To assess suicidal ideation, participants were asked to complete Beck's Scale for Suicidal Ideation (SSI).
Depression was measured via the Beck Depression Inventory (BDI), which is a commonly used scale. The BDI is a self-report measure consisting of 21 questions, with each item scored on a 4-point scale (0 to 3). Total scores range from 0 to 63. Higher scores indicate more severe depressive symptoms. The recommended cutoff value for the Korean version of the BDI is ≥16, which differentiates depressive from normal control groups. The BDI has a sensitivity of 77% and a specificity of 84%.
The 14-item Perceived Stress Scale
Fisher's exact tests were performed to compare the number of individuals with posttraumatic embitterment disorder and the number of individuals with Hwa-byung between both the depressive and non-depressive groups and between the suicidal and non-suicidal groups. Mann-Whitney U tests were performed to compare scores on the SSI, BDI, perceived stress, STAXI, and Hwa-byung scales between individuals with and without PTED. Similar analyses were performed to compare individuals with and without Hwa-byung.
In total, 315 individuals satisfying both the inclusion and exclusion criteria consented to take part in this study. A total of 25 individuals with incomplete data were excluded. Analyses focused on the remaining 290 participants. Demographic data were obtained, including age, sex, education, and occupation (
Among the 290 participants, 5 (1.7%; 4 females) were diagnosed with PTED and 6 (2.1%; 3 females) were diagnosed with Hwa-byung. There were no significant differences in the gender distribution for either PTED (p=0.39) or Hwa-byung (p=0.99) diagnoses. A representative case vignette for both PTED and Hwa-byung follows.
A 48-year-old man, previously employed as a factory worker, reported experiencing frequent outbursts of anger since suffering an injury at work about one year prior. The subject fell from a workplace about 5 m high and received multiple fractures of the ribs and spine. During his recovery, he has suffered from the memory of falling down and feelings of injustice towards his employer's irresponsible attitude. Six months post-injury, his application for an extension of worker's compensation insurance was rejected. He said that he felt deep embitterment towards society as a whole and he often feels like taking revenge on his employer and the staff of the worker's compensation insurance company. He spoke of these stories in a calm manner, despite nearly constant dysphoria since their occurrence. He has difficulties with concentration, sleep, and appetite.
A 60-year-old woman labeled herself as having “Hwa-byung”. She has experienced frequent hot and burning sensation in the upper part of her body from the chest to head since learning of her husband's affair more than 30 years ago. When this sensation occurs, it begins in the chest and eventually spreads to the top of her head. When it is most severe, she feels a sensation reminiscent of someone pouring hot pepper on her chest, neck, and face. She has tried to cool down her body with air-conditioning, but it is useless. She has also experienced a feeling of something welling up in her throat. She designated her husband's repeated affairs as the cause of her symptoms. She has had to maintain her unwanted married life and endure this unfair situation for a long time due to considerations of her child and her lack of financial independence. She has felt angry and hateful to her husband for his unfaithfulness. She has also harbored feelings of bitterness and resentment towards a situation in which she has no way to revenge him and has no influence on her husband's behavior.
Scores on the SSI, PSS, BDI, and Hwa-byung scales were significantly higher among females than males (p<0.05). No differences were observed on the STAXI between females and males (p>0.05). When participants were divided into groups based on core and additional PTED diagnostic criteria, 6 participants met core criteria only and 28 met additional criteria only. The number of participants who met both criteria (core criteria and additional criteria) was 5. These 5 participants were diagnosed with PTED. No participant was diagnosed with both PTED and Hwa-byung. These results were replicated in a group that met sub-diagnostic criteria for PTED and the group diagnosed with Hwa-byung.
The percentage of individuals with higher suicidal ideation than normal was 10.1% (n=20), while the percentage of participants with more depressive symptoms than normal was 12.1% (n=25) (
Psychiatric symptom scale scores were compared between individuals with and without PTED and those with and without Hwa-byung (
The present study is the first to compare the prevalence and relationships among clinical variables related to PTED and Hwa-byung in a Korean cohort. Although the numbers of PTED and Hwa-byung diagnoses were small in the present study (owing mainly to the low prevalence rates in the general population), significant differences were observed between the PTED and Hwa-byung diagnostic groups for various clinical metrics.
The present findings suggest some shared psychopathological components of PTED and Hwa-byung. For instance, individuals with PTED demonstrated higher Hwa-byung scale scores than those without PTED. Despite this commonality, some differences between PTED and Hwa-byung emerged, suggesting that they are separate disease entities. For instance, anger inhibition and expression was more strongly associated with Hwa-byung than with PTED; conversely, depression was more associated with PTED than with Hwa-byung. This suggests that PTED likely has a different pathogenesis than suppression or partial expression of anger as observed in Hwa-byung.
Further discrimination between the two disease states comes from results showing no co-occurrence of PTED and Hwa-byung in the present cohort. This was still the case when using more liberal disease criteria: i.e., only using criteria A (core symptoms) or B (accessory symptoms) provisions. Additionally, the number of individuals at higher risk for suicide and depression was significantly different between the Hwa-byung and non-Hwa-byung groups, but this was not the case in the PTED-diagnosed group relative to the non-PTED-diagnosed group.
Nevertheless, PTED and Hwa-byung have common psychopathological components and similar theoretical etiologies. As previously mentioned, embitterment, the core psychopathological symptom of PTED, is similar to the concept of “Haan/Hahn” in Hwa-byung.
However, PTED and Hwa-byung include several distinctions in terms of possible pathogenic mechanisms. First, acute stress is usually a critical factor in PTED while lifelong stress is more indicative of Hwa-byung. Second, PTED is attributed to the direct context of the adverse event(s).
The prevalence of PTED in the general population was previously reported at approximately 2.5%.
Previously reported prevalence rates for Hwa-byung range from 4.2% to 13.3%.
In spite of exclusion of current psychiatric diagnosis and past suspected psychiatric disorders, many subjects showed depressive signs (12.1%) and suicidality (10.1%). This result can be explained by the high sensitivity of the measuring tools for depressive signs and suicidality used in this study. For screening tools, cut-off scores were decided by giving priority to sensitivity, and therefore a relatively high percentage of participants were found to be at risk for depression and suicide. In the standardization study for the Korean BDI, the cut-off value was determined the be the point at which 15.6% of subjects were classified as having depressive signs.
PTED was first described among unemployed immigrants from East and West Germany after the fall of the Berlin Wall.
Hwa-byung is translated to either “fire-illness” or “anger-disease.” “Hwa” means both fire and anger.
While PTED focuses bitter “emotion” itself toward unjust treatment, Hwa-byung focuses more on distorted expressions of emotion in situations in which patient cannot avoid or fight against chronic persecution and hide their anger and aggression from persecutors for their survival in society. This can be adaptive in order for patient's to maintain their social status in Korean society. Differences between Hwa-byung and some personality disorders can be explained in this context. With respect to Hwa-byung, anger-prone personality or impulsivity disorders emphasize individual sensitivity to stress.
A few limitations of the present study should be noted. First, given the small number of PTED participants, some results should be interpreted with caution (and non-significant Fisher's exact test results should be acknowledged based on this limitation). However, the Mann-Whitney U tests results confirmed that PTED was not related to depression or suicidality. Second, random selection and age stratification were not applied during subject recruitment. However, the original sample size of 290 was large enough to be representative of the population. Demographic characteristics such as gender distribution, age distribution, and occupation distribution were similar across the survey population and representative of the entire Korean population.
The present study suggests that PTED and Hwa-byung have different clinical features. The study also suggests that embitterment is not merely a feeling of inner anger as is often associated with Hwa-byung. Hwa-byung was related more to the suppression or partial expression of anger, while PTED was more associated with depression. Finally, the results indicate that PTED and Hwa-byung is not an overlapping diagnosis.
SSI cutoff values are ≥9 for adults, ≥14 for undergraduates, and ≥16 for middle and high school students. The Korean BDI cutoff value is ≥16.
PTED: posttraumatic embitterment disorder, SSI: total score on Beck's Scale for Suicidal Ideation, BDI: total score on the Beck Depression Inventory
PTED: posttraumatic embitterment disorder, SSI: total score on Beck's Scale for Suicidal Ideation, PSS: total score on the Perceived Stress Scale, BDI: total score on the Beck Depression Inventory, STAXI: total score on the State-Trait Anger Expression Inventory, Anger-out: total score on the anger-out subscale of the STAXI, Anger-in: total score on the anger-in subscale of the STAXI, HB: Hwa-byung