Introduction: Embitterment may occur after stressful but normal life events, such as job loss, divorce, or unjust events. Embitterment is a normal affect, but it may become clinically relevant in case it becomes very strong and long-lasting, and impairs daily functioning. Objective: Until now, no epidemiological data on the frequency of high embitterment in the general population have been available. Methods: A national representative survey of 2,531 people was carried out in Germany in 2019. The participants gave ratings for their embitterment due to perceived events (Posttraumatic Embitterment Scale), their psychological capacity profile (Mini-ICF-APP-S), sick leave duration, and sociodemographics. Results: About 11.7% of the investigated representative population report moderate embitterment, and another 3.8% high embitterment. Embitterment was only low correlated with other psychopathology, here work anxiety (r = 0.281**). There are no differences between embittered and nonembittered in respect to age, sex, household members, and professional distribution. Those with the highest embitterment have been unemployed more often and have lower income. At least 7.2% of those with high embitterment have a severe psychological capacity impairment and are in need of support by thirds to fulfill daily duties. In 55% of the 802 who reported a stressful event, injustice by an important person has been reported. Injustice by an institution (14%) or societal injustice (12%) was least often reported as a relevant stressful event. Conclusion: Physicians, therapists, and public health must be aware of embitterment as a specific mental health problem which occurs frequently and may become chronic with work and life participation problems.

Embitterment as a Specific Affect and Potential Mental Health Problem

Embitterment and posttraumatic embitterment disorder (PTED) begin to find attention in research and clinical practice only in recent years, although the phenomenon has been observed even earlier [1, 2]. Embitterment as an emotion known by everybody after unjust events consists of a nagging wish to undo what had happened, combined with anger toward the aggressor, mourning about the loss, feeling helpless, stuck in frozen activity level, thoughts of revenge. Embitterment is a specific and complex affect and may in some cases become a mental health problem. It can occur as a PTED [3], or as a syndrome additional to another mental health problem, or as a personality trait. There are embitterment phenomena that do not appear as a single-event-related disorder (in 31% of cases of increased embitterment score) but as symptoms comorbid to other mental disorders [4]. Research has found associations between embitterment and other psychopathology, such as neuroticism, interpersonal problems, depression, and anxiety [5, 6]. The affect embitterment can be measured dimensionally [7]. High embitterment is associated with low well-being, low life satisfaction, and higher perceived stress [6].

As a reactive affect, embitterment may occur in persons after having perceived a deeply hurting unjust event, which hurts own basic beliefs, comes along with humiliation or breach of trust. Even in early observation, embitterment has been described as a kind of reactive affect occurring in response to life events [1]. Similarly, in Asian culture the phenomenon of “hwa-byung” may occur as a clinical entity, characterized by frustration, anger, somatization, and wish to take revenge after social stressors such as infidelity, conflicts, or trust breaches [8].

As injustice, humiliation, breach of trust are frequent events and may occur in any life domain where people interact, embitterment may theoretically occur in all age groups, professions, persons of different social backgrounds, religion, or culture. Stressful events or potential sources of embitterment can be very diverse and occur in any domain of life [2, 9‒16]. Until now, research on embitterment was mainly done in groups exposed to specific conditions, such as people with chronic illness, or in work settings: in patients with mental disorders, about one third reported increased embitterment scores [4], aggressive phantasies in 3.2% [11]. In Korean nursing professionals, 26.3% reported prolonged embitterment after patients’ safety incidents, and 7.3% of them experienced severe embitterment [10]. 68% of refugees and asylum seekers reported elevated levels of embitterment [12]. In soldier patients in an armed forces hospital, 13.9% had a clinical diagnosis of posttraumatic embitterment [17]. In war veterans with PTSD, 35% had high embitterment, and in 8% of veterans without PTSD [14]. Embitterment was also observed in patients with chronic illness, finding rates of 18–27% with levels of high embitterment in rheumatic patients [16].

Empirical research has also shown that embitterment is in 25% of cases accompanied by work problems, such as unemployment [18]. Typical unjust events are, e.g., unfair termination from a job, or a promotion which failed to happen, or an unfair allocation of resources [19]. Especially embitterment related to the work setting is accompanied with danger of sick leave or work disability; 93% of persons embittered in relation to the work context reported sick leave in the past 12 months [15].

In this respect, work-related capacity impairments and work anxiety have been identified as potential additional problems accompanying embitterment. Work anxiety is a specific mental health problem, which is directly associated with negative social medicine consequences, i.e., sick leave and problems in work ability [20]. Work-phobic anxiety is the form of anxiety which is accompanied by the longest sick leaves [21]. Because of its relevance as an additional complication for work participation, work-phobic anxiety should be considered as an accompanying symptom when investigating embitterment.

Another social medicine problem of embitterment is psychological capacity impairments. According to the internationally established biopsychosocial model of health of the ICF [22], symptoms alone do not explain work ability problems. For describing work ability, a person’s capacity level is relevant, i.e., the activity spectrum and what a person can do. Psychological capacities such as adherence to rules, flexibility, interactional capacities, mobility, proactivity, and endurance are increasingly necessary in our modern working world [23]. Persons with embitterment or work anxiety have work ability problems or a reduced capacity level [15, 23].

In sum, embitterment is an emotion and potential mental health problem relevant to different settings of life, be it family, work, other social or societal groups. Although embitterment has been a topic of interest in different research settings, there have been few reports on the frequency of its occurrence in representative national samples. Estimates of increased embitterment scores have been reported from 40 to 45% in Asian samples [24, 25], about 15% clinically relevant. In a German observation study in people in a city train, half of the investigated reported embitterment, 2.5% being clinically relevant [26]. Rates of 1.7–2.1% were found in a general population survey [27].

Thus, in order to get an idea about the frequency of embitterment in the whole general population, representative data are necessary. Such data allow estimations about which groups are potentially prone to be affected, may have problems in work participation, and potentially will be in need of support.

Research Questions

The research questions in this representative study are the following:

  1. How is embitterment distributed in a general, population representative, sample? How many people suffer from moderate or high embitterment?

  2. Are there differences between people with low and high embitterment in terms of sociodemographic and work-related characteristics, perceived stressful events, and comorbid work anxiety?

The here investigated research question, selection of questionnaires, and data analysis were elaborated by the author. The data collection, i.e., the representative survey, was conducted by a professional organization which undertakes representative surveys throughout Europe [28]. The survey was done throughout the German Republic in 2019. Ethics approval was obtained from the faculty of life sciences at the Technische Universität Braunschweig (D-2019-03).

2,531 participants contributed to the survey with full data. 2,030 were of working age, i.e., between 18 and 67 years old.

Procedure

The representative sampling was based on a nationwide division of the populated area of Germany into sample areas. An overlap-free spatial definition of sample areas was assured. Then, areas were chosen. Within these areas, a random selection of households was done. For person selection, an administrative person for the respective area must identify all persons in the selected household and select a target person for the interview. This selection of the target person was done by a predetermined random procedure according to the internationally used “Kish selection grid” [29]. The representative sampling procedure was fully independent of the interviewer.

In the interview, the randomly chosen participants were asked basic sociodemographic and work-related data. After that, they completed the following three self-rating questionnaires.

Posttraumatic Embitterment Scale

Embitterment was assessed with the nineteen-item PTED embitterment self-rating scale [7]. It starts with the statement “During recent years, there was a severe and negative life event…,” which is followed by answers such as “…that hurt my feelings and caused considerable embitterment,” “…that triggers feelings of satisfaction when I think that the party responsible has to live through a similar situation,” or “… that caused me to withdraw from friends and social activities.” Ratings shall be made for each item on a five-point Likert scale, ranging from 1 = “not true at all” to 5 = “extremely true.” The mean score from the PTED scale indicates the overall degree of embitterment. The PTED scale measures dimensional embitterment; i.e., it can be used as a screening for the general embitterment load that the person perceives due to one or more stressful life events. The PTED scale can be used in clinical samples as well as in general population samples (e.g., [6]). The PTED scale can be used for measuring embitterment as a dimensional phenomenon, but not as a tool for the categorical diagnosis of an embitterment disorder. Other studies have also used the PTED scale for measuring the level of embitterment, e.g., in general population samples or general clinical samples [6, 16]. Cronbach’s alpha in this present investigation was 0.976.

Workplace Phobia Scale

The Workplace Phobia Scale (WPS) [21] is a self-rating scale consisting of 13 items for measuring work anxiety, i.e., anxiety with work-related panic and work-related avoidance behavior. It was derived from the Job-Anxiety Scale (JAS, [20]) which covers different dimensions of work-related anxiety. The WPS’s psychometric properties have been tested using a psychosomatic inpatient sample. The split-half reliability was 0.97 and Cronbach’s alpha 0.96. The items are rated on a Likert scale, whereby “0 = no agreement” and “4 = full agreement.” The mean score is relevant for data analysis. The WPS has been validated using structured diagnostic interviews as clinical criteria [21, 30]. The WPS is given to the participants with the title Questionnaire on Workplace Problems and examines “behavior, thoughts, and feelings which can occur in relation to the workplace.”

Self-Rating for Psychological Capacities (Mini-ICF-APP-S)

The assessment of capacities and capacity limitations should be based on observer expert ratings. However, given that self-perceived capacity level is a strong predictor of future real behavior (e.g., work ability [31]), important information can also be obtained from capacity self-ratings. A self-rated capacity profile reflects the person’s self-image and may provide information that can be useful for planning further counselling, capacity training, or work adjustment. The Mini-ICF-APP-S is a self-rating of psycho-mental capacities [32] which covers 13 psychological capacity dimensions: adherence to rules, planning and structuring, flexibility, competency, decision-making and judgment, proactivity, assertiveness, contact to others, group integration, dyadic relationships, endurance, self-care, and mobility. This capacity concept is internationally validated and established [33‒36]. The Mini-ICF-APP-S capacity self-rating includes 13 items which each represent one capacity dimension. Descriptions of each capacity dimension are provided. The rating points are described at a behavioral level, i.e., the extent to which the person can (or finds it difficult to) perform capacity-related activities. The self-rating therefore enables a bipolar rating from “(0) this is definitely one of my strengths” to “(3) this is somehow possible,” “(4) this does not always work” to “(7) I am completely unable to do this.” This mean score over all items makes it possible to describe the global psychological capacity level as relatively strong or rather weak. Cronbach’s alpha in this present investigation was 0.919.

Data Analysis

Data have been analyzed with SPSS. Descriptive data and comparisons of means and frequencies have been calculated by χ2 test and ANOVA [37]. Missing data in the self-rating questionnaires occurred very few (none in the embitterment scale, 1–21 per item in the Mini-ICF-APP-S, 42 persons did not fill in the WPS). Missings were not replaced.

About 11.7% of the investigated representative population report moderate embitterment, and another 3.8% high embitterment (Table 1). Thus, 15.5% of this general population sample is affected from potentially relevant embitterment.

Table 1.

Characteristics of representative general population sample with perceived stressful event (n = 802) in groups with low, moderate, and high embitterment according to the Posttraumatic Embitterment Scale (PTED Scale)

 Characteristics of representative general population sample with perceived stressful event (n = 802) in groups with low, moderate, and high embitterment according to the Posttraumatic Embitterment Scale (PTED Scale)
 Characteristics of representative general population sample with perceived stressful event (n = 802) in groups with low, moderate, and high embitterment according to the Posttraumatic Embitterment Scale (PTED Scale)

Women are a bit over-represented in the group reporting stressful events (59.1%, Table 1), but there is only low correlation of female sex and embitterment (r = 0.085**, Spearman correlation **p < 0.001, N = 2,531, online suppl. Table; see www.karger.com/doi/10.1159/000526457 for all online suppl. material). There are no differences between the three embitterment-level groups in terms of the sociodemographic characteristics age, sex, household members, and distribution of professional position (Table 1).

Highly embittered persons have less often completed a school degree at high school level (12 classes) and have longer sick leave times in the past 12 months. There are also differences in economic characteristics: those with the highest embitterment have been unemployed more often than others. There are more often persons with low income <1,000 EUR per month (41.2%) in the high embittered group.

Interestingly, in the group with highest embitterment there are comparatively many Muslims (11.6%) and a rather low proportion of people without religious denomination (20%) as compared to the low embittered group (2.8% Muslims, 27.3% without religious denomination). The embitterment-level groups show systemic differences in their psychological capacity levels: people with moderate or high embitterment perceive their psychological capacities to be lower than those with low embitterment (Table 2). At least 7.2% of those with high embitterment have a severe capacity impairment and are in need of support by thirds to adhere to daily capacity demands.

Table 2.

Characteristics of representative general population sample and the groups with stressful events and low, moderate, and high embitterment

 Characteristics of representative general population sample and the groups with stressful events and low, moderate, and high embitterment
 Characteristics of representative general population sample and the groups with stressful events and low, moderate, and high embitterment

There is a similar ranking of stressful events, irrespective of the embitterment degree: in more than half of cases who reported a stressful event, injustice by an important person has been reported (54.6%), followed by other personal stressful event (32.8%), and injustice by an important person at work only ranging on the third place (24.9%). Injustice by an institution (13.8%) and societal injustice (11.5%) were least often reported as a relevant stressful event (Table 2).

Embitterment and work anxiety are qualitatively different psychopathologies, but correlate with each other on a low level (r = 0.281**, Spearman correlation **p < 0.001, N = 2,531). Some persons with high embitterment have high work anxiety as an additional psychopathological symptom. In respect to the whole sample, there are 81.2% with neither embitterment nor work anxiety, 11.9% with embitterment, 3.6% with embitterment and work anxiety, and 3.3% with work anxiety only.

Prevalence of Embitterment

The main result of this representative study is that a considerable proportion of the general population (15.5%) is affected by moderate or even high (clinically relevant) embitterment. This rate is within the range of embitterment prevalence which was found in different contexts until now. Prevalence estimations range about 1.7–15% in general populations [25‒27], or 14–33% in patients with mental disorders [4, 7, 17]. Elevated rates of embitterment in larger groups or nations have been observed in times of crisis, e.g., 16% in the 2020 pandemic situation [38], partly even long-lasting and increasing in about 70% of persons affected from a severe catastrophe [13]. Adding to these international empirical data, the here found rate of 3.8% high embittered is an important addition to the epidemiology and underlines that embitterment is a relevant and not seldom clinical entity.

Meaning of Embitterment in the Context of Work and Stressful Events

High embittered persons reported comparingly more work-related problems than persons with low embitterment: high embitterment (3.8% of this sample) was accompanied by longer periods of sick leave (on average nearly 5 weeks, as compared to 1 week in people without embitterment), lower income, more unemployment times, and higher probability for severe capacity impairment.

This fits to other research findings: embitterment was associated with work-related problems in several studies [11, 15, 19]. Workplaces contain characteristics, such as potentials for social conflicts and uncertainties, which can trigger unpleasant affects like anxiety and embitterment [39]. There may be conflicts between colleagues, resource allocation fights, humiliation, or possibilities for failure and feeling insufficient or being treated unjust [40]. Besides low socioeconomic status [41‒43], injustice is associated with reduced mental well-being [44]. In reaction to perceived injustice at work, counterproductive employee behavior may occur [45].

Embitterment obviously comes along with work-related problems, and injustice by a professionally important person was mentioned by one-fourth of the persons affected by stressful events. This fits to other findings which indicate a relatively high importance of the work context, besides humiliation or injustice or interactional problems with third parties: for example, in patients with mental disorders, 44.2% mentioned problems with the employer as a burden (ranking on place 5 in a list of 20 life burdens) [46].

Embitterment and Work Anxiety

Work-related embitterment can also be accompanied by work-phobic anxiety. This can be seen when the person can no longer tolerate the work environment and colleagues or supervisors who might be associated with the unjust work event. Physiological arousal and avoidance tendencies when thinking of the workplace may occur, potentially resulting in work absence or sick leave [46]. Our data show that people with high embitterment are often affected by longer sick leave. A comorbidity problem of embitterment and work-phobic anxiety might have an even more severe impact on work participation. However, our data also show that embitterment and work anxiety are different phenomena and are only partly correlated. We can distinguish persons with work anxiety, persons with embitterment, and persons with work anxiety and embitterment. Thus, these two specific psychopathologies, but also their potential combination, should be considered in research and practice when it comes to questions about sick leave and event-related mental health problems.

Limitations, Strength, and Conclusion

This is a representative investigation using a large national sample and is therefore representative for the German population. A limitation is that the data are national and cross-sectional only. Thus, no causal conclusions can be drawn from the here reported data. Furthermore, we used self-ratings only. There was no structured research interview for categorical diagnosis of general mental disorders (e.g., anxiety or depressive syndromes), and no clinical differential diagnostic including psychopathology history.

Nevertheless, the data show that embitterment is distinguishable from other psychopathologies (here: low correlation with work anxiety). The here reported epidemiological representative survey supports international findings from heterogenous countries and contexts, in that the frequency of people with high and clinically relevant embitterment is about 1.7–15% over different professional groups and social settings. In times of crisis or after catastrophic events, there may be an even higher rate of severe embitterment [38].

Future research should investigate the impacts of embitterment on life participation of those affected. Clinicians, counsellors, (occupational) health managers, or occupational physicians should be aware of embitterment and should be informed about possible preventive and intervention measures. Embitterment is not an uncommon phenomenon in the general population, but potentially one that might be overseen or (mis)treated as “depression” or “PTED” in case the phenomenon “embitterment” was not taken into consideration as a potential differential diagnostic psychopathology.

We thank Prof. Dr. Elmar Brähler and the USUMA for organizing and conducting the representative survey.

This study protocol was reviewed and approved by the faculty of life sciences, Technische Universität Braunschweig, approval number D-2019-03. Participants gave written informed consent.

The authors have no conflicts of interest to declare.

Funding for this study was provided by the German Federal Pension Agency, Grant No. 0421/40-64-50-01. This is independent research: the funder was not involved in study design, data collection, analysis, and interpretation of data, or writing of the report.

The data that support the findings of this study are available on request from the corresponding author.

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