Stressor Criterion Research Articles

The PTSD Criterion A debate: A brief history, current status, and recommendations for moving forward.

Posttraumatic stress disorder (PTSD) Criterion A, also known as the "stressor criterion," has been a major source of debate ever since PTSD was added to the third edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM) in 1980. Since then, the traumatic stress field has held an ongoing debate about how to best define Criterion A and the events that it covers. Because of the COVID-19 pandemic and recent race-based incidents, the Criterion A debate has been reinvigorated. In this paper, we review briefly the history of Criterion A and changes in its language across different editions of the DSM. We then describe the four main positions held by scholars involved in the Criterion A debate and carefully examine the support for those positions. We conclude by offering recommendations for moving forward.

The Involvement of Neonatal Intensive Care Unit and Other Perinatal Factors in Postpartum PTSD After Cesarean Section.

The experience of a neonate hospitalised in the Neonatal Intensive Care Unit (NICU) is an understandably traumatic experience for the parents, especially, for the mothers of neonates. This mental distress resulting from preterm birth and/or NICU hospitalisation can be understood as post-traumatic symptomatology, according to the Diagnostic and Statistical Manual-5 version. The aim of this study is to investigate the impact of the admission of a neonate to the NICU (from any reason) on the development of postpartum post-traumatic stress disorder (PTSD) in a sample of women after cesarean sections. A total of 469 women who gave birth with cesarean section from July 2019 to June 2020 participated in this study, from the original sample of 490 women who consented to participate. Data were obtained from the researcher's socio-demographic questionnaire, the past traumatic Life Events Checklist, the perinatal stressor Criterion A, and the Post-Traumatic Stress Checklist from the Diagnostic and Statistical Manual-5 version. A percentage of 46.64% of sample experienced postpartum PTSD. Factors associated with PTSD were placenta previa type4, abruption, bleeding (β = .07, p = .049), premature contractions (β = .08, p = .039), heavy medical history or previous gynecological history and preeclampsia (β = .08, p = .034), abnormal heart rate, premature rupture of membrane, premature contractions, infections (β = .14, p = .004), life of child in danger (β = .12, p = .025), complications involving child (β = .15, p = .002), complications involving both (child and mother) (β = .12, p = .011), traumatic cesarean section (β = .041, p < .001) and prematurity (β = .12, p = .022). Additional measures must be taken for mothers of children who have been admitted to the NICU with psychological support interventions and reassessment of their mental state.

The Involvement of Past Traumatic Life Events in the Development of Postpartum PTSD after Cesarean Delivery.

Background: Although childbirth is considered a natural process, a high percentage of postpartum women consider it traumatic. Any previous traumatic event in a woman’s life can be revived through a traumatic birth experience, especially after a complicated vaginal delivery or cesarean delivery. The purpose of this study was to clarify the relationship between previous traumatic life events and posttraumatic stress disorder (PTSD) in postpartum women after cesarean section and which specific events exerted the greatest influence. Methods: A sample of 469 women who had undergone cesarean sections at a Greek university hospital consented to participate in this prospective study. Data from a medical/demographic questionnaire, life events checklist, perinatal stressor criterion A, and posttraumatic stress checklist were used to evaluate past traumatic life events and diagnose postpartum posttraumatic stress. Results: Out of 469 women, 25.97% had PTSD and 11.5% a PTSD profile, while 2.7% had PTSD and 2.7% a PTSD profile. Also, it appeared that only specific direct exposure to a traumatic event and/or witnessing one were predictors of postpartum PTSD. Conclusions: This survey identified specific traumatic life events, psychiatric history, stressor perinatal criterion A, preterm birth, and emergency cesarean section as risk factors for the development of PTSD or a PTSD profile in women after cesarean delivery.

Identifying stressor criteria that hinder or challenge junior clinical medical student learning

Introduction What makes something a stressor within clinical students’ education is unclear. Medical students moving from a predominantly protected classroom environment to a situated–work environment provided an ideal transition point to explore the criteria that might make a learning experience a stressor and whether these stressors hinder or challenge learning. Method Data on the stressors associated with learning experiences in clinical education were collected from New Zealand undergraduate medical students. Free text comments, in a survey-based questionnaire were supplemented by focus group data. Using inductive thematic analysis with grounded theory, themes were generated about the characteristics of stressors; referred to here as stressor criteria. These stressor criteria were then classified according to their impact on perceived learning. Results Under the broad headings of the nature of the learning task, external factors, internal factors, and social interaction; 12 stressor criteria groupings were defined. Some of these criteria were a positive challenge to learning (e.g. legitimacy of the task, novelty of the learning, social interactions) and others a hindrance. Discussion Not all stressors hinder learning. Instead, and depending on their nature, many result in perceived assistance to learning. Stressors hindering learning need to be recognised by the teacher, especially those that can be converted from a hindrance to an assistance.

The Exploratory Factor Analysis and Analysis of Reliability for Role Stressor, Leadership Style, Workplace Bullying and Job Performance Criteria

The Exploratory Factor Analysis and Analysis of Reliability for Role Stressor, Leadership Style, Workplace Bullying and Job Performance Criteria

Development and Validation of a Measure of Birth-Related PTSD for Fathers and Birth Partners: The City Birth Trauma Scale (Partner Version)

Research suggests that some fathers and birth partners can experience post-traumatic stress disorder (PTSD) after witnessing a traumatic birth. Birth-related PTSD may impact on many aspects of fathers’ and birth partners’ life, including relationship breakdown, self-blame and reducing plans for future children. Despite the potential impact on birth partners’ lives there is currently no measure of birth-related PTSD validated for use with birth partners. The current study therefore adapted the City Birth Trauma Scale for use with birth partners. The City Birth Trauma Scale (Partner version) is a 29-item questionnaire developed to measure birth-related PTSD according to DSM-5 criteria: stressor criteria (A), symptoms of re-experiencing (B), avoidance (C), negative cognitions and mood (D), and hyperarousal (E), as well as duration of symptoms (F), significant distress or impairment (G), and exclusion criteria or other causes (H). A sample of 301 fathers/birth partners was recruited online and completed measures of birth-related PTSD, bonding, and demographic details. Results showed the City Birth Trauma Scale (Partner version) had good reliability (α = 0.94) and psychometric and construct validity. The fathers/birth partners version has the same two-factor structure as the original scale: (1) general symptoms and (2) birth-related symptoms, which accounted for 51% of the variance. PTSD symptoms were associated with preterm birth and maternal and infant complications. Overall, the City Birth Trauma Scale (Partner version) provides a promising measure of PTSD following childbirth that can be used in research and clinical practice.

Children's Exposure to Single Incidents of Terrorism: Perspectives Over 25 Years Since the Oklahoma City Bombing.

This paper traces advances in our knowledge about children's exposure and reactions to terrorist events over the last 25years, beginning with the 1995 Oklahoma City bombing, and offers observations about cross-cutting issues including implications for services. Direct and indirect interpersonal exposures have been examined in community samples and in samples of children selected because of their event experiences. Despite its present exclusion from the stressor criterion for a diagnosis of posttraumatic stress disorder, considerable research has documented an association between children's initial subjective reaction and outcomes. Few studies have examined the influence of community or distant effects on outcomes, but contact with media coverage has been well studied. This review confirms the central role of exposure in influencing children's reactions to terrorist incidents and supports recent efforts to distinguish specific experiences that constitute children's event exposures.

When Nowhere Is Safe: Interpersonal Trauma and Attachment Adversity as Antecedents of Posttraumatic Stress Disorder and Developmental Trauma Disorder.

Developmental trauma disorder (DTD) has been proposed as clinical framework for the sequelae of complex trauma exposure in children. In this study, we investigated whether DTD is associated with different traumatic antecedents than posttraumatic stress disorder (PTSD). In a multisite sample of 236 children referred from pediatric or mental health treatment, DTD was assessed using the DTD Structured Interview. Trauma history was assessed using the Traumatic Events Screening Instrument (TESI). On an unadjusted basis, both DTD, odds ratios (ORs) = 2.0–3.8, 95% CI [1.17, 7.19]; and PTSD, ORs = 1.8–3.0, 95% CI [1.04, 6.27], were associated with past physical assault and/or abuse, family violence, emotional abuse, neglect, and impaired caregivers; and DTD was associated community violence, OR = 2.7, 95% CI [1.35, 5.43]. On a multivariate basis after controlling for the effects of PTSD, DTD was associated with family and community violence and impaired caregivers, ORs = 2.0–2.5, 95% CI [1.09, 5.97], whereas PTSD was only associated with physical assault and/or abuse after controlling for the effects of DTD, OR = 2.4, 95% CI [1.07, 4.99]. Exposure to both interpersonal trauma and attachment adversity was associated with the highest DTD symptom count, controlling for the PTSD symptom count. Although childhood PTSD and DTD share several traumatic antecedents, DTD may be uniquely associated with pervasive exposure to violent environments and impaired caregiving. Therefore, DTD warrants further investigation as a framework for the assessment and treatment of children with histories of interpersonal victimization and attachment adversity.

Development of a Measure of Postpartum PTSD: The City Birth Trauma Scale.

Post-traumatic stress disorder (PTSD) affects 4% of women after birth yet there are very few questionnaire measures of postpartum PTSD that have been validated in this population. In addition, none of the available questionnaires assess postpartum PTSD in accordance with criteria specified in the latest edition of the Diagnostic and Statistical Manual [DSM-5, (1)]. The City Birth Trauma Scale is a 29-item questionnaire developed to measure birth-related PTSD according to DSM-5 criteria of: stressor criteria (A), symptoms of re-experiencing (B), avoidance (C), negative cognitions and mood (D), and hyperarousal (E), as well as duration of symptoms (F), significant distress or impairment (E), and exclusion criteria or other causes (H). Two additional items from DSM-IV were also included on the basis of evidence suggesting they might be important in this population. The first was criterion A2 that women responded to events during birth with intense fear, helplessness or horror. The second was symptoms of emotional numbing. Items were first reviewed by researchers (n = 9) and postpartum women (n = 8) and revised accordingly. The questionnaire was then completed by 950 women recruited online. Results showed the City Birth Trauma Scale had excellent reliability (Cronbach's α = 0.92) and is easy to understand (Flesch reading score 64.17). Exploratory factor analysis found two factors which together accounted for 56% of the variance: (i) Birth-related symptoms (40.8% variance) and (ii) General symptoms (15.5% variance). PTSD symptoms were highly associated with distress, impaired functioning, and women reporting they wanted treatment (r = 0.50–0.61). Removing DSM-IV A2 criteria only increased births classified as traumatic by 2%. Adding the item on emotional numbing did not change the psychometric properties of the scale. These items were therefore removed. The City Birth Trauma Scale has good psychometric properties and the two symptom clusters identified are consistent with previous research on symptoms of postpartum PTSD. This scale therefore provides a promising measure of PTSD following childbirth that can be used in research and clinical practice. Future research should examine the scale's predictive validity using clinical interviews.

APA Welcomes Public Comments For Proposed DSM-5 Changes

APA Welcomes Public Comments For Proposed <i>DSM-5</i> Changes

Did the DSM-5 Improve the Traumatic Stressor Criterion?: Association of DSM-IV and DSM-5 Criterion A with Posttraumatic Stress Disorder Symptoms

Objective: A recent meta-analysis found that DSM-III- and DSM-IV-defined traumas were associated with only slightly higher posttraumatic stress disorder (PTSD) symptoms than nontraumatic stressors. The current study is the first to examine whether DSM-5-defined traumas were associated with higher levels of PTSD than DSM-IV-defined traumas. Further, we examined theoretically relevant event characteristics to determine whether characteristics other than those outlined in the DSM could predict PTSD symptoms. Method: One hundred six women who had experienced a trauma or significant stressor completed questionnaires assessing PTSD, depression, impairment, and event characteristics. Events were rated for whether they qualified as DSM-IV and DSM-5 trauma. Results: There were no significant differences between DSM-IV-defined traumas and stressors. For DSM-5, effect sizes were slightly larger but still nonsignificant (except for significantly higher hyperarousal following traumas vs. stressors). Self-reported fear for one's life significantly predicted PTSD symptoms. Conclusions: Our results indicate that the current DSM-5 definition of trauma, although a slight improvement from DSM-IV, is not highly predictive of who develops PTSD symptoms. Our study also indicates the importance of individual perception of life threat in the prediction of PTSD.

Lung Cancer Diagnosis and Treatment as a Traumatic Stressor in DSM-IV and DSM-5: Prevalence and Relationship to Mental Health Outcomes.

Little research has examined how lung cancer survivors whose cancer experience met the Diagnostic and Statistical Manual of Mental Disorders (DSM) traumatic stressor criterion differ with regard to posttreatment mental health status from survivors whose cancer experience did not. No research of which we are aware has examined the impact of the revised DSM-5 traumatic stressor criterion on this question. Non-small-cell (NSC) lung cancer survivors (N = 189) completed a telephone interview and questionnaire assessing distress and growth/benefit-finding. Survivors were categorized into Trauma and No Trauma groups using both the DSM-IV and DSM-5 stressor criterion. Using the DSM-IV criterion, the Trauma group (n = 70) reported poorer status than the No Trauma group (n = 119) on 10 of 10 distress indices (mean ES = 0.57 SD) and better status on all 7 growth/benefit-finding indices (mean ES = 0.30 SD). Using the DSM-5 stressor criterion, differences between the Trauma (n = 108) and No Trauma (n = 81) groups for indices of distress (mean ES = 0.26 SD) and growth/benefit-finding (mean ES = 0.17 SD) were less pronounced. Those who experience cancer as a traumatic stressor show greater distress and growth/benefit-finding, particularly when the more restrictive DSM-IV stressor criterion defines trauma exposure.

Unexpected adverse childhood experiences and subsequent drug use disorder: a Swedish population study (1995–2011)

Exposure to extraordinary traumatic experience is one acknowledged risk factor for drug use. We aim to analyse the influence of potentially life-changing childhood stressors, experienced second-hand, on later drug use disorder in a national population of Swedish adolescent and young adults (aged 15-26 years). We performed Cox proportional hazard regression analyses, complemented with co-relative pair comparisons. Sweden. All individuals in the Swedish population born 1984-95, who were registered in Sweden at the end of the calendar year that they turned 14 years of age. Our follow-up time (mean 6.2 years; range 11 years) started at the year they turned 15 and continued to December 2011 (n = 1,409,218). Our outcome variable was drug use disorder, identified from medical, legal and pharmacy registry records. Childhood stressors, as per DSM-IV stressor criteria, include death of an immediate family member and second-hand experience of diagnoses of malignant cancer, serious accidental injury and victim of assault. Other covariates include parental divorce, familial psychological wellbeing and familial drug and alcohol use disorders. After adjustment for all considered confounders, individuals exposed to childhood stressors 'parental death' or 'parental assault' had more than twice the risk of drug use disorder than those who were not [hazard ratio (HR) = 2.63 (2.23-3.09) and 2.39 (2.06-2.79), respectively]. Children aged under 15 years who experience second-hand an extraordinary traumatic event (such as a parent or sibling being assaulted, diagnosed with cancer or dying) appear to have approximately twice the risk of developing a drug use disorder than those who do not.

Can Sudden, Severe Emotional Loss Be a Traumatic Stressor?

Aspects of the stressor criterion for posttraumatic stress disorder (PTSD) have been controversial since its inception, and the theoretical or empirical reasons for decisions about it have not been clear. To investigate whether sudden events involving severe emotional loss have the potential to precipitate PTSD, we assessed exposure to Criterion A stressors, sudden abandonment, sudden move or loss of home, and symptoms of PTSD and dissociation in a community sample of 427 adults. In regression analyses, models that included a severe emotional loss stressor accounted for a significant amount of additional variance in PTSD and dissociation symptoms beyond that accounted for by a model including only Criterion A stressors. The findings suggest that limiting Criterion A1 to events involving actual or threatened death or injury may be overly restrictive. Future research is needed to replicate these findings in a clinical sample and to prospectively examine the conditional probability of PTSD following these events.

Work-related post-traumatic stress disorder

Work-related post-traumatic stress disorder (PTSD) is an important condition encountered by many occupational health practitioners. To carry out an in-depth review of the research on occupational groups that are at particular risk of developing work-related PTSD. A literature search was conducted in the databases OVID MEDLINE, OVID Embase, Ovid PsycINFO, ISI Web of Science and CSA Health and Safety Science Abstracts. Professionals such as police officers, firefighters and ambulance personnel often experience incidents that satisfy the stressor criterion for the PTSD diagnosis. Other professional groups such as health care professionals, train drivers, divers, journalists, sailors and employees in bank, post offices or in stores may also be subjected to work-related traumatic events. Work-related PTSD usually diminishes with time. Mental health problems prior to the traumatic event and weak social support increase the risk of PTSD. Prevention of work-related PTSD includes a sound organizational and psychosocial work environment, systematic training of employees, social support from colleagues and managers and a proper follow-up of employees after a critical event.

The stressor criterion for posttraumatic stress disorder: does it matter?

The definition of the stressor criterion (DSM criterion A1) for posttraumatic stress disorder (PTSD) is hotly debated with major revisions being considered for DSM-5. We examine whether symptoms, course, and consequences of PTSD vary predictably with the type of stressful event that precipitates symptoms. We used data from the 2009 PTSD diagnostic subsample (N = 3,013) of women from the Nurses' Health Study II. We asked respondents about exposure to stressful events that qualified under DSM-III or DSM-IV or did not qualify under DSM criterion A1. Respondents selected the event they considered worst and reported subsequent PTSD symptoms. Among participants who met all other DSM-IV PTSD criteria, we compared distress, symptom severity, duration, impairment, receipt of professional help, and 9 physical, behavioral, and psychiatric sequelae (eg, physical functioning, unemployment, depression) by precipitating event group. Various assessment tools were used to determine fulfillment of PTSD criteria B through F and to assess these 14 outcomes. Participants with PTSD from DSM-III events reported, on average, 1 more symptom (DSM-III, mean = 11.8 symptoms; DSM-IV, mean = 10.7 [P < .001]; non-DSM, mean = 10.9 [P < .01]) and more often reported that symptoms lasted 1 year or longer compared to participants with PTSD from other groups (DSM-III vs DSM-IV, P < .01; DSM-III vs non-DSM, P < .001). However, sequelae of PTSD did not vary systematically with precipitating event type. Results indicate the stressor criterion as defined by the DSM may not be informative in characterizing PTSD symptoms and sequelae. In the context of ongoing DSM-5 revision, these results suggest that criterion A1 could be expanded in DSM-5 without much consequence for our understanding of PTSD phenomenology. Events not considered qualifying stressors under the DSM produced PTSD as consequential as PTSD following DSM-III events, suggesting PTSD may be an aberrantly severe but nonspecific stress response syndrome.

The PTSD Stressor Criterion as a Barrier to Malingering: DSM-5 Draft Commentaries

This commentary focuses on the proposed changes to the trauma stressor criterion for PTSD for DSM-5, specifically its likely impact on malingering. PTSD is particularly susceptible to malingering because the diagnosis relies so heavily on a patient’s subjective symptoms. Because the traumatic event that is the trigger of the PTSD syndrome is generally based on objective fact and thus often easily corroborated, this element of the diagnosis is usually more challenging to malinger than subjective reports of symptoms. Therefore, one of the main gateways for limiting the misuse of the PTSD diagnosis in forensic settings is the criterion defining the range of qualifying traumas. Proposed changes to criterion A of PTSD in the draft include modifying the types of qualifying trauma by replacing “threat to physical integrity” with “sexual violation,” and clarifying the modes of exposure by replacing the phrase “confronted with” with two criterion: “learning that the event occurred to a close relative or close friend” and “experiencing repeated or extreme exposure to aversive details of the event.” Each of these changes has the potential to significantly broaden the range of qualifying stressors and consequently expand the potential pool of individuals who might be in a position to malinger the disorder. Given the likelihood that the DSM-5 field trials will be unable to provide information relevant to assessing the impact of making these changes in forensic settings, it would be prudent to resist the inclination to tinker with the wording unless other mechanisms are available to ensure that the wording changes do more good than harm.

Are traumatic events necessary to elicit symptoms of posttraumatic stress?

A diagnosis of posttraumatic stress disorder (PTSD) has been conceptualized as being precipitated by a particularly traumatic (e.g., combat exposure, rape, and violent assault). Recent research suggests that common stressful events (e.g., relational problems, divorce, and expected death of a loved one) may also be capable of eliciting posttraumatic symptomatology. The current study replicated and extended these previous findings, examining three groups of exposure: those who reported experiencing only traumatic events in the past year, those who reported experiencing only significant stressful life events in the last year, and those who experienced both types of events. Consistent with previous findings, we found that all three groups of exposure, including those experiencing only stressful life events, experienced similar amounts of PTSD symptomatology across symptom clusters. These data add to the growing literature that suggests that the type of events that cause symptoms of PTSD may be broader than the current diagnostic criteria indicate, and as such calls for more rigorous research in this area to better understand the diagnostic implications of these findings. Since the formal inclusion of posttraumatic stress disorder (PTSD) into the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III; American Psychiatric Association (APA), 1980), controversy has arisen with the diagnosis, much of it centered on Criterion A1 (the stressor criterion). In DSM-III, this criterion held that an individual had to experience an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone (APA, 1980). One of the first critiques of PTSD came from Breslau and Davis (1987), who claimed that the connection between this criterion and the symptom constellation of the PTSD diagnosis had not been adequately tested in an empirical manner. An additional criticism of this early criterion concerned the definition of a traumatic as one that occurred rarely in the population. Epidemiological studies have shown that traumatic stressors are relatively common, with most people experiencing at least one traumatic within their lifetime (Breslau, Davis, Andreski, & Peterson, 1991). In addition to these early criticisms of PTSD as a construct, several research studies have documented that events not necessarily considered traumatic elicit the symptom constella- tion thought to be associated with PTSD, raising questions con- cerning the disorder's symptom specificity. A study conducted by Joseph, Mynard, and Mayall (2000) on English adolescents found a relationship between high scores on measures of posttraumatic stress symptoms and stressful life events that normally would not be classified as traumatic by the current PTSD inclusion criteria (e.g., parental separation, trouble with the police, and family member with a drug or alcohol prob- lem). Additionally, Mol and colleagues (2005) used a general population sample to examine whether stressful events could gen- erate symptoms of PTSD and found that those who identified a stressful life as their worst subjective experience endorsed higher levels of PTSD symptoms than did those whose worst experience was a traumatic event. Similarly, Gold, Marx, Soler- Baillo, and Sloan (2005) divided college undergraduate partici- pants into two groups: those who endorsed a traumatic consistent with the A1 criterion of PTSD and those who experi- enced a negative life not consistent with that criterion. Consistent with previous research, individuals who reported expe- riencing negative life events not consistent with the traumatic nature of the A1 criterion showed equal, if not more, posttraumatic symptomatology than did those who indicated the experience of a traumatic in their life. A more recent study using structured clinical interviews found similar results in a sample of people seeking treatment for major depression (Bodkin, Pope, Detke, & Hudson, 2007). These recent findings underscore a perceived problem with the construct of PTSD and the criterion that has received increased attention as we move closer to the release of DSM (5th ed.). These studies also highlight the importance of additional research in this area to further explore the A1 criterion of PTSD and the stressors that can lead to a posttraumatic stress symptom constellation.

Improving the Reliability of the Diagnosis of Post-Traumatic Stress Disorder in Civil Litigation

Post-traumatic stress disorder (PTSD) has become one of the most frequently diagnosed psychiatric disorders, although there is little evidence that PTSD can be reliably diagnosed using an unstructured clinical interview. There are reports, however, of reasonable agreement in the diagnosis of the disorder between clinicians using structured interviews. PTSD is unusual in the inclusion of a necessary cause for the disorder in the A, or stressor criteria, which can lead expert witnesses in civil cases to pre-empt the court by deciding the cause of the patients' condition. Removing the A criterion in the diagnostic criteria for PTSD in DSM-V, or at least excluding opinion about the A criterion from expert evidence, would separate the diagnosis of PTSD from judgements about its aetiology.

(Post-traumatic) embitterment disorder: Critical evaluation of its stressor criterion and a proposed revised classification

Background: In 2003, the German psychiatrist Michael Linden proposed the new mental disorder concept of “post-traumatic embitterment disorder (PTED)”. PTED is defined as the mental reaction to a critical event that is normal, but not everyday, such as conflict at work. The patient sees this event as unjust and as a violation of basic beliefs. The principal aspect of the reaction pattern is a prolonged feeling of embitterment. Aim: In the present paper, the concept of PTED is systematically evaluated. Moreover, future developments in terms of diagnostic systems of mental disorders (ICD-11, DSM-V) are addressed. Results: The evaluation of critical points concerning PTED revealed that the question of whether PTED is a mental disorder of the post-traumatic type cannot be finally answered. It is not possible to specify an empirical criterion by means of which traumatic and non-traumatic life events can be differentiated. An empirical criterion for determining the traumatic nature of a given event depends on whether this event has already been classified as traumatic (i.e. circular argument). Conclusions: For the purpose of a clear classification of embitterment disorders, the new concept of adjustment disorders of Andreas Maercker and co-workers is introduced. Based on the criteria and their findings, the best and most viable possibility to classify embitterment disorders in accordance with the current adjustment disorder and post-traumatic stress disorder definitions of ICD and DSM is by regarding embitterment disorders as a subtype of adjustment disorders.