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Do all cases of PTSD have an EP ?



And should PTSD be classified as a (Structural) Dissociative Disorder (DD)

This is a very nice question to think over, given by Dr. Colin Ross in his commentary (2014 pg 285) on the Ten reasons for conceiving and classifying post-traumatic stress disorder as a dissociative disorder (E.Nijenhuis 2014)

My personal response to this question:
Let us take a closer look at the Apparently Normal Personality STATE (ANP) – the self and ego states of oneself daily life handling system and a pathologically traumatized Emotional Personality PART (EP) such as given by the theory of a Structural Dissociation of the Personality (Hart, Nijenhuis, Steele 2005, 2006) to account to the basic dissociative elements which lead to the development of a Post-traumatic stress Disorder (PTSD) e.g.: a Primary structural dissociation of the personality (the Haunted Self 2006).

complex trauma discussion

My own Introduction:
Nobody likes to think over a traumatic event or experience. And if thinking about it, or get slightly reminded at a traumatizing experience triggers a pathologically behavior and or emotions (stress) we start automatically avoiding those nasty memories. Such a mental avoidant behavior towards a memory is basic dissociative behavior, and also the first sign to the development of a Post-Traumatic Stress Disorder. We avoid that pathologically (damaged/traumatized) emotional personality part (EP) during our daily life. Our normal functioning starts to develop abnormal behavior towards a memory.

Here the first personality break develops itself to the existence of an ANP and EP:

  1. Our daily life functioning goes on but at the same time starts avoiding a traumatic memory. The Personality no longer functions normal, but apparently normal  (ANP) .
  2. If the memory gets triggered (emotional respond) a pathologically stress reaction caused by an unconscious memory (EP) steps in and influences our normal daily life functioning. We no longer function as normal because we carry an EP around, so the personality – the ANP – gets influenced by an emotional damaged/traumatized personality part.

Such an EP is not in executive control because if such an EP gets triggered the ANP is aware of the nasty emotions and bodily stress. The person is able to point out which object or event in the present time makes him or her restless or stressed. But….. the traumatizing memory can stay full or partial in the dark of the unconscious mind. Thinking over the reason why the object or event triggers emotional stress is partial or fully dissociated and safely stored in the unconscious state of mind by an EP –  mental avoidance – basic dissociation.

If the partial or fully dissociated memory hits the conscious state of mind (remembers – recognition to the past), the Apparently Normal Personality state relives the traumatic event (the past) – a fully, pathologically emotional stress reaction can take over the wellbeing of daily life function – the Personality – the ANP gets overstressed (fear, panic, disturbed behavior,… etc.).

In this context you could conclude that dissociation stands on the basics of every PTSD development, because a traumatizing event or experience which causes pathologically behavior or emotional stress is bound to an Apparently Normal Personality STATE (ANP) and a pathologically (traumatized | damaged) Emotional Personality PART (EP).

The traumatizing memory of an EP can be partial or fully dissociated by the mental state of the ANP (Self and Ego States) until it gets unlocked  (confronting memory, reliving, lifting avoidance). Standard PTSD treatment policy (van Balkom e.a. 2013).

My Conclusion would be:

Dissociation belongs to the basic elements of developing PTSD symptoms.
Because this basic dissociative element leads to basic PTSD symptoms (from mild to severe), so there is no PTSD without Dissociation.
To the theory of a Structural Dissociation of the personality this is called a

Primary Structural Dissociation – PTSD (one ANP – one EP)


My restricted answer to a part of the first question page 285 Commentary Colin A. Ross 2014:
Yes, all cases of PTSD have an EP.



I look forward to the answer e.g. commentary of Ellert Nijenhuis or one of his specialized team member(s) to the full commentary of Colin Ross (2014).



With much respect for all the clinical traumatology researchers
Just simply Nique (December 2014)
Cl.E Top Referent Trauma Center Assen-Drenthe, the Netherlands


* Ross CA (2014) 33,3 pg 285 – question 1
* Nijenhuis ERS, TRTC Assen-Drenthe the Netherland (2014) Ten Reasons for conceiving and classifying posttraumatic stress disorder as a dissociative disorder. Psichiatria e Psicoterapia 33, 1, 74-106.
The Haunted Self (Nijenhuis, vd Hart, Steele, 2005, 2006)

* And Nique EU Disja 2014 ANP EP daily life handlingsystem


You can find me also on



google Complex-Trauma

Complex-Trauma or Complex-PTSD

complex trauma discussionREVIEW
review and own commentarry in pdf 


review of Dutch Journal


Silence-Deafens-pngA Complex-Trauma and a Complex-PTSD is not the same

Lots of people suffer a Complex Trauma (traumatic experiences),
but not all of them meet also the criteria (symptoms) of a Complex PTSD (clinical diagnose)

* * *

Psych-traumatology handles three terms to define and indicate a Psychologically-trauma.

  1. PTSD, Post-traumatic stress syndrome
  2. Complex Trauma (multiple and divers traumatic experiences)
  3. C-PTSD or CPTSD, a clinical condition: a Complex-Trauma with typical PTSD symptoms which is indicated for Complex-PTSD treatment

Although the upcoming ICD-11 will also carry a category to classify CPTSD, the DSM-5 carries no record to the classification of a Complex – Post Traumatic Stress Disorder (CPTSD or C-PTSD). As results one is bound to the diagnose of PTSD to diagnose a CPTSD. However, the guidelines for the treatment of a PTSD and a CPTSD vary enormously.

If we talk about a ‘Complex Trauma’
we talk about multiple traumatic experiences, in other words; the traumatic experiences are complex

If we talk about a Complex-PTSD
we talk about a clinical (diagnostically) PTSD condition, in other words; the symptoms of the PTSD are complex.

And here the misunderstanding starts, because a Complex-Trauma does not automatically mean one is suffering a Complex Post Traumatic Stress Disorder; many patient groups this is not examined or are the prevalence’s relatively low. So it is very important to understand and use these terms proper. And it is also very important to specify both, a complex-trauma and complex-PTSD, in a descriptive diagnosis.

To do so we need to know ‘What do we define as complex’ ?

  1. The traumatic experience (Single Trauma or Complex Trauma – multiple traumatic experiences)
  2. The consequences of the Trauma (the symptoms mild, complex or multiple complex (comorbidity disorders).
  3. And which treatment policy is needed

In order of this line you can define:

  1. PTSD treatment is indicated if a client suffers PTSD symptoms (often caused by a single Traumatic-experience)
  2. A Complex Trauma:
    Is characterized by long duration, repetition, interpersonal context and the disruption of development phases. But… if one suffered a Complex Trauma, this means not automatically one also suffers a CPTSD. And here misunderstandings often arise !
  3. CPTSD is classified if one suffers complex-PTSD symptoms

Lots of times these terms get confused with each other because one know no distinction between a Complex Trauma ‘and’ a Complex PTSD and that brings consequences for treatment. The most characteristic difference between the treatment of a PTSD and a CPTSD is in the can or cannot lift avoidance and in the confrontation with traumatic memories.

Treatment policy:
To the treatment of a PTSD confrontation with traumatic memories is standard treatment policy (van Balkom e.a., 2013), but at the core of a CPTSD treatment we need to focus on psychosocial stabilization – the phase I of the treatment guidelines of CPTSD (Cloitre e.a.,2012) because one first needs to explore if the client is stable enough to enter a phase II of the treatment (confrontation with traumatic memories). The assessment of whether or not to directly start a phase II and skip the stabilization phase, needs much more research. Therefore Jackie June ter Heid, Rolf Kleber en Trudy Mooren (2014) call for a better understanding and use of terms.


Situations and causes which lead to symptoms:
Until this moment there is still no agreement on which elements are typical to define a Complex Trauma. In view of the lack of agreement on what complex trauma involves, it seems wise for treating physicians in communication about their patients (such as treatment plans including reference letters) to specify characteristics of the complex trauma history, either to speak of prolonged or repeated or interpersonal or early trauma.

Translated Review of the Dutch Journal:
11 Oct 2014
Auteur(s) :Jackie June ter Heide, Rolf Kleber, Trudy Mooren

Review by Nique EU Disja



Other Reference:

* Ross CA (2014) 33,3 pg 285 – question 1
* Nijenhuis ERS, TRTC Assen-Drenthe the Netherland (2014) Ten Reasons for conceiving and classifying posttraumatic stress disorder as a dissociative disorder. Psichiatria e Psicoterapia 33, 1, 74-106.
The Haunted Self (Nijenhuis, vd Hart, Steele, 2005, 2006)

* And Nique EU Disja 2014 ANP EP daily life handlingsystem


You can find me also on



google Complex-Trauma

The Horror of a Psychologically-Trauma

complex trauma discussionThe Horror of a Psychologically-Trauma

Is it just fear? An anxiety disorder?

Some clinicians focus on ‘one’ emotion if they talk about cause, diagnose and treatment of a ‘psychologically-Trauma’. There are even clinicians which carry the opinion that a Psychologically-Trauma is an anxiety disorder caused by fear. Because fear alone can trigger unimaginable human strength or unimaginable human surviving capacities


Some say: fear is Horror and Horror is fear.
But is horror really only fear?

I dare to disagree with such an underestimating statement to the suffering of a psychologically-trauma. Because a psychologically-trauma is a lot more than fear that causes an anxiety disorder. That is also why PTSD is not categorized as an anxiety disorder but as a disorder caused by suffering extreme stress.

Fear is just one of the unbearable sensations which tortures the body and mind of a psychologically-traumatized daily life handling-system of once personality (the self- and ego- states). Fear can make you Run away, fear can make you Freeze, fear can make you Cry, fear can make you suffer without you even knowing ‘why’. Nobody will disagree that fear can cause all that, but does it mean you suffer a psychologically-trauma if you suffer or suffered only Fear: NO !

The word  ‘pain’ barely used . . .
But the definition of suffering pain says a lot:. “an unpleasant sensory and emotional experience associated with acute or potential tissue damage or described in terms of such damage”. Suffering physical pain, mental pain, emotional pain and psychologically pain all at once, will cause an ‘injury’ – psychologically and or physically. And (Child) sexual and or physical abuse causes such an ‘injury’ because it’s an horrific event.

A psychologically-injury

An horrific event triggers bodily responses, sensations, feelings and emotions all at once. Horror overloads your daily life handling-system (ego- and self-states), your mental state and common sense with extreme stress.  Even by witnessing a ‘horrific event’ you can get emotionally and bodily over-stressed and it even can cause a phobia for experiencing (witnessing or remembering) it ever again

Horrific events or a horrific experiences can make us lose our common sense, activate unwanted bodily responses, can cause uncontrollable sensations, feelings and emotions or can even cause an unimaginable strength which can lead us to do the unthinkable as if we are in a hypnotic state. .

Stop Child AbuseEver heard of:
Blind madness?
Blind sadness?
Blind fear?
Or over excitement – uncontrollable joy which make one scream and or shiver ?

Ever heard that someone who broke his leg or finger was able to pull it right back on its place right after the event happened? Ever heard that pain can reach a level of numbness? Ever heard that people weren’t able to notice their physical wounding’s (or the pain) right after they injured themselves or right after a severe accident? Ever felt the pain your muscles causes if your laugh gets out of control? Ever felt that powerless feeling caused by intense out of control laughing? Ever heard that over activated emotions can cause you leaving and or losing your common sense?

The unimaginable can occur if our daily life handling-system, our personality, gets overloaded (stressed out), it can force you in to a survival mode. And afterwards, if we get back in our mindful state, we feel the physical and psychologically chaos and shock that starts torturing our mind and body; some get cold and or start to tremble, some feel the pain of their muscles if they start to unlock (relax) again, some get scared by an instant only by the thoughts (memory) of what they did during that over-activated personality state, some shut bodily and mindfully down and or are extremely exhausted afterwards, some feel pain all over their body by the muscles which where over contracted, some experience a huge headache afterwards, and some just start laughing as a response to a severe accident that just happened.


If we think over what just happened to us during a horrific event or what we just experienced or did in a total over-stressed personality state – collecting or doing the impossible or the unthinkable – afterwards; we realize we lost or did leave our mindful state for that short moment of time.

Suffering a psychologically-trauma is all above mentioned.
Suffering a psychologically-trauma is an ongoing, repeating, over activation of the body and mind, of feelings and emotions, of more than one personality-state.

Suffering a psychologically-trauma eats your life !
We start dissociating to survive, because It relieves the suffering. And if you unlock the Traumatic Memory the unthinkable can happen all over again, so it’s very important to reach out for proper and very experienced Help.

Don’t underestimate suffering a psychologically-trauma.
Because suffering a psychologically-trauma is a whole lot more than suffering the emotion of fear. A psychologically-trauma will force you to live your life in an ongoing on-guard state and or survival mode.

Seek help
Seek very good and experienced help if you suffer a psychologically-trauma.


© Nique
CE at the Dutch Top Referent Trauma Center Assen-Drenthe,
National Mental Healthcare Department, The Netherlands


Other Reference:

* Ross CA (2014) 33,3 pg 285 – question 1
* Nijenhuis ERS, TRTC Assen-Drenthe the Netherland (2014) Ten Reasons for conceiving and classifying posttraumatic stress disorder as a dissociative disorder. Psichiatria e Psicoterapia 33, 1, 74-106.
The Haunted Self (Nijenhuis, vd Hart, Steele, 2005, 2006)

* And Nique EU Disja 2014 ANP EP daily life handlingsystem


You can find me also on



google Complex-Trauma