DSM-5 & ICD-11

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

ICD-11 PTSD & Complex PTSD

ICD-11  PTSD & Complex PTSD

PTSS, CPTSS and BPS – A latent class analysis
Published: 15 September 2014

There has long been debate about whether Complex Posttraumatic Stress Disorder (Complex PTSD) is distinct from Borderline Personality Disorder (BPD) comorbid with PTSD. Part of the difficulty in this evaluation has been the lack of clear and consistent characterization of Complex PTSD. The World Health Organization (WHO) Working Group on the Classification of Stress-Related Disorders has proposed the inclusion of Complex PTSD as a new diagnosis related to but separate from PTSD (Maercker et al., 2013). Both of these disorders are viewed as distinct and separate from BPD. An emerging and accumulating empirical literature is demonstrating consistent and clear differences between ICD-11 PTSD and Complex PTSD. In addition, it is important to determine the construct validity of Complex PTSD as empirically distinct from BPD particularly among those with a trauma history. This investigation evaluated whether ICD-11 Complex PTSD could be distinguished from DSM-IV BPD in a treatment-seeking population of women with childhood abuse.
The WHO proposed that the development of ICD-11 be guided by the principle of clinical utility. Characteristics of clinical utility include the organization of disorders that are consistent with clinicians’ mental health taxonomies, that contain a limited number of symptoms so that they can be easily recalled and used in the field, and that are based on distinctions important for management and treatment (Reed, 2010). The distinction between ICD-11 PTSD and Complex PTSD are consistent with these guidelines (see Cloitre, Garvert, Brewin, Bryant, & Maercker, 2013; Maercker et al., 2013). For example, ICD-11 PTSD is construed as a fear-based disorder and symptoms are limited to and consistent with fear reactions and consequent avoidance and hypervigilence. In contrast, Complex PTSD has been described as typically associated with chronic and repeated traumas and includes not only the symptoms of PTSD but also disturbances in self-organization reflected in emotion regulation, self-concept and relational difficulties (see Cloitre et al., 2013) a symptom profile that has been demonstrated as associated with prolonged trauma (Briere & Rickards, 2007).

Three studies have found evidence supporting the validity of the ICD-11 PTSD versus Complex PTSD distinction (see Table 1 for description of the diagnoses). Recently, in order to evaluate whether PTSD and Complex PTSD could be empirically distinguished from each other, Cloitre and colleagues (2013) performed a latent profile analysis (LPA) on assessment data from 302 treatment-seeking individuals with diverse trauma histories, ranging from single events (e.g., 9/11 attacks) to sustained exposures (e.g., childhood or adult physical and/or sexual abuse). The results were consistent with the ICD-11 formulation for Complex PTSD, with the best fitting LPA model delineating three classes of individuals: (1) a Complex PTSD class, with high levels of both PTSD symptoms as well as disturbances in self-organization related to affect regulation problems, negative self-concept, and relational difficulties; (2) a PTSD class, with high levels of PTSD symptoms but relatively low on the disturbances in self-organization that define Complex PTSD; and (3) a class relatively low on symptoms of both PTSD and Complex PTSD. Notably, these identified classes were identical when including an additional 86 participants with BPD, providing further support for the stability of the identified classes. Cloitre et al. (2013) also found that chronic trauma was more predictive of Complex PTSD than PTSD and that Complex PTSD resulted in significantly greater functional impairment than PTSD.

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The difference between OSDD+ and DID

(c) Nique TRTCenter NLThe difference between a secondary and tertiary SD 

a secondary (OSDD+) and a tertiary (DID) structural dissociation of the personality
Other Specified Dissociative Disorder (300.15) and the Dissociative Identity Disorder (300.14)

As we explained and know already…

DID is a Dissociative Disorder (DD)

A Dissociative Disorder (DD) leads very rarely to a diagnose of a dissociative Identity disorder (DID), more common is a secondary SD. Read also my previous post and the notification I shared of Prof.Ph.D. Onno van der Hart and Ph.D. Ellert Nijenhuis.

OSDD criterea

And although a trauma related secondary Structural Dissociation, diagnoses OSDD+ in combination with another (personality) disorder such as BPD, far more often occurs than a DID, you will find hardly websites that inform you about a OSDD+. It is also a very severe Trauma related disorder which presents itself with a wide range of dissociative symptoms and switching behavior under the influence of EP’s (more than one). But its also very often mistaken with DID and diagnosed as a DID – but it isn’t a DID.

That alone should ring a bell to the leg of understanding a Trauma related SD !!

Why are there so much websites and blogs about DID and nearly none about OSDD+ (DSM-5  code 300.15  – ICD F44.89 – ) And why are most of the DID related websites focused on, and explaining ANP-EP switching behavior and not ANP-ANP switching behavior which is more common to a DID?
I leave that answer to my readers who are willing to understand the theory of a trauma related structural dissociation of the personality (SD), but I will give you all some theoretically and educational stuff to think over in order to understand even better the difference between a OSDD+ and DID, e.g.  the difference between a secondary and a tertiary structural dissociation of the personality.

DID critereaDID versus OSDD+ and again I start with writing . . .

Switching behavior caused and under the influence of Emotional personality parts ANP-EP’s switching is not a phenomenon that occurs most commonly as a symptom of a dissociative identity disorder (DID) – a Tertiary Structural Dissociation of the Personality. Indeed it is more common to a Secondary Structural Dissociation of the personality OSDD + very often in combination with a Borderline Personality disorder.

So there are also other disorders that have symptoms of identity problems, or which causes switching behavior, such as a theatrical personality disorder, a Borderline personality disorder (BPD), a Bipolar disorder, Schizophrenia etc.. A Dissociative Disorder (DD) has a wider range of being a co-morbidity disorder.


Take notice:
a tertiary Structural Dissociation – a trauma related Dissociative Identity disorder (DID) – is a poly-symptomatic condition which is characterized by a hidden presentation (Boon/Daijer). Diagnoses of a ‘trauma related’ structural dissociation of the personality can only be done by an experienced clinical trauma psychologist/psychotherapist which is specially taint to do so.

By KamarzaIt’s hard to accept a diagnose of a mental disorder

I know that most of us who suffer mentally problems don’t like to be lined out with a Personality disorder or an other mentally disorder diagnose which we don’t like to accept or were we don’t want to hear about. I’m no different to that. I also walked the way rejection. I also rejected every mental disorder diagnose for years – I wanted to be accepted as ‘Neuro typical without any mental problems’. I didn’t want to hear or know about it, I didn’t suffer a mental disorder, I also didn’t want to hear about my history or about the past. I was strong, nothing was wrong with me because I could survive everything, it had to be a physical problem – but it was a big lie, told by my own misleading mind. I hated to be diagnosed or to accept ‘I have problems and I need help’. So I know how hard it is to accept a diagnose of a mental disorder .

Especially a diagnose which is so painful and hard to understand, and which carries a  very stigmatizing character. But I did accept eventually and I also will beat the monster inside of me.

So a diagnose will never be something to please or pleasure, and in a way it will always hurt until you learn to accept who you are and which problems you need to face and fight. So I don’t write to please, pleasure or hurt someone. I write to explain something. Because the diagnose of a tertiary and also secondairy “structural dissociation” – is still very misplaced, misunderstood, unknown and very often wrongly explained.

And likewise,there are DID sufferers misdiagnosed with a personality or other mentally disorder,
there are also OSDD+ sufferers misdiagnosed with a the diagnose MPD or DID

Suffering a DID 

In my previous column the diagnostically reality of a SD-DID sufferer I wrote:

Are all DID diagnoses a tertiary structural dissociation?
And I answered to it:
Technically and to the theory of a Structural Dissociation: YES
Realistic and to the present time of a global diagnostically acceptance and understanding of a Structural Dissociation: NO

Until this moment a level 2 and 3 of the structural dissociation of the personality are a diagnostically mess and you also get easily misinformed about a level 3 SD-DID. Because there is still no suitable diagnostically DSM category to define a Complex Trauma (CPTSD) with severe dissociative symptoms. And there is also still a big leg of understanding to the SD theory and diagnosticians who can proper diagnose a trauma related structural dissociation of the personality. 

Result: Level 2 and 3 of a Structural Dissociation are totally mixed up as a Dissociative Identity Disorder. And DID sufferers still get stigmatized by a global a populistic presentation of unrealistic switching behavior which isn’t a realistic match to someone who suffers a Tertiary Structural dissociation of the personality. 

In reaction someone commented to it:

The diagnosis of MPD (multiple personality disorder) was renamed as DID
but the DSM criteria barely changed, so that part I don’t follow

The DSM – DID criteria A holds:

  • Disruption of identity characterized by two or more distinct personality states. ANP states !

Here the biggest misunderstanding starts already.
Lots of people mess up the explanation and understanding of the EP and ANP (alters, hosts, personality parts or personality state, etc.):

An Emotional personality Part (EP)
An Apparently Normal Personality state (ANP)

  1. Emotional Personality part (EP)
    Every human being is gifted with emotions and a personality.
    So everyone can also develop EP’s during live (no age boundaries) – Emotional parts of the personality. But an EP is NO autonomic functioning personality state that takes care of daily life events (its not task oriented). Also EP’s aren’t a realistic match to the present time and they don’t take care of everyday life (the present time). EP’s are emotional personality Parts which are stocked in a traumatizing experience, a memory in the past. And EP’s react to everything that (could) trigger a traumatizing memory or a part of that nasty memory – they go in contact with that memory.
  1. Apparently Normal Personality state (ANP)
    ANP’s are very ingenious Personality states. Survival oriented personality states. They function fully autonomic and they stay fully in contact with the present time. Their main function is ‘not remembering traumatizing experiences at all’. They act Apparently Normal. They take care of everyday life emotions and tasks. And they don’t leave a lot of room to EP’s to take over or to react on situations which could trigger EP’s (remembering the past or a part of the personality that goes in contact with that experience in of the past). If you don’t know the person who suffers a DID very well, you probably wouldn’t notice their switching behavior. This also causes difficulties to diagnose a DID because very often it’s the same ANP which will present itself to a diagnostician. DID is poly-symptomatic condition which is characterized by a hidden presentation. Someone who suffers a DID very often also suffers a very superficial emotional life. Their life is very often tasks oriented and not emotional oriented. A very common pronunciation of someone who suffers a DID is: I wear the feeling as if I’m only able to function like a robot.

Thinking this over, you could ask yourself at the same time:

  • Is someone who suffers acting-out behavior, impulsive behavior, etc. able to live a life of a DID sufferer? A very stable, emotional superficial, task oriented life?
  • The second question you could ask yourself is;
    Would someone who suffers a DID present oneself on a vulnerable way – by the presentation of an emotional personality part? Or is the life of someone who suffers a DID more task oriented with a constantly avoiding of being vulnerable on any way (a hidden presentation)?
  • The third question you could ask yourself is;
    Does someone who suffers DID shows unstable behavior that is strongly influenced and inflicted by emotional personality parts? Does someone who suffers DID know how to live an emotionally life? Or are they only acquainted with a superficial emotional and Surviving task oriented life style?
  • The fourth question you could ask yourself is;
    Would you be able to diagnose someone with DID who you know barely and who you didn’t observe over a reasonable time expand, and where you have no knowledge of development and behavior history, and were you have no excess to an extensive hetero case history etc.. Could you diagnose someone with DID just within a couple of clinical diagnostically meetings / appointments with filling out some questionnaire lists?

To all the professionals out there I would like to say, please…..
Don’t take it lightly if you are up to diagnose someone who suffers Switching behavior. Switching behavior is not a phenomenon that only occurs as a symptom of a dissociative identity disorder (DID), likewise hearing voices or having interrupting thoughts, or suffering amnesia to a Traumatic Experience (a partial or full dissociation – ANP to EP) and or a general micro amnesia.
Please inform yourself very extensively about a Trauma related Structural Dissociation of the personality before you diagnose someone with it.


DSM-5General diagnostically information:

DSM-5 300.14 –  ICD F44.81 diagnostically criteria A, B, C, D and E;

Disruption of identity characterized by two or more distinct personality states. The disruption in identity involves marked discontinuity in sense of self and sense of agency accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.

Here we are talking about ANP’s (and not about EP’s). The Apparently Normal Personality state. Living the present time, taking care of daily tasks, having their own distinct behavior, thinking and feelings about their environment and oneself. Daily life emotion and task oriented personality parts – the ANP’s.

for example:

ANP 1 would also wear a skirt
ANP 2 would never wear a skirt

ANP 1 has a soft and warm voice
ANP 2 has a clear but cold voice

ANP 1 can’t read without reading glasses
ANP 2 read without them and doesn’t need reading glasses

ANP 1 drinks coffee with sugar and milk
ANP 2 drinks only black coffee

ANP 1 loves to cook
ANP 2 doesn’t know how to cook and also doesn’t like to cook

ANP 1 has parents or a parent
ANP 2 has no parents, was adopted and doesn’t know her own parents


Recurrent gaps in the recall of every day events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.

For example:

If ANP 1 is out, ANP 2 doesn’t take in the memory of that daily life tasks. The task which where done by ANP 1. Likewise the other way around. Sometimes an ANP has some recognition (can recall memories) about doing tasks done by another ANP but then it still doesn’t recognize it as something done by the own self (someone else did it, not me). Both (and very rarely even three) ANP’s have different memories of doing tasks in the present time and they have also a different recognition/memories of a past. The ANP’s don’t have a autobiographically memory that fits the reality of the own past (a autobiographically memory that fits one main healthy personality).

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The amnesia, the different life styles and also living a very superficial emotional life which is task and survival oriented causes severe insecurity, loneliness and suppressed emotional chaos. Someone who suffers a DID is without self-knowing, constantly living a high alert state. They get easily confused and exhausted because they are ongoing on a wake to avoid being vulnerable to the outside and also inside world.  It’s also not uncommon that someone who suffers a DID slips in to an isolated life style (a very pour social life) because they can’t keep up the different preferences of each ANP. The pour emotional life causes very often a severe inner loneliness. Emotions are likely experienced as a fragile state and the ANP’s don’t like a fragile state so they avoid those feelings by an automatically switching back and forward between the different ANP states. This causes memory gaps during daily life (broken time and chaotic memory fragments) which mess up daily life. The presence of more than one ANP also causes ongoing conflicting thoughts: did I do this already, no I didn’t do this, yes you did, no I didn’t etc. And also new experiences, new life events or new daily life tasks causes conflicting situations and chaotic thoughts as; do I like or need to do this, no I don’t, yes I do, no I don’t and I won’t do this, yes I would like or need to do this (etc.). Also trusting someone is very chaotic and causes severe inner conflicts; can I trust this therapist, no you can’t, yes you can, you need help, no I don’t need help, etc..

I by myself always say:
someone who suffers DID, suffers the loneliness of surviving the own inner self (oneself) and no longer a traumatic event or the past. There was a time our instinct created this survival mode because it was needed, but it also caused that we didn’t learn how to feel and live life – we only learnt how to survive and that’s not living, it’s surviving! Our inner self which is constantly on the run, trying to escape from the own autobiographical memory.

The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.

The symptoms are not attributable to the physiological effects of a substance (e.g. blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).


ptsd vrijI want to close this column with a very personal note:

I don’t switch at all to personality states which loose contact with the reality of daily life. The ANP’s which are a part of my whole personality, are very stable daily life task oriented.  Lots of people don’t understand at all if we talk about our switching behavior. And very often there goes a big misunderstanding to the difference between ANP to ANP switching behavior, and ANP under the influence of EP switching behavior.

I suffer, I suffer a lot by the switching behavior back and forward between more than one ANP state. A specific symptom that comes with a Tertiary Structural dissociation of the personality and which is common to the Dissociative Identity Disorder – a A typical diagnostically criteria. A very typical symptom to the third level of a SD.
Within a therapeutically frame and only within a therapeutically frame, and with the help of an experienced clinical psychologist and (hypno)therapist we bring the phobic ANP’s step by step in contact with each other and each experiences (the ANP’s and EP’s) in order to learn recognizing, working together (the ANP’s) and handling our own autobiographically being (one personality state). So we hopefully can learn to feel and functioning as one personality. And although I’m very aware of the even more severe agony someone suffers diagnosed with OSDD+ and the switching behavior that comes with it, I want to write: you will not find us switching to a vulnerable ANP sate that goes under the influence of an EP part. We will avoid that on all times, which is also very common to DID sufferers.

And please keep in mind that I’m not writing this to hurt someone, but to explain the difference between a Trauma related secondary and tertiary structural dissociation, because a SD level 2 and 3 doesn’t express itself on the same way. I hope there will be a sufferer of a OSDD+  a secondary structural disoociation of the personality that has the gusts to also tell and write about it. Because it’s known that a level 2 of a structural dissociation of the personality even comes with more dissociative symptoms and agony in life.

Understanding and even healing doesn’t come with rejecting or denial. It only comes with the acceptance of our own being and recognizing what causes our own behavior and suffering that comes with it. A secondary structural dissociation of the personality is also a very severe ‘Trauma related’ disorder witch causes even more and very severe agony in life. The co-morbidity of this disorder is far too much under exposed, accepted and recognized. It should even get more attention and research than DID.


Complex Trauma PTSD