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Complex post-traumatic stress disorder: a new diagnosis in ICD-11

  • Chris R. Brewin (a1)


The World Health Organization's proposals in ICD-11, released for comment by member states in 2018, introduce for the first time in a major diagnostic system a distinction between post-traumatic stress disorder (PTSD) and complex post-traumatic stress disorder (CPTSD). This article sets the new diagnosis of CPTSD within the context of previous similar formulations, describes its definition and requirements, and reviews the evidence concerning its epidemiology, differential diagnosis, assessment and treatment.


After reading this article you will be able to:

  • understand the relationship between CPTSD and precipitating events
  • distinguish CPTSD from PTSD and borderline personality disorder
  • recognise current issues and practices in psychological treatment.


C.B. was an unpaid member of the Working Group on Classification of Stress-Related Disorders for the World Health Organization's International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. The views expressed in this article are those of the author and do not represent the official policies or positions of the International Advisory Group or the WHO.


Corresponding author

Correspondence Professor Chris R. Brewin, Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London WC1E 6BT, UK. Email:


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American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM-IV). APA.
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM-IV). APA.
American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (5th edn) (DSM-5). American Psychiatric Publishing.
Anketell, C, Dorahy, MJ, Shannon, M, et al. (2010) An exploratory analysis of voice hearing in chronic PTSD: potential associated mechanisms. Journal of Trauma & Dissociation, 11: 93107.
Armstrong, JG, Putnam, FW, Carlson, EB, et al. (1997) Development and validation of a measure of adolescent dissociation: the Adolescent Dissociative Experiences Scale. Journal of Nervous and Mental Disease, 185: 491–7.
Ben-Ezra, M, Karatzias, T, Hyland, P, et al. (2018) Posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as per ICD-11 proposals: a population study in Israel. Depression and Anxiety, 35: 264–74.
Bisson, JI, Brewin, CR, Cloitre, M, Maercker, A (2019) PTSD and Complex PTSD: Diagnosis, assessment, and screening. In Effective treatments for PTSD (3rd edn) (eds EB Foa, TM Keane, MJ Friedman, JA Cohen). Guilford.
Brewin, CR, Gregory, JD, Lipton, M, et al. (2010a) Intrusive images in psychological disorders: characteristics, neural mechanisms, and treatment implications. Psychological Review, 117: 210–32.
Brewin, CR, Patel, T (2010b) Auditory pseudo-hallucinations in United Kingdom war veterans and civilians with posttraumatic stress disorder. Journal of Clinical Psychiatry, 71: 419–25.
Brewin, CR (2013) ‘I wouldn't start from here’ – an alternative perspective on PTSD from the ICD-11: comment on Friedman (2013). Journal of Traumatic Stress, 26: 557–9.
Brewin, CR, Cloitre, M, Hyland, P, et al. (2017) A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD. Clinical Psychology Review, 58: 115.
Brewin, CR (2019) Treating voice-hearing in PTSD. Advances in Cognitive Therapy, 20: 3–.
Carlson, EB, Putnam, FW (1993) An update on the Dissociative Experiences Scale. Dissociation: Progress in the Dissociative Disorders, 6: 1627.
Cloitre, M, Stovall-McClough, KC, Nooner, K, et al. (2010) Treatment for PTSD related to childhood abuse: a randomized controlled trial. American Journal of Psychiatry, 167: 915–24.
Cloitre, M, Garvert, DW, Weiss, B, et al. (2014) Distinguishing PTSD, complex PTSD, and borderline personality disorder: a latent class analysis. European Journal of Psychotraumatology, 5: doi 10.3402/ejpt.v5.25097.
Cloitre, M, Shevlin, M, Brewin, CR, et al. (2018) The International Trauma Questionnaire: development of a self-report measure of ICD-11 PTSD and complex PTSD. Acta Psychiatrica Scandinavica, 138: 536–46.
Cloitre, M, Hyland, P, Bisson, JI, et al. (2019) ICD-11 PTSD and complex PTSD in the United States: a population-based study. Journal of Traumatic Stress, in press.
Corstens, D, Longden, E, May, R (2012) Talking with voices: exploring what is expressed by the voices people hear. Psychosis: Psychological, Social and Integrative Approaches, 4: 95104.
de Jongh, A, Resick, PA, Zoellner, LA, et al. (2016) Critical analysis of the current treatment guidelines for complex PTSD in adults. Depression and Anxiety, 33: 359–69.
Ebert, A, Dyck, MJ (2004) The experience of mental death: the core feature of complex posttraumatic stress disorder. Clinical Psychology Review, 24: 617–35.
Ford, JD (1999) Disorders of extreme stress following war-zone military trauma: Associated features of posttraumatic stress disorder or comorbid but distinct syndromes? Journal of Consulting and Clinical Psychology, 67: 312.
Ford, JD, Spinazzola, J, van der Kolk, B, et al. (2018) Toward an empirically based developmental trauma disorder diagnosis for children: factor structure, item characteristics, reliability, and validity of the Developmental Trauma Disorder semi-structured interview. Journal of Clinical Psychiatry, 79(5): 17m11675.
Frost, R, Hyland, P, Shevlin, M et al. (2018) Distinguishing Complex PTSD from Borderline Personality Disorder among individuals with a history of sexual trauma: a latent class analysis. European Journal of Trauma and Dissociation, doi 10.1016/j.ejtd.2018.08.004.
Frost, R, Hyland, P, McCarthy, A, et al. (2019) The complexity of trauma exposure and response: profiling PTSD and CPTSD among a refugee sample. Psychological Trauma: Theory, Research, Practice and Policy, 11: 165–75.
Hendriks, L, de Kleine, RA, Broekman, TG, et al. (2018) Intensive prolonged exposure therapy for chronic PTSD patients following multiple trauma and multiple treatment attempts. European Journal of Psychotraumatology, 9(1): 1425574.
Herman, JL (1992) Complex PTSD – a syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5: 377–91.
Hyland, P, Shevlin, M, Fyvie, C, et al. (2018) Posttraumatic stress disorder and complex posttraumatic stress disorder in DSM-5 and ICD-11: clinical and behavioral correlates. Journal of Traumatic Stress, 31: 174–80.
ISTSS Guidelines Committee (2019) ISTSS Guidelines Position Paper on Complex PTSD in Adults. ISTSS (
Karatzias, T, Hyland, P, Bradley, A, et al. (2019a) Is self-compassion a worthwhile therapeutic target for ICD-11 complex PTSD (CPTSD)? Behavioural and Cognitive Psychotherapy, 47: 257–69.
Karatzias, T, Murphy, P, Cloitre, M, et al. (2019b) Psychological interventions for ICD-11 complex PTSD symptoms: systematic review and meta-analysis. Psychological Medicine, Mar 12: doi 0.1017/S0033291719000436 [Epub ahead of print].
Keeley, JW, Reed, GM, Roberts, MC, et al. (2016) Disorders specifically associated with stress: a case-controlled field study for ICD-11 mental and behavioural disorders. International Journal of Clinical and Health Psychology, 16: 109–27.
Kennedy, F, Kennerley, H, Pearson, D (eds) (2013) Cognitive Behavioural Approaches to the Understanding and Treatment of Dissociation. Routledge.
Knefel, M, Tran, US, Lueger-Schuster, B (2016) The association of posttraumatic stress disorder, complex posttraumatic stress disorder, and borderline personality disorder from a network analytical perspective. Journal of Anxiety Disorders, 43: 70–8.
Litvin, JM, Kaminski, PL, Riggs, SA (2017) The Complex Trauma Inventory: a self-report measure of posttraumatic stress disorder and complex posttraumatic stress disorder. Journal of Traumatic Stress, 30: 602–13.
Maercker, A, Brewin, CR, Bryant, RA, et al. (2013) Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11. World Psychiatry, 12: 198206.
Maercker, A, Hecker, T, Augsburger, M, et al. (2018) ICD-11 prevalence rates of posttraumatic stress disorder and complex posttraumtic stress disorder in a German nationwide sample. Journal of Nervous and Mental Disease, 206: 270–6.
McCarthy-Jones, S, Longden, E (2015) Auditory verbal hallucinations in schizophrenia and post-traumatic stress disorder: common phenomenology, common cause, common interventions? Frontiers in Psychology, 6: 1071 (doi: 10.3389/fpsyg.2015.01071).
Murphy, S, Elklit, A, Dokkedahl, S, et al. (2016) Testing the validity of the proposed ICD-11 PTSD and complex PTSD criteria using a sample from Northern Uganda. European Journal of Psychotraumatology, 7: 32678.
National Institute for Health and Care Excellence (2018) Post-Traumatic Stress Disorder (NICE Guideline NG116). NICE.
Pelcovitz, D, van der Kolk, B, Roth, S, et al. (1997) Development of a criteria set and a structured interview for disorders of extreme stress (SIDES). Journal of Traumatic Stress, 10: 316.
Resick, PA, Bovin, MJ, Calloway, AL, et al. (2012) A critical evaluation of the complex PTSD literature: implications for DSM-5. Journal of Traumatic Stress, 25: 241–51.
Sachser, C, Keller, F, Goldbeck, L (2017) Complex PTSD as proposed for ICD-11: validation of a new disorder in children and adolescents and their response to trauma-focused cognitive behavioral therapy. Journal of Child Psychology and Psychiatry, 58: 160–8.
Vallières, F, Ceannt, R, Daccache, F, et al. (2018) ICD-11 PTSD and complex PTSD amongst Syrian refugees in Lebanon: the factor structure and the clinical utility of the International Trauma Questionnaire. Acta Psychiatrica Scandinavica, 138: 547–57.
Waller, NG, Putnam, FW, Carlson, EB (1996) Types of dissociation and dissociative types: a taxometric analysis of dissociative experiences. Psychological Methods, 1: 300–21.
World Health Organization (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. WHO.
World Health Organization (2018) ICD-11: International Classification of Diseases 11th Revision. WHO ( Accessed 22 Jul 2019.



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Complex post-traumatic stress disorder: a new diagnosis in ICD-11

  • Chris R. Brewin (a1)
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