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TIRCIA · Professionals · In depth

Complex PTSD (ICD-11): identify, assess, treat

What the classification says, what the studies show, and what this means for EMDR practice

By Marie-Agnès Thulliez · Author · Publishing Director20-minute read

For thirty years, clinicians described patients who did not fit the framework of post-traumatic stress disorder (PTSD). They did have flashbacks and avoidance, but also pervasive shame, emotions they could not regulate and relationships that kept falling apart. Since the 11th revision of the International Classification of Diseases (ICD-11) came into force in January 2022, this picture has had an official name: complex PTSD (CPTSD, code 6B41).

This in-depth article reviews, for practitioners, the exact criteria, how to distinguish CPTSD from other diagnoses, the assessment tools, what treatment studies say and their limitations, and the concrete adjustments it calls for in EMDR therapy.

In brief

  • ICD-11 defines complex PTSD as the full set of PTSD symptoms plus three severe and persistent “disturbances in self-organisation”: emotional dysregulation, negative self-concept and relational difficulties.
  • The DSM-5-TR, the American classification, does not include this diagnosis. Its dissociative subtype of PTSD covers a different reality.
  • Prevalence is estimated at between 1% and 8% in the general population, and can reach 50% in mental health services (Maercker et al., 2022).
  • Trauma-focused therapies reduce PTSD symptoms in patients with features of complex PTSD. The evidence is of moderate quality for cognitive behavioural therapies (CBT) and low quality for EMDR, and trials in patients diagnosed according to ICD-11 are still rare.
  • The value of a stabilisation phase before memory work remains debated, with few and divergent trials. Dissociative disorders, for their part, call for a phase-oriented approach.

1. Where the diagnosis comes from

In 1992, Judith Herman proposed the term “complex PTSD” to describe survivors of prolonged and repeated trauma: childhood abuse, domestic violence, captivity, torture (Herman, 1992). She observed that, beyond PTSD symptoms, these people showed lasting changes in the regulation of emotions, in consciousness, in self-perception and in relationships.

During the DSM-IV field trials, the American Psychiatric Association tested a related category, DESNOS (Disorders of Extreme Stress Not Otherwise Specified). It did not make it a diagnosis: its symptoms appear only among the associated features of PTSD (van der Kolk et al., 2005). The DSM-5 (2013) instead broadened the PTSD criteria, adding a cluster of “negative alterations in cognitions and mood” and a dissociative subtype. The DSM-5-TR (2022) keeps this approach.

The World Health Organization (WHO) made the opposite choice. ICD-11, adopted in 2019 and in force since 1st January 2022, narrows PTSD down to a few core symptoms and creates, alongside it, a distinct diagnosis of complex PTSD. The two diagnoses are mutually exclusive: a patient receives one or the other. According to a review published in The Lancet, the prevalence of CPTSD lies between 1% and 8% in the general population, and can reach 50% in mental health services (Maercker et al., 2022).

Key points

  • The term “complex PTSD” comes from Judith Herman (1992), who proposed it to describe survivors of prolonged and repeated trauma.
  • The DSM-5 (2013) broadened the PTSD criteria instead of creating a distinct diagnosis, an approach retained by the DSM-5-TR (2022).
  • ICD-11, in force since 1 January 2022, makes complex PTSD a distinct diagnosis; PTSD and CPTSD are mutually exclusive.
  • Prevalence of CPTSD (Maercker et al., 2022): between 1% and 8% in the general population, up to 50% in mental health services.

2. The ICD-11 criteria

The diagnosis rests on three conditions: exposure to one or more extremely threatening or horrific events; the presence of the six symptom clusters described below, persisting for at least several weeks, with the three disturbances in self-organisation being severe and persistent; and significant impairment in personal, family, social, educational or occupational functioning (WHO, ICD-11).

ICD-11 specifies that the events involved are most often prolonged or repeated, and that escape was difficult or impossible. The type of event, however, is not enough to make the diagnosis: the symptom profile is what decides. The definition refers to “an event or series of events”, so a single event does not rule out complex PTSD. Conversely, a person who experienced repeated abuse in childhood may present with PTSD only.

Symptom clusterWhat ICD-11 describesHow it presents in session
The three PTSD symptom clusters
Re-experiencing in the presentVivid intrusive memories, flashbacks or nightmares, experienced as happening here and now, with intense emotion.“I’m back there”, strong bodily reactions, fear on waking.
AvoidanceAvoidance of thoughts and memories related to the event, or of situations, people and activities that are reminders of it.Taboo subjects, cancelled sessions, a life organised around what must not be encountered.
Sense of current threatHypervigilance or exaggerated startle reactions.Always back to the wall, watching the exits, startling at the slightest noise.
The three disturbances in self-organisation
Emotional dysregulationHeightened emotional reactivity, violent outbursts, reckless or self-destructive behaviour, or conversely emotional numbing and dissociative symptoms under stress.Disproportionate anger, self-cutting, binge drinking, or “switching off” and inner emptiness.
Negative self-conceptBeliefs about oneself as diminished, defeated or worthless, with shame, guilt or a sense of failure related to the event.“I’m dirty”, “it’s my fault”, “I’m worthless”; shame more present than fear.
Relational difficultiesDifficulty sustaining relationships and feeling close to others.Isolation, mistrust, broken or avoided relationships, a fragile therapeutic alliance.

Table reworded from the ICD-11 definition (WHO, code 6B41) and its clinical descriptions (World Health Organization [WHO], 2024). The right-hand column gives clinical examples.

The place of dissociation

A frequently misunderstood point: dissociation is not a symptom cluster in its own right in CPTSD. The ICD-11 clinical descriptions list it among the possible forms of emotional dysregulation (“dissociative symptoms under stress”), alongside emotional numbing. Flashbacks themselves have a dissociative dimension. A highly dissociative patient may therefore have CPTSD, or a dissociative disorder, which is diagnosed separately.

Key points

  • The diagnosis requires exposure to one or more extremely threatening or horrific events, the six symptom clusters and significant functional impairment.
  • The type of event is not enough: the symptom profile is what decides, and a single event does not rule out complex PTSD.
  • The three PTSD symptom clusters are joined by three disturbances in self-organisation: emotional dysregulation, negative self-concept, relational difficulties.
  • Dissociation under stress is one possible form of emotional dysregulation; a highly dissociative patient may also have a dissociative disorder, diagnosed separately.

3. How it differs from other diagnoses

Complex PTSD and personality disorder with borderline pattern

This is the most frequent confusion, and it has consequences for treatment planning. In ICD-11, borderline disorder is no longer a separate category: it corresponds to a personality disorder, rated by severity, with the “borderline pattern” specifier (6D11.5). The clinical descriptions require it to be distinguished from CPTSD.

In 280 women seeking help for childhood abuse, a latent class analysis identified four profiles: low symptoms, PTSD, complex PTSD and borderline disorder. The CPTSD and borderline profiles were clearly distinct (Cloitre et al., 2014). Four symptoms strongly increased the likelihood of belonging to the borderline profile rather than the CPTSD profile: frantic efforts to avoid abandonment, an unstable self-image, unstable and intense relationships, and impulsivity. In practice, the key distinction is that in CPTSD the self-image is negative but fairly stable (“I’m worthless”), and the relational difficulties come without the panic-stricken fear of abandonment. A recent clinical guide, illustrated with cases, sets out these differences in detail (Karatzias et al., 2023).

Complex PTSD and the DSM-5-TR dissociative subtype

The DSM-5-TR dissociative subtype refers to PTSD accompanied by persistent depersonalisation or derealisation. It makes no reference to self-concept or relationships. A patient may therefore meet the criteria for one without meeting those for the other.

Complex PTSD and dissociative disorders

Significant amnesia, a sense of having parts of oneself that act outside one’s control, lost time: these signs point towards a dissociative disorder, in particular dissociative identity disorder (DID, 6B64) or partial dissociative identity disorder (6B65) in ICD-11. Identifying them profoundly changes how treatment is conducted (see the safety box in section 6), hence the value of systematic screening for dissociation in these patients.

Key points

  • CPTSD is most often confused with personality disorder with borderline pattern, from which the clinical descriptions require it to be distinguished.
  • A marker drawn from a study of 280 women: in CPTSD, the self-image is negative but fairly stable, without panic-stricken fear of abandonment.
  • The DSM-5-TR dissociative subtype (persistent depersonalisation or derealisation) makes no reference to self-concept or relationships.
  • Significant amnesia, a sense of parts of oneself acting outside one’s control and lost time point towards a dissociative disorder, hence the value of systematic screening.

4. Assessment

Assessment serves to establish the diagnosis, and also to choose the pace of treatment and to measure progress. Three tools are useful in practice.

  • The International Trauma Questionnaire (ITQ). A self-report questionnaire built for the ICD-11 criteria: twelve symptom items, six for PTSD and six for disturbances in self-organisation, supplemented by questions on functional impairment (Cloitre et al., 2018). A French version has been validated in 750 adults from the general population exposed to potentially traumatic events and recruited online (Peraud et al., 2022). It has not yet been evaluated in a clinical population, and a self-report questionnaire alone is not enough to make the diagnosis. In France, the Centre national de ressources et de résilience (Cn2r, National Centre for Resources and Resilience) offers it as a free download (in French).
  • The International Trauma Interview (ITI). A structured clinical interview that follows the same criteria. A Swedish validation in 186 adults proved promising (Bondjers et al., 2019). To our knowledge, no validated French version exists yet.
  • Screening for dissociation. The Dissociative Experiences Scale (DES) is one of the most widely used screening tools (Bernstein and Putnam, 1986). It is a screening tool, distinct from a diagnostic one: a high score calls for a structured interview, and a low score does not rule out a dissociative disorder.

Beyond scores, the clinical history locates the patient’s window of tolerance: their capacity to stay in contact with an emotion without tipping into overwhelm or shutdown (Siegel, 1999). It also identifies the resources available to them, their support network and their current safety: ongoing violence, contact with the perpetrator, substance use, legal proceedings. Suicide risk and self-harm, common in these patients, are formally assessed from the outset. These elements matter more than the diagnosis itself when deciding on the pace.

Key points

  • The French version of the ITQ, validated in the general population (Peraud et al., 2022), has not yet been evaluated in a clinical population.
  • A self-report questionnaire is not enough to make the diagnosis; the DES screens without diagnosing, and a low score does not rule out a dissociative disorder.
  • The clinical history locates the window of tolerance, resources and current safety: these elements matter more than the diagnosis when deciding on the pace.
  • Suicide risk and self-harm, common in these patients, are formally assessed from the outset.

5. What treatment studies say

One clarification is needed from the start: most of the available trials were designed before ICD-11. They involve patients with PTSD presenting features of complex PTSD, or people exposed to complex trauma, rather than patients diagnosed according to current criteria. The conclusions that follow are therefore partly indirect.

Trauma-focused therapies remain effective

A meta-analysis of 51 randomised trials covered patients with PTSD whose characteristics suggested at least one of the three clusters of disturbances in self-organisation (Karatzias et al., 2019). None of these trials had diagnosed CPTSD according to ICD-11, which was not yet possible.

On PTSD symptoms, CBT, exposure alone and EMDR do better than usual care. For EMDR, the effect is large, but the quality of the evidence is rated low and rests on only four trials. For CBT, the evidence is of moderate quality and rests on twenty-seven trials.

On disturbances in self-organisation, all three approaches have moderate to moderately large effects on relational difficulties, with a very small number of trials for EMDR. CBT and exposure clearly improve self-concept, but only one EMDR trial provided usable data on this point, and few trials measured emotional dysregulation. Benefits are smaller when the comparison group receives a non-specific intervention, and trauma in childhood is associated with poorer outcomes.

A network meta-analysis published the following year covers people exposed to complex trauma (childhood sexual abuse, domestic violence, refugees, veterans), without requiring a CPTSD diagnosis (Coventry et al., 2020). Trauma-focused interventions outperform non-trauma-focused interventions on PTSD symptoms, with markedly smaller effects in veterans and war-affected populations. Against an active control, the effect of psychotherapies is modest. At six months, a benefit persists compared with no active treatment, but it is smaller and rests on far fewer trials.

Multi-component treatments, in particular those combining cognitive restructuring and imaginal exposure, achieve the best results on PTSD. Phase-based approaches combining skills training and trauma-focused work appear the most promising for emotional dysregulation and relational difficulties. The authors note, however, that they were unable to assess the specific contribution of the skills modules.

Key point

Trauma-focused therapies remain indicated in complex PTSD. The available data, still partly indirect, indicate that they remain the foundation of treatment. The value of adding specific work on emotion regulation and relationships is plausible, but still poorly demonstrated.

The stabilisation debate

In 2012, the expert consensus guidelines of the International Society for Traumatic Stress Studies (ISTSS) advocated three-phase treatment for CPTSD: stabilisation, then memory work, then reintegration (Cloitre et al., 2012). This consensus predates ICD-11. The ISTSS general PTSD guidelines, revised in 2019 on the basis of a systematic review of trials, strongly recommend several trauma-focused therapies for adults, including EMDR, without a specific recommendation for CPTSD (Bisson et al., 2019).

The STAIR programme (Skills Training in Affective and Interpersonal Regulation) illustrates this logic: a skills module in emotional and interpersonal regulation, followed by narrative exposure work. In a randomised trial of 104 women with PTSD related to childhood abuse, this sequence produced more lasting remissions than exposure preceded by supportive counselling alone (27% versus 13%), with fewer dropouts and fewer cases of worsening (Cloitre et al., 2010).

In 2016, twenty-one researchers, including Ad de Jongh, Patricia Resick and Lori Zoellner, challenged the 2012 recommendation (De Jongh et al., 2016). Their argument: no rigorous study shows that a stabilisation phase is necessary, or that direct memory work is dangerous for these patients. Prolonged, systematic stabilisation might therefore delay effective treatment. Marylene Cloitre replied in the same journal (Cloitre, 2016).

More recent comparative trials leave the question open. In a Dutch randomised trial of 149 patients with PTSD related to childhood abuse, prolonged exposure alone, intensified exposure and STAIR followed by exposure produced large and comparable improvements at one year. Adding STAIR did not further improve emotion regulation, interpersonal problems or self-esteem, and dropout rates did not differ (Oprel et al., 2021). A 2026 meta-analysis, limited by the small number of trials, finds no difference between approaches with and without a preliminary phase on most outcomes. Multi-phase approaches did, however, outperform single-phase approaches on PTSD, and phase-based approaches, like those that include exposure, did better on emotion regulation (Lee et al., 2026).

On the direct-treatment side, an intensive eight-day Dutch programme combining prolonged exposure, EMDR, psychoeducation and physical activity, with no preliminary stabilisation phase, was evaluated in 308 patients with PTSD, who stayed on site during the programme. Of the 203 who met the ITQ criteria for CPTSD, 87.7% no longer met them at the end of the programme, and no suicide, suicide attempt or hospitalisation occurred during it (Voorendonk et al., 2020). The study had no control group and no follow-up after the programme. It excluded patients who had attempted suicide in the previous three months and analysed only those who had completed the measures. It shows that these patients can tolerate intensive trauma-focused treatment in a residential setting with a dedicated team; its findings cannot be transferred as they stand to outpatient care.

The UK guidelines of the National Institute for Health and Care Excellence (NICE) take an intermediate position. For people with complex PTSD, they advise increasing the duration or number of sessions to build trust, taking into account the safety and stability of their situation, and helping them manage barriers to trauma-focused therapies, such as dissociation, emotional dysregulation or negative self-image (NICE, 2018, recommendation 1.7.3). They do not provide for a mandatory preliminary stabilisation phase.

This debate concerns complex PTSD. For dissociative disorders, clinicians who draw on the theory of structural dissociation of the personality (van der Hart et al., 2006) and the guidelines of the International Society for the Study of Trauma and Dissociation (ISSTD, 2011) maintain a phase-oriented approach. To our knowledge, direct treatment has not been evaluated in a controlled way in these patients.

6. In EMDR practice

The following guidance reflects clinical opinion, consistent with the data above and the EMDR protocol (Shapiro, 2018). It is derived from clinical experience rather than from comparative trials.

  1. Assess before choosing the pace. Administer the ITQ and a dissociation screening from the first sessions, and formally assess suicide risk and self-harm. If a risk is present, establish a safety plan and coordinate with the patient’s GP or psychiatrist.
  2. Prepare according to the patient’s needs, rather than the label. EMDR phase 2 remains essential. It is extended when the patient is putting themselves at risk, is still living in an unsafe situation, dissociates strongly, has a dissociative disorder or cannot return to their window of tolerance. Before phase 3, check that there is no current danger, and review substance use and the legal context; warn the patient that temporary activation between sessions is possible.
  3. Choose resources that serve reprocessing. Calm place or safe place, staying alert to the negative associations common in these patients; resource installation (Korn and Leeds, 2002), and CIPOS (Constant Installation of Present Orientation and Safety) by Jim Knipe, which alternates grounding in the present with brief, timed contacts with the memory (Knipe, 2014). The aim is to widen the window of tolerance so that memory work becomes possible.
  4. Target shame and self-concept. In these patients, negative cognitions often concern self-worth (“I’m bad”, “I don’t deserve to exist”) more than danger. Identifying them early makes it possible to use the affect bridge to find the source memories of shame and to choose targets that reach the heart of the clinical picture.
  5. Titrate activation during reprocessing. Shorten the sets of bilateral stimulation, narrow the target if necessary, use cognitive interweaves, and check regularly that the patient maintains dual attention. The Flash technique, which sits outside the standard protocol and remains little studied, is sometimes used during preparation to reduce the charge of a memory before reprocessing it (Manfield et al., 2017). It is reserved for practitioners trained in it, and used with caution in highly dissociative patients.
  6. Make the relationship a lever. Relational difficulties are re-enacted in the alliance: cancellations, mistrust, withdrawal. Naming them and working with them is part of the treatment.
  7. Measure along the way. We suggest repeating the ITQ regularly, for example every eight to ten sessions. Improvement in PTSD without change in the disturbances in self-organisation indicates that shame, emotions or relationships need to be targeted more. With these patients, supervision by an EMDR supervisor is strongly recommended.

Safety point: dissociative disorders

If dissociative identity disorder or partial DID is suspected (amnesia, lost time, voices or parts that take control), the standard EMDR protocol needs to be adapted rather than applied as it stands. The diagnosis should be clarified with a structured interview or a dedicated instrument. Treatment then follows a phase-oriented approach, in line with the ISSTD guidelines (2011), and requires specific training in EMDR with dissociative patients as well as supervision.

Key points

  • From the first sessions: ITQ, dissociation screening, assessment of suicide risk and self-harm; if there is a risk, a safety plan and medical coordination.
  • Phase 2 remains essential; it is extended in cases of danger, lack of safety, marked dissociation or difficulty returning to the window of tolerance.
  • In these patients, negative cognitions often concern self-worth more than danger, hence the value of targeting shame.
  • Suspected DID or partial DID: adapt the standard protocol; clarify the diagnosis, use a phase-oriented approach (ISSTD), with specific training and supervision.

Clinical vignette

Fictional case, built from common clinical situations.

Sophie, 38, seeks help for nightmares and anxiety that prevent her from working. She grew up with an alcoholic and violent father. On the ITQ, she meets the criteria for the three PTSD symptom clusters and the three disturbances in self-organisation, with functional impairment, and the clinical interview confirms the diagnosis. She describes herself as “a failure”, avoids any close relationship, and swings between bursts of anger and moments when she “cuts herself off from everything”. Dissociation screening shows a moderate score. The targeted interview finds no amnesia, no lost time and no sign of a dissociative disorder. She has no active suicidal ideation, no self-harm and no problematic alcohol use, and she no longer has contact with her father.

The therapist devotes four sessions to preparation: psychoeducation about CPTSD, a calm place, and CIPOS so that Sophie learns to come back to the present when she feels the shutdown coming. She keeps this phase short, as Sophie is not in danger and manages to return to her window of tolerance. Reprocessing begins with a memory of humiliation at school, linked to the cognition “I’m useless”, before moving on to the scenes of violence.

After fifteen sessions, the nightmares have decreased markedly. The ITQ shows an improvement in PTSD symptoms, but the self-image remains very negative. The therapist then redirects the work towards the source memories of shame and towards current relational situations. The ITQ made it possible to see objectively what remained to be treated, by measuring the two dimensions of the diagnosis separately.

What is established, and what is not

  • Established: complex PTSD is a diagnosis distinct from PTSD in ICD-11, with precise criteria. A dedicated self-report questionnaire (ITQ) exists in French, validated in the general population.
  • Well supported: trauma-focused CBT and exposure reduce PTSD symptoms in patients who have experienced complex trauma or present features of CPTSD.
  • Plausible but weakly supported: the effectiveness of EMDR in this population (four trials, low-quality evidence), and the value of adding emotional and interpersonal regulation components.
  • Debated: the need for a stabilisation phase before memory work in CPTSD.
  • Little studied: the effectiveness of treatments in randomised trials of patients diagnosed according to ICD-11, and the specific effect of EMDR on disturbances in self-organisation.
  • Not recognised: complex PTSD in the DSM-5-TR, which complicates comparison with DSM-based studies.

Frequently asked questions

Should you always stabilise before treating memories?

Not systematically. No study shows that lengthy stabilisation imposed on everyone improves outcomes, and the available comparative trials are few and divergent. EMDR preparation remains necessary. It is extended in cases of self-endangerment, current lack of safety, severe dissociation, an associated dissociative disorder or inability to return to the window of tolerance.

Can complex PTSD be diagnosed in France?

Yes, clinically, using the ICD-11 criteria, the WHO’s reference classification in force since 2022. In France, hospital coding (PMSI) still uses ICD-10, and the DSM remains widely used in research and psychiatry. This is why the term does not yet appear in all clinical reports. Practice in other countries varies according to the classification used locally.

Does childhood trauma mean complex PTSD?

Not necessarily. Repeated trauma in childhood increases the risk, but the diagnosis rests on the presence of the six symptom clusters. Many people who experienced early abuse present with PTSD, or with other difficulties.

Is EMDR recommended for complex PTSD?

NICE recommends EMDR for adults with PTSD more than three months after a non-combat-related trauma (recommendation 1.6.19), without a specific recommendation for complex PTSD. For the latter, it advocates adapting trauma-focused therapies (recommendation 1.7.3). The data on EMDR in this population are encouraging but rest on few trials. It is used with the adjustments described above.

Further resources on TIRCIA

In one sentence

Complex PTSD adds to PTSD a lasting disturbance in one’s relationship with oneself, with emotions and with others, and trauma-focused therapies, adjusted to the patient, are its best-supported foundation, even though the evidence remains partly indirect.

For EMDR practitioners, this means assessing both dimensions and the risk, preparing according to the patient’s real needs, identifying dissociative disorders, and targeting shame as much as fear.

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This article summarises the scientific evidence available at the date of publication. It is no substitute for clinical training, supervision, or the advice of a health professional.

Declaration of interests: the author is the director of TIRCIA, some of whose online programmes are mentioned in this article.

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