A diagnostic questionnaire for childbirth related posttraumatic stress disorder: a validation study

Abstract

Background: Labor and delivery can entail complications and severe maternal morbidities that threaten a woman's life or cause her to believe that her life is in danger. Women with these experiences are at risk for developing posttraumatic stress disorder. Postpartum posttraumatic stress disorder, or childbirth-related posttraumatic stress disorder, can become an enduring and debilitating condition. At present, validated tools for a rapid and efficient screen for childbirth-related posttraumatic stress disorder are lacking.

Objective: We examined the diagnostic validity of the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, for detecting posttraumatic stress disorder among women who have had a traumatic childbirth. This Checklist assesses the 20 Diagnostic and Statistical Manual of Mental Disorders, posttraumatic stress disorder symptoms and is a commonly used patient-administrated screening instrument. Its diagnostic accuracy for detecting childbirth-related posttraumatic stress disorder is unknown.

Study design: The sample included 59 patients who reported a traumatic childbirth experience determined in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, posttraumatic stress disorder criterion A for exposure involving a threat or potential threat to the life of the mother or infant, experienced or perceived, or physical injury. The majority (66%) of the participants were less than 1 year postpartum (for full sample: median, 4.67 months; mean, 1.5 years) and were recruited via the Mass General Brigham's online platform, during the postpartum unit hospitalization or after discharge. Patients were instructed to complete the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, concerning posttraumatic stress disorder symptoms related to childbirth. Other comorbid conditions (ie, depression and anxiety) were also assessed. They also underwent a clinician interview for posttraumatic stress disorder using the gold-standard Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. A second administration of the Checklist was performed in a subgroup (n=43), altogether allowing an assessment of internal consistency, test-retest reliability, and convergent and diagnostic validity of the Checklist. The diagnostic accuracy of the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, in reference to the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, was determined using the area under the receiver operating characteristic curve; an optimal cutoff score was identified using the Youden's J index.

Results: One-third of the sample (35.59%) met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria for a posttraumatic stress disorder diagnosis stemming from childbirth. The Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, symptom severity score was strongly correlated with the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, total score (ρ=0.82; P<.001). The area under the receiver operating characteristic curve was 0.93 (95% confidence interval, 0.87-0.99), indicating excellent diagnostic performance of the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. A cutoff value of 28 optimized the sensitivity (0.81) and specificity (0.90) and correctly diagnosed 86% of women. A higher value (32) identified individuals with more severe posttraumatic stress disorder symptoms (specificity, 0.95), but with lower sensitivity (0.62). Checklist scores were also stable over time (intraclass correlation coefficient, 0.73), indicating good test-retest reliability. Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, scores were moderately correlated with the depression and anxiety symptom scores (Edinburgh Postnatal Depression Scale: ρ=0.58; P<.001 and the Brief Symptom Inventory, anxiety subscale: ρ=0.51; P<.001).

Conclusion: This study demonstrates the validity of the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, as a screening tool for posttraumatic stress disorder among women who had a traumatic childbirth experience. The instrument may facilitate screening for childbirth-related posttraumatic stress disorder on a large scale and help identify women who might benefit from further diagnostics and services. Replication of the findings in larger, postpartum samples is needed.

Keywords: CAPS-5; CB-PTSD; Clinician-Administered PTSD Scale for the DSM-5; PCL-5; PTSD; PTSD Checklist for DSM-5; childbirth; childbirth-related PTSD; deliveries; diagnosis; maternal mental health; maternal morbidity; obstetrical; postpartum; postpartum PTSD; postpartum depression; postpartum psychopathology; postpartum screening; posttraumatic stress disorder; validation.

Figure 1.

Association of DSM-5 PTSD (PCL-5) total symptom severity scores with PTSD (CAPS-5) diagnosis symptom scores. The figure represents a scatter plot of the PTSD childbirth-related symptom severity scores obtained on the PCL-5 and CAPS-5. PTSD diagnosis, endorsement (red) or not (blue) per clinician (CAPS-5) evaluation. PCL-5: PTSD Checklist for DSM-5; CAPS-5: Clinician-Administered PTSD Scale for DSM-5; CB-PTSD: Childbirth-related PTSD. Missing data on the PCL-5 (less than 0.35% on all data points, 1 item for 2 patients) were handled using the most conservative estimate, i.e., computing a sum score of all validated items.

Figure 2.

Receiver operating characteristic (ROC) curve for the PCL-5 in relation to the PTSD (CAPS-5) diagnosis. The straight diagonal line represents the line of no information, while the curved line depicts the strength of the PCL-5's performance in accurately identifying women with CB-PTSD. PCL-5: PTSD Checklist for DSM-5; CAPS-5: Clinician-Administered PTSD Scale for DSM-5.