Complex Post-Traumatic Stress Disorder in the perinatal period: a case report and narrative review.

Objective. The paper is aimed at exploring how traumatic experiences may interact with specific vulnerability factors during the perinatal period, leading to the development of post-traumatic spectrum disorders. In particular, we describe a clinical case of a woman who developed complex Post-Traumatic Stress Disorder (C-PTSD) during pregnancy and provide a brief narrative review of this psychopathological entity, focusing on the main issues in its identification and clinical management.
Methods. We report the clinical history of a woman who experienced intrusive thoughts with aggressive content three months after childbirth and was then hospitalized following self-aggressive behaviours, receiving diagnosis of C-PTSD in comorbidity with Borderline Personality Disorder. Afterwards, we performed a narrative review of thePubMed, Scopus, and Web of Science datasets, variously combining the keywords “c-PTSD”, “cPTSD”, “Complex PTSD”, “Complex Posttraumatic Stress Disorder”, “Complex Post Traumatic Stress Disorder” with “Pregnancy” “Perinatal period” “Peripartum”, “Postpartum”, and “Childbirth”.
Results. The included papers underline the heterogeneity of Post-Traumatic Stress Disorder (PTSD) presentations in the perinatal period. Apart from C-PTSD, which represents about 30% of all PTSD cases in this population, other clinical entities, particularly “chronic PTSD” and “childbirth-related PTSD”, have been described. Univocal criteria for C-PTSD in the perinatal period have not been established so far. Among the main risk factors for developing perinatal C-PTSD, a history of exposure to physical and sexual assault plays a relevant role. Dissociative and affective symptoms, which represent clinical features strongly associated with C-PTSD, are also common in women who experienced childbirth-related bereavement and perinatal loss. Disease trajectories of perinatal PTSD can vary, but the early identification and the prompt administration of psychological interventions, particularly Cognitive Behavioral Therapy and Eye Movement Desensitization and Reprocessing, is crucial to reduce symptom severity and reach remission.
Conclusion. The adequate identification of C-PTSD in the perinatal period remains an open issue, underlining the need to provide univocal criteria, also given the complexity of differential diagnosis. A better definition of specific risk factors, including personality characteristics, is needed to implement tailored treatment approaches.

INTRODUCTION

Traumatic experiences, such as abuse or neglect during childhood, and early interpersonal traumas, like physical or sexual abuse during early in life, may have a potentially chronic impact on mental health. These early life stressors could contribute to the development of the psychopathological framework of complex Post-Traumatic Stress Disorder (C-PTSD) ¹. Previous literature characterizes the existence of two different profiles of trauma-related disorders, namely simple (S-PTSD) and complex (C-PTSD) ², based on the timing and type of trauma - isolated/accidental for S-PTSD and chronic/interpersonal for C-PTSD ³. These two psychopathological entities also present different clinical correlates. In particular, depressive and dissociative symptoms are more prevalent in C-PTSD ⁴. The World Health Organization recognizes C-PTSD as a stand-alone clinical entity, as listed in the 11^th edition of the International Classification of Diseases (ICD-11) ⁵. On the other hand, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) ⁶, does not recognize C-PTSD as a formal diagnostic category and uses the term Extreme Stress Disorder Not Otherwise Specified (DESNOS) instead. For the diagnosis of DESNOS, exposure to multiple, early, and chronic traumas associated with significant impairment in one or more areas of functioning, such as relationships and impulse control, should be reported together with the presence of re-experiencing and hypervigilance symptoms ⁷.

As previously mentioned, the presence of dissociative states in C-PTSD is crucial for identifying this clinical picture. Dissociative symptoms represent one of the factors that contribute to the difficult-to-treat nature of C-PTSD. Indeed, subjects with dissociative symptoms exhibit over-modulation of emotions, mediated by the excessive inhibition of limbic areas by the medial prefrontal cortex, which may reduce the clinical response to psychotherapies ⁸. This represents a major issue in the treatment of C-PTSD, as psychotherapy is considered the treatment of choice for trauma-related disorders ⁹. Notably, concerns in the diagnosis and treatment of C-PTSD add complexity to the already unresolved questions related to the clinical management of PTSD, which still represents a difficult-to-treat condition ¹⁰. The presence of PTSD during the perinatal period has been extensively explored. Previous studies have elucidated how post-traumatic symptoms may exacerbate during this period. Indeed, in case of lifetime PTSD, symptom relapses frequently occur after childbirth ¹¹. Exposure to trauma is a predisposing factor for psychological distress during the perinatal period, with the possible development of post-traumatic symptoms even after several years. The occurrence of this psychopathological condition may negatively impact the mother-child relationship ¹², the neurodevelopment of the child, and the role of the dyad at a familiar and societal level ¹³. Children who were born from mothers suffering from PTSD are more likely to develop personality disorders, anxiety disorders, and sleep disturbances, as well as hypersensitivity to aggression ^14,15. It has been suggested that screening for PTSD and related disorders during pregnancy may also have cross-diagnostic value, potentially identifying mothers at risk of developing maternity blues and postpartum depression ¹⁶. In this paper, we describe a clinical case of C-PTSD that occurred during pregnancy and its relationship with the experience of maternity, with a particular focus on the issue of differential diagnosis and comorbidity. We then perform a narrative review of the literature to discuss the main challenges concerning the possible occurrence of C-PTSD during the perinatal period.

CASE REPORT

F.G. was born in Romania and raised by a family experiencing poor socio-economic conditions. Her father suffered from an alcohol-related disorders and F.G. frequently assisted and experienced physically and psychologically aggressive behaviours. When she was a child, F.G. felt inhibited in expressing her emotions due the fear or parental reactions.

At the age of twelve, one of her younger brothers died by suicide while F.G. was alone at home looking after her siblings. She was the one who discovered his body. Her parents blamed her for what happened and even suspected that she might have been directly involved.

At the age of fifteen, F.G. experienced sexual assault by a neighbour. When she informed her mother about this episode, F.G. did not perceive any emotional support. As a result, F.G. progressively developed feelings of anger towards her parents, emotions that persisted strongly at the time of evaluation.

F.G. moved out of the parental house when she was eighteen, right after high school diploma, and started working in a fashion factory. Lately in her life, additional traumatic events occurred, including a life-threatening car accident. At twenty-one, she moved to Italy and began working in nightclubs, where she met her husband. During this period, she suffered from sleep and eating disturbances, mainly due to disrupted circadian rhythms. F.G. reported having a positive relationship with her husband and her mother-in-law.

Even since the first trimester of pregnancy and during the first three months after her daughter was born, the patient suffered from sleep disorders. Three months after childbirth, F.G. began experiencing intrusive images with aggressive content, specifically visions where her child was the victim and she was the aggressor. These images typically occurred during the evening, when she was alone at home with the baby while her husband was at work. Despite these intrusive thoughts, she managed to continue her daily activities, although she experienced fear of causing harm to her baby and thus removed potentially dangerous objects from her home.

Due to the persistence of these symptoms, F.G. accessed the Community Mental Health Centre four months after childbirth, where she was diagnosed with an obsessive-compulsive disorder. At first, treatment involved a tricyclic antidepressant (clomipramine), benzodiazepines, and hypnotics. After a few weeks, she was admitted to the Psychiatric Inpatient Unit on voluntary bases after presenting at the Emergency Department following an episode of zolpidem overuse.

During her hospitalization, F.G. exhibited low mood, dysphoria, anxiety, and preoccupation towards aspects of her family life. Her thoughts were polarized on the intrusive images she experienced, which depicted aggression towards her daughter. These thoughts were distressing and led her to implement continuous avoidance behaviours.

The psychiatric history of F.G. was meticulously documented. We identified multiple traumas spanning her childhood, adolescence, and early adulthood, underscoring the need to explore potential PTSD. To this end, we employed the Structured Clinical Interview for DSM-5-Clinical Version (SCID-5-CV) ¹⁷ and diagnosed PTSD based on DSM-5 criteria. Criteria for obsessive-compulsive disorder were not met. Furthermore, the Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD) ¹⁸ revealed criteria consistent with Borderline Personality Disorder (BPD).

The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) ¹⁹ assessment indicated absence of symptoms. Additionally, the Davidson Trauma Scale (DTS) ²⁰ was used to provide a detailed characterization of PTSD symptoms, confirming the highest scores in hypervigilance domain. From this assessment, we concluded that the distressing thoughts were intrusive re-experiences rather than obsessions, significantly influencing F.G.’s relationship with her daughter. The positive history for prolonged interpersonal traumatic experiences, the presence of the core symptoms of PTSD, and the evidence of emotional dysregulation, difficulties in interpersonal relationships, and negative self-concept, led to the diagnosis of C-PTSD according to the ICD-11 definition.

During her hospitalization, comprehensive monitoring including blood tests and brain MRI did not reveal any underlying medical conditions. Daily clinical interviews were conducted by psychiatrists. Following the diagnostic phase, F.G. underwent integrated psychotherapy sessions twice weekly, led by a clinical psychologist at the unit. The primary objective of this psychotherapeutic approach was to redefine her lifestyle habits upon discharge, enhancing her capacity to manage residual intrusive symptoms. Interviews highlighted a profound sense of inadequacy, with a compensatory focus solely on maternal roles, potentially overshadowing other interests and passions.

In addition to individual therapy, F.G. participated in group dialectical-behavioural therapy, emphasizing the importance of pharmacological adherence. To manage her symptoms, she was prescribed low-dose atypical antipsychotic treatment with lurasidone.

This integrated treatment plan resulted in significant clinical improvement, prompting F.G.’s discharge and subsequent commitment to the Community Mental Health Centre after a two-week inpatient stay.

C-PTSD AND PERINATAL PERIOD IN LITERATURE

Methods

We conducted a review of the literature on correlations between Complex Post-Traumatic Stress Disorder (CPTSD) and pregnancy. The keywords “c-PTSD,” “cPTSD,” “Complex PTSD,” “Complex Posttraumatic Stress Disorder,” and “Complex Post Traumatic Stress Disorder” were combined with “Pregnancy” “Perinatal period” “Peripartum”, “Postpartum”, and “Childbirth” were variously combined in the PubMed, Scopus, and Web of Science datasets. To broaden our search, terms like “Chronic PTSD”, “Chronic Post-Traumatic Stress Disorder”, and “Chronic Posttraumatic Stress Disorder” were added using the MeSH terms method. This search yielded 20 articles, of which 11 were selected for further analysis. Additionally, one article was selected after screening the references of each examined paper.

RESULTS

Validity of C-PTSD category in the perinatal period

One study investigated the validity of the proposed ICD-11 distinction between PTSD and C-PTSD in three distinct trauma groups including bereaved parents. The study found that 10.4% of bereaved parents reported C-PTSD, a lower rate compared to the other two groups. Additionally, 64% of the bereaved parents experienced low levels of PTSD/C-PTSD symptoms, suggesting a higher level of resilience compared to the victims of sexual and physical assault ²¹. The association between perinatal bereavement was further investigated by a recent mixed-methods study, using the International Trauma Questionnaire (ITQ) to assess if participants met the criteria for PTSD or C-PTSD. The research found that 10.8% of the included women met the criteria for PTSD, 29.7% for C-PTSD, and 40.5% experienced traumatic stress overall ²².

Prevalence of PTSD in the perinatal period

Most of the included papers explored the correlation between pregnancy or childbirth and chronic PTSD, defined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as stress symptoms persisting for more than six months. Earlier studies suggested that at least 1.5% of women might develop chronic PTSD as a result of childbirth ²³. Peritraumatic dissociation was found to be common after pregnancy loss and was strongly related to acute and chronic PTSD symptoms, with determinants including less control over emotions, dissociative tendencies, and lower education ²⁴. One longitudinal study with three-to-six-month follow-up focused on evaluating the incidence of chronic PTSD after childbirth in relation to pre-partum (personality characteristics and pre-existing risk factors) and intra-partum obstetrical and neonatal variables. The results showed that the incidence of chronic PTSD was 2.4%, with an additional 32.1% of subjects being at least partially symptomatic. Intra-partum variables did not seem to influence the development of chronic PTSD. Expectations and support were found to be modulated by anxiety levels and did not show a direct relationship with chronic PTSD ²⁵. A more recent study aimed to assess the prevalence of PTSD one year after childbirth, identifying possible risk factors. The presence of PTSD was measured by the Trauma Event Scale (TES), developed specifically for PTSD following childbirth and in accordance with DSM-IV criteria. Post-traumatic stress symptoms were also measured by the Impact of Event Scale (IES). The results suggested that one year after childbirth, about one out of twenty women has a PTSD profile and one out of forty meets the criteria for a PTSD diagnosis. PTSD was markedly more prevalent in women who reported bad memories of childbirth two days after delivery ²⁶.

PTSD trajectories in women during the perinatal period

The nature and predictors of birth-related PTSD trajectories among women in the perinatal period have been studied to identify the differences between those who develop PTSD and those who develop chronic PTSD following a traumatic birth. A study on this topic assessed women with a gestational age of 26-35 weeks who experienced a traumatic birth. Using the DSM-IV criteria for PTSD, four trajectory groups were identified at 4-6 weeks after childbirth, namely resilient (61.9%): women who did not meet the criteria for birth-related PTSD at both 4-6 weeks and 6 months postpartum; recovered (18.5%): women who met the criteria for birth-related PTSD at 4-6 weeks postpartum but not at 6 months postpartum; delayed-PTSD (5.8%): women who did not meet the criteria for birth-related PTSD at 4-6 weeks postpartum but did at 6 months postpartum; and chronic-PTSD (13.7%): women who met the criteria for birth-related PTSD at both time points. Women with chronic-PTSD were more likely to have postpartum complications and experienced increased severity of affective symptoms, PTSD symptoms, and fear of childbirth, possibly evolving into tokophobia, at both 4-6 weeks and 6 months postpartum compared to women in other trajectories. Women with delayed-PTSD had higher rates of caesarean-section delivery, preterm birth, and further traumatic events after birth than those in other groups. The study also showed that depression and anxiety are significant components of PTSD and are highly comorbid with PTSD after birth, contributing to the persistence of birth-related PTSD. Lack of social support also appeared to be a risk factor for birth-related PTSD, with women receiving less support than expected, particularly after a traumatic birth, being more vulnerable to developing birth-related PTSD ²⁷. Another study followed up women at the 6th, 12th, and 18th week after childbirth. The childbirth stressor was operationalized using the Traumatic Event Scale (TES). Predictors of chronic PTSD trajectory included perceived traumatic childbirth, fear of childbirth, depression, anxiety, psychological violence, higher WHODAS 2.0 total score, multigravidity, stressful life events related to health risks, relational problems, and income instability. In contrast, multiparity and higher mental quality of life scores were protective factors ²⁸.

The correlation between chronic PTSD and mothers with very low birth weight (VLBW) preterm infants was also studied. A prospective, cross-sectional study investigated a cohort of mothers attending follow-up visits with their VLBW preterm infants born before 32 weeks of gestation. The DTS based on DSM-IV criteria for chronic PTSD was used. The results showed that 44% exhibited symptomatic stress 6 months after their baby’s birth. Chronic PTSD was more common among mothers of infants aged 7-12 months (37.5%) and persisted for several years, with 18.7% continuing to experience chronic PTSD symptoms between 3 and 5 years after birth. Mothers aged 27-31 showed the highest frequency of chronic PTSD. The three most common chronic PTSD symptoms were painful images and memories of the event (59%), increased nervousness (51%), and irritability with frequent anger outbursts (48%). Chronic PTSD was significantly more prevalent among mothers of infants born at ≤ 28 weeks (46.8%) compared to those without chronic PTSD (31.7%). Preterm infants with a birth weight < 1000 g were significantly more frequent among mothers with chronic PTSD (53%) versus those without stress (34%). Severe morbidity was significantly more common in preterm infants of mothers with chronic PTSD (44%) versus those without stress (27%) ²⁹.

A case study reported on a 31-year-old Sudanese nulliparous woman with a history of genital mutilation and multiple traumas in her second trimester of pregnancy ³⁰. The woman underwent genital mutilation/cutting type IIIa and was referred for antepartum defibulation to facilitate vaginal birth. After genital mutilation, she suffered from long-term symptoms including superficial dyspareunia, prolonged menstrual periods with primary dysmenorrhea, and obstructed micturition with voiding efforts. She did not experience further violence or trauma during her journey to Europe. However, she experienced psychological and physical violence in 2014 due to political persecution, which led to a miscarriage at 8 weeks gestation. Defibulation was performed without complications, but the patient experienced distress and flashbacks of the initial micturition after her mutilation, meeting the criteria for PTSD. A psychiatric evaluation revealed anxiety and depressive symptoms with low mood, anhedonia, decreased motivation, sleep disturbance, and decreased appetite.

Treatment approaches for perinatal PTSD

Despite the lack of extensive research on the treatment of C-PTSD after childbirth, there is evidence regarding PTSD treatment in the postpartum period. Cognitive Behavioural Therapy (CBT) has shown its effectiveness for psychological trauma after childbirth and for women who miscarried, had a termination, or a stillbirth. Eye Movement Desensitization and Reprocessing (EMDR) also demonstrated efficacy in reducing PTSD symptoms in women who experienced traumatic delivery ³¹. Research has also shown the effectiveness of EMDR treatment for women diagnosed with PTSD following perinatal loss ³¹. Compassion Focused Therapy (CFT) represents another promising approach in decreasing PTSD symptoms after symptoms childbirth, despite no studies have determined the effectiveness of CFT to treat PTSD or C-PTSD after perinatal bereavement ²². Four sessions of grief counselling over a two-week period significantly reduced PTSD symptoms in women post-stillbirth ³¹. There are only preliminary results in favour of expressive writing and family support programs. There is no evidence supporting the effectiveness of debriefing, self-help materials, and yoga ³¹. A single case study reported on a pregnant woman with C-PTSD after childhood sexual abuse (CSA) who underwent a 12-week exposure-based dialectical behaviour therapy for PTSD (DBT-PTSD). The patient was a 25-year-old woman, 13 weeks pregnant, with a history of CSA and emotional neglect. She exhibited symptoms like intrusions, nightmares, irritability, and avoidance behaviour. Her symptoms were reactivated by a recent traumatic event. She requested cue-exposure therapy before the birth of her second child. The treatment included distress tolerance skills, exposure therapy, and self-care skills. During treatment, PTSD symptoms initially increased but decreased below baseline levels by the end. The course of pregnancy was unaffected by treatment-induced psychological and physical symptoms, and the patient gave birth to a healthy boy. Six months postpartum, the reduction in PTSD-related symptoms was stable, with only a modest increase in avoidance behaviour ³².

DISCUSSION

The present clinical case highlights several challenges in managing post-traumatic spectrum disorders in the perinatal period. Indeed, these conditions represent multi-facet, difficult-to-treat clinical entities that are often neglected in this populations. The main issues underlined in the presented clinical case involved the misdiagnosis of C-PTSD, which was initially identified as an obsessive-compulsive spectrum disorder, the complex clinical picture possibly due to BPD comorbidity, and the difficulties in C-PTSD treatment in an acute inpatient setting.

In our clinical case, attention to the personal history of the patient was crucial in order to elucidate the presence of previous traumatic events. Lack of attention to women with a history of mistreatment or trauma represents a significant clinical issue, especially in the perinatal period ¹². Indeed, this represents a transitional period that increases the risk of developing psychiatric disorders, particularly in mothers who were previously exposed to traumatic events ³³. An estimated percentage going from 12.3 to 16.8% of women develop clinically significant traumatic stress symptoms following childbirth, and 4.7 to 6.3% develop diagnosable CB-PTSD ³⁴. Conservatively, these rates translate to 6.6 million affected women worldwide each year. When considering high-risk groups, approximately 1 in 5 women develop CB-PTSD following a complicated delivery ³⁵. Adequate screening of lifetime traumatic events should be thus carried out during pregnancy and the postpartum ³⁶. It has been suggested that childbirth can trigger the experience of re-traumatization for sexual abuse survivors, manifesting in a sense of defeat, loss of control, and objectification. This experience may influence obstetrical outcomes and is partly associated with birth-related procedures. A history of sexual abuse may be associated with the onset of PTSD following childbirth, suggesting an increased risk of maternal psychiatric morbidity among traumatized women, which aligns with the notion that trauma exposure increases vulnerability to PTSD in future traumas ³⁷. PTSD symptoms can be evoked and maintained by reminders of the trauma; as a result, the infant may become an unfortunate constant reminder of the birth trauma and trigger distress in the mother. Unlike other forms of PTSD, the symptoms develop in close temporal proximity to the birth of the child. The potential negative effects of CB-PTSD on the child may exacerbate distress ³⁸. Emerging evidence suggests that mothers with CB-PTSD experience difficulty with maternal-infant bonding ³⁹ during a critical time of infant neural development, compared with mothers with PTSD resulting from other traumas. Heightened neural and physiological reactivity to a trauma reminder, a core feature of PTSD, may interfere with providing maternal sensitive care. Infants may exhibit behavioural problems mediated by symptoms of maternal issues, a potential complication of untreated CB-PTSD ³⁸.

When left untreated, CB-PTSD can impair maternal functioning during the postpartum period and pose risks to the child’s health, suggesting that CB-PTSD is a distinct subtype of PTSD ⁴⁰.

Correctly identifying PTSD during the postpartum period is crucial, as women experiencing this condition may also display significant impairment in their relationship with their child, as demonstrated in our clinical case. The harmful effects of maternal PTSD on the mother-baby relationship are particularly severe in women with a history of child abuse and neglect ¹². Moreover, impulse control disturbances may occur as a possible effect of affective dysregulation in C-PTSD, which was the main cause of the patient coming to our attention in the presented case. The heterogeneity of clinical presentations, together with the different reasons for which women with C-PTSD can be hospitalized in the perinatal period, suggest the strong need for well-validated criteria and assessment tools that may help the identification of these condition in the clinical practice. Indeed, one major difficulty associated with diagnosing C-PTSD is the lack of well-validated and reliable assessment instruments. One potential diagnostic tool is the one developed by Litvin and collaborators, based on ICD-11 criteria ⁴¹, while others advocate using the Child Trauma Questionnaire (CTQ) ⁴². Maternal PTSD has also been measured using the National Women’s Study (NWS) PTSD module ⁴³. In some cases, combining these diagnostic scales can increase diagnostic accuracy.

Another factor that might have contributed to the diagnostic difficulties and to the clinical complexity of the condition in our case study was the comorbidity with BPD, which occurs in a high percentage of PTSD cases ^44;45. Similarly, C-PTSD is frequently reported in outpatients or inpatients with BPD, especially those treated for substance-related disorders ⁴⁶. There is ongoing debate on whether C-PTSD is simply a “repackaging” or a “duplicate” of BPD or a separate entity. In subjects suffering from BPD, symptoms are often caused or exacerbated by complex traumatic stress reactions ^47;48. Several studies have shown that a combination of childhood victimization history and PTSD is associated with several BPD presentations, including deficits in empathy, affective cognitive management, self-harm, psychotic symptoms, anxiety, and feelings of guilt ⁴⁷. Subjects with a diagnosis of BPD show specific psychopathological profiles when PTSD is present in comorbidity. A recent study highlighted that subjects with PTSD and BPD are more likely to develop substance-related disorders due to reduced stress tolerance ⁴⁸. Notably, structural grey matter abnormalities in prefrontal areas associated with cognitive control and increased activation of the insula, with decreased activation of para-hippocampal areas, have been demonstrated ⁴⁷. Based on these premises, some authors argued that C-PTSD is the resultant of PTSD with comorbid BPD ⁴⁹, while recent findings underlined that the two psychopathological entities were bridged only by the shared affective dysregulation domain ⁵⁰. Although it is clear that PTSD may complicate BPD, the role of trauma in worsening BPD psychopathology requires further clarification, particularly for what concerns trauma-related emotional dysregulation. As supported by our clinical case, where the two distinct diagnoses were made, the two entities maintain separate identities defined by specific psychopathological domains. Previous research indicates that while C-PTSD involves hypervigilance linked to the fear of being harmed, BPD involves extreme sensitivity to perceived abandonment or rejection ⁵¹. Experiencing trauma and major family-related environmental stressors during childhood is a risk factor not only for BPD but also for a larger group of psychiatric disorders with serious functional impairment ¹³. In summary, although BPD and C-PTSD partially overlap, this does not suffice to conceptualize C-PTSD as a substitute or a subtype of BPD. In the case we presented, hypervigilance and intrusive re-experiences were the psychopathological domains that mostly guided the clinical judgment towards the diagnosis of C-PTSD. As for the brief psychotherapy provided, the main focus was emotional modulation since subjects suffering from C-PTSD may present difficulties in having confidence in themselves (including their reactions, emotions, or thoughts) or others (who are perceived as unreliable).

The present paper has limitations. First, we presented a clinical case of a woman diagnosed with C-PTSD during an inpatient stay, and subsequently the follow-up was relatively brief and data concerning long-term outcomes was limited. The clinical scales used for the assessment did not include any measure of treatment outcomes, which was only evaluated on qualitative bases. As for the narrative review, evidence concerning perinatal C-PTSD was limited. One of the main issues contributing to this was the heterogeneity of the psychopathological entities described referring to post-traumatic spectrum in the perinatal period. Moreover, the different study designs and the small sample sizes limited the possibility of performing a quantitative synthesis of the included papers.

CONCLUSIONS

Early recognition of post-traumatic stress disorder, particularly when complicated, during pregnancy and the postpartum period, represents a significant clinical challenge. This challenge should be addressed by implementing comprehensive screening for traumatic experiences in this population. Univocal criteria for the definition of complex post-traumatic stress disorders are strongly needed to improve diagnostic accuracy and adequately clarifying the clinical correlates of this psychopathological entity. Considering differential diagnosis and comorbidities is crucial for improving diagnostic accuracy and validity, and for tailoring integrated treatment strategies.

Acknowledgements

None.

Funding

None.

Conflict of interest statement

GM received travel grants from Angelini and Janssen and served as a speaker, consultant, or participated in advisory boards for Angelini and LaborEst (not related to the present research). AT received research support from Lundbeck, received travel grants from Angelini, and served as a speaker, consultant, or participated in advisory boards for Angelini (not related to the present research). FB, IL, FS, GC, VP, FC, PMB, PM, and KA declare no conflicts of interest.

Authors contributions

GM and FB: conceptualization; GM: methodology; FB, FC, VP, KA: investigation & data curation; GM, FB, FS, GC, IL: writing - first draft; PMB, PM: writing - review & editing; AT: supervision.

Ethical consideration

No Ethical permission was necessary for the present study due to its design. Informed consent was regularly obtained for the case report.