The EPDS was not designed to measure anxiety. However high scores on items 3, 4 and 5 have been found to be correlated with symptoms of anxiety. This can be the case even with a low overall EPDS score.
The anxiety subscore is calculated by adding up the subtotal from responses to items 3, 4 and 5. If this subscore is ≥4, further assessment of anxiety is suggested but any score can be followed up.
For women with anxiety subscore ≥4:
- Ask additional questions to assess anxiety symptoms
• Are you feeling more tense or irritated than usual?
• Do you find yourself worrying about little things that normally do not bother you?
• How long have you been feeling like this?
- Consider using a validated anxiety instrument to obtain more information, such as:
- • The Depression Anxiety Stress Scale (DASS: Lovibond & Lovibond, 1995)
If significant anxiety appears likely:
- Develop a management plan.
- Refer, if appropriate to the woman’s regular General Practitioner, or an appropriate mental health professional for a full diagnostic assessment.
Diagnostic Criteria for Specific Anxiety Disorders.
There are many different types of anxiety disorders that may require further questioning.
Common Anxiety Disorders can include Generalised Anxiety Disorder, Panic Disorder, Obsessive-Compulsive Disorder and Post Traumatic Stress Disorder:
Generalised Anxiety Disorder:
A. Anxiety/worry over most days over a number of events/activities (occurring more days than not for at ≥ 6-months).
B. Difficulty controlling worry
C. The anxiety or worry is associated with at least three of six listed below (with some having being present more days than not for ≥ 6 months):
- Restlessness or feeling keyed up or on edge.
- Being fatigued easily.
- Difficulty concentrating.
- Muscle tension.
- Sleep disturbance.
D. The symptoms of anxiety cause clinically significant distress or impairment in social, occupational and other important areas of functioning.
At least one panic attack followed by ≥ 1 month of worry or concern about panic attacks and/or change in behaviour due to panic attacks.
Note: a panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, during which time four or more symptoms appear:
- Palpitations, pounding heart, accelerated heart rate.
- Numbness or tingling sensations.
- Trembling or shaking.
- Sensations of shortness of breath or smothering.
- Feelings of choking.
- Chest pain or discomfort.
- Nausea or abdominal distress.
- Feeling dizzy, unsteady, light-headed, or faint.
- Chills or heat sensations.
- Paraesthesia (numbness or tingling sensations).
- Derealisation (feelings of unreality) or depersonalisation (detached from oneself)
- Fear of losing control or “going crazy”
- Fear of dying.
Obsessive Compulsive Disorder (OCD)
A. Presence of obsessions, compulsions, or both:
- Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
- The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):
- Repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
- The behaviours or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviours or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Post-Traumatic Stress Disorder (PTSD)
A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
- Directly experiencing the traumatic event(s).
- Witnessing, in person, the event(s) as it occurred to others.
- Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
- Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)
B. Presence of one (or more) of the following:
- Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)
- Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
- Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring.
- Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
- Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
- Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or traumatic event(s).
- Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
- Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia, and not to other factors such as head injury, alcohol, or drugs).
- Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “No one can be trusted”).
- Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
- Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
- Markedly diminished interest or participation in significant activities.
- Feelings of detachment or estrangement from others.
- Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
- Irritable behaviour and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.
- Reckless or self-destructive behaviour.
- Exaggerated startle response.
- Problems with concentration.
- Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
F: Duration of the disturbance (Criteria B, C, D and E) is ≥ 1 month.
For more information about EPDS and anxiety
• Matthey S. Using the Edinburgh Postnatal Depression Scale to screen for anxiety disorders. Depress Anxiety. 2008;25(11):926–931. doi:10.1002/da.20415
• Matthey S, Fisher J, Rowe H. Using the Edinburgh postnatal depression scale to screen for anxiety disorders: conceptual and methodological considerations. J Affect Disord. 2013;146(2):224–230. doi:10.1016/j.jad.2012.09.009
• Swalm D, Brooks J, Doherty D, Nathan E, Jacques A. Using the Edinburgh postnatal depression scale to screen for perinatal anxiety. Arch Womens Ment Health. 2010;13(6):515–522. doi:10.1007/s00737-010-0170-6