Anxiety Disorders

19 (2005) 295–311

Anxiety symptoms and disorders at

eight weeks postpartum
Amy Wenzel*, Erin N. Haugen,
Lydia C. Jackson1, Jennifer R. Brendle
Department of Psychology, University of North Dakota,
Grand Forks, ND 58202-8380, USA

Received 26 November 2003; received in revised form 17 February 2004; accepted 2 April 2004

Abstract

Although the prevalence, risk factors for, and consequences of postpartum depression
have been studied extensively, little work has examined the nature of postpartum anxiety
disorders in community samples. In the present study, 147 community women completed a
diagnostic interview and a battery of self-report inventories approximately eight weeks
after childbirth. The rate of generalized anxiety disorder was elevated as compared to the
rate in women representative of the general population. Depending on the particular
domain of anxiety being considered, 10–50% of women reporting anxiety symptoms
endorsed comorbid depressive symptoms. In hierarchical multiple regression analyses,
different combinations of demographic and vulnerability variables predicted symptoms of
somatic anxiety, social anxiety, and depression, although there were no significant
predictors of worry symptoms. In addition, number of children, depression, and social
anxiety predicted postpartum relationship distress. These results suggest that postpartum
anxiety disorders are more common than postpartum depression and worthy of systematic
study.
# 2004 Elsevier Inc. All rights reserved.

Keywords: Postpartum; Anxiety; Prevalence; Comorbidity

*
Corresponding author. Tel.: þ1-701-777-4496; fax: þ1-701-777-3454.
E-mail address: amy_wenzel@und.nodak.edu (A. Wenzel).
1
Present address: McLean Hospital/Harvard University, Boston, MA, USA.

0887-6185/$ – see front matter # 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.janxdis.2004.04.001
296 A. Wenzel et al. / Anxiety Disorders 19 (2005) 295–311

Although prevalence, causes, and course of postpartum depression have been

well researched (cf. O’Hara, 1994), few investigators have examined the nature of
postpartum anxiety. Because depression and anxiety frequently co-occur (cf.
Maser & Cloninger, 1990), it is likely that women who report depressive
symptoms in the postpartum period also experience clinically significant symp-
toms of anxiety. Moreover, anxiety disorders are common in the absence of
depression, particularly in women (cf. Brown, Campbell, Lehman, Grisham, &
Mancill, 2001), and the mean age of onset of many anxiety disorders is in the early
20s (Kessler, McGonagle, Swartz, Blazer, & Nelson, 1993), a time at which many
women are contemplating childbirth. Thus, it is likely that postpartum anxiety is a
common experience in part because of its prevalence among women of child-
bearing age, and preliminary research suggests that childbirth is a stressor that is
related to a higher incidence of anxiety disorders than what would be expected by
chance (e.g., Sholomskas et al., 1993).
Perhaps the most well researched anxiety disorder associated with childbirth is
obsessive compulsive disorder (OCD; see Abramowitz, Schwartz, Moore, &
Luenzmann, 2003 for a comprehensive review). Although the number and
severity of stressful life events generally do not differentiate individuals with
OCD from individuals without OCD, childbirth is the one specific event that
individuals with OCD endorse more frequently than other stressful life events
(Albert, Maina, & Bogetto, 2000; Maina, Albert, Bogetto, Vaschetto, & Ravizza,
1999). Several researchers have demonstrated that, at least in a subset of
vulnerable women, OCD develops or worsens during pregnancy and continues
to cause distress in the postpartum period (Altemus, 2001; Diaz, Grush, Sichel, &
Cohen, 1997), although several cases of OCD limited to pregnancy (e.g., Iancu,
Lepkifker, Dannon, & Kotler, 1995) and the puerprium (e.g., Hertzberg, Leo, &
Kim, 1997) have been documented. In their case series of 15 women who
developed postpartum OCD, Sichel, Cohen, Dimmock, and Rosenbaum
(1993) determined through a retrospective chart review that eight women had
no previous psychiatric history, and seven had histories of either panic disorder
(PD) or generalized anxiety disorder (GAD). In addition, they observed that
intrusive thoughts of harming the baby were the most predominant source of
distress. However, unlike cases of non-postpartum onset OCD, women reported
little distress associated with compulsions (see Wisner, Peindl, Gigliotti, &
Hanusa, 1999, for similar results). In contrast, Wenzel, Gorman, O’Hara, and
Stuart (2001) found that dysphoric women from a community sample often
endorsed compulsive cleaning and checking behaviors but not aggressive urges to
harm the infant.
Unlike OCD, symptoms of PD often improve during pregnancy (e.g., George,
Ladenheim, & Nutt, 1987), perhaps due to the fact that progesterone levels
naturally increase during gestation and might have an anxiolytic effect by binding
to GABA receptors in a similar manner as barbiturates (Villenponteaux, Lydiard,
Laraia, Stuart, & Ballenger, 1992). However, the postpartum period represents a
time of great risk for the worsening of panic symptoms in women with preexisting
 A. Wenzel et al. / Anxiety Disorders 19 (2005) 295–311 297

PD (Cohen, Sichel, Dimmock, & Rosenbaum, 1994; Cohen et al., 1996; Metz,
Sichel, & Goff, 1988) as well as for women with no previous psychiatric history
(Sholomskas et al., 1993). Only two studies have examined prevalence of
postpartum PD in a community sample of childbearing women. Matthey, Barnett,
Howie, and Kavanagh (2003) reported rates of 2.7 and 0.5% in two samples of
new mothers (n’s ¼ 216 and 192) at six weeks postpartum who did not endorse
postpartum depression. In a sample of women from the community who reported
dysphoria, Wenzel et al. (2001) found that 11% of their sample who were between
four and seven months postpartum reported having a panic attack in the previous
month, although only 1.5% were assigned diagnoses of PD.
Recently, several investigators have examined traumatic stress symptoms in
relation to difficult pregnancies and childbirths. For example, Ayers and Pickering
(2001) reported that the point prevalence of PTSD symptoms was 8.1% during
pregnancy, 6.9% at six weeks postpartum, and 3.5% at six months postpartum. In
their sample of 298 women who had recently given birth, Czarnocka and Slade
(2000) found that 3% of women who were six weeks postpartum endorsed
clinically significant symptoms representative of all three symptoms areas of
PTSD (i.e., reexperiencing, numbing/avoidance, increased arousal), and an
additional 24.2% endorsed clinically significant symptoms in at least one of
these three areas. Many women who experience traumatic stress symptoms
following childbirth attribute their distress to a sense of uncontrollability during
the procedure (Ballard, Stanley, & Brockington, 1995; Keogh, Ayers, & Francis,
2002), which may be exacerbated by unresponsive medical staff (Allen, 1998;
Czarnocka & Slade, 2000; Wijma, Söderquist, & Wijma, 1997). Moreover, Wijma
et al. (1997) indicated that traumatic stress symptoms are particularly likely to
emerge in nulliparous women. Although symptoms decrease dramatically follow-
ing childbirth in many women (e.g., Allen, 1998), a small subset of women
experiences persistent traumatic stress symptoms for several months or even
years, which often results in avoidance of the infant and in disturbed mother-
infant attachment behaviors (e.g., Ballard et al., 1995).
Surprisingly, few researchers have examined prevalence of GAD in postpartum
samples. It is logical that the postpartum period would be a time of vulnerability
for the development of this anxiety disorder, as women are often overwhelmed by
changing roles, multiple demands on their time, additional financial burdens, and
lack of sleep. In one exception, Ballard, Davis, Handy, and Mohan (1993)
recruited 200 couples from a postnatal ward and conducted psychiatric interviews
with both mothers and fathers. At six weeks postpartum, more than 6% of the
mothers met RDC criteria for GAD, and the symptom profiles of anxious mothers
were largely independent of the symptom profiles of depressed mothers. Matthey
et al. (2003) found that between 1.9 and 3.1% of first-time mothers were
diagnosed with acute adjustment disorder with anxiety at six weeks postpartum,
which was operationally defined as meeting all diagnostic criteria for GAD except
the six months criterion. Moreover, Wenzel, Haugen, Jackson, and Robinson
(2003) documented cases of three women with postpartum GAD at eight weeks
298 A. Wenzel et al. / Anxiety Disorders 19 (2005) 295–311

postpartum. These women reported some degree of chronic worry throughout

their lives, but all endorsed a level of clinical significance that began during
pregnancy or the puerperium. Further, the rate of sub-syndromal postpartum
generalized anxiety symptoms was more than three times the rate of sub-
syndromal postpartum depressive symptoms. Results from both Matthey et al.
(2003) and Wenzel et al. (2003) raise the possibility that postpartum generalized
anxiety is distinct from postpartum depression in at least some cases.
In all, results from these studies clearly suggest that postpartum anxiety is a
common phenomenon and that the early postpartum period represents a time of
risk for the development of anxiety disorders. However, the majority of this
literature consists of case studies or retrospective chart reviews, making it difficult
to draw accurate conclusions about the prevalence of anxiety disorders during the
puerperium and the prevalence of anxiety disorders that have a specific post-
partum onset. Moreover, most existing research has been conducted in hospital
settings with participants who were receiving treatment for their anxiety disorder
(e.g., Cohen et al., 1994; Sichel et al., 1993), which provides little information
about the prevalence of postpartum anxiety in the community at large. The few
existing prospective studies are limited by their small sample sizes (e.g., Cohen
et al., 1996; Wenzel et al., 2003), their use of self-report inventories rather than
diagnostic interviews to approximate rates of anxiety disorder diagnoses (e.g.,
Czarnocka & Slade, 2000), or their use of convenience samples recruited for the
purposes of a larger study (e.g., Wenzel et al., 2001). The study by Matthey et al.
(2003) improves upon these methodological limitations, although these investi-
gators did not examine rates of OCD and PTSD, and they did not specify the
particular type of phobia under investigation. Furthermore, instances of post-
partum GAD have rarely been considered in this literature, and no known studies
have examined the relation between childbirth and social anxiety symptoms.
Thus, the present study was designed to investigate comprehensively the
prevalence of postpartum anxiety disorders in a sample of women from the
community at large who had recently given birth. Women whose birth records
were available in the local newspaper were contacted, and those who agreed to
participate completed a diagnostic interview and a battery of self-report inven-
tories when they were approximately eight weeks postpartum. Three types of
prevalence rates were examined in this study: (a) the prevalence of postpartum
anxiety disorders and symptoms at a sub-syndromal level, (b) the prevalence of
postpartum anxiety disorders and symptoms that were associated specifically
with postpartum onset, and (c) the prevalence of comorbid postpartum anxiety
and postpartum depression. In addition, demographic factors (e.g., age, number
of children in the household), vulnerability factors (i.e., personal psychiatric
history, family psychiatric history), and one situational factor (i.e., breastfeeding
status) were entered into regression analyses to identify statistically significant
predictors of self-reported anxiety and depression. Finally, the effects of post-
partum anxiety and depression on one outcome factor—relationship quality—
were considered.
 A. Wenzel et al. / Anxiety Disorders 19 (2005) 295–311 299

1. Method

1.1. Participants

Birth records for women who delivered infants in Grand Forks, ND and its
surrounding communities were obtained from announcements in the area’s major
newspaper (n ¼ 754) over a nine month period. For women whose contact
information was available through public data bases (e.g., telephone books,
directory assistance; n ¼ 403), a letter describing the study was sent when they
were approximately six weeks postpartum, and soon thereafter they were con-
tacted by telephone to inquire about their interest in this study (see O’Hara, Stuart,
Gorman, & Wenzel, 2000, for a similar recruitment method). Of the 271 women
who could be reached by telephone, 200 agreed to participate, although 53 did not
follow through with scheduling an interview and/or completing the questionnaire
booklet, mainly due to lack of time required for participation (i.e., approximately
1.5 h). Thus, the present study reports on a final sample of 147 women (54.2% of
the total number of women contacted; 19.5% of the total birth announcements)
who agreed to participate and completed both study assessments (i.e., self-report
inventories, diagnostic interview). There were no differences in demographic
variables between women who completed both assessments and women who
completed only one of the assessments, and women who completed only the self-
report assessment did not score differently than women who completed both
assessments on any inventory.
All women completed assessments when they were approximately eight weeks
postpartum (mean age of infants was 60.8 days, S:D: ¼ 27:5 days). Participants
had a mean age of 29.1 years and were in involved in their current romantic
relationships for a mean of 7.8 years. Twenty-eight percent of these women were
having their first child, 93% were married, and 97% were Caucasian. All women
provided their informed consent prior to participation in this research.

1.2. Measures and procedure

1.2.1. Diagnostic interview

The following modules from the Structured Clinical Interview for DSM-IV
Disorders-Non-Patient Version (SCID-NP; First, Spitzer, Gibbon, & Williams,
1997) were administered: GAD, PD, agoraphobia (AG), social phobia (SOC),
OCD, PTSD, major depressive disorder (MDD), and dysthymic disorder (DYS).
Participants were regarded as meeting diagnostic criteria for PTSD only if their
traumatic stress symptoms pertained to childbirth. Clinical psychology graduate
students under the supervision of the first author administered the interview.
Interviewers completed a 10-h diagnostic interviewing workshop with the first
author that involved intensive training on each of the study modules, demonstration
of interviewing skills, role playing, and didactic instruction about special issues
associated with the diagnosis of anxiety and depressive disorders in postpartum
300 A. Wenzel et al. / Anxiety Disorders 19 (2005) 295–311

women. Interviews were completed over the telephone, a procedure similar to that
used by O’Hara and his colleagues (e.g., O’Hara et al., 2000), in order to eliminate
the need for participants in rural areas to travel to the laboratory. Previous research
has established a high concordance between diagnostic interviews completed in
person and over the telephone (Rohde, Lewinsohn, & Seeley, 1997).
For each disorder, one of two types of diagnoses was assigned to women.
Participants were assigned diagnoses of these disorders if they provided informa-
tion consistent with DSM-IV diagnostic criteria, which included substantial life
interference and distress. These women were regarded as being syndromal anxiety
or depressive disorder cases. In contrast, participants were regarded as having
sub-syndromal manifestations of these disorders if (a) they fulfilled the majority,
but not all of, DSM-IV diagnostic criteria for a disorder, and these symptoms
caused life interference and distress, or (b) they fulfilled all of the DSM-IV
diagnostic criteria for a disorder, but their symptoms did not cause sufficient life
interference or distress to warrant a diagnosis. Both syndromal and sub-syndromal
instances of anxiety and depressive disorders were considered in this report to
capture the full range of psychopathology experienced by a community sample of
postpartum women (cf. Abramowitz et al., 2003).
Interrater reliability was assessed for every fourth interview completed by each
interviewer. Percent agreement for each diagnosis was as follows: GAD, 90.1%;
PD, 100%; AG, 100%; SOC, 95.2%; OCD, 100%; PTSD, 100%; MDD, 100%;
and DYS, 100%. Discrepancies between raters were resolved by consensus.
Interviewers also obtained information pertaining to their personal and family
psychiatric history. Consistent with the protocol used by O’Hara et al. (2000),
interviewers asked participants whether they have ever seen anybody for psy-
chiatric or emotional difficulties, whether they had ever been hospitalized as a
patient in a psychiatric hospital, whether there were times in their lives in which
they had experienced emotional difficulties but did not seek treatment, and
whether they had received treatment for drug or alcohol abuse. Participants
who responded affirmatively to any of these questions provided additional
information about these instances, including the time period over which this
occurred, their age, the specific difficulty for which they were seeking treatment,
the length of time of the episode (if different than the length of time for which they
were seeking treatment), and the type of treatment received. Individuals who
responded positively to one or more of these questions and who provided specific
detail about the episode in response to the follow-up probes were regarded as
having a personal psychiatric history. To assess family psychiatric history,
interviewers asked whether anyone in their family had experienced psychiatric
or emotional difficulties, whether anyone in their family had been hospitalized as
a patient in a psychiatric hospital, whether anyone in their family had received
treatment for drug or alcohol abuse, and whether anyone in their family had
attempted or committed suicide. Participants were regarded as having a family
psychiatric history if they responded affirmatively to one or more of these
questions.
 A. Wenzel et al. / Anxiety Disorders 19 (2005) 295–311 301

1.2.2. Self-report inventories

In addition to the diagnostic interview, women in this sample completed the
following self-report inventories: the Beck Anxiety Inventory (BAI; Beck,
Epstein, Brown, & Steer, 1988), Beck Depression Inventory-II (BDI; Beck &
Steer, 1987), Penn State Worry Questionnaire (PSWQ; Meyer, Miller, Metzger, &
Borkovec, 1990), Social Interaction Anxiety Scale (SIAS; Mattick & Clark,
1998), and Dyadic Adjustment Scale (Spanier, 1976). These inventories were
mailed to participants, and they returned them in stamped envelopes provided by
the investigators. Coefficient alphas obtained on the sample in the present study
were .87, .83, .95, .93, and .88 for the BAI, BDI, PSWQ, SIAS, and DAS,
respectively.

2. Results

2.1. Rates of postpartum anxiety and depressive disorders

Table 1 displays prevalence rates of anxiety and depressive disorders, pre-

valence rates of sub-syndromal cases of anxiety and depressive disorders, and the
number of participants who endorsed a postpartum onset of their symptoms.
Postpartum prevalence rates of these diagnoses were as follows: GAD, 8.2%;
OCD, 2.7%; PD, 1.4%; AG, 0%; SOC, 4.1%; PTSD, 0%; MDD, 4.8%; and DYS,
2.7%. One-year prevalence rates of these disorders in women representative of the
general population are GAD, 4.3%; OCD, 2.6%; PD, 1.4%; AG, 3.8%; SOC,

Table 1
Anxiety and depressive disorder diagnoses

Diagnosis Syndromal cases (n) Sub-syndromal cases (n)

Total PP onset Total PP onset

Generalized anxiety disorder 12 (8.2%) 5 29 (19.7%) 8

Obsessive compulsive disorder 4 (2.7%) 3 8 (5.4%) 2
Panic disorder 2 (1.4%) 1 0 (0%) –
Agoraphobia 0 (0%) – 0 (0%) –
Social phobia 6 (4.1%) 4 22 (15.0%) 5
Posttraumatic stress disorder 0 (0%) – 3 (2.0%) 3
Major depressive disorder 7 (4.8%) 3 11 (7.5%) 4
Dysthymic disorder 4 (2.7%) – 6 (4.1%) –
Note. PP ¼ postpartum. Values in parentheses are percentages of the total sample of 147 participants.
Participants denoted as syndromal cases met DSM-IV criteria for anxiety or depressive disorder
diagnoses. Participants were denoted as sub-syndromal cases if (a) they fulfilled the majority, but not
all of, DSM-IV diagnostic criteria for a disorder, and these symptoms caused life interference or
distress, or (b) they fulfilled all of the DSM-IV diagnostic criteria for a disorder, but their symptoms
did not cause sufficient life interference or distress to warrant a diagnosis. Postpartum onset was not
calculated for dysthymic disorder because, by definition, individuals with this diagnosis had been
experiencing symptoms for at least the previous two years.
302 A. Wenzel et al. / Anxiety Disorders 19 (2005) 295–311

9.1%; MDD, 6.6%; and DYS, 3.0% (Kessler et al., 1994, 2003; Robins & Reiger,
1991). Thus, GAD was more common in postpartum women than in women
representative of the general population, OCD, PD, and DYS were equally as
common, and AG, SOC, and MDD were less common. The rate of postpartum
PTSD was not compared to rates from large epidemiological studies, as it was
only assigned when symptoms pertained specifically to anxiety associated with
childbirth.
In addition, the most common sub-syndromal expressions of postpartum
anxiety and depressive symptomatology were in the realm of generalized anxiety
(19.7%) and social anxiety (15.0%). Eleven participants (7.5%) reported
sub-syndromal symptoms of major depression, eight participants (5.4%) reported
sub-syndromal obsessive-compulsive symptoms, six participants (4.1%) reported
sub-syndromal dysthymic symptoms, and three participants (2.0%) reported sub-
syndromal traumatic stress symptoms. No participant described instances of sub-
syndromal panic or AG.
Slightly more than 40% of participants diagnosed with either GAD or MDD,
and over half of the participants diagnosed with OCD and SOC endorsed a
postpartum onset of their disorder. Many of these women indicated that they had
experienced sub-syndromal expressions of these disorders but that they reached a
diagnostic level following childbirth. One woman diagnosed with PD indicated
that its onset was in the past month, and the other woman indicated that she had
been struggling with this disorder since adolescence. Fewer than half of the
individuals with sub-syndromal symptoms of anxiety and depressive disorders
endorsed a postpartum onset of their symptoms. The one exception to this
observation is for PTSD, where all participants with traumatic stress symptoms
indicated a postpartum onset because this diagnosis was considered in the context
of traumatic childbirth.

2.2. Comorbid anxiety and depression

Table 2 displays rates of syndromal and sub-syndromal instances of depression

in individuals who were diagnosed with an anxiety disorder and in individuals
who reported sub-syndromal symptoms of anxiety. Six of the eight participants
diagnosed with GAD and over 40% of the participants reported sub-syndromal
generalized anxiety symptoms endorsed either syndromal or sub-syndromal
depressive symptoms. One of the two participants diagnosed with PD was also
diagnosed with a depressive disorder. In contrast, fewer than half of participants
who were diagnosed with OCD or who reported sub-syndromal obsessive
compulsive symptoms also endorsed symptoms of depression. Half of the
participants who were diagnosed with SOC also reported syndromal or sub-
syndromal instances of depression, although less than 25% of the sub-syndromal
socially anxious participants endorsed concurrent depressive symptoms. Only one
of the three women who endorsed traumatic stress symptoms associated with
childbirth reported sub-syndromal depressive symptoms.
 A. Wenzel et al. / Anxiety Disorders 19 (2005) 295–311 303

Table 2
Comorbidity among anxiety and depressive disorders

Diagnosis Syndromal cases (n) Sub-syndromal cases (n)

Syndromal Sub-syndromal Syndromal Sub-syndromal

depression depression depression depression

Generalized anxiety disorder 2 (25.0%) 4 (50.0%) 6 (22.2%) 6 (22.2%)

(8 syndromal cases;
27 sub-syndromal cases)
Obsessive compulsive disorder 1 (25.0%) 1 (25.0%) 1 (12.5%) 2 (25.0%)
(4 syndromal cases;
8 sub-syndromal cases)
Panic disorder 1 (50.0%) 0 (0%) – –
(2 syndromal cases;
0 sub-syndromal cases)
Social phobia 2 (33.3%) 1 (16.7%) 2 (9.1%) 3 (13.6%)
(6 syndromal cases;
22 sub-syndromal cases)
Posttraumatic stress disorder – – 0 (0%) 1 (33.3%)
(0 syndromal cases;
3 sub-syndromal cases)
Note. Syndromal cases were participants meeting diagnostic criteria for an anxiety disorder.
Participants were denoted as sub-syndromal cases if (a) they fulfilled the majority, but not all of,
DSM-IV diagnostic criteria for a disorder, or and these symptoms caused life interference or distress
(b) they fulfilled all of the DSM-IV diagnostic criteria for a disorder, but their symptoms did not
cause sufficient life interference or distress to warrant a diagnosis. Syndromal depression ¼ DSM-IV
diagnosis of major depressive episode or dysthymic disorder. Sub-syndromal depression ¼ report of
symptoms consistent with a DSM-IV diagnosis of major depressive episode or dysthymic disorder.
Values in parentheses are percentages of the total number of participants designated as syndromal
anxiety disorder cases or sub-syndromal anxiety disorder cases.

2.3. Regression analyses

A series of four hierarchical multiple regressions was conducted to predict

symptoms on four standard self-report inventories of anxious and depressive
symptoms—the PSWQ, the BAI, the SIAS, and the BDI. Variables included into
Step 1 were demographic characteristics known to affect the course of postpartum
affective disorder (i.e., mother’s age, baby’s age at the time of assessment, number
of children in the household, and socioeconomic status; cf. O’Hara & Swain,
1996; O’Hara, Neunaber, & Zekoski, 1984). Step 2 included two variables
regarded as vulnerability factors for the development of postpartum depression
and anxiety (i.e., personal psychiatric history, family psychiatric history). Finally,
a situational factor (i.e., breastfeeding status) was entered into the regression
analysis at Step 3.
Overall, the regression models were statistically significant in predicting
scores on the BAI, the SIAS, and the BDI but not the PSWQ. Table 3 displays
the regression table that summarizes predictors of BAI scores. Although the
304 A. Wenzel et al. / Anxiety Disorders 19 (2005) 295–311

Table 3
Predictors of Beck Anxiety Inventory scores

Variable B S.E. (B) b r2 Dr2 P

Step 1 .06 – ns
Mother’s age 0.19 0.11 .16 ns
Baby’s age 0.01 0.02 .06 ns
Number of children 0.14 0.49 .03 ns
SES 0.06 0.04 .13 ns
Step 2 .164 .104 .001
Personal psychiatric history 2.51 1.05 .20 .018
Family psychiatric history 2.42 0.92 .22 .010
Step 3 .165 .001 .001
Breastfeeding status 0.25 0.88 .02 ns
Note. Mother’s age calculated in years. Baby’s age calculated in days. SES ¼ socioeconomic status.
SES became a significant predictor of BAI scores in Step 2 (b ¼ :17; P ¼ :042).

model tested in Step 1 including only demographic variables was not statistically
significant, the model tested in Step 2 including the vulnerability factors
accounted for significantly more variance in BAI scores (r 2 ¼ :164;
P ¼ :001). Both personal psychiatric history and family psychiatric history were
significant positive predictors (b’s ¼ :20, .22; P’s ¼ :018, .01, respectively), and
socioeconomic status became a significant negative predictor in this context
(b ¼ :17; P ¼ :042). Inclusion of breastfeeding status in Step 3 did not add
significantly to the explanatory power of the regression model.
Table 4 displays the regression table that summarizes predictors of SIAS
scores. The model consisting only of demographic variables was significant and
accounted for 12.1% of the variance (P < :001). Both mother’s age (b ¼ :26;
P ¼ :004) and socioeconomic status (b ¼ :17; P ¼ :045) were negative pre-
dictors of SIAS scores. Adding the vulnerability factors in Step 2 did not increase

Table 4
Predictors of Social Interaction Anxiety Scale scores

Variable B S.E. (B) b r2 Dr2 P

Step 1 .121 – .001

Mother’s age 0.71 0.24 .26 .004
Baby’s age 0.01 0.04 .04 ns
Number of children 1.17 1.12 .15 ns
SES 0.17 0.09 .17 .045
Step 2 .136 .015 .002
Personal psychiatric history 3.02 2.52 .10 ns
Family psychiatric history 1.36 2.21 .05 ns
Step 3 .171 .035 .001
Breastfeeding status 4.96 2.01 .19 .017
Note. Mother’s age calculated in years. Baby’s age calculated in days. SES ¼ socioeconomic status.
 A. Wenzel et al. / Anxiety Disorders 19 (2005) 295–311 305

Table 5
Predictors of Beck Depression Inventory scores

Variable B S.E. (B) b r2 Dr2 P

Step 1 .061 – ns
Mother’s age 0.21 0.11 .17 ns
Baby’s age 0.02 0.02 .13 ns
Number of children 0.77 0.49 .14 ns
SES 0.02 0.04 .04 ns
Step 2 .109 .048 .013
Personal psychiatric history 2.42 1.09 .19 .028
Family psychiatric history 0.84 0.95 .08 ns
Step 3 .143 .034 .003
Breastfeeding status 2.11 0.89 .19 .02
Note. Mother’s age calculated in years. Baby’s age calculated in days. SES ¼ socioeconomic status.

the explanatory power of the regression model. However, the inclusion of

breastfeeding status in Step 3 accounted for an additional 3.5% of the variance
(b ¼ :19; P ¼ :017). Specifically, mothers who were not breastfeeding reported
higher levels of social anxiety than mothers who were breastfeeding. Thus, age,
socioeconomic status, and breastfeeding status were significant predictors in a
model that accounted for 17.1% of the variance in SIAS scores.
Table 5 displays the regression table that summarizes predictors of BDI scores.
The model consisting only of demographic variables was not significant. How-
ever, personal psychiatric history was a significant predictor of BDI scores
(b ¼ :19; P ¼ :028), which drove the regression model to be significant at Step
2 (r 2 ¼ :109; P ¼ :013). Moreover, the inclusion of breastfeeding status
accounted for additional variance in Step 3 (b ¼ :19; P ¼ :02). In a similar
manner as the pattern of findings associated with SIAS scores, mothers who were
not breastfeeding reported higher BDI scores than mothers who were breastfeed-
ing. Thus, in the final model, personal psychiatric history and breastfeeding status
were significant predictors in a model that accounted for 14.3% of the variance in
BDI scores.
Table 6 displays results for a final regression analysis that was conducted to
examine the manner in which anxious and depressive symptomatology predicted
a specific type of postpartum dysfunction—relationship distress as measured by
the DAS. Variables included into Step 1 were demographic characteristics known
to affect the quality of postpartum marital relationships (i.e., length of the
relationship, baby’s age at the time of the assessment, number of children in
the household; cf. Haugen, Schmutzer, & Wenzel, in press). To replicate a well
established finding in the literature that depression has deleterious effects on the
marital relationship (e.g., O’Mahen, Beach, & Banawan, 2001), BDI scores were
included into Step 2. Finally, scores on the three anxiety self-report inventories
(i.e., PSWQ, BAI, SIAS) were included in Step 3 to isolate the degree to which
they predicted relationship distress above and beyond depressive symptoms.
306 A. Wenzel et al. / Anxiety Disorders 19 (2005) 295–311

Table 6
Predictors of relationship distress

Variable B S.E. (B) b r2 Dr2 P

Step 1 .052 ns
Length of relationship 0.02 0.03 .06 ns
Baby’s age 0.04 0.04 .08 ns
Number of children 3.37 1.32 .23 .012
Step 2 .178 .126 .001
BDI 1.05 0.21 .40 .001
Step 3 .197 .019 .001
PSWQ 0.10 0.10 .10 ns
BAI 0.08 0.27 .03 ns
SIAS 0.22 0.11 .20 .035
Note. Length of relationship calculated in months. Baby’s age calculated in days. BDI ¼ Beck
Depression Inventory; PSWQ ¼ Penn State Worry Questionnaire; BAI ¼ Beck Anxiety Inventory;
SIAS ¼ Social Interaction Anxiety Inventory.

Results indicated that the demographic characteristics as a whole did not reach
statistical significance, although number of children in the household was a
statistically significant predictor in this model (b ¼ :23; P ¼ :012). The overall
regression model at Step 2 was significant (r 2 ¼ :178; P ¼ :001), and both the
number of children in the household (b ¼ :17; P ¼ :043) and BDI scores
(b ¼ :40; P ¼ :001) were negative predictors of DAS scores. Inclusion of the
anxiety self-report inventories at Step 3 added an additional 1.9% of the variance
to the model (r 2 ¼ :197; P < :001). Specifically, the SIAS was a significant
negative predictor of DAS scores (b ¼ :20; P ¼ :035). In all, the number of
children in the household, BDI scores, and SIAS scores were significant pre-
dictors in a model that accounted for 19.7% of the variance in DAS scores.

3. Discussion

The present study is the first comprehensive investigation of the prevalence of

postpartum anxiety disorders in a community sample of women. Results indicated
that the rate of postpartum GAD was elevated as compared to the rate that
characterizes women in the general population. In addition, between 40 and 50%
of the women who were assigned anxiety or depressive disorder diagnoses
endorsed a postpartum onset of their symptoms. Comorbid depressive symptoms
were particularly common in individuals with sub-syndromal or syndromal
instances of generalized anxiety. In contrast, there were few instances of women
endorsing clinically significant levels of traumatic stress symptoms stemming
from childbirth. SP, although diagnosed at a lower rate than in women repre-
sentative of the general population, was associated with a postpartum onset in four
of the six cases. In all, these results suggest that postpartum anxiety is commonly
 A. Wenzel et al. / Anxiety Disorders 19 (2005) 295–311 307

experienced by women in the community and that it occurs at a higher rate than
postpartum depression. We view this finding as noteworthy, given that O’Hara and
his colleagues have reported that the rate of major depression in the postpartum
period is not higher than the rate of major depression characterizing women
representative of the general population (O’Hara, Zekoski, Philipps, & Wright,
1990). It will be important to examine rates of anxiety disorders in a control group
of women who have not recently delivered to consider more precisely whether the
postpartum period puts women at a particularly high risk for the development of
anxiety disorders.
Although there were no significant predictors of worry symptoms, as measured
by the PSWQ, a number of variables predicted depressive and other types of
anxiety symptoms. Lower socioeconomic status predicted higher scores on the
BAI and SIAS, and younger age predicted higher scores on the SIAS. A personal
psychiatric history predicted higher scores on the BAI and BDI, and a family
psychiatric history accounted for additional variance in BAI scores. The absence
of breastfeeding predicted higher scores on the SIAS and BDI. This latter finding
is particularly interesting, as many researchers have associated psychopathology
with the hormonal fluctuations associated with lactation (Ingram, Greenwood, &
Woolridge, 2003). It is possible that psychological factors, rather than biological
factors, contribute to this significant relation, as the decision not to breastfeed
might be associated with variables such as discomfort with public exposure, a lack
of self-confidence, or a lack of energy. However, it is important to note that all of
these factors combined accounted for less than 20% of the variance in self-
reported anxiety and depressive symptoms, suggesting that other variables may be
more important in explaining the occurrence of these symptoms.
Postpartum psychopathology, particularly depression and social anxiety, was
associated with lower relationship quality. It is well established that depression is
both a cause and effect of marital distress in women (O’Mahen et al., 2001).
However, this study adds to an increasingly large literature suggesting that social
anxiety is associated with relationship distress above and beyond depressive
symptoms (cf. Davila & Beck, 2002; Wenzel, 2002). The design of the present
study does not allow for consideration of whether these symptoms affect relation-
ship distress in a different manner in the postpartum period as compared to other
periods in the lives of childbearing women. Moreover, the study is cross-sectional
in nature, making it difficult to isolate the manner in which these processes unfold
over time. However, these results do provide preliminary evidence of psycho-
social disturbance associated with some types of postpartum psychiatric symp-
toms, and future researchers are encouraged to assess the degree of dysfunction
associated with postpartum anxiety in other realms of functioning, such as the
relationship with the infant.
Although this study is a unique contribution to the literature on postpartum
psychopathology, several limitations must be noted. As in most research using
samples of individuals from the community, the extent to which the women who
agreed to participate in the study are representative of the general population of
308 A. Wenzel et al. / Anxiety Disorders 19 (2005) 295–311

childbearing women is unclear. Over half of the women whose birth records were
included in the area’s local newspaper were unable to be contacted for the study, a
rate similar to postpartum depression studies using nearly identical recruitment
methods (e.g., O’Hara et al., 2000; Wenzel et al., 2001). In addition, many women
who initially agreed to participate did not follow through with completing one or
more study assessments. Thus, the 147 women whose data were included in
analyses for the present study represented only 19.5% of the women whose birth
announcements were included in the local newspaper. It will be important for
researchers in this area to work toward developing innovative recruitment
techniques to capture as many childbearing women as possible into their pro-
tocols.
Second, this study is mainly descriptive in nature and leaves open many
questions about the nature and course of postpartum anxiety symptoms and
anxiety disorders. As with postpartum depression (O’Hara & Swain, 1996), it is
likely that psychiatric symptoms during pregnancy account for the greatest
amount of variance in postpartum anxiety. It will be important for future
researchers to assess women during pregnancy and track their symptomatology
following childbirth. Moreover, data collected in this study do not address
whether the nature of postpartum anxiety is different than instances of anxiety
that occur at other times in women’s lives and whether postpartum anxiety
disorders follow a different course. Metz et al. (1988) noted that postpartum PD
was characterized by the symptoms typically seen in panic patients in their clinic,
whereas Sichel et al. (1993) indicated that the absence of compulsions in their
sample of postpartum women was atypical. As mentioned previously, a long-
itudinal study using samples of postpartum and non-postpartum women matched
for demographic variables such as age, marital status, and socioeconomic status
would begin to address these issues. In addition, the prevalence rates for sub-
syndromal anxiety and depression were quite high, which raises the question of
whether these symptoms and experiences are more normative than dysfunctional.
A closer examination of the degree to which sub-syndromal symptoms are
problematic is warranted, as well as a consideration of whether sub-syndromal
symptoms put women at risk for experiencing full syndromes in the future.
Finally, prevalence rates of eight-week anxiety and depressive disorders were
compared to one year prevalence rates from large epidemiological studies, which
limits their interpretability.
Despite these limitations, this study provides important information about the
rates of postpartum anxiety in a community sample of women. Results from this
study establish that postpartum anxiety symptoms and disorders are common
occurrences and that they warrant further attention. It will be important for health
professionals to recognize that maladjustment in the postpartum period may not
necessarily be confined to symptoms of depression (cf. Matthey et al., 2003). We
encourage future researchers to examine changes in diagnostic status throughout
the first year postpartum and the variables with which these changes covary to
elucidate the possible mechanisms underlying the etiology and maintenance of
 A. Wenzel et al. / Anxiety Disorders 19 (2005) 295–311 309

postpartum anxiety. Moreover, it will be important for researchers in this area to

demonstrate empirically that established treatments for anxiety disorders are
efficacious for this population.

Acknowledgments

This research was funded by a University of North Dakota Summer Graduate

Research Professorship, a University of North Dakota New Faculty Scholar
Award, and a University of North Dakota Faculty Seed Grant. Portions of this
research were presented at the 11th Biannual Meeting of the International
Conference on Personal Relationships and the 36th Annual Meeting of the
Association for Advancement of Behavior Therapy. The authors would like to
thank Peter Schmuzter, Jason McCray, Kirsten Robinson, Melanie Goyette, Talia
Tweten, Lindsey Olsen, Chrystie Brady, and Joni Kraft for their assistance with
this project.

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