Definition and characteristics of separation anxiety disorder
Separation Anxiety Disorder is an anxiety disorder in which the individual experiences excessive anxiety concerning separation from home or from those to whom the person is strongly emotionally attached to.
In children, the latter are usually the parents while if the condition is present in adulthood, it may be the spouse or intimate other.
It is important to note that separation anxiety differs from separation anxiety disorder in that the former is a normal stage during early infant development e.g. up to 2 years of age while the latter is a abnormal condition which occurs after this.
Very detailed criteria for Separation Anxiety Disorder in children are provided in the Diagnostic and Statistical Manual, 4th Edition, of the American Psychiatric Society, DSM-IV).
The DSM-IV puts this disorder in the section called “Other Disorders of Infancy, Childhood, or Adolescence” reflecting the previous focus entirely on children although more recent work has clearly shown that separation anxiety disorder also occurs in adults (Shear et al 2006; Silove et al, 2010).
The DSM-IV criteria are for those under 18 and are as follows:
Three or more of the following:
- recurrent excessive distress when separated from home or major attachment figures, or this separation is anticipated
- persistent and excessive worry about losing, or about possible harm to attachment figures
- persistent and excessive worry that some unexpected and challenging event will lead to separation from a major attachment figure for example that they will get lost or kidnapped
- persistent reluctance or refusal to go to school or elsewhere because of fear of separation
- persistent and excessive fear of being alone or without major attachment figures at home or without significant adults in other settings
- persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
- repeated nightmares involving the theme of separation
- repeated complaints of physical symptoms such as headaches stomachaches, nausea, or vomiting, when separation from major attachment figures occurs or is anticipated.
- Duration is of at least four weeks.
- Onset is before age 18 years
- Clinically significant distress or impairment in functioning
Using these criteria, the diagnosis of separation anxiety disorder was initially restricted to children.
However, as mentioned above, recent studies have used similar criteria but omitted the requirement that onset be before age 18, to survey and assess for the existence of Adult Separation Anxiety in adults and have clearly shown that it does exist in both adults and children (Silove et al, 2010a, Silove et al, 2010b).
Lifetime prevalence of Separation Anxiety
A large epidemiological study by Shear et al (2006) found the lifetime prevalence of childhood separation anxiety disorder of 4.1%. Surprisingly this same study found the lifetime prevalence of this disorder for adult was 6.6%.
A previous report by Kessler et al (2005) which was conducted only on adults and included retrospective reports gave a lifetime prevalence figure of 5.2%. Comparing this to the prevalences obtained for other anxiety disorders in this same 2005 study, separation anxiety disorder ranked just 5th.
However given that it is only recently that the adult form of this disorder was even recognized to exist, this is an amazingly high prevalence ranking just below generalized anxiety disorder with a lifetime prevalence of 5.7%.
Treatments for Separation Anxiety
Treatment of children with separation anxiety disorder would seem to be of great importance since the study by Kessler et al showed that “Approximately one-third of the respondents who were classified as childhood cases (36.1%) had an illness that persisted into adulthood…”.
In other words, the occurrence of childhood separation anxiety disorder puts the individual at increased risk of developing some other kind of psychological problem in adulthood. They can include adult separation anxiety disorder, personality disorders (Osone & Takahashi, 2006; Silove et al,2010), and or other anxiety disorders.
Adults with separation anxiety disorder are not in less need of treatment since the study by Silove et al 2010 concluded that “Patients with ASAD (adult separation disorder) attending an anxiety clinic are highly symptomatic and disabled.”
Despite the evidence that childhood separation anxiety puts children at high risk for developing various mental disorders, there has been only one randomized controlled study of the effectiveness of a treatment program specifically designed for childhood separation anxiety disorder (Schneider et al 2011).
These authors used a Cognitive Behavioural Treatment (CBT) approach and found it to be highly effective.
Schneider et al results indicated that “76.19% of children allocated to the treatment group definitively no longer fulfilled DSM-IV criteria for SAD (separation anxiety disorder) at follow- up, compared to 13.64% in the waiting list group. Between 91 and 100% of children rated themselves or were rated by their father, mother or therapist as very much or much improved...”.
This brief review of the literature indicates that:
- Separation anxiety definitely occurs in adults
- In fact it is higher in adults than in children by about 50%
- Much more research required on treatment for separation anxiety disorder both in children and adults where it is frequently comorbid with other psychological problems especially other anxiety disorders. A cognitive behavioural approach to treatment of children has been shown to be effective and should be put into practice on a much more widespread basis in view of the high need to avoid the occurrence of psychological problems in adulthood.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. (4th ed., text rev.) Washington, DC: Author.
Kessler, Ronald C., Berglund, Patricia, Demler, Olga, Jin, Robert, Merikangas, K. R., Walters, Ellen E., (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, Vol. 62(6), 593-602.
Osone, A., & Takahashi, S. (2006). Possible link between childhood separation anxiety and adulthood personality disorder in patients with anxiety disorders in Japan. Journal of Clinical Psychiatry, 67, 1451–1457.
Schneider, S., Blatter-Meunier, J., Herren, C., Adornetto, C. In-Albon, T. & Lavallee, K. (2011) Disorder-specific cognitive-behavioral therapy for separation anxiety disorder in young children: A randomized waiting-list-controlled trial. Psychotherapy and Psychosomatics, 80(4), 206-215.
Shear, K., Jin, R., Ruscio, A. M., Walters, E. E., & Kessler, R. C. (2006). Prevalence and Correlates of Estimated DSM-IV Child and Adult Separation Anxiety Disorder in the National Comorbidity Survey Replication. The American Journal of Psychiatry, 163(6), 1074-1083.
Silove, D., Marnane, C., Wagner, R., & Manicavasagar, V. (2010a). Associations of personality disorder with early separation anxiety in patients with adult separation anxiety disorder. Journal of Personality Disorders, 25(1), 128–133.
Silove, D. M., Marnane, C. L., Wagner, R., Manicavasagar, V. L., & Rees, S. (2010b). The prevalence and correlates of adult separation anxiety disorder in an anxiety clinic. BMC Psychiatry, 10, Article ID 21.