Separation Anxiety Disorder

Primer

Separation anxiety disorder is a mental disorder characterized by an excessive fear or anxiety concerning separation from a home or attachment figure(s). The anxiety exceeds what is expected at the individual's developmental level.

Epidemiology
  • The 12-month prevalence of separation anxiety disorder among adults in the United States is between 1 to 2%.[1]
    • In children it is estimated to be 4%.[2]
  • It is equally common between males and females clinically, but seen more frequently in females in the community.[3]
Prognosis
  • Separation anxiety disorder can occur as early as during preschool age and can occur at any time during childhood and more rarely in adolescence.
    • Symptoms can wax or wane over the course of the disorder.
  • The vast majority of children with separation anxiety disorder do not have impairing anxiety over the course of their lifetimes, and many as adults do not recall their history of anxiety.[4]
  • Separation anxiety is actually a protective factor against substance use.[5]
Comorbidity
  • Separation anxiety in childhood increases the risk for developing panic disorder, followed by major depressive disorder.
  • In children, separation anxiety disorder is highly comorbid with generalized anxiety disorder and specific phobia.
  • In adults, specific phobia, PTSD, panic disorder, generalized anxiety disorder, social anxiety disorder, agoraphobia, obsessive-compulsive disorder, personality disorders, depressive disorders, and bipolar disorder are common.[6]
Risk Factors
  • Risk factors include major life stressors such as the death of a relative or a pet, illness of a loved one, parental divorce, change of schools, immigration, and disasters that involve separation.[7]
  • Parental overprotection and intrusiveness is also associated with separation anxiety disorder.
  • Separation anxiety disorder in children may be heritable (estimated 73% in a community sample of twins).[8]
Cultural
  • There is significant variation in countries and cultures on the age where one expects the offspring should leave the parental home. Thus, it is important to assess separation anxiety disorder within a cultural context. [9]

DSM-5 Diagnostic Criteria

Criterion A

Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least 3 of the following:

  1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.
  2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
  3. Persistent and excessive worry about experiencing an untoward event (e.g. - getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
  4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.
  5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.
  6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.
  7. Repeated nightmares involving the theme of separation.
  8. Repeated complaints of physical symptoms (e.g. - headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.
Criterion B

The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.

Criterion C

The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.

Criterion D

The disturbance is not better explained by another mental disorder, such as:

DSM-IV to DSM-5 Changes

DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 15, DSM-IV to DSM-5 Separation Anxiety Disorder Comparison.

Specifiers

Panic Attack Specifier

Specify if:

  • Recurrent unexpected panic attacks. An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time at least 4 of the following symptoms occur (Note: The abrupt surge can occur from a calm state or an anxious state):
  1. Sweating
  2. Trembling or shaking
  3. Unsteady, dizziness, light-headed, or faint
  4. Derealization (feelings of unreality) or depersonalization (being detached from one self)
  5. Excessive/accelerated heart rate, palpitations, or pounding heart
  6. Nausea or abdominal distress
  7. Tingling, numbness, parathesesias
  8. Shortness of breath
  9. Fear of losing control or “going crazy”
  10. Fear of dying
  11. Choking feelings
  12. Chest pain or discomfort
  13. Chills or heat sensations
Note: The symptoms presented in this specifier are for the purpose of identifying a panic attack. However, panic attacks are not a mental disorder. Panic attacks can occur in the context of any anxiety disorder as well as other mental disorders (e.g. - depressive disorders, posttraumatic stress disorder, substance use disorders) and some medical conditions (e.g. - cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic attack is identified, it should be noted as a specifier (e.g. - “social anxiety disorder with panic attacks”). For panic disorder, the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier.
Note: Culture-specific symptoms (e.g. - tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

Signs and Symptoms

  • Note that heightened separation anxiety from attachment figures are part of normal early childhood development and can indicate the development of secure attachment relationships (e.g. - around 1 year of age, when infants develop stranger anxiety).[10]
  • When separated from major attachment figures such as their parents, children with separation anxiety disorder may show apathy, sadness, social withdrawal, or difficulty concentrating.
    • This can lead to school refusal, academic difficulties, and social isolation.
    • When alone (typically in the evening or the dark), young children may report unusual perceptual experiences (e.g. - seeing people peering into their room, creatures reaching for them, or feeling there are eyes staring at them).
  • In children, individuals may present as demanding, intrusive, and in need of constant attention. When this continues into adulthood, individuals can appear dependent and overprotective.[11]
  • Adults with separation anxiety are usually worried about their children and spouses and experience significant discomfort when separated from them (e.g. - will continuously check on the whereabouts of love one).[12]

Screening and Rating Scales

  • Children's Separation Anxiety Scale (CSAS)[13]

Pathophysiology

Differential Diagnosis

  • Generalized anxiety disorder (GAD)
    • Separation anxiety disorder is distinguished from GAD in that the anxiety predominantly concerns separation from attachment figures. Other worries are not part of the larger clinical presentation.
  • Panic disorder
    • Threats of separation can lead to panic attacks. In separation anxiety disorder, however, the anxiety concerns the possibility of being away from attachment figures. Contrast this with panic disorder, which is concern about being incapacitated by an unexpected panic attack.
  • Agoraphobia
    • In agoraphobia, the fears are about being trapped or incapacitated in situations from which escape is perceived as difficult in the event of panic-like symptoms or other incapacitating symptoms.
  • Conduct disorder
    • School avoidance (truancy) is common in conduct disorder, but anxiety about separation is not the cause for school absences. Additionally, these individuals usually stays away from home when avoiding school.
  • Bereavement
    • Yearning and preoccupation with the deceased are normal, expected responses in bereavement.
  • Major depressive disorder and bipolar disorders
  • Social anxiety disorder
    • School refusal may be due to social anxiety disorder, and school avoidance is due to fear of being judged negatively by others, and not about separation from the attachment figures.
  • Posttraumatic stress disorder (PTSD)
    • Fear of separation from loved ones is common after traumatic events such as a disasters, particularly when periods of separation from loved ones were experienced during the traumatic event. In PTSD, the main symptoms are intrusions, and avoidance of memories associated with the traumatic event. In separation anxiety, the worries are about the well-being of attachment figures and separation from them.
  • Illness anxiety disorder
    • Individuals with illness anxiety disorder worry about specific illnesses they may have, but the main concern is about the medical problem itself, and not about separation from attachment figures.
    • These disorders may be associated with reluctance to leave home, but the main concern is not worry or fear of untoward events befalling attachment figures. However, individuals with separation anxiety disorder can become depressed while being separated from close figures.
  • Oppositional defiant disorder (ODD)
    • Children and adolescents with separation anxiety disorder may be oppositional in the context of being forced to separate from attachment figures. ODD is only diagnosed if there is persistent oppositional behavior unrelated to separation from attachment figures.
  • Psychotic disorders
    • Unlike the hallucinations in psychotic disorders, any unusual perceptual experiences in separation anxiety disorder are based on a misperception of an actual stimulus. These are better described as illusions, and occur only in certain situations (e.g. - nighttime). Additionally, they are reversed by the presence of an attachment figure.
  • Personality disorders
    • Dependent personality disorder is characterized by a tendency to rely on others, whereas separation anxiety disorder involves concern about the proximity and safety of main attachment figures.
    • Borderline personality disorder is characterized by fear of abandonment by loved ones, but there are additional issues around identity, suicidal behaviours, interpersonal functioning, and impulsivity.

Investigations

  • As clinically indicated.

Physical Exam

  • As clinically inidcated.

Treatment

Psychotherapy

Pharmacological

  • Psychological therapies are always preferred over pharmacotherapy.
  • Generally speaking, selective serotonin reuptake inhibitors and tricyclic antidepressants are the most commonly studied medications for anxiety disorders in children.
    • Fluoxetine, fluvoxamine, and sertraline have been studied.[14]
  • Benzodiazepines should never be used (no better than placebo)![15]

Guidelines

Resources

For Patients
For Providers
Articles
Research

References

1) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
2) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
3) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
4) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
5) Ohannessian, C. M. (2014). Anxiety and substance use during adolescence. Substance abuse, 35(4), 418-425.
6) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
7) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
8) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
9) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
10) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
11) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
12) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
13) Méndez, X., Espada, J. P., Orgilés, M., Llavona, L. M., & García-Fernández, J. M. (2014). Children's separation anxiety scale (CSAS): psychometric properties. PloS one, 9(7), e103212.
14) Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.
15) Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.