6.6 Separation Anxiety Disorder

Separation anxiety disorder A disorder that typically arises in childhood and is characterized by excessive anxiety about separation from home or from someone to whom the person is strongly attached.

Separation anxiety disorder is characterized by excessive anxiety about separation from home or from someone to whom the person is strongly attached. This disorder occurs most commonly in children but can also affect adults. In what follows, we examine separation anxiety disorder in detail and then turn to its causes and treatment.

What Is Separation Anxiety Disorder?

During different phases of development, an infant or a toddler will normally become distressed on separating (or even thinking about separating) from a parent. (In this section the word parent refers to the person from whom the child fears separation; that person may be the mother, father, some other family member, caretaker, or another person involved in the child’s life.) An adult may become distressed about leaving his or her partner the morning after a big fight, or if the partner is sick. To qualify for a diagnosis of separation anxiety disorder, the anxiety, distress, or impaired functioning must be excessive and typically is exhibited over a period of at least 6 months for adults (see TABLE 6.14).

Table : TABLE 6.14 • DSM-5 Diagnostic Criteria for Separation Anxiety Disorder
  1. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three 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.
  2. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.
  3. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.
  4. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright ©2013). American Psychiatric Association. All Rights Reserved.

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Separation anxiety is more than a child’s getting upset about temporarily saying goodbye to a parent. Children with separation anxiety disorder may become so homesick when away from home that activities—such as a sleepover at a friend’s or a stay at overnight camp—are interrupted in order to return home. Or these children may want to know the parent’s whereabouts at all times, using a cell phone to make frequent contact during any physical separation. And when away from the parent, they may also have physical symptoms of anxiety: dizziness, stomachaches, nausea and vomiting, and feeling faint (American Psychiatric Association, 2013).

Some children with separation anxiety disorder fear that they will get permanently “lost” from their parents, and their dreams have similar themes. And like people with agoraphobia, they may be unable to leave the house alone (at an age when it would be appropriate to do so) or even to be in their room alone. Such children often try to stay within a few feet of the parent, moving from room to room as the parent moves from room to room. At bedtime, they may be unable to fall asleep unless someone else is in the room with them, and during the night, they may crawl into bed with parents or a sibling. If parents lock their bedroom door at night, the child may sleep on the floor right outside the door. If children with this disorder are separated from their parent, they may have persistent fantasies about reuniting. Also, like people with generalized anxiety disorder, they may have recurrent fears about harm befalling their parent or themselves, as JC did, in Case 6.6. TABLE 6.15 lists additional facts about separation anxiety disorder.

Table : TABLE 6.15 • Separation Anxiety Disorder Facts at a Glance
Prevalence
  • About 4% of adults had separation anxiety disorder in childhood (Shear et al., 2006).
  • Separation anxiety disorder is the most prevalent anxiety disorder among children, particularly those younger than 12 years old.
Onset
  • The disorder can begin as early as the preschool years.
  • Separation anxiety disorder may emerge after some type of stressful event, such as a move, the death of a pet, or the illness of a relative.
Comorbidity
  • Children with separation anxiety disorder are more likely to experience other anxiety disorders—especially generalized anxiety disorder—than are children in the general population (Brückl et al., 2006; Verduin & Kendall, 2003).
Course
  • Symptoms often wax and wane.
  • As the child gets older, symptoms tend to lessen; at some point before adulthood, most people no longer meet the criteria for the disorder (Foley, Pickles et al., 2004; Shear et al., 2006).
Gender Differences
  • In the general population, more females than males have this disorder; however, comparable numbers of males and females with this disorder are treated as outpatients.
Cultural Differences
  • Different ethnic groups and cultures have different norms about what constitutes appropriate responses to separation in children, which can affect parents’ inclination to perceive a separation problem and create different thresholds for diagnosis across cultures.
Source: Unless otherwise noted, the source for information is American Psychiatric Association, 2013.
This little girl might just be looking for something in the laundry basket, but a child with separation anxiety may want to know where his or her parent is at all times—even following the parent from room to room.
Commercial Eye/Getty Images

CASE 6.6 • FROM THE OUTSIDE: Separation Anxiety Disorder

JC is a 9-year-old boy who lives with his mother and attends the third grade, where he is an A student. During the last 2 weeks, he has refused to go to school and has missed 6 school days. He is awake almost all night worrying about going to school. As the start of the school day approaches, he cries and screams that he cannot go, chews holes in his shirt, pulls his hair, digs at his face, punches the wall, throws himself on the floor, and experiences headaches, stomachaches, and vomiting. If he attends school, he is less anxious until bedtime. As his separation anxiety has increased, he has become gloomy, has stopped reading for fun, and frequently worries about his mother’s tachycardia [rapid heart rate].

JC was seen once by a psychiatrist at age 3 years for problems with separation anxiety. He did well in preschool and kindergarten. He was seen at a community mental health center during the first grade for school refusal, but did well again during the second grade. In addition to having recurrent symptoms of separation anxiety disorder, he is phobic of dogs, avoids speaking and writing in public, and has symptoms of generalized anxiety disorder and obsessive-compulsive disorder. His mother has a history of panic disorder.

(Hanna, Fischer, & Fluent, 2006, pp. 56–57)

Adults who have this disorder may worry about the loss of a loved one through an accident or illness or may not be able to fall sleep away from home unless the loved one is with them. The diagnosis of separation anxiety disorder is only made when another disorder, such as agoraphobia or generalized anxiety disorder, does not better account for the symptoms.

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CURRENT CONTROVERSY

Separation Anxiety Disorder: Anxiety Disorder or Developmental Difference?

DSM-5 has chapters of disorders that are loosely organized based on when the disorders tend to emerge over the lifespan. Separation anxiety disorder, an extreme case of fear and worry related to current or potential separation from others, can occur across the lifespan but tends to emerge first in childhood. However, it is grouped with anxiety disorders, not with neurodevelopmental disorders (see Chapter 14). Is separation anxiety disorder in the most appropriate place in the DSM-5?

On the one hand, grouping the disorder with anxiety disorders makes sense because it shares symptoms with other anxiety disorders, including the pattern of fear out of proportion to danger, worry about possible future events, and physical symptoms triggered by anxiety. Treatment for this disorder is similar to treatment for other anxiety disorders. Separation anxiety does not share the types of symptoms related to executive and intellectual functioning that are found in neurodevelopmental disorders.

On the other hand, separation anxiety disorder, like the neurodevelopmental disorders, typically starts in early childhood and can occur throughout the lifespan. Separation anxiety itself is a normal developmental process; what makes this a disorder is the range and severity of symptoms and the appearance of symptoms at a later age than would be expected. This could be seen as a divergence from the normal path of development.

CRITICAL THINKING When a disorder “fits” in more than one category of disorders, as does separation anxiety disorder, would it be better if such disorders were cross-listed in the relevant categories)? What would be the advantages and disadvantages to doing this?

(James Foley, College of Wooster)

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Understanding and Treating Separation Anxiety Disorder

Separation anxiety disorder is more common among first-degree relatives (parents and siblings) than in the general population, and the disorder is considered to be moderately heritable (Roberson-Nay et al., 2012). However, the heritability probably reflects a heritability of anxiety in general: Separation anxiety is more common among children whose mothers have panic disorder than among children whose mothers don’t have that disorder, as was true of JC in Case 6.6 (Cronk et al., 2004).

But other factors create feedback loops: Overprotective family members may reinforce behaviors associated with anxiety about separation and may punish behaviors associated with actual separation. If so, then children in such families who have temperaments that are high in harm avoidance and reward dependence (see Chapter 2) may be especially vulnerable because they will be relatively responsive to reward and punishment. Moreover, separation anxiety disorder is more common in children whose fathers are absent (Cronk et al., 2004), perhaps because that absence leads the child to have a heightened fear of losing the remaining parent.

As with other anxiety disorders, treatment of separation anxiety disorder may involve CBT (with exposure and cognitive restructuring; Schneider et al., 2011). Family therapy is included in treatment; the therapist identifies any family patterns that maintain the disorder and helps parents change their interaction patterns to encourage and reinforce their child to engage in appropriate separation behaviors (Siqueland et al., 2005).

Thinking Like A Clinician

Nia is 12 years old and going through puberty. Lately she’s been coming home right after school and staying home during the weekend, no longer hanging out with her friends. In fact, Nia is unhappy when her mother (her parents are divorced) leaves her alone to go shopping or to go out in the evening; sometimes she tearfully begs her mother not to leave but won’t—or can’t—explain why she feels so upset. Based on what you have learned, how do you think Nia—and her mother—should proceed? Should they wait and hope the symptoms pass or try to find out more? Explain your answer in detail.