Separation Anxiety Disorder

An Anxiety Disorder

Anxiety Disorders • Separation Anxiety Disorder• Selective Mutism • Specific Phobia• Social Anxiety Disorder (social phobia)• Panic Disorder • Agoraphobia• Generalized Anxiety Disorder • Substance/Medication-Induced Anxiety Disorder • Anxiety Disorder Due to Another Medical Condition• Other Specified Anxiety Disorder • Unspecified Anxiety Disorder

Anxiety Disorders

• Similarities • Differences

• Introduced DSM-III, 1980– 3 of 9 symptoms @ least 2 weeks– Anxiety Disorders of Childhood

•DSM-III to DSM-IV– 3 of 8 criteria @ least 4 weeks– No more Anxiety Disorders of Childhood

• IV to IV-TR– Prevalence and Course sections were updated

• IV-TR to DSM-5 – Anxiety Disorder – Wording – No more specific onset of 18yo– Addition of 6mo or more duration criterion

History of Separation Anxiety Disorder in the DSM

Separation Anxiety Disorder: DSM-5 A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to

whom the individual is attached, as evidenced by at least three (or more) of the following: (1) Recurrent excessive distress when separation from home or 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) (4) Persistent reluctance or refusal to go out, away from the home, to school, to work, or elsewhere because of fear

of separation (5) Persistently 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 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 C. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or

other important areas of functioning. D. 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

Specify if: Early Onset: if onset occurs before age 6 years

A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced

by at least three (or more) of the following: (1) Recurrent excessive distress when separation from home or 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) (4) Persistent reluctance or refusal to go out, away from the home, to school, to

work, or elsewhere because of fear of separation (5) Persistently 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 for Separation Anxiety Disorder

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

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

D. 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

Specify if: Early Onset: if onset occurs before age 6 years

Criterion for Major Depressive Disorder

Prevalence • Little controlled research on SAD • Prevalence rate of 2-4 % • One study did report 2.8% [2.8%, 95% confidence

interval (CI) 2.1-3.8, for current disorder]• 15-35% prevalence rate in samples of children

with anxiety disorders • Suggestion that SAD occurs more frequently in

girls but there is very little support• Prevalence rate does NOT increase with age

Of youth who will develop SAD

Age 10 Age 13

75%

90%

Prevalence rate declines with age

9-10yo 11yo 12yo0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

4.50%

Development, Onset, Course, Duration

https://www.youtube.com/watch?v=jEkFp0Ux4OQ

Development, Onset, Course, Duration cont…

• Course is marked by exacerbation and remission over a period of years

• As many as 30-44% of children with SAD show evidence of psychological problems that continue into adult life

• May precede the development of conditions such as panic disorder and agoraphobia

Associated Features • Behavioral

– Social withdrawal– Difficulty concentrating on work or play– Homesick and Uncomfortable– Anger or Aggression

• Emotional – Apathy– Sadness

• Physical Symptoms– Nausea/Vomiting – Headaches– Stomaches

• Cognitive– Evening or dark perceptual experiences– Fears

• Accidents • Illness • Monsters• Of getting lost • Of being kidnapped

Associated Features cont.

What do children with Separation Anxiety Disorder look like?

• Demanding • Intrusive

• Frustration• Resentment• Conflict

Difference in expression between younger and older children

• Younger Children 5-8yo– More symptoms – Unrealistic worry– School refusal

• Older Children 9-12yo– Excessive distress

• Adolescence– Somatic complaints – School refusal more common

Risk of Subsequent Psychopathology

Models of Separation Anxiety

• Environmental Change• Genetic• Parent-Child Attachment • Developmental Considerations • Cognitive Factors • Behavioral Factors• Stress Factors

Environmental Change

Environmental Change

STRESSSeparation

Anxiety Disorder

Genetic Influence

History of panic disorder, anxiety, or depression

Predisposition toward later development of anxiety disorders

Parent-Child Attachment

…Emotional distance

Behaviors

Developmental Considerations

Between and Within

Slower rate of development can foster separation anxiety

Cognitive Factors

Anxiety &

Irrational Behaviors

Behavioral Factors

Crying andClinging Behavior

= distract attention away

Nurtures anxiety and fear

Stress Factors

Change(stress factor)

Feel uncomfortable

Anxious Response

Neurobiology of Separation Anxiety Disorder

• Research done on the neurobiology of SAD has not been exclusively conducted on SAD. Literature has included SAD when analyzing all anxiety disorders in groups of children.

• They amygdala has been one of the most prominent structures identified as being involved in anxiety disorders.

• Until more research has been conducted solely on SAD any conclusions drawn would be an extrapolation of the findings from the other anxiety disorders

Accounting for Variance: Genetics Bolton D, Eley TC, O’Connor TG, et al.

• Twin pair study of 6-6.5yo • N = 854 • MZ and DZ

Accounting for Variance: Genetics cont.

Accounting for Variance: HPA-Axis

Accounting for Variance: HPA-Axis and hormonal influences during pregnancy

Maternal endocrine activation during pregnancy and/or early separation or loss

Lower cortisol levels

Anxiety, learned helplessness, depression

Accounting for Variance: HPA-Axis and Cognitive Appraisal

• Cognitive processes may trigger the stimulation of the HPA axis activity – The interpretation of a situation as being stressful or

not– Separation anxiety disorder is derived from theories

of anxiety disorders generally, which are predominately cognitive theories

Accounting for Variance: HPA-Axis and Cognitive Appraisal and Gender

• The pattern of results from the previous findings suggests there may be some gender-related differences with regard to the cognitive appraisal and anticipation of threat

Accounting for Variance: Family DynamicCronk, N. J., Slutske, W. S., Madden, P. a F., Bucholz, K. K., & Heath, A. C. (2004). Risk for separation anxiety disorder among girls: paternal absence,

socioeconomic disadvantage, and genetic vulnerability. Journal of abnormal psychology, 113(2), 237–47. doi:10.1037/0021-843X.113.2.237

• N=1,887• Female MZ and DZ twin pairs• Looking across 4 SAD Categories @

– Attachment– Paternal Absence– Socioeconomic Disadvantage

4 Categories of SAD

• SAD-Symptoms– Presence of 3 or more symptoms

• SAD-Cluster– Presence of 3 or more symptoms occuring together for a

period of at least 1 month• SAD-Impair

– Presence of 3 or more symptoms causing impairment in functioning and/or treatment seeking

• SAD-Full– Presence of 3 or more symptoms with clustering and

impairment/treatment seeking, consistent with DSM-IV

Race

Income

Paternal Absence

a=additive genetic factorc=shared environmental factorp=paternal absence effects=socioeconomic disadvantage effect

What this study says…

• Effects of paternal absence on SAD are rather robust. • As predicted, paternal absence appears to be an

important predictor of all categories of SAD– Suggesting that the loss or threat of loss of a father figure

has important consequences for separation anxiety in girls.

• Attachment theory, suggest that the loss of a parent (or attachment figure) in the preschool years or younger would be most detrimental to subsequent development.

What this means…

• Socioeconomic disadvantage – 0.1%-1.0% total variance– 0.4%-2.7% shared environmental effects

• Paternal Absence– 1.0%-3.0% total variance– 4.3%-8.7% shared environmental effects

• “Important role for genes”• High Heritability estimates for parent-reported

symptoms of SAD in girls

Maddie Marks’ Model

ReferencesAllen, J. L., Lavallee, K. L., Herren, C., Ruhe, K., & Schneider, S. (2010). DSM-IV criteria for childhood

separation anxiety disorder: informant, age, and sex differences. Journal of anxiety disorders, 24(8), 946–52. doi:10.1016/j.janxdis.2010.06.022

Beesdo K, Bittner A, Pine DS, et al. Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry. 2007;64(8):903–12. [PubMed]

Bittner, A., Egger H.L., Erkanli, A., Costello J.E., Foley D.L., Angold, A. (2007). What do childhood anxiety disorders predict? Journal of Child Psychology and Psychiatry 2007;48:1174e83.

Bolton D, Eley TC, O’Connor TG, et al. Prevalence and genetic and environmental influences on anxiety disorders in 6-year-old twins. Psychol Med. 2006;36(3):335–44. [PubMed]

Brückl TM, Wittchen H-U, Höfler M, Pfister H, Schneider S, Lieb R. Childhood separation anxiety and the risk of subsequent psychopathology: results from a community study. Psychotherapy and Psychosomatics 2007;76:47e56.

Cronk, N. J., Slutske, W. S., Madden, P. a F., Bucholz, K. K., & Heath, A. C. (2004). Risk for separation anxiety disorder among girls: paternal absence, socioeconomic disadvantage, and genetic vulnerability. Journal of abnormal psychology, 113(2), 237–47. doi:10.1037/0021-843X.113.2.237-

Dabkowska, M., Araszkiewicz, A., Dabkowska, A., & Wilkosc, M. (2011). Separation Anxiety in Children and Adolescents. DIFFERENT VIEWS OF ANXIETY DISORDERS, 313.

References cont.Goodwin, R., J. D. Lipsitz, T. F. Chapman, S. Mannuzza, and A. J. Fyer. "Obsessive-compulsive Disorder

and Separation Anxiety Co-morbidity in Early Onset Panic Disorder" Psychological Medicine 31, no. 7 (October 2001): 1307-1310.

Kaplow, J. B., P. J. Curran, A. Angold, E. J. Costello.; "The Prospective Relation between Dimensions of Anxiety and the Initiation of Adolescent Alcohol Use." Journal of Clinical Child Psychology 30, no. 3 (2001): 316-326.

Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry.2005;62:593–602. [PubMed]

Pine DS, Cohen P, Gurley D, et al. The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Arch Gen Psychiatry. 1998;55:56–64.[PubMed]

Weems, C. F., & Carrion, V. G. (2007). Clinical Case Studies. doi:10.1177/1534650103253818

Wittchen HU, Lieb R, Schuster P, et al. When is onset? Investigations into early developmental stages of anxiety and depressive disorders. In: Rapoport JL, editor. Childhood onset of “adult” psychopathology. Clinical and research advances.Washington, DC: American Psychiatric Press, Inc; 1999. pp. 259–302.