separation anxiety disorder
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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 - PowerPoint PPT PresentationTRANSCRIPT
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.