Separation Anxiety Disorder
Psychology 7936 Child Psychopathology
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Overview of DSM-5 Separation Anxiety Disorder
Neurobiological substrates
Environmental influences
New model of Separation Anxiety Disorder
Treatment
DSM-V and Separation Anxiety Disorder (SAD)
• 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. Excessive distress in anticipation or when experiencing separation
2. Persistent/Excessive worry about the loss of a major attachment
figure (MAF) or harm to said figure
3. Excessive worry about experiencing an untoward event such as
kidnapping
4. Persistent refusal to go out, away from home (e.g., to school)
because of fear of separation
5. Excessive fear about being alone without MAF
(American Psychiatric Association, 2013)
DSM-V and Separation Anxiety Disorder
6. Refusal to sleep away from home or to go to sleep without being near
MAF
7. Repeated nightmares involving separation from MAF
8. Repeated complaints of physical symptoms such as headaches or
stomachaches when separation occurs or is anticipated
(American Psychiatric Association, 2013)
DSM-5 model of Separation Anxiety Disorder
DSM-5 Schematic of Separation Anxiety Disorder
Environment
• Life stress or loss (e.g., a
death in the family)
• Parental
overprotection/intrusiveness
• Entering a relationship
• Becoming a parent
Genetic/Physiological
Genetic predisposition
Enhanced sensitivity to CO2
Core features:
• Distress in anticipation or when
experiencing separation
• Persistent/Excessive worry about the loss
of MAF
• Excessive worry about an untoward event
such as kidnapping
• Persistent refusal to go out, away from
home
• Excessive fear about being alone without
MAF
• Refusal to sleep away from home or to go
to sleep without being near MAF
• Repeated nightmares involving repeated
separation from MAF
• Psychosomatic complaints when
separation occurs or is anticipated
Onset of Separation Anxiety Disorder
• Anxiety exceeds what is expected given the person’s
developmental level:
• Infants from 6 to 30 months usually exhibit separation anxiety with
intensity increasing between 13 and 18 months.
• Separation anxiety usually declines between 3 and 5 years of age when the
child is able to understand that separation is temporary.
(Bernstein & Victor, 2009)
Onset of Separation Anxiety Disorder cont’d
• SAD is thought to have two separate onsets (Kearney, Sims,
Pursell, & Tillotson, 2010):
• Juvenile period onset (JSAD)
• Adulthood period onset (ASAD)
• In children, SAD typically begins between 7-9 years old
(Last, Perrin, Hersen, & Kazdin, 1992).
• Some children develop SAD as a result of stressful life event
• Some children exhibit symptoms without a clear precipitating
event
(Bernstein & Victor, 2009)
Prevalence of Separation Anxiety Disorder
• Rates of SAD are reported at 3-6.8% (Bernstein & Victor, 2009).
• SAD is more prevalent in children compared to adolescents.
• Some studies show a higher rate of SAD in girls whereas others
show equal rates (Bernstein & Victor, 2009).
• One study found 50% of youth sampled exhibited subclinical levels
of SAD but do not meet full criteria (Kashani & Orvaschel, 1990).
Prevalence of Separation Anxiety
(Kashani & Orvaschel, 1990)
Prevalence of Separation Anxiety
(Kashani & Orvaschel, 1990)
Anxiety Disorder Prevalence in Children (N =70)
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
8 years
SAD
Fear of strangers
12 years
Past imperfections
17 years
Social situations
Impairment and diagnosis of SAD
• Data suggest that until 6 or
more symptoms are
present, impairment
remains relatively low.
• Impairment was measured
using Child and Adolescent
Psychiatric Assessment
and parent reports.
(Foley et al., 2008)
Course
• Longitudinal studies show (Kearney et al., 2010):
• First assessment (M = 3.5 years old):
• 26.7% met criteria (i.e., 3+ SAD symptoms)
• 43.3% were subclinical (i.e., 1 or 2 symptoms)
• 30% had non-clinical status
• Second assessment 3.5 years later (M = 7 years old):
• 6.8% of children met SAD criteria
• 25% were subclinical
• 68.2% had non-clinical status
• SAD was assessed using Anxiety Disorder Interview Schedule for
DSM-IV: Child and Parent Versions (ICC = .85; Silverman,
Saavedra, & Pina, 2001).
Prognosis in childhood
• One study examined the course of childhood psychiatric disorders
and found (Cantwell & Baker, 1989):
• A total of 151 cases were included of which 9 children met SAD criteria.
• The children aged from 2.4 – 6.6 years old.
• Of those 9 children:
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4 were absent of psychopathology 5 years later
1 still had SAD
2 had behavioral disorders
3 had anxiety disorders
• Another study found that at 18 month follow-up 20% of children still
met criteria for SAD (Foley et al., 2008).
• There does appear to be some lasting effect of the disorder in a
substantial amount of adults who had SAD as children.
Prognosis into adulthood
• There is evidence that SAD leads to panic disorder and anxiety
disorder proneness in adults (Manicavasagar, Silove, Curtis, &
Wagner, 2000).
• 50-75% of children with panic disorder currently or previously met
criteria for SAD (Bernstein & Victor, 2009).
• 75% of adults with anxiety as a presenting problem report having
SAD symptoms as a child (Milrod et. al., 2014).
• There is equivocal evidence that Adult
Separation Anxiety Disorder is related to
anxious attachment (Manicavasagar et al.,
2009).
Prognosis Adolescent and adulthood
• A meta-analysis looked at odds ratios for risk of adult
psychopathology and found:
• Panic disorder with and without agoraphobia did not yield significantly
different odds ratios (i.e., OR = 3.59, OR = 4.19, respectively).
• Panic disorder: Odds Ratio = 3.45, N = 25 studies
• Any anxiety disorder: Odds ratio = 2.19, N = 5 studies*
• Major depressive disorder: Non-significant after adjusting for publication
bias*
• Substance use: Non-significant odds ratio
* results take publication bias into account
(Kossowsky et al., 2013)
Comorbidity of Separation Anxiety Disorder
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Generalized anxiety disorder:
Specific Phobia:
ADHD:
Social phobia:
33-74%
13-58%
17-22%
8-20%
• Enuresis:
• Sleep terror disorder:
• Dysthymic disorder:
8%
8%
2-13%
• Major depressive disorder:
• Panic disorder:
0-8%
2-4%
(Bernstein & Victor, 2009; Last, Perrin, Hersen, & Kazdin, 1992; Verduin & Kendall, 2003)
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2.
3.
4.
5.
Overview of DSM-5 Separation Anxiety Disorder
Neurobiological substrates
Environmental influences
New model of Separation Anxiety Disorder
Treatment
Hypercapnia
• Data originally showed that individuals with Panic Disorder (PD)
had an enhanced sensitivity to air that contains 35% CO2.
• Inhaling the concentration of CO2 induces panic attacks in 50-70% of
individuals with PD
• Children with SAD were found to also react to a 35% CO2 mixture.
• Monozygotic twins have a significantly higher concordance rate
compared to dizygotic twins for the hypercapnia phenotype (i.e.,
55.6% and 12.5%, respectfully; Bellodi et al., 1998).
• Extensive genetic research found that a gene that influences
hypercapnia also influences panic attacks (Battaglia et al., 2009)
• The SAD to Panic Disorder conversion hypothesis suggested a
connection between the two disorders.
Genetic structural equation model
• A: Additive genetic
effects
• CPL: Childhood
parental loss
• E: Unique
environmental
influence
• L: Common latent
variable determined by
latent genetic and
environmental factors
related to all
phenotypes
(Battaglia et al., 2009)
Suffocation False Alarm (SFA) Theory
• The theory proposes that panic is caused by an alarm system that begins
physiological false alarms.
• In the lab, if lactate is infused intravenously and CO2 is inhaled, most panic prone
individuals will have a panic attack.
• The hypothesized cause for CO2 and Lactate initiated panic is that, generally, an
increase in CO2 and lactate in the brain indicates suffocation.
• This theory is supported by:
• High prevalence rates of panic in those with lung disease, asthma, COPD and those
who were tortured with suffocation compared to other methods.
• There is a much higher prevalence of PD in those with asthma (6-24% compared to 13%)
• Cigarette smoking is a risk factor for panic attacks, quitting smoking reduces the
chance of a panic attack.
(Preter & Klein, 2008)
SFA and Separation Anxiety Disorder
• As mentioned previously, SAD in childhood is significantly
related to Panic Disorder
• 50-75% of children with PD met SAD criteria, Odds ratio of
SAD to PD: 3.45 and 75% of adults with anxiety as a
presenting problem report having SAD symptoms as a child .
• Separation anxiety and PD are therefore theorized to be
similarly controlled by opioidergic processes (Preter & Klein,
2008).
• Separation distress in primates is moderated by opioid
agonists (Kalin, Shelton, & Barksdale, 1988).
SFA and Separation Anxiety Disorder
• Kalin et al. (1988)
administered 0.1
mg/kg of morphine
to infant primates
and found
significantly less
distress vocalizations,
whereas Naloxone
(0.1 mg/kg) &
Morphine together
partially blocked the
effect.
(Preter & Klein, 2008)
http://bp3.blogger.com/_9M9yKRI9XVw/R07MCQ9iPZI/AAAAAAAAAKc/tP8yH_S2oWQ/s1600-h/bupfig01en.jpg
SFA and Separation Anxiety Disorder
(Kalin et al., 1988)
SFA and Separation Anxiety Disorder
• Clonidine, however, does not reduce the effect of “separation-induced”
vocalizations in infant primates (Kalin & Shelton, 1988).
• 67 µg/kg was used originally and showed reduced activity levels, but
not reduced vocalizations
• Dosage was then increased to 100 µg/kg and behavioral sedation was
observed in addition to reduced vocalizations
• This study suggests that sedative effects are not the cause of reduced
separation vocalizations
• Additionally, a placebo-controlled trial shows that codeine allows higher
levels of CO2 in the blood to be tolerated while breath holding (Stark et
al., 1983).
• These data support the theorized SFA mechanism that SAD and PD are
similarly due to an episodic functional endogenous opioid deficit.
(Preter & Klein, 2008)
1.
2.
3.
4.
5.
Overview of DSM-5 Separation Anxiety Disorder
Neurobiological substrates
Environmental influences
New model of Separation Anxiety Disorder
Treatment
Attachment and Separation Anxiety Disorder
• DSM-V cites attachment issues as a risk factor.
• Recent meta-analytic evidence shows:
• Insecure attachment does not appear to be significantly
related to separation anxiety
• The relationship was non-significant, small (r = .28, 95% CI [.06, .62]) and the confidence interval contained 0.
• Two samples were used for a total N of 59, so these results
may be an artifact of sample size
(Colonnesi et al., 2011)
Effects of Maternal Separation Anxiety
• Maternal separation anxiety: “an unpleasant emotional
state that reflects a mother’s concerns and
apprehensions about leaving her child.” Anxiety may be
reflected in feelings of worry, sadness, or guilt that
accompany short-term separations
Effects of Maternal Separation Anxiety
• One study examined the effect of Maternal separation anxiety on
children (Biadsy-Ashkar & Peleg, 2013).
• Differentiation of self: the degree to which one is differentiated from
another. A healthy/differentiated person does not experience the loss
or separation from another as a loss of the self (Biadsy-Ashkar &
Peleg, 2013).
• Differentiation was measured with the Differentiation of Self
Inventory (DSI; (Skowron & Friedlander, 2009).
• DSI is comprised of four subscales:
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Emotional reactivity
I-position
Emotional cutoff
Fusion with others
Effects of Maternal Separation Anxiety
• Separation anxiety in children was measured during a video
taped strange situation type procedure.
• Two raters independently rated displayed separation anxiety in
children.
• Studies were conducted in kindergarten classrooms between
7:30 am and 9:00 am.
• Data were collected over three days.
• Multiple regression analyses were completed
• N = 38
(Peleg, Halaby, Einaya, Whaby, 2006)
• EC: Emotional cutoff,
the extent to which the
mother ineffectively
handles emotionally
charged situations is
negatively related to
secure separation.
• PSEC: The more the
mother worries about
separation with the
child the more the child
experiences separation
anxiety, possibly
interacting with the
relationship of EC
1.
2.
3.
4.
5.
Overview of DSM-5 Separation Anxiety Disorder
Neurobiological substrates
Environmental influences
New model of Separation Anxiety Disorder
Treatment
DSM-5 model of Separation Anxiety Disorder
DSM-5 Schematic of Separation Anxiety Disorder
Environment
• Life stress or loss (e.g., a
death in the family)
• Parental
overprotection/intrusiveness
• Entering a relationship
• Becoming a parent
Genetic/Physiological
Genetic predisposition
Enhanced sensitivity to CO2
Core features:
• Distress in anticipation or when
experiencing separation
• Persistent/Excessive worry about the loss
of MAF
• Excessive worry about an untoward event
such as kidnapping
• Persistent refusal to go out, away from
home
• Excessive fear about being alone without
MAF
• Refusal to sleep away from home or to go
to sleep without being near MAF
• Repeated nightmares involving repeated
separation from MAF
• Psychosomatic complaints when
separation occurs or is anticipated
New model of Separation Anxiety Disorder
Environment
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Life stress or loss
Maternal characteristics
Attachment
Non-specified
environmental effects
• Positive/negative
reinforcement exchanges
OR1: 2.19
Core features
8 DSM
Criteria
Any anxiety
disorder
OR1: 3.45 Panic disorder
Anxiety prone
genotype
Secondary features
Episodic
deficit in
endogenous
opioids
Enhanced
sensitivity to CO2
and lactate
Suffocation false
alarm
1
OR indicates Odds Ratio
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Clinging/shadowing
behavior
School refusal
Can’t have sleepovers
Sadness,
Inattention
Demanding attention
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Overview of DSM-5 Conduct Disorder
Neurobiological substrates
Environmental influences
New model of Conduct Disorder
Treatment
APA Division 53
• There is no section for Separation Anxiety Disorder.
• As a substitution, the Anxiety General Symptoms section can be
used.
• There are no Well-established psychosocial treatments for
Anxiety.
• Probably efficacious treatments:
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Individual CBT for Anxiety
Group CBT for Anxiety (without parents)
Group CBT Anxiety with parents
Social skills training
Exposure treatment
APA Division 53
• Possibly efficacious treatments:
• Individual CBT for Anxiety with parents
• Group CBT for Anxiety with parental anxiety management for anxious
parents
• Family CBT for Anxiety
• Parent CBT for Anxiety
• Group CBT for Anxiety with parents plus internet therapy
Potentially Harmful Treatments (PHT;
Lilienfeld, 2007)
• Probably harmful: probably produce harm in some clients
a) Randomized controlled trials replicated by at least one other team
b) Meta-analyses of RCTs for the treatment or
c) Consistent and sudden incidence of low-base-rate adverse events
following therapy
• Possibly harmful: preliminary evidence showing harmful effects
a) Quasi-experimental design that have been replicated by at least one
independent team or
b) Replicated single case designs
Potentially Harmful Treatments (Lilienfeld,
2007)
• Possibly harmful: Relaxation treatment for Panic-Prone Patients
• These data suggest that caution should be taken with children who
have SAD because of the shared etiology with PD.
• Small-sample controlled case studies suggest that some patients with PD
experience paradoxical increases in anxiety and panic attacks during
relaxation.
• The studies did not include habituation in treatment by graded exposure.
• More research is needed.
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