Separation Anxiety Disorder (SepAD)

Separation Anxiety Disorder (SepAD)

Separation Anxiety Disorder (SepAD)

For years, separation anxiety disorder (SepAD) was diagnosed in childhood—and stayed there. More recently, however, evidence has accumulated that the condition also affects adults. This can happen in two ways. Perhaps one-third of children with SepAD continue to have symptoms of the disorder well into their adult years. However, some patients develop symptoms de novo in their late teens or even later—sometimes even beginning in old age. SepAD has a lifetime prevalence of about 4% for children and 6% for adults; for adults, the 12-month prevalence is nearly 2%. It is more common in females than in males, though boys are more likely to be referred for treatment.

ORDER COMPREHENSIVE SOLUTION PAPERS ON Separation Anxiety Disorder (SepAD)

In children, SepAD may begin with a precipitant such as moving to a new home or school, a medical procedure or serious physical diagnosis, or the loss of an important friend or pet (or a parent). Symptoms often show up as school refusal, but younger children may even show reluctance at being left with a sitter or at day care. Children may enlist physical complaints, imagined or otherwise, as justification for remaining home with parents.

Adults, too, may fear that something horrible will happen to an important attachment figure—perhaps a spouse, or even a child. As a result, they are reluctant to leave home (or any place of safety); they may fear even sleeping alone, and they experience nightmares about separation. When apart from the principal attachment figure, they may need to telephone or otherwise touch base several times a day. Some may try to ensure safety by setting up a routine of following the other person.

When the onset is early in childhood, this condition is likely to remit; with later onset, symptoms are more likely to continue into adulthood and to confer more severe disability (though the intensity may wax and wane). Children with SepAD tend to drift into subclinical forms or nonclinical status. Most adults and children also have other disorders (especially mood, anxiety, and substance use disorders), though SepAD is often the condition present the longest.

Children with SepAD often have parents with an adult form of the same disorder, and, as with most anxiety disorders, there is a strong genetic component.

Essential Features of Separation Anxiety Disorder

Because they fear what might happen to a parent or someone else important in their lives, these patients resist being alone. They imagine that the parent will die or become lost (or that they will), so that even the thought of separation can cause anxiety, nightmares, or perhaps vomiting spells or other physical complaints. They are therefore reluctant to attend school, go out to work, or to sleep away from home—perhaps even in their own beds.

The Fine Print

The D’s: • Duration (6+ months in adults, though extreme symptoms—such as total school refusal—could justify diagnosis after a shorter duration; 4+ weeks in children) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (mood disorders, other anxiety disorders, PTSD)

Nadine Mortimer

At age 24, Nadine Mortimer still lived at home. The only reason for her evaluation, she told the clinician, was that her mother and stepfather had just signed on to join the Peace Corps; she, Nadine, would be left behind. “I just know I won’t be able to stand it.” She sobbed into her Kleenex.

Being alone had frightened Nadine from the time she was very small. She thought she could trace it back to her father’s death: He was a mechanic who drove a racing car for fun until the weekend he encountered a wall at the far turn of their hometown track. Her mother’s response was strangely stoic. “I think I took on the job of grieving for both of us,” Nadine commented. Within the year, her mother had remarried.

Her first day of first grade, Nadine had been so fearful that her mother had stayed in the classroom. “I was afraid something terrible would happen to her too, and I wanted to be there, for safety.” After several weeks, Natalie had been able to tolerate being left, but the following year, she threw up when Labor Day rolled around. After a few miserable weeks in second grade, she was withdrawn and home-schooled.

In 10th grade, she was reading and doing math at 12th-grade level. “But my socialization skills were near nil. I’d never even been to a sleepover at another girl’s house,” she said. So her parents bribed her with a cell phone and a promise that she could call any time. By the time Nadine was in junior college—hardly farther away than her high school—she’d negotiated for a smart phone with a GPS device; now she could track her mother’s whereabouts to within a few feet. With that, she said, she could “roam comfortably, stores and whatnot, as long as I could check Mom’s location whenever I wished.” Once, when her battery died, she had suffered a panic attack.

Nonetheless, she still didn’t graduate from junior college, and after a semester she returned home to be with her mother. “I know it seems weird,” she told the interviewer, “but I always imagine that someday she won’t come home to me. Just like Daddy.”

Evaluation of Nadine Mortimer

From the time she started school (criterion B), Nadine had had clear symptoms of SepAD. She worried that harm might befall her mother and was severely distressed when they were separated; she’d vomited at the mere prospect of a new school year (A). As a result, she had almost no friends and had never slept away from home (C). There was no sign of other disorders to exclude (D).

Modified by her adult status, many of these same symptoms persisted—panic symptoms when she couldn’t keep close tabs on her mother, from whom she refused to live apart. She even retained the same fear of harm befalling her mother if they ever were separated. The prospect of her parents’ leaving for a new career deeply affected her. Even if Nadine hadn’t had symptoms as a child, her adult disorder was troubling enough to qualify for the diagnosis of SepAD.

A significant problem remains in the differential diagnosis of SepAD: How does one distinguish it from agoraphobia? There is some overlap, but patients with SepAD are afraid of being away from a parent or other significant person, whereas the fear for a person with agoraphobia is of being in a place from which escape will be difficult. The mute testimony of her smart phone suggests that Nadine’s anxiety was of the former type, not the latter. I would put her current GAF score at 45.

The DSM-IV criteria for SepAD employed a number of behaviors only appropriate to children; perhaps this explains why it wasn’t recognized in adults earlier. Even now, panic symptoms may sometimes draw clinicians off the scent of adult SepAD.