Adult Separation Anxiety Disorder
Separation Anxiety Disorder is well recognized as a juvenile psychiatric disorder, but it appears to be rarely diagnosed in adulthood. It has traditionally been characterized and assessed as a disorder that is unique to childhood. Yet the core symptoms of Separation Anxiety — excessive and often disabling distress when faced with actual or perceived separation from major attachment figures — may persist or even arise during adulthood.
Fifteen years ago Adult Separation Anxiety Disorder (ASAD) did not exist, at least as far as the psychiatric community was concerned. ASAD has only been recognized as a specific mental disorder since the late 90′s, with the pioneering work of Vijaya Manicavasagar of the Psychiatry Research and Teaching Unit, Liverpool Hospital, New South Wales, Australia. He said in 1997 that:
[A]dults may experience: wide-ranging separation anxiety symptoms, such as extreme anxiety and fear, when separated from major attachment figures; avoidance of being alone; and fears that harm will befall those close to them. … Separation anxiety disorder may be a neglected diagnosis in adulthood.
Katherine Shear, M.D. is a professor of psychiatry at Columbia University and the lead investigator of an important new study. She finds recent research setting ASAD apart from childhood Separation Anxiety Disorder unsurprising. She says:
Our group in Pittsburgh, as well as colleagues in Australia and in Italy, has observed adult separation anxiety disorder in clinical populations for a number of years now. It is clear that this is an identifiable syndrome.
Just what is Adult Separation Anxiety Disorder?
Separation Anxiety Disorder is a psychological condition in which an individual has excessive Anxiety regarding separation from places or from people to whom the individual has a strong emotional attachment. In children, the strong emotional attachment is likely to a parent; in Adult Separation Anxiety Disorder, the attachment might be to a spouse or friend.
Separation Anxiety Disorder should not be confused with Separation Anxiety, which occurs as a normal stage of development for healthy, secure babies. Separation Anxiety typically starts at around 8 months of age and increases until 13-15 months, when it begins to decline.
If Americans were asked to give examples of ASAD, they might cite the classic Hollywood film “Casablanca,” where Ilsa (Ingrid Bergman) clings to Rick (Humphrey Bogart) shortly before they part forever. Or they might point to the Hollywood thriller “Psycho,” where lead character Norman Bates (Anthony Perkins) sleeps next to his mother long after she has died.
A sample case of ASAD is that of “Stacy,” who was treated by Katherine Shear successfully (see “What is the treatment for Adult Separation Anxiety Disorder?” below, for more details on her treatment.):
Stacy (not her real name) was an accomplished professional woman in her 30′s. But she couldn’t stand not knowing exactly where her husband was, or being away from him for long. She disliked golf, but accompanied him to every weekend game. It got so bad that if she couldn’t immediately contact him at work, she would leave her own office to find him, even though she knew she was behaving irrationally. She just couldn’t bear being out of touch.
Infant Separation Anxiety is one of the most strongly preserved behaviors in human beings. Given the importance of attachment relationships in adulthood, ASAD may be more easily elicited in adults than is commonly recognized, and might be the norm under certain extreme life circumstances. (See “What’s in the future for Adult Separation Anxiety Disorder research?” below for more information.)
Separation Anxiety would appear to be a core form of Anxiety that is associated with anxious attachment. Nevertheless, as yet no research has examined the relationship of attachment styles to ASAD. In his research, Manicavasagar found that those with ASAD had a prominent Need for Approval and Preoccupation with Relationships attachment styles.
What is the prevalence of Adult Separation Anxiety Disorder?
A new finding that rocks the boat is that ASAD is actually more prevalent than childhood Separation Anxiety Disorder. Katherine Shear and her colleagues produced a groundbreaking study of ASAD in 2006, based on thousands of respondents to the National Comorbidity Survey Replication, a national mental health survey taken between 2001 and 2003.
Shear found that, while the lifetime estimate of childhood Separation Anxiety Disorder was 4.1 percent, the adult estimate for ASAD was 6.6 percent.  In the current American population, that’s 20,207,408 adults who will suffer with ASAD in their lifetimes! Shear believes these numbers are low:
Because separation anxiety disorder is only rarely diagnosed among adults in treatment, documentation of nontrivial prevalence and clinical significance would point to a problem of low recognition and treatment.
Approximately one-third of adults (36.1 percent) had a childhood case of Separation Anxiety Disorder that persisted into childhood. However, the vast majority (77.5 percent) of adults with ASAD had its first onset of the disorder in adulthood. The ages of onset of ASAD are ranked as follows:
- 30-44 years at onset
- 18-29 years at onset
- 45-59 years at onset
- 60+ years at onset
The accompanying chart shows that most childhood cases of Separation Anxiety Disorder begin the illness in early or middle childhood. Adult-onset cases of ASAD begin in late teens or early 20′s, with 80 percent of all first onsets occurring by age 30.
More women than men suffer from ASAD. And Separation Anxiety Disorder, both the adult and the childhood versions, seems to run in families. Manicavasagar states the results of one of his studies showed that:
Sixty-three percent of children diagnosed with juvenile separation anxiety disorder had at least one parent who suffered from the putative adult variant of the disorder. Affected parents reported high levels of separation anxiety in their own childhoods.
What are the diagnostic criteria for Adult Separation Anxiety Disorder?
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) of the American Psychiatric Association is the standard used in the US and UK for diagnosing mental disorders. Since it was published last in 1994, it does not treat ASAD as a separate diagnosis. It only mentions obliquely that adults may have a disorder similar to childhood Separation Anxiety Disorder.
The ICD-10 Classification of Mental and Behavioural Disorders (ICD), published by the World Health Organization in 1992, is the standard in some other parts of the world. Its entry on Separation Anxiety Disorder does not mention adults at all. Its diagnostic criteria are roughly the same as those of the DSM-IV.
The diagnostic criteria for Separation Anxiety Disorder in the DSM-IV are as follows:
A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:
- Recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated.
- Persistent and excessive worry about losing, or about possible harm befalling, major attachment figures.
- Persistent and excessive worry that an untoward event will lead to separation from a major attachment figure(e.g.; getting lost or being kidnapped).
- Persistent reluctance or refusal to go to school or elsewhere because fear of separation.
- Persistent and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings.
- Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home.
- Repeated nightmares involving the theme of separation.
- Repeated complaints of physical symptoms (such as headaches, stomach aches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated.
B. The duration of the disturbance is at least 4 weeks.
C. The onset is before age 18 years.
D. Part 1 OR Part 2
- Part 1. The disturbance causes clinically significant distress.
- Part 2. The disturbance causes clinically significant impairment in social, academic (occupational), or other important areas of functioning.
E. The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and, in adolescents and adults, is not better accounted for by Panic Disorder with Agoraphobia.
- Depressed Mood
- Somatic [bodily] or Sexual Dysfunction
- Anxious or Fearful or Dependent Personality
Some disorders have similar or even the same symptoms. The clinician, therefore, in his diagnostic attempt, has to differentiate against the following disorders which he needs to rule out to establish a precise diagnosis.
Pervasive Developmental Disorders:
- Schizophrenia, or other Psychotic Disorders
- Generalized Anxiety Disorder
- Panic Disorder with Agoraphobia
- Agoraphobia Without History of Panic Disorder
- Conduct Disorder
- Developmentally appropriate levels of separation anxiety.
Who is most affected by Adult Separation Anxiety Disorder?
There are more women than men with ASAD. However, men are more likely than women to have the first onset of ASAD in adulthood.
The odds of being not married are elevated both among those who had childhood Separation Anxiety Disorder and those with ASAD. This suggests that childhood Separation Anxiety Disorder might be a risk factor for subjects remaining unmarried and, once married, for marital instability. The marital status of adults with ASAD are ranked as follows:
- Separated, widowed, or divorced
- Never married
- Married or cohabiting
Education seems to play a large role in an adult’s susceptibility to ASAD. Those with fewer years of education are more likely to suffer from ASAD than those who have more years. The number of years of education among those with ASAD are ranked:
- 0-11 years of education
- 12 years of education
- 13-15 years of education
- 16+ years of education
ASAD plays havoc with employment, with a large portion of ASAD sufferers being unemployed or employed in a non-traditional manner. It is not known whether ASAD caused the unemployment, or if the ASAD was triggered by the unemployment. The following list shows the employment status of ASAD sufferers in rank order:
- Unemployed or non-traditional employment
How does Adult Separation Anxiety Disorder affect your life?
ASAD takes a dreadful toll on a person’s life and on the lives of those around them. For the person with ASAD the recurring distress, worrying, fear and sleep disturbances make every day a confusing and torturous experience. For those who are the “subject of attachment” — the spouse, friend, parent, etc — the continual clinginess, neediness, and drama of life with a person with ASAD can be almost more than one can take.
ASAD is extremely hard on relationships. Many people cannot handle such neediness in a partner. Those with childhood Separation Anxiety that persists into adult life may not be able to form stable romantic relationships at all. As noted above, people with ASAD are much more likely not to have been married or to be divorced or separated.
The suffering of ASAD can take many faces: Adults may endure ASAD when dealing with a marital separation, a rocky relationship, or the death of a loved one. Occasionally, a parent may struggle with ASAD as a child becomes more socialized and less dependant upon mom or dad for companionship.
ASAD is often linked to personal and social impairment. As noted above, ASAD is associated with roughly doubling of the odds that a sufferer will have low (0–12 years) education, be unemployed, and be unmarried or experiencing marital disruption. This is consistent with the findings of several studies that ASAD can be seriously damaging to one’s life.
The following table shows the personal and social impairment experienced by people with ASAD:
- Any personal and social impairment: 56.1 percent
- Severe personal and social impairment: 21.1 percent
- Any personal and social impairment: 51.6 percent
- Severe personal and social impairment: 21.7 percent
- Any personal and social impairment: 66.6 percent
- Severe personal and social impairment: 28.0 percent
- Any personal and social impairment: 66.4 percent
- Severe personal and social impairment: 31.5 percent
Maximum impaired performance in any role area
- Any personal and social impairment: 73.4 percent
- Severe personal and social impairment: 45.0 percent
Those with two or more simultaneous mental disorders often report significant impairment in their daily roles. Nearly half of the respondents in Shear’s study experienced severe role impairment if their ASAD was associated with another mental disorder.
But “pure” ASAD can be debilitating, too: One-fourth of those with ASAD alone reported severe role impairment. Because this is the case, the question arises whether co-occurring ASAD accounts for some of the impairment previously attributed to other Anxiety, mood, or substance use disorders alone. None of the many studies that estimated the societal costs of these co-occurring conditions included ASAD as a possible contributor to impairment. (See “Adult Separation Anxiety Disorder and other mental disorders” below for more information.)
Adult Separation Anxiety Disorder and other mental disorders
ASAD often occurs along with other psychiatric conditions, especially other Anxiety Disorders or mood disorders. Research findings indicate that up to 91.1 percent of people with ASAD could be classified as meeting the criteria for at least one other mental disorder found in the DSM-IV.
People with ASAD are nearly three times as likely to become addicted to illegal drugs, compared to those without the disorder. They are nearly five times more likely to have an additional Anxiety Disorder and four times more likely to have a mood disorder. Katherine Shear, lead author of one of the most important ASAD studies to date, says:
I think that separation anxiety disorder is a vulnerability factor for all kinds of mental health problems.
There is a question that has not been fully answered by research up to this point: Which comes first, ASAD or other mental disorders? There is compelling research that indicates that ASAD predates other DSM-IV Axis I disorders, which include depression, Anxiety Disorders, bipolar disorder, and schizophrenia. This means that the ASAD could actually cause other mental disorders.
In addition, a significant proportion of people with Anxiety Disorders tend to relapse, or remain significantly symptomatic, despite improvements in medications and psychiatric therapy. Theorists have proposed that untreated attachment anxieties and Separation Anxiety Disorder occurring along with other mental disorders contribute to the ineffectiveness of treatment. In other words, if co-occurring ASAD is untreated, it tends to cause the treatment to be ineffective or fail entirely.
The following table lists the most common co-occurring mental disorders that appear with ASAD:
- Panic Disorder: 14.8 percent
- Agoraphobia without Panic Disorder: 5.8 percent
- Generalized Anxiety Disorder (GAD): 16.1 percent
- Specific phobias: 35.8 percent
- Social Anxiety Disorder (SAD or Social Phobia): 34.5 percent
- Post Traumatic Stress Disorder (PTSD): 23.7 percent
- Obsessive-Compulsive Disorder (OCD): 9.9 percent
- Any other Anxiety Disorder: 65.6 percent
- Major depressive disorders: 40.8 percent
- Dysthymia: 8.9 percent
- Bipolar disorder: 19.4 percent
- Any mood disorder: 61.7 percent
- Alcohol abuse: 33.1 percent
- Alcohol dependence: 20.1 percent
- Drug abuse: 22.5 percent
- Drug dependence: 12.6 percent
- Any substance abuse disorder: 35.9 percent
Any mental disorder: 88.5 percent
It has also been found that adults with borderline personality disorder (BPD) have higher rates of Separation Anxiety Disorder than others — around 31 percent. The relationship is not explained by the presence of Panic Disorder, Post Traumatic Stress Disorder (PTSD), or multiple Anxiety Disorders. It was found also that the duration of ASAD was longer than in borderline personality disorder patients without ASAD.
Why has Adult Separation Anxiety Disorder not been studied before now?
There seems to be a number of factors at play in the reason why ASAD has not been recognized as a separate diagnosis from childhood Separation Anxiety Disorder. First, psychiatry’s diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), only mentions it in passing as a part of the childhood disorder. Katherine Shear says that:
…part of the problem is that it’s not highlighted as a separate condition for adults [in the DSM-IV]. In the book, the entry on the childhood diagnosis notes that it can continue into adulthood, and the diagnostic criteria for some other anxiety disorders suggest ruling it out. But ASAD does not have its own entry.
In defense of the DSM-IV, it was published in 1994, well before research began that clearly showed a separate diagnosis was needed for ASAD. And the ICD-10 Classification of Mental and Behavioural Disorders, mostly used in Europe and Asia, was published in 1992. These publication dates are long before research indicated that ASAd was a separate diagnosis.
Another reason is that ASAD is often mistaken for other Anxiety or mood disorders, particularly Panic Disorder with Agoraphobia. This is especially true if childhood Separation Anxiety Disorder persists into adulthood, where its symptoms may be overlooked, or obscured by other mental disorders. Notably, it was only in early 2009 that research was completed that:
…finally dispel the notion that separation anxiety and anxious attachment are relevant to panic disorder with agoraphobia, suggesting instead that that constellation is confined to a separate group, namely that of adult separation anxiety disorder.
What is the treatment for Adult Separation Anxiety Disorder?
Due to the recentness of the separate diagnosis for ASAD, there is no standard treatment for the disorder. Most therapies treat it similarly to other Anxiety Disorders with a combination of medication and therapy, especially a form of cognitive behavioral therapy called exposure therapy. Exposure therapy is often used to treat phobias. It involves slowly increasing the person’s ability to tolerate a stressful situation.
The person named Stacy, whose story was told above in the “Just what is Adult Separation Anxiety Disorder?” section, was treated successfully by Katherine Shear. She used an antidepressant similar to Prozac that also helps reduce obsessive thinking. In addition, Shear used cognitive behavioral therapy, along with exposure therapy, to slowly increase Stacy’s tolerance of separation from her husband. Working with the couple together, Shear gradually helped Stacy learn how to cope with longer and longer periods without her husband by helping her see that each increment didn’t result in catastrophe. When one situation or time period was no longer stressful, another would be tackled.
Sadly, the majority of people with ASAD remain untreated, even though many obtain treatment for co-occurring mental conditions such as Anxiety Disorders or depression. The vast majority of patients are treated for co-occurring conditions rather than for ASAD. Less than one-third of patients with ASAD (31.9 percent) report that ASAD was ever a focus of their treatment. This suggests that treatment providers often fail to recognize ASAD in the context of other co-occurring mental conditions.
Although those age 60 and older represent the smallest group of adults with ASAD, the number is still significant. This age group is subject to more separations from friends and loved ones due to moves to another city to be close to children, moves to a nursing home, and deaths. Clinicians working with the elderly need to routinely explore ASAD as it may complicate how other Anxiety and affective disorders appear in the patient, and require specific forms of intervention.
They need to be aware of the occurrence, prevalence, and comorbidities [co-occurance] of this syndrome, which could be confused with agoraphobia and which could complicate another Axis I disorder [such as Anxiety Disorders and depression], since it is co-occurring with so many. Following the principle of measurement-based care, it will be very important to follow these symptoms in patients who are treated for adult separation anxiety and/or co-occurring conditions.
What’s in the future for Adult Separation Anxiety Disorder research?
As mentioned, ASAD started being recognized as a distinct disorder in the late 1990′s. Since then research has proven that it is very different from childhood Separation Anxiety Disorder. Still, the absence of research on the treatment of ASAD suggests that researchers have largely overlooked this disorder, along with psychiatrists and other mental health care professionals.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is currently being revised, and the new edition is due out in 2012. The committees working on the revision must take into account the distinctness of ASAD from childhood Separation Anxiety Disorder in the new edition. As it stands in the current edition, the diagnostic criteria mention ASAD only in passing, concerning itself almost entirely with the childhood disorder. In considering the possible revision of diagnostic criteria for adults, it would be useful to focus on issues of symptom overlap with other mental disorders, and the differences of ASAD with a number of the disorders mentioned above.
The treatment of ASAD is only in its infancy. It relies on treatments for other Anxiety Disorders and the intuition of psychiatrists and other mental health professionals. Therapies specific to ASAD need to be developed, especially the modification of conventional exposure-based cognitive-behavioral treatments, to provide better strategies that address ASAD.
- The extent that dependence of family members and others on each other is culturally determined and acceptable, and when it is pathological.
- When the pain of separation from a loved one during war, natural disasters, or other dire circumstances is to be expected, and when it is not.
- What are normal and abnormal responses to the loss of a loved one through death?
- Whether co-occurring mental disorders involving ASAD are because of overlapping symptoms, imprecision of diagnostic criteria, or other factors that confound evaluation and treatment.
- Whether the mental disorders involved in co-occurrances with ASAD cause it, and if so, whether early successful treatment of Separation Anxiety Disorder in childhood and early adulthood would lower the rates of secondary ASAD.
- Whether adult separation anxiety disorder has any effect on the persistence or severity of other co-occurring mental disorders.
Updated April 13, 2009
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