Adult Separation Anxiety Disorder: Not Just Kids, Part 1

Adult Separation Anxiety Disorder (ASAD) did not exist 15 years ago, at least as far as the psychiatric community was concerned.

Separation Anxiety Disorder is well recognized as a psychiatric disorder of childhood, but it is rarely diagnosed in adults. 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.

A recent study led by Katherine Shear found that the adult lifetime estimate for ASAD was a conservative 6.6 percent of the American population. That’s 20,207,408 adults who will suffer with ASAD in their lifetimes! In contrast, only 4.1 percent of children will have childhood Separation Anxiety Disorder.

This two-part post accompanies the posting of the reference article on Adult Separation Anxiety Disorder. The current post is the first of two. The two posts are a short version of the reference article, which has full information about the disorder. The information in this post falls under the following headings:

• Just what is Adult Separation Anxiety Disorder?
• How many people have Adult Separation Anxiety Disorder?
• What are the diagnostic criteria for Adult Separation Anxiety Disorder?

Tomorrow’s post continues with these headings:

• How does Adult Separation Anxiety Disorder affect your life?
• Adult Separation Anxiety Disorder and other mental disorders
• What is the treatment for Adult Separation Anxiety Disorder?

Just what is Adult Separation Anxiety Disorder?

Fear of being separated from others is the core symptom

ASAD has only been recognized as a specific mental disorder since the late 90’s, with the pioneering work of Vijaya Manicavasagar.. He said in 1997 that:{{1}}

[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. 

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.{{2}}

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):{{3}}

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.

How many people have Adult Separation Anxiety Disorder?

Almost 7% of adults have ASAD

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. She found that, while the lifetime estimate of childhood Separation Anxiety Disorder was 4.1 percent, the adult estimate for ASAD was 6.6 percent. {{4}}

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:{{5}}

1. 30-44 years at onset
2. 18-29 years at onset
3. 45-59 years at onset
4. 60+ years at onset

What are the diagnostic criteria for Adult Separation Anxiety Disorder?

The DSM-IV only mentions ASAD in passing

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.

The diagnostic criteria for Separation Anxiety Disorder in the DSM-IV are as follows. Note that adults are mentioned only in section “E,” and childhood ages are stated specifically in “C”:{{6}}

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: 

1. Recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated. 
2. Persistent and excessive worry about losing, or about possible harm befalling, major attachment figures. 
3. Persistent and excessive worry that an untoward event will lead to separation from a major attachment figure(e.g.; getting lost or being kidnapped). 
4. Persistent reluctance or refusal to go to school or elsewhere because fear of separation.  
5. Persistent and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings. 
6. Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home. 
7. Repeated nightmares involving the theme of separation. 
8. 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. 

What do you think?

People have been living with ASAD for thousands of years. It seems odd to me that it has only been diagnosed as a separate Anxiety Disorder in the past 15 years. 

Although it is relatively new diagnosis (about 7 percent of the population), it has been one of the most popular and persistent terms in my search engine requests. This shows that people are hungry for information about it, since there is not much information out there. An indication of this is how long it took me to research and write the reference article: over 30 hours!

• Do you know anybody that you think has ASAD?
• Do you think that ASAD deserves a separate diagnosis, or is it just human nature?

Artwork by Cristine Cambrea, found at Bucks County Gallery of Fine Art

As always, your comments are welcome!

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[[1]]Manicavasagar, Vijaya; Silove, Derrick; Curtis, J. (1997, September). Separation anxiety in adulthood: a phenomenological investigation. Retrieved April 6, 2009 from http://www.ncbi.nlm.nih.gov/pubmed/9298320?dopt=Abstract [[1]]

[[2]]Arehart-Treichel, Joan. (2006, July 7). Adult Separation Anxiety Often Overlooked Diagnosis. Retrieved April 1, 2009 from http://pn.psychiatryonline.org/cgi/content/full/41/13/30 [[2]]

[[3]]Szalzvitz, Maia. (2006). Pathological Clinginess: Study: Adult Separation Anxiety Disorder is prevalent yet poorly understood. Retrieved April 1, 2009 from http://health.msn.com/health-topics/articlepage.aspx?cp-documentid=100235522 [[3]]

[[4]]Shear, Katherine; Jin, Robert; Meron Ruscio, Ayelet; Walters, Ellen; Kessler, Ronald. (2006, June). Prevalence and Correlates of Estimated DSM-IV Child and Adult Separation Anxiety Disorder in the National Comorbidity Survey Replication. Retrieved April 1, 2009 from http://ajp.psychiatryonline.org/cgi/content/full/163/6/1074 Table 1 [[4]]

[[5]]Shear, Katherine.(2006, June). Table 2 [[5]]

[[6]]Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Arlington, VA: American Psychiatric Association. 1994. [[6]]