Separation Anxiety Disorder in Adults: Clinical Features, Diagnostic Dilemmas and Treatment Guidelines

By Vijaya Manicavasagar and Derrick Silove

Separation Anxiety Disorder in Adults provides a comprehensive foundation for understanding the development, manifestation, and treatment of adult separation anxiety. The book explores precursors and triggers to both childhood and adult separation anxiety disorder, comorbidity with other disorders and conditions, and characteristics of populations and individuals with separation anxiety. Assessment and treatment are comprehensively covered, discussing how treatment for adults difers from that for children. Clinical review questionnaires are included for immediate use in practice.

• Reviews the diagnosis, assessment, management, and treatment of adult separation anxiety
• Covers how treatment for adults differs from that for children
• Identifies precursors and triggers to separation anxiety
• Discusses comorbidity with other disorders and conditions
• Includes clinical review questionnaire measures

• Language: English
• Publisher: Academic Press
• Release date: Mar 12, 2020
• ISBN: 9780128125557

Vijaya Manicavasagar

Vijaya Manicavasagar's work has focused on defining the diagnostic criteria for adult separation anxiety disorder and its overlap with other anxiety disorders including panic disorder and agoraphobia. She has recently run treatment studies for depression and bipolar disorder using innovative psychological interventions such as mindfulness meditation and wellbeing groups. Author of over 100 journal articles and 3 books.

Book preview

Separation Anxiety Disorder in Adults

Clinical Features, Diagnostic Dilemmas and Treatment Guidelines

Vijaya Manicavasagar

University of New South Wales and Black Dog Institute, Sydney, NSW, Australia

Derrick Silove

University of New South Wales, Sydney, NSW, Australia

Table of Contents

Cover image

Title page

Copyright

Foreword

Preface

Acknowledgements

Chapter 1. A journey of discovery: separation anxiety disorder in adults

Childhood SEPAD

The impetus to investigate SA and SEPAD in adulthood

Case studies

Summary of early clinical observations

Book outline

Conclusions

Chapter 2. Making a diagnosis of separation anxiety disorder in adulthood

SEPAD in childhood and adolescence

Clinical indicators of adult SEPAD

Formal diagnostic criteria for SEPAD

Conclusions

Chapter 3. The assessment of separation anxiety and separation anxiety disorder

Measures based on psychodynamic and attachment theories

Phenomenological and operationalized measures

Measures of childhood SA

Retrospective measures of childhood SA

Measures of SA in adults

Diagnosing SEPAD in adults

Measures of parental SA

Conclusions

Chapter 4. Characteristics of populations and individuals with adult separation anxiety disorder

Prevalence and sociodemographic characteristics of childhood SEPAD

Prevalence of adult SEPAD

Prevalence in clinics and other selective populations

Demographic correlates of adult SEPAD

Psychosocial impairments and disability associated with adult SEPAD

Conclusions

Chapter 5. Adult separation anxiety and Attachment Theory

A brief overview of Attachment Theory

Separation anxiety as a survival mechanism of infancy and childhood

Parental overprotectiveness and separation anxiety

Observed behaviours versus inferred intrapsychic mechanisms

Working models and attachment styles

Separation anxiety and attachment styles

Conclusions

Chapter 6. Developmental models of separation anxiety disorder

Changes in concepts and definitions of SEPAD over time

Evidence for the transformation model (the SA-PD/Ag hypothesis)

Evidence in support of the generic developmental model

Longitudinal studies

Longitudinal studies of school phobic children

Longitudinal studies of children with childhood SEPAD

Comment on cross-sectional and longitudinal studies

Conclusions

Chapter 7. Exploring the continuity hypothesis of separation anxiety

Studies supporting associations between childhood and adult SEPAD

Adult-onset SEPAD

Conclusions

Chapter 8. The biological foundations of separation anxiety

The biology of interpersonal bonds

Attachment and responses to stress

Physiological impacts of separations

Twin studies

Brain regions and neural pathways associated with separation anxiety

Administration of intranasal oxytocin

Multiple pathways

Conclusions

Chapter 9. Precursors and triggers to childhood and adult separation anxiety disorder

Impacts of the early family environment

Dysfunctional attachment relationships

Specific early parenting styles

Elevated parental SA

Impacts of temperament and personality styles

Significant life events and separation experiences

Impacts of trauma

The role of learning

Socioeconomic factors

Conclusions

Chapter 10. Comorbidity with other disorders and conditions

Comorbidity with other mental disorders

Comorbidity associated with adult separation anxiety disorder

Specific comorbidities

SEPAD as an expression of temperament or personality disorder

Comorbidities with other behavioural patterns

Summary of overlap and comorbidities

Conclusions

Chapter 11. Implications for the treatment of adult separation anxiety disorder

A brief overview of the treatment of childhood SEPAD

Why is it necessary to identify specific treatments for adult SEPAD?

Approach to treating adults with SEPAD

Pragmatic components of psychological interventions for adult SEPAD

A structured approach to therapy

Barriers to treatment

Conclusions

Chapter 12. Issues and challenges associated with understanding adult separation anxiety disorder

Construct, trajectories and models of development

Prevalence

Developmental factors and precipitants of adult SEPAD

Attachment styles and SA

Clinical issues

Conclusions

The Separation Anxiety Symptom Inventory (SASI)

ASA-27

Index

Copyright

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Foreword

Anxiety about being separated from loved ones, that is ‘separation anxiety’, is an important and adaptive fear that is necessary for our survival. However, separation anxiety in children, which has been extensively studied, may develop into a severe and persistent condition that is no longer adaptive. In these cases, a diagnosis of separation anxiety disorder may be made. Such children follow their parents around, refuse to sleep over at friends' homes and may be unwilling to attend school. Fortunately, effective treatments are available for children who fear of separation from their parents and careers.

Recent research has found that separation anxiety is not confined to childhood. Adults may suffer from severe and persistent fears of being separated from their loved ones as well, with their fears being directed at their children, partners, parents or other close attachments. If these fears relate to their children, parents may become highly overprotective and unable to let them go off on their own. If the fears relate to their partners, adults with high levels of separation anxiety may become highly controlling, dependent and jealous. If the fear concerns their own parents, they may become intensely overinvolved with their parents to the detriment of their own lives.

Despite its severe impact on the social, relational and occupational lives of so-affected individuals, separation anxiety disorder in adults has long been unrecognized as an anxiety disorder. Fortunately, in the latest version of the Diagnostic and Statistic Manual for Mental disorders, the DSM-5, separation anxiety disorder is described as one of the anxiety disorders in adults as well as in children. Still, severe separation anxiety in adults is usually overlooked or misdiagnosed by researchers and clinicians alike. Symptoms of the separation anxiety disorder are often attributed to the other more familiar adult anxiety disorders, such as panic disorder or agoraphobia, or personality disorder, and, as a result, adults with separation anxiety disorder may be treated suboptimally.

This book "Adult Separation Anxiety" written by Professors Manicavasagar and Silove is therefore much awaited. It describes adult separation anxiety from an evolutionary, developmental, relational, parenting, diagnostic and treatment perspective and gives an extensive oversight of the authors and others research into this important field. It is the result of over 25 years of dedicated research and clinical work of the authors. This book is highly recommended for students, researchers and clinicians who want to understand what separation anxiety is, how it is caused and maintained and what we can do about it.

Susan Bögels, psychotherapist,

professor at the University of Amsterdam,

author of the book: Mindful Parenting:

A guide for mental health practitioners

Preface

It is a natural human response to become fearful when separated and isolated from close others, anxieties that are deeply rooted in our evolutionary history. As an intensely collectivist species, members of Homo Sapiens rely heavily on the group to ensure individual survival. In the primordial state, being separated, lost or isolated signified extreme danger. The lost individual was a ready target for mega fauna or hostile tribes of other humans if denied the protection of the group.

It is understandable that fear of separation in infants and children – manifesting as separation anxiety (SA) – has drawn most attention of clinicians. The period of psychosocial development leading to maturity is prolonged in the human species, representing a time of high reliance on adult caretakers for protection and nurturance. Overt signs of SA in the young are unmistakable and readily interpreted by adults in all cultures. When left even for short periods by their primary caretaker – often but not always the mother – infants exhibit a stereotypic distress reaction that manifests as obvious agitation, heightened motor activity, psychophysiological arousal and in many instances, crying and screaming – explicit signals communicating the need for the caretaker to take active steps to restore the integrity of the primary bond, the child's insurance against danger. There is an expansion of alarm signals reflecting the SA response in toddlers to include clinging, shadowing of the attachment figure and more explicit protest behaviours including tantrums. Older children experience nightmares and fantasies of being attacked – or of harm befalling the attachment figure(s) – and manifest their anxieties in indirect ways through somatic complaints such as stomachaches and headaches.

These indicators of SA have long been recognized in children – and the extreme and disabling form, Separation Anxiety Disorder (SEPAD), often associated with school refusal, is one of the most common disorders presented to child anxiety clinics. It is only recently, however, that the adult form of the disorder has been recognized. Approximately 25 years ago, the present authors initiated a program of research at the University of New South Wales in Sydney, Australia, to identify and codify symptoms of SA in adults. Early findings were independently documented in other centres, particularly at the University of Pisa, in Italy. These observational studies indicate a remarkable level of symmetry between the core features of SA in children and adults, although, as to be expected, the expression of symptoms and related behaviours manifested differently according to the stage of maturation of the individual. For example, adults expressed their SA via behaviours such as procrastination when needing to leave the home; rationalizing their avoidance of attending study or work – not because of fear of the actual place but because of anxieties about separation from attachments; excessive checking on the whereabouts of attachment figures throughout the day and/or prolonging communications by phone with these persons in order to maintain contact and be reassured of their safety and accessibility.

Early phenomenological enquiries lead to the development of systematic measures of adult SEPAD (at first referred to by the acronym ASAD, now SEPAD). Applying these measures revealed a high prevalence of SEPAD first in ambulatory clinics and then in the general population. This cumulative body of evidence formed the foundation for a major reconceptualization of SEPAD from a disorder of childhood to one that could manifest throughout the life course, a change adopted by contemporary psychiatric classification systems, including the Diagnostic and Statistical Manual edition 5 of the American Psychiatric Association, and the International Classification of Diseases 11th Revision. SEPAD now is one of the core subtypes of anxiety disorder – alongside categories such as panic disorder and agoraphobia – that can occur at all ages through the life course.

Further research has challenged existing developmental theories concerning the pathways leading to adult SA; possible hereditary and psychosocial factors underlying the disorder and patterns of associated comorbidity and disability. This body of research has uncovered several important leads concerning the early family influences, gender patterns of inheritance, socioeconomic and educational correlates and biological underpinnings of adult SEPAD.

Nevertheless, much more needs to be learned about adult SEPAD. SEPAD is a uniquely interpersonal disorder – the focus of anxiety being centred on the whereabouts, safety and accessibility of close others. We therefore need to unravel in much greater depth the cultural, social and interpersonal factors that accommodate, ameliorate or exacerbate SA symptoms. Already there is evidence that the traumas of mass conflict and other large-scale events that lead to population dislocations may play a role in generating severe SA symptoms both in children and adults. Given the risk posed by climate change to the stability of the world population, SEPAD may emerge as an even greater problem than it is today.

We need to understand more fully the familial dynamics that shape SA symptoms and their containment and why some families appear to unintentionally ‘collude’ with the person's fears through the process of overaccommodation of adoption of the underlying anxieties. Equally, more knowledge is needed concerning issues of under- and misdiagnosis of adult SEPAD at the clinical level, a tendency that may result in inadequate or ineffective treatment. Importantly, there is a pressing need to formulate, test and implement tailored psychological and pharmacological interventions to address more specifically the core symptoms and disabilities associated with the adult form of SEPAD.

This is the first book to attempt to cover in a comprehensive manner all these key issues relating to the adult form of SEPAD, our purview extending from theory to research and practice. Our aim is to summarize contemporary knowledge in the field to better inform clinicians and researchers of the stage of knowledge of this emerging area in mental health. Given the high prevalence and levels of psychosocial disability associated with adult SEPAD identified across countries, identification and treatment of the problem represents an important public health issue. Our overall hope is that this book will help pave the way for improvements in the recognition, assessment, diagnosis and treatment of adults with SEPAD and a greater understanding of the place of the diagnosis within the general body of the anxiety disorders.

We are privileged to be in the company of other, prominent investigator groups internationally who have played a critical role in extending and disseminating knowledge about adult SEPAD. Amongst these pioneers are the group led by Professor Stephano Pini at the University of Pisa in Italy who have produced ground-breaking clinical and biological research in this area; Professor Catherine Shear and her colleagues at Pittsburgh and Columbia Universities who have developed measures to assess and diagnose adult SEPAD and who initiated the study of the epidemiology of the disorder and Professor Barbara Milrod and her group at Weill Cornell Medical College in New York who have developed and tested important clinical insights in the psychodynamic treatment of the disorder. We also acknowledge the important role that the World Health Organization World Mental Health Survey data have played in establishing the prevalence and risk factors associated with adult SEPAD at a cross-country level and raising awareness of the psychosocial impact of this disorder in adults.

Vijaya Manicavasagar, and Derrick Silove

Acknowledgements

We are indebted to a number of people for their support and encouragement over the 25-year period of inquiry into adult Separation Anxiety Disorder at the University of New South Wales.

We are indebted to Scientia Professors Gordon Parker and Philip Mitchell for their leadership and encouragement during their successive periods of tenure as Head of School of Psychiatry at the University.

We especially acknowledge our close colleague, Dr Renate Wagner, and her team at the Bankstown Clinic for Anxiety and Traumatic Stress, for providing access to patients in the service and for the tireless efforts they made to advance research in this field.

We extend our thanks to academic colleagues Professors Susan Rees, Valsa Eapen and Mark Dadds, Drs Jane Kohlhoff and Alvin Tay amongst others, for their collaborative work in this area. We especially appreciate help of support staff of the Psychiatry Research and Teaching Unit (Ms Ana Ladesic, Ms Gordana Sobacic and Ms Stavroula Smith) who took care of the often hidden administrative functions necessary to advance the research endeavour. We also thank Ms Claire Marnane who dedicated much time and effort to assisting us in developing and publishing our early findings in the field. We thank Mr Dusan Hadzi-Pavlovic and Dr Mohammed Mohsin for the statistical support provided to advance this work.

We are also grateful for the support we have received from overseas colleagues, Professors Stephano Pini and his group at the University of Pisa who have pursued seminal work in the field and Professors Susan Bogels and Catherine Shear who have contributed much to research and awareness raising about the importance of adult separation anxiety disorder. Their contributions have been fundamental to the gradual process of recognition that separation anxiety disorder can manifest throughout the life course.

Mr Michael Taylor, a good friend, provided much needed encouragement when it all got to be too much. Ms Jacqueline Boyd and Ms Dianne McDonald provided a consistent ‘cheer squad’ encouraging us at times when progress seemed slow. Dr Stephen Mackie's enduring support requires special mention.

We extend our appreciation to Ms Barbara Makinister and Ms Narmatha Mohan of Elsevier Publishing who provided helpful guidance throughout the process of developing and publishing this book. We are especially grateful for their forbearance through the delays and occasional hindrances that created challenges to timely publication.

We particularly wish to thank all the many patients and research participants for their generosity and commitment in providing the essential data needed to identify and document the features of adult SEPAD. They gave freely of their time in the knowledge that the rewards for doing so were uncertain – at a time when little was known about the disorder or its treatment.

Vijaya Manicavasagar, and Derrick Silove

Chapter 1

A journey of discovery

separation anxiety disorder in adults

Abstract

The drive to maintain physical proximity to caregivers and protectors is deeply entrenched in the human species as it is in many others. In a primordial state, members of the early home species who accidentally became separated from others were at high risk of being killed by predators or other tribes. Fear of being separated, or separation anxiety, therefore is one of the most primitive of all fear responses, a legacy of our early evolutionary history in which our species, like all others, struggled for survival in situations of great danger.

Keywords

Anxiety disorder; Attachment Theory; Childhood SEPAD; Cognitive behaviour; Mixture analysis; Separation anxiety

The drive to maintain physical proximity to caregivers and protectors is deeply entrenched in the human species as it is in many others. In the primordial state, members of early hominid species who accidentally became separated from others were at high risk of being killed by predators or other tribes. Fear of being separated, or separation anxiety (SA), therefore is one of the most primitive of all fear responses, a legacy of our early evolutionary history in which our species, like all others, struggled for survival in situations of great danger.

When unexpectedly separated, the synchronized response of cognitive awareness of the danger, subjective emotion of fear and physiological arousal act in unison as a potent motivator of action to reestablish contact with close others. Although a small minority of persons live as hermits, loners or social isolates, they are by far the exception. In general, Homo Sapiens is a collective species in which individuals are highly reliant on their primary bonds with other family members and depending on the culture and context, the wider kinship group and society as a whole. This allegiance to the group does not occur simply out of preference or obligation, but because the tendency to affiliate, form and maintain bonds is deeply ingrained in our biological makeup, which, in turn, has been shaped by the drive to survive by seeking and maintaining protection against external dangers. To ensure the effectiveness of the SA system, it is as important for individuals to be concerned for the safety, health and well-being of close others (the protectors) as they are for themselves.

In some people, SA – reflected in fears that danger will befall the self or close others when separated – is excessive and persists in a way that causes the individual great distress and social dysfunction. Should such individuals consult a mental health professional, then it is likely that they will be given a diagnosis of separation anxiety disorder (SEPAD), a category included in the major international classification systems of mental disorders, such as the Diagnostic and Statistical Manual edition 5 (DSM-5, American Psychiatric Association, 2013) and the International Classification of Diseases (ICD-11, World Health Organisation, 2018) used by psychiatrists, psychologists and others working in the field.

Traditionally, SEPAD has been regarded as a disorder of childhood. We have all observed children clinging to their mothers to prevent her from leaving home, or desperately insisting that a parent remain close to them when going to sleep, or becoming tearful and protesting when being left for the first time at school. Even if excessive at the time, these short-term reactions to separation amongst children usually fall within the bounds of age-appropriate response patterns. There is an expectation by adults (parents and teachers) that, with appropriate reassurance and encouragement, the child will grow out of this tendency towards excessive SA. Nevertheless, in some children, the SA reaction becomes a source of overwhelming and persisting distress and symptoms elaborate into a wide range of dysfunctional behaviours that disrupt the lives of the individual, creating major concerns for parents, teachers and the school. Although many children grow out of a period of SEPAD, in some, the problem may persist, leading to major difficulties in the family and potentially impacting adversely on the child's education, psychosocial development and future employment possibilities. In settings of severe and persisting SA, mental health care is warranted and it is likely that a diagnosis of SEPAD will be made and a set of psychological and, in some instances, medical treatments will be instituted.

Over the past two decades, there has been a major transformation in the notion of SA as a normative or, in the case of SEPAD, a pathological reaction confined to infancy and childhood. Although fragmented accounts have been recorded in earlier literature regarding the symptoms of SA in adulthood, it is only in this relatively short timeframe that a systematic approach has been applied to identifying, describing and characterizing the SA reaction in adults. The main focus of this book is to describe this major transformation in the conceptualization of SA and SEPAD as reaction patterns that can occur – and indeed have their onset – at any time in the life course, a shift in thinking that has only gradually become accepted by professionals in the mental health disciplines.

Recognition of SA and SEPAD as reactions that can occur throughout the life course commenced with the discovery, almost a quarter of a century ago, that adults attending anxiety clinics commonly experienced severe SA symptoms and that these experiences had not been attended to or given adequate importance by clinicians in the past. In essence, these observations meant that persons of all ages could experience the defining characteristic of SA and, in its extreme form, SEPAD, which is a persisting state of excessive and inappropriate anxiety