Separation Anxiety Disorder - Anatomy of Psych

What is separation anxiety disorder?

Separation anxiety disorder is anxiety disorder characterized by excessive fear or anxiety when separated from home or an attachment figure. The yearly prevalence rate of separation anxiety disorder in the United States is 1-2% in adults and 4% in children. Separation anxiety is a protective factor against substance use but increases the risk of developing panic disorder and major depressive disorder.

What does separation anxiety disorder look like?

Signs & Symptoms

Recurrent and excessive distress about anticipating or being away from home or loved ones
Constant, excessive worry about losing a parent or other loved one to an illness or a disaster
Constant worry that something bad will happen, such as being lost or kidnapped, causing separation from parents or other loved ones
Refusing to be away from home because of fear of separation
Not wanting to be home alone and without a parent or other loved one in the house
Reluctance or refusing to sleep away from home without a parent or other loved one nearby
Repeated nightmares about separation
Frequent complaints of headaches, stomachaches or other symptoms when separation from a parent or other loved one is anticipated

DSM-5 Criteria

Criterion A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least 3 of the following:

Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.
Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
Persistent and excessive worry about experiencing an untoward event (e.g. getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.
Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.
Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.
Repeated nightmares involving the theme of separation.
Repeated complaints of physical symptoms (e.g. headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.

Criterion B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 4 months or more in adults.

Criterion C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.

Criterion D. The disturbance is not better explained by another mental disorder, such as:

Refusing to leave home because of excessive resistance to change (autism spectrum disorder)
Delusions or hallucinations concerning separation (psychotic disorders)
Refusal to go outside without a trusted companion (agoraphobia)
Worries about ill health or other harm befalling significant others (generalized anxiety disorder)
Concerns about having an illness (illness anxiety disorder)

Subtypes & Specifiers

Specifiers:

Panic attacks
- Recurrent unexpected panic attacks. An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time at least 4 of the following symptoms occur (Note: The abrupt surge can occur from a calm state or an anxious state):
  - Sweating
  - Trembling or shaking
  - Unsteady, dizziness, light-headed, or feeling faint
  - Derealization (feelings of unreality) or depersonalization (being detached from one self)
  - Excessive/accelerated heart rate, palpitations, or pounding heart
  - Nausea or abdominal distress
  - Tingling, numbness, parathesesias
  - Shortness of breath
  - Fear of losing control or “going crazy”
  - Fear of dying
  - Choking feelings
  - Chest pain or discomfort
  - Chills or heat sensations

Differential Diagnosis

Generalized anxiety disorder
Panic disorder
Agoraphobia
Conduct disorder
Bereavement
Major depressive disorder
Bipolar disorders
Posttraumatic stress disorder
Illness anxiety disorder
Oppositional defiant disorder
Psychotic disorders
Personality disorders

How is separation anxiety disorder investigated?

Children's Separation Anxiety Scale (CSAS)

How is separation anxiety disorder treated?

Cognitive behavioral therapy is the first-line option for treating separation anxiety disorder

[1] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

[2] Boyd, M. A. (2019). Psychiatric & mental health nursing for Canadian practice. Wolters Kluwer.

[3] McCauley Ohannessian, C. (2014). Anxiety and substance use during adolescence. Substance abuse, 35(4), 418–425.

[4] Townsend, M. C. (2015). Psychiatric mental health nursing. F.A. Davis.