Separation Anxiety Disorder

Psychology 7936 Child Psychopathology

1. Overview of DSM-5 Separation Anxiety Disorder2. Neurobiological substrates3. Environmental influences4. New model of Separation Anxiety Disorder5. Treatment

DSM-V and Separation Anxiety Disorder (SAD)• Developmentally inappropriate and excessive fear or anxiety

concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:

1. Excessive distress in anticipation or when experiencing separation2. Persistent/Excessive worry about the loss of a major attachment

figure (MAF) or harm to said figure3. Excessive worry about experiencing an untoward event such as

kidnapping4. Persistent refusal to go out, away from home (e.g., to school)

because of fear of separation5. Excessive fear about being alone without MAF

(American Psychiatric Association, 2013)

DSM-V and Separation Anxiety Disorder

6. Refusal to sleep away from home or to go to sleep without being near MAF

7. Repeated nightmares involving separation from MAF8. Repeated complaints of physical symptoms such as headaches or

stomachaches when separation occurs or is anticipated

(American Psychiatric Association, 2013)

DSM-5 model of Separation Anxiety Disorder

Core features:• Distress in anticipation or when

experiencing separation• Persistent/Excessive worry about the loss

of MAF• Excessive worry about an untoward event

such as kidnapping• Persistent refusal to go out, away from

home• Excessive fear about being alone without

MAF• Refusal to sleep away from home or to go

to sleep without being near MAF• Repeated nightmares involving repeated

separation from MAF• Psychosomatic complaints when

separation occurs or is anticipated

DSM-5 Schematic of Separation Anxiety Disorder

Genetic/PhysiologicalGenetic predispositionEnhanced sensitivity to CO2

Environment• Life stress or loss (e.g., a

death in the family)• Parental

overprotection/intrusiveness• Entering a relationship• Becoming a parent

Onset of Separation Anxiety Disorder• Anxiety exceeds what is expected given the person’s

developmental level:• Infants from 6 to 30 months usually exhibit separation anxiety with intensity

increasing between 13 and 18 months.• Separation anxiety usually declines between 3 and 5 years of age when the

child is able to understand that separation is temporary.

(Bernstein & Victor, 2009)

Onset of Separation Anxiety Disorder cont’d• SAD is thought to have two separate onsets (Kearney, Sims,

Pursell, & Tillotson, 2010):• Juvenile period onset (JSAD)• Adulthood period onset (ASAD)

• In children, SAD typically begins between 7-9 years old (Last, Perrin, Hersen, & Kazdin, 1992).• Some children develop SAD as a result of stressful life event• Some children exhibit symptoms without a clear precipitating

event

(Bernstein & Victor, 2009)

Prevalence of Separation Anxiety Disorder• Rates of SAD are reported at 3-6.8% (Bernstein & Victor, 2009).• SAD is more prevalent in children compared to adolescents.• Some studies show a higher rate of SAD in girls whereas others

show equal rates (Bernstein & Victor, 2009).• One study found 50% of youth sampled exhibited subclinical levels

of SAD but do not meet full criteria (Kashani & Orvaschel, 1990).

Prevalence of Separation Anxiety

(Kashani & Orvaschel, 1990)

Prevalence of Separation Anxiety(Kashani & Orvaschel, 1990)

8 years 12 years 17 years0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Anxiety Disorder Prevalence in Children (N =70)

SAD Fear of strangersPast imperfections Social situations

Impairment and diagnosis of SAD• Data suggest that until 6 or

more symptoms are present, impairment remains relatively low.• Impairment was measured

using Child and Adolescent Psychiatric Assessment and parent reports.

(Foley et al., 2008)

Course• Longitudinal studies show (Kearney et al., 2010):• First assessment (M = 3.5 years old): • 26.7% met criteria (i.e., 3+ SAD symptoms)• 43.3% were subclinical (i.e., 1 or 2 symptoms)• 30% had non-clinical status

• Second assessment 3.5 years later (M = 7 years old):• 6.8% of children met SAD criteria• 25% were subclinical• 68.2% had non-clinical status

• SAD was assessed using Anxiety Disorder Interview Schedule for DSM-IV: Child and Parent Versions (ICC = .85; Silverman, Saavedra, & Pina, 2001).

Prognosis in childhood• One study examined the course of childhood psychiatric disorders

and found (Cantwell & Baker, 1989):• A total of 151 cases were included of which 9 children met SAD criteria.• The children aged from 2.4 – 6.6 years old.• Of those 9 children:

• 4 were absent of psychopathology 5 years later• 1 still had SAD• 2 had behavioral disorders• 3 had anxiety disorders

• Another study found that at 18 month follow-up 20% of children still met criteria for SAD (Foley et al., 2008).• There does appear to be some lasting effect of the disorder in a

substantial amount of adults who had SAD as children.

Prognosis into adulthood• There is evidence that SAD leads to panic disorder and anxiety

disorder proneness in adults (Manicavasagar, Silove, Curtis, & Wagner, 2000).• 50-75% of children with panic disorder currently or previously met

criteria for SAD (Bernstein & Victor, 2009).• 75% of adults with anxiety as a presenting problem report having

SAD symptoms as a child (Milrod et. al., 2014).• There is equivocal evidence that Adult Separation Anxiety Disorder is related to anxious attachment (Manicavasagar et al., 2009).

Prognosis Adolescent and adulthood• A meta-analysis looked at odds ratios for risk of adult

psychopathology and found:• Panic disorder with and without agoraphobia did not yield significantly

different odds ratios (i.e., OR = 3.59, OR = 4.19, respectively). • Panic disorder: Odds Ratio = 3.45, N = 25 studies• Any anxiety disorder: Odds ratio = 2.19, N = 5 studies*• Major depressive disorder: Non-significant after adjusting for publication

bias*• Substance use: Non-significant odds ratio

* results take publication bias into account

(Kossowsky et al., 2013)

Comorbidity of Separation Anxiety Disorder• Generalized anxiety disorder: 33-74%• Specific Phobia: 13-58%• ADHD: 17-22%• Social phobia: 8-20%• Enuresis: 8%• Sleep terror disorder: 8%• Dysthymic disorder: 2-13%• Major depressive disorder: 0-8%• Panic disorder: 2-4%

(Bernstein & Victor, 2009; Last, Perrin, Hersen, & Kazdin, 1992; Verduin & Kendall, 2003)

1. Overview of DSM-5 Separation Anxiety Disorder2. Neurobiological substrates3. Environmental influences4. New model of Separation Anxiety Disorder5. Treatment

Hypercapnia• Data originally showed that individuals with Panic Disorder (PD)

had an enhanced sensitivity to air that contains 35% CO2.• Inhaling the concentration of CO2 induces panic attacks in 50-70% of

individuals with PD• Children with SAD were found to also react to a 35% CO2 mixture.

• Monozygotic twins have a significantly higher concordance rate compared to dizygotic twins for the hypercapnia phenotype (i.e., 55.6% and 12.5%, respectfully; Bellodi et al., 1998).• Extensive genetic research found that a gene that influences

hypercapnia also influences panic attacks (Battaglia et al., 2009)• The SAD to Panic Disorder conversion hypothesis suggested a

connection between the two disorders.

Genetic structural equation model• A: Additive genetic

effects• CPL: Childhood

parental loss• E: Unique

environmental influence

• L: Common latent variable determined by latent genetic and environmental factors related to all phenotypes

(Battaglia et al., 2009)

Suffocation False Alarm (SFA) Theory• The theory proposes that panic is caused by an alarm system that begins

physiological false alarms.• In the lab, if lactate is infused intravenously and CO2 is inhaled, most panic prone

individuals will have a panic attack.• The hypothesized cause for CO2 and Lactate initiated panic is that, generally, an

increase in CO2 and lactate in the brain indicates suffocation.

• This theory is supported by:• High prevalence rates of panic in those with lung disease, asthma, COPD and those

who were tortured with suffocation compared to other methods.• There is a much higher prevalence of PD in those with asthma (6-24% compared to 1-

3%)• Cigarette smoking is a risk factor for panic attacks, quitting smoking reduces the

chance of a panic attack.

(Preter & Klein, 2008)

SFA and Separation Anxiety Disorder• As mentioned previously, SAD in childhood is significantly

related to Panic Disorder• 50-75% of children with PD met SAD criteria, Odds ratio of

SAD to PD: 3.45 and 75% of adults with anxiety as a presenting problem report having SAD symptoms as a child .

• Separation anxiety and PD are therefore theorized to be similarly controlled by opioidergic processes (Preter & Klein, 2008).• Separation distress in primates is moderated by opioid

agonists (Kalin, Shelton, & Barksdale, 1988).

SFA and Separation Anxiety Disorder• Kalin et al. (1988)

administered 0.1 mg/kg of morphine to infant primates and found significantly less distress vocalizations, whereas Naloxone (0.1 mg/kg) & Morphine together partially blocked the effect.

(Preter & Klein, 2008)http://bp3.blogger.com/_9M9yKRI9XVw/R07MCQ9iPZI/AAAAAAAAAKc/tP8yH_S2oWQ/s1600-h/bupfig01-en.jpg

SFA and Separation Anxiety Disorder

(Kalin et al., 1988)

SFA and Separation Anxiety Disorder• Clonidine, however, does not reduce the effect of “separation-induced”

vocalizations in infant primates (Kalin & Shelton, 1988).• 67 µg/kg was used originally and showed reduced activity levels, but

not reduced vocalizations• Dosage was then increased to 100 µg/kg and behavioral sedation was

observed in addition to reduced vocalizations• This study suggests that sedative effects are not the cause of reduced

separation vocalizations• Additionally, a placebo-controlled trial shows that codeine allows higher

levels of CO2 in the blood to be tolerated while breath holding (Stark et al., 1983).• These data support the theorized SFA mechanism that SAD and PD are

similarly due to an episodic functional endogenous opioid deficit.

(Preter & Klein, 2008)

1. Overview of DSM-5 Separation Anxiety Disorder2. Neurobiological substrates3. Environmental influences4. New model of Separation Anxiety Disorder5. Treatment

Attachment and Separation Anxiety Disorder• DSM-V cites attachment issues as a risk factor.• Recent meta-analytic evidence shows:• Insecure attachment does not appear to be significantly

related to separation anxiety• The relationship was non-significant, small (r = .28, 95% CI

[-.06, .62]) and the confidence interval contained 0.• Two samples were used for a total N of 59, so these results

may be an artifact of sample size

(Colonnesi et al., 2011)

Effects of Maternal Separation Anxiety•Maternal separation anxiety: “an unpleasant emotional

state that reflects a mother’s concerns and apprehensions about leaving her child.” Anxiety may be reflected in feelings of worry, sadness, or guilt that accompany short-term separations

• One study examined the effect of Maternal separation anxiety on children (Biadsy-Ashkar & Peleg, 2013).• Differentiation of self: the degree to which one is differentiated

from another. A healthy/differentiated person does not experience the loss or separation from another as a loss of the self (Biadsy-Ashkar & Peleg, 2013).• Differentiation was measured with the Differentiation of Self

Inventory (DSI; (Skowron & Friedlander, 2009).• DSI is comprised of four subscales:

• Emotional reactivity• I-position• Emotional cutoff• Fusion with others

Effects of Maternal Separation Anxiety

• Separation anxiety in children was measured during a video taped strange situation type procedure.• Two raters independently rated displayed separation anxiety in

children.• Studies were conducted in kindergarten classrooms between

7:30 am and 9:00 am. • Data were collected over three days.• Multiple regression analyses were completed• N = 38(Peleg, Halaby, Einaya, Whaby, 2006)

Effects of Maternal Separation Anxiety

• EC: Emotional cutoff, the extent to which the mother ineffectively handles emotionally charged situations is negatively related to secure separation.• PSEC: The more the

mother worries about separation with the child the more the child experiences separation anxiety, possibly interacting with the relationship of EC

1. Overview of DSM-5 Separation Anxiety Disorder2. Neurobiological substrates3. Environmental influences4. New model of Separation Anxiety Disorder5. Treatment

DSM-5 model of Separation Anxiety Disorder

Core features:• Distress in anticipation or when

experiencing separation• Persistent/Excessive worry about the loss

of MAF• Excessive worry about an untoward event

such as kidnapping• Persistent refusal to go out, away from

home• Excessive fear about being alone without

MAF• Refusal to sleep away from home or to go

to sleep without being near MAF• Repeated nightmares involving repeated

separation from MAF• Psychosomatic complaints when

separation occurs or is anticipated

DSM-5 Schematic of Separation Anxiety Disorder

Genetic/PhysiologicalGenetic predispositionEnhanced sensitivity to CO2

Environment• Life stress or loss (e.g., a

death in the family)• Parental

overprotection/intrusiveness• Entering a relationship• Becoming a parent

New model of Separation Anxiety Disorder

Panic disorderOR1: 3.45

Any anxiety disorder

OR1: 2.19

1 OR indicates Odds Ratio

Episodic deficit in endogenous opioids

Enhanced sensitivity to CO2 and lactate

Environment• Life stress or loss• Maternal characteristics• Attachment• Non-specified

environmental effects• Positive/negative

reinforcement exchanges

Anxiety prone genotype

Suffocation false alarm

Secondary features• Clinging/shadowing

behavior• School refusal• Can’t have sleepovers• Sadness, • Inattention• Demanding attention

Core features8 DSM Criteria

1. Overview of DSM-5 Conduct Disorder2. Neurobiological substrates3. Environmental influences4. New model of Conduct Disorder5. Treatment

• There is no section for Separation Anxiety Disorder.• As a substitution, the Anxiety General Symptoms section can be

used.• There are no Well-established psychosocial treatments for

Anxiety.• Probably efficacious treatments:• Individual CBT for Anxiety • Group CBT for Anxiety (without parents)• Group CBT Anxiety with parents• Social skills training• Exposure treatment

APA Division 53

• Possibly efficacious treatments:• Individual CBT for Anxiety with parents• Group CBT for Anxiety with parental anxiety management for anxious

parents• Family CBT for Anxiety• Parent CBT for Anxiety• Group CBT for Anxiety with parents plus internet therapy

APA Division 53

Potentially Harmful Treatments (PHT; Lilienfeld, 2007)• Probably harmful: probably produce harm in some clients

a) Randomized controlled trials replicated by at least one other teamb) Meta-analyses of RCTs for the treatment orc) Consistent and sudden incidence of low-base-rate adverse events

following therapy

• Possibly harmful: preliminary evidence showing harmful effectsa) Quasi-experimental design that have been replicated by at least one

independent team orb) Replicated single case designs

Potentially Harmful Treatments (Lilienfeld, 2007)• Possibly harmful: Relaxation treatment for Panic-Prone Patients• These data suggest that caution should be taken with children who

have SAD because of the shared etiology with PD.• Small-sample controlled case studies suggest that some patients with PD

experience paradoxical increases in anxiety and panic attacks during relaxation.• The studies did not include habituation in treatment by graded exposure.• More research is needed.

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