Separation Anxiety Disorder DSM-5 309.21 (F93.0)
DSM-5 Category: Obsessive-Compulsive and Related Disorders
Separation and anxiety disorder is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Ed.) diagnosis assigned to individuals who have an unusually strong fear or anxiety to separating from people they feel a strong attachment to. The diagnosis is given only when the distress associated with the separation is unusual for an individuals developmental level, is prolonged and severe. The need to stay in close proximity to caretakers can make it difficult for children with this disorder to go to school, stay at friends houses or be in a room by themselves. In adults it can make normal developmental activities like moving away from home, getting married or being an independent person very difficult.
Symptoms of Separation and Anxiety Disorder
- Unusual distress at the discussion or experience of being parted from their attachment figure.
- Excessive fears that harm will befall their attachment person.
- Persistent worry of an unexpected event that could lead to separation from the attachment figure.
- Refusal to leave the attachment figure.
- Excessive fear of being alone.
- Nightmares about separation.
- Anxiety about sleeping and being separated from the attachment figure.
- Physical complaints when separation is immanent.
Children with anxiety disorder may be clingy, follow parents around the house, and unable to sleep alone. They may have difficulty sleeping when parents are away and worry about parents being killed or otherwise unable to return home. Sleepovers are avoided, and nightmares may occur. Children may be resistant to going to school because of the separation from parents. They may want a detailed time line of where parents will be and when they will return home. Physical symptoms of stomach aches and vomiting are common to children with separation anxiety.
Adults with separation anxiety may have fears of being alone and demand to know where their partner/child or parent is at all times. They may have difficulties with separating from their adult children or partner, and have fears of harm befalling their loved ones.
Diagnostic Criteria for Separation and Anxiety Disorder
The criteria for diagnosis of separation and anxiety disorder include the following:
- Developing 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:
- 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 (eg. Getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
- Persistent reluctance or refusal to go out, be away from home, go to school, go to work, or elsewhere because of fear of separation.
- Persistent and excessive fear 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 (eg.headaches, stomach aches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.
- The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.
- The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.
- The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.
In children the the attachment figure they have difficulty separating from is usually a parent. It is important to note that distress upon separation from a parent is normal for a child at the ages of 8 months until 13-15 months. Separation anxiety disorder is the most common anxiety disorder in children younger than 12 years. Shear (2006), found that separation anxiety in children occurs at a rate of 4.1 %, and 6.6% in adults.
Separation anxiety disorder was originally viewed as a childhood disorder. It is now recognised as an adult disorder as well, and 36.1% of adults with Separation Anxiety had separation anxiety that began in childhood (Shear, 2006). However, the majority 77.5% of adults with separation anxiety developed it in adulthood (Shaer, 2006).. Adult separation anxiety may involve anxiety related to separation from a parent, relationship partner, or an adult child who moves away. It may lead to impairment in the ability to complete housework, personal and social impairment, and work problems. People with separation anxiety are more likely to have another anxiety disorder or mood disorder. Separation anxiety frequently develops after a distressing event especially the loss of a loved one, or a divorce.
Treatment for Separation and Anxiety Disorder
Treatment that involves both medication and psychotherapy have higher success rates for alleviating the symptoms of Separation Anxiety (Masi, Planner, Mucci, Berloffa, Magazu, Parolin, 2012). Art therapy with parent-child pairs has been found helpful with improving parent child relationships and decreasing anxiety (Plante & Bernache, , 2008). Cognitive behavior therapy (CBT) and exposure therapy are the most common treatments for children with Separation anxiety. Exposure therapy is based on the anticipation that the anxiety will decrease with graded exposure to the stressful situation. Exposure occurs in a very gradual manner and increases the person’s ability to tolerate distance from the attachment person. Interventions that include parent training in addition to CBT has been found to be more effective then CBT alone (Barrett, Dadds and Rapee, 1996).
Parent training involves teaching parents to reward courageous separation behaviours and ignore anxiety driven behaviour. Kirsten, Grenyer, Wagner & Manicavavasagar (2008) argue that treatment for Separation Anxiety should address attachment processes in therapy. Strong attachments can be an inner resource that combats anxiety and depression. According to Mikulincer and Shaver (2007) secure attachments are associated with happiness and well being. Strong attachment relationships create a sense of value and safety, increase happiness and reduce anxiety (Mikulincer & Shaver, 2007). People can develop more secure attachments through psychotherapy. According to Siegel (2012) the therapeutic relationships can provide attachment experiences that allow integration of the brain which leads to healthier functioning. In addition, developing self-compassion (which means being kinder to yourself) is associated with lower levels of anxiety (Neff, Kirkpatrick & Rude, 2007).
Living With Separation Anxiety Disorder
Children with separation anxiety often appear withdrawn, sad and are unable to focus when apart from their attachments person. They may have fears of flying, car accidents or other events that could result in the loss of the attachment figure. It will often lead to school avoidance, which can lead to social problems and scholastic challenges. When separation is enforced children may become aggressive. Children may complain of physical problems like stomach aches, and go to great lengths to avoid separation. Bedtime can become very stressful when kids do not want to be left alone. Parents may unintentionaly encourage anxious behaviours by attending to them versus discouraging anxious behaviors.
The excessive worrying, fear and sleep disturbance can be quite debilitating, making it difficult to function at school and work. It can be exhausting for the attachment figures who are the subject of clinginess, neediness and volatile behaviors of the person with separation anxiety. Adults with separation anxiety may seem controlling, dependent and /or overprotective. They may resist their partner or child’s attempts to do things independently. It can lead to an inability to hold a job, financial problems, and interpersonal conflict. Separation anxiety may arise with marital separation, a breakup or death of a loved one. The tendency for children and adults to avoid independent activity may exacerbate the difficulty by limiting social interactions with others.
Fortunately psychotherapy is available to deal with the difficult emotions that people with separation anxiety struggle with. Children and adults can learn to tolerate separation and develop healthier relationships with themselves and loved ones.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Barrett, P., Dadds, M., & Rapee, R. (1996). Family treatment of childhood anxiety: A controlled trial. Journal of Consulting and Clinical Psychology, 64, 333-342. http://dx.doi.org/10.1037/0022-006X.64.2.333
Kirsten, L., Greynyer, B., Wagner, R., Manicavasagar, V. (2008). Impact of separation anxiety on psychotherapy outcomes for adults with anxiety disorders. Counselling and Psychotherapy Research, 8(1), 36-42. doi:10.1080/14733140801892620
Masi, G. , Pfanner, C., Mucci, M., Berloffa, S., Magazu, A., Parolin,. G (2012). Pediatric Social Anxiety Disorder: Predictors of response to pharmacological treatment. Journal of Child and Adolescent Psychopharmacology, 22(6), 410-414. doi:10.10189/cap2012..0007
Mikulincer, M., & Shaver, P. (2007). Attachment in adulthood: Structure, dynamics, and change. New York: Guilford Press.
Neff, K., Kirkpatrick, K., & Rude, S. (2007). Self-compassion and its link to adaptive psychological functioning. Journal of are search in Personality, 41, 139-154. doi:10.1016/j.jrp.2006.03.004
Plante, P., & Berneche, R. (2008). A phenomenological study addressing the reinforcement of emotional ties between parent and child through the elaboration and evaluation of dyadic art therapy groups. The Canadian Art Therapy Association Journal, 21(1), 8-27. http://do.doi.org/10.1080/08322473.2008.11432297
Shear, K., Jin, R., Meron Ruscio, A., Walter, E., Kessler, R. (2006, June). Prevalence and Correlates of Estimated DSM-IV Child and Adult Separation Anxiety Disorder in the national comorbidity survey replication. American Journal of Psychiatry, vol. 163 (6) pgs. 1066-1073. doi:10.1176/ajp.2006 163.61074
Siegel, D. (2012). The developing mind: How relationships and the brain interact to shape who we are. New York. The Guilford Press.
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