Adult separation anxiety disorder in DSM-5

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Highlights

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    Adult separation anxiety disorder has been under-diagnosed, as it was placed under “childhood onset” disorders in DSM-IV.

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    Separation anxiety disorder in adulthood is prevalent, often comorbid and debilitating.

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    A substantial portion of adults report first onset separation anxiety disorder in adulthood.

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    Research on the epidemiology, etiology, and treatment of adult separation anxiety disorder, using DSM-5 criteria, is needed.

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    Prospective-longitudinal studies on trajectories of separation anxiety disorder from childhood to adulthood are important.

Abstract

Unlike other DSM-IV anxiety disorders, separation anxiety disorder (SAD) has been considered a disorder that typically begins in childhood, and could be diagnosed only in adults “if onset is before 18.” Moreover, SAD is the only DSM-IV anxiety disorder placed under “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” whereas most anxiety disorders typically start – and are diagnosed – in childhood. Therefore, adult SAD may have been under-recognized and under-diagnosed. A literature review was carried out on behalf of the Anxiety, Obsessive–Compulsive Spectrum, Posttraumatic, and Dissociative Disorders DSM-5 workgroup to explore the evidence for SAD in adulthood, focusing on potentially relevant clinical characteristics and risk factors. The review revealed that SAD in adulthood is prevalent, often comorbid and debilitating. The DSM-IV age-of-onset criterion was not supported as a substantial portion of adults report first onset in adulthood. Research on putative risk factors is limited to childhood SAD: SAD runs in families, albeit patterns of familial aggregation and heritability estimates indicate low specificity. Tentative evidence for biomarkers and biased cognitive processes exists, again pointing to moderate SAD-specificity only. Further research on the epidemiology, etiology, and treatment of ASAD, using DSM-5 criteria, is needed, and particularly prospective-longitudinal studies to understand the developmental trajectories of separation anxiety disorder from childhood to adulthood.

Section snippets

Separation anxiety disorder in adults

This review evaluates issues relevant to adult separation anxiety disorder (ASAD) for DSM-5. Separation anxiety disorder (SAD) is classified in the DSM-IV under “Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence.” The apparent effect of this placement is that separation anxiety disorder is not considered – and therefore likely is underdiagnosed – in adults. Also, because of its classification under childhood-onset disorders, it is separated from all other anxiety disorders,

Statement of the issue

This review explores the evidence for separation anxiety disorder as a diagnosis in adulthood, using the validators provided by the DSM-5 Task Force. The following questions are addressed: 1) What is the prevalence of ASAD, and its effect on psychosocial functioning? 2) Should ASAD require a childhood onset, as in DSM-IV? 3) What is the continuity of ASAD across the lifespan, and is this continuity specific to ASAD? 4) What is the pattern of comorbidity in adults? 5) Is there familial

Search methods

ASAD research published since the release of DSM-IV (i.e., 1994 through 2011) was searched using PsycINFO and PubMed searches for English language articles and books. Search terms included (combinations of) (adult) separation anxiety (disorder), family or parental (history), concordance, twins, genetics for studies on the familial aggregation and putative biomarkers for (adult) separation anxiety (disorder). These terms were crossed with information processing (bias), memory, attention, and

Definitions

The literature focuses primarily on adult separation anxiety disorder (ASAD), generally measured using semi-structured interviews based on DSM criteria. Adult-onset ASAD refers to an adult separation anxiety disorder diagnosis without a documented history of childhood separation anxiety disorder, whereas childhood-onset ASAD refers to an adult separation anxiety disorder diagnosis in individuals who have also met the criteria of separation anxiety disorder in childhood. We also reviewed

Prevalence, gender differences, cultural variation, and effects on psychosocial functioning

The National Comorbidity Survey Replication (NCS-R), a study of 5692 adults (Shear, Jin, Ruscio, Walters, & Kessler, 2006) found ASAD to be common in the U.S.: The lifetime prevalence rate of ASAD was 6.6%. Diagnosis was based on retrospective assessment using a criterion set parallel to that of the DSM-IV, “making age-appropriate modifications to the criterion A symptom questions” (p. 1075). The large majority (77.5%) of those diagnosed with ASAD reported onset in adulthood, more than half of

Adult-onset separation anxiety disorder

Unlike other DSM-IV anxiety diagnoses, DSM-IV separation anxiety disorder can be diagnosed in adults “Only if onset is before 18,” albeit the reason for this criterion is unclear. Moreover, evidence suggests that separation anxiety may only reach the level of a disorder for the first time in young adulthood, for example when moving out of the parents' house, in relation to a first serious romantic relationship (i.e., fear of losing the partner) or after having children (i.e., fear of losing a

Course/continuity across the lifespan

Because ASAD generally has not been included as a possible adult “outcome” of CSAD, prospective longitudinal data are not yet available as to whether CSAD typically continues into adulthood. Rather, we have to rely on retrospective reports of adults with ASAD about their childhood separation fears. Although retrospectively recalled CSAD is more prevalent in adult patients with two or more (vs. only one) anxiety disorders, it is unknown whether this finding represents a recall bias, or whether

Comorbidity with other psychopathology and personality disorders

Comorbidity is the rule rather than the exception in mental disorders, commonly as high as 50–60%. By investigating the pattern of comorbidities of ASAD with other disorders, more insight can be obtained into whether manifestations of ASAD are unique and autonomous or whether they are multiform and heterogeneous to other disorders (Klein & Riso, 1993). As ASAD symptoms may not be distinguished easily from dependent PD, and share features with panic disorder and agoraphobia, we specifically

Familial aggregation

There are virtually no data on familial aggregation of ASAD per se, so in this section we review primarily literature on CSAD. According to bottom-up studies, separation anxiety disorder seems to run in families. Elevated rates of separation anxiety disorder were found in 1th and 2th degree relatives of children with separation anxiety disorder (Last, Hersen, Kazdin, Orvaschel, & Perrin, 1991). Also, children with higher separation anxiety symptom scores were more likely to have either a

Underlying biomarkers

Similar to other anxiety disorders, there is little knowledge on underlying specific biomarkers that may argue for or against validity of the SAD diagnosis in either children or adults. For ASAD, most studies come from Pini's group, favoring the role of a particular peripheral-type benzodiazepine receptor binding. Chelli et al. (2008) suggested reduction of 18 kDa translocator protein (TSPO) density related specifically to the presence of ASAD in a sample of 40 adult outpatients with DSM-IV

Temperamental and personality antecedents or concomitants

The literature on antecedents of ASAD is almost non-existent, so we review briefly the larger body of literature on putative antecedents of separation anxiety symptoms, which largely focuses on maternal separation anxiety towards the offspring, typically defined as an unpleasant emotional state evidenced by expressions of worry, sadness or guilt when a mother has to leave her child(ren).

Maternal separation anxiety on a symptom level typically is measured using the Maternal Separation Anxiety

Information processing bias in (A)SAD

Cognitive processes reflect relations between experienced events and subsequent emotional responses, so biases occurring in these processes are crucial for the development and maintenance of anxiety disorders (Beck et al., 1985, Foa and Kozak, 1986). Cognitive biases in information processing in anxiety disordered individuals include biased or selective attention, biased judgment, and biased memory (Vasey & MacLeod, 2001), and have been shown to trigger negative interpretations of ambiguous

Behavior genetics

We did not locate any twin or adoption studies of ASAD specifically, but the data are relatively consistent, with a higher prevalence of lifetime SAD in MZ compared to DZ twins (e.g., Ehringer, Rhee, Young, Corley, & Hewitt, 2006), and a higher concordance on SAD for MZ than for DZ twins, especially in girls (e.g., Bolton et al., 2006, Ogliari et al., 2010, Silove et al., 1995) although Ehringer et al. (2006) found this only for 12-month, not lifetime diagnosis, and results varied depending on

Environmental risk factors

Behavior-genetics research on CSAD shows unique environmental risk factors to be strong, especially in boys, but such research has not been carried out for ASAD. Research on the comorbidity of ASAD (see Comorbidity with other psychopathology and personality disorders section), however, provides some insight into possible environmental risk factors for ASAD. The large overlap between ASAD and PTSD suggests that trauma, and related fear for personal safety, is a risk factor for ASAD, whereas the

Differential diagnosis

What differential-diagnostic issues will arise now that ASAD is systematically considered as an adult anxiety diagnosis in DSM-5? Initially, the disorder closest to ASAD would seem to be the DSM-IV-TR diagnosis of panic disorder with agoraphobia (Silove, Marnane, et al., 2010), with the difference being that fear of having a panic attack does not drive separation anxiety as it does to agoraphobia. Patients with ASAD may develop panic attacks in the face of separation from loved ones, but the

Treatment

ASAD has been found to be a debilitating condition, and 75% of those with ASAD in the NCS-R community sample had received treatment for emotional problems, although ASAD had not been a focus of treatment in most (68%). Moreover, we could find no studies in which ASAD was the specific target of treatment other than case studies (e.g., Butcher, 1983). It is unknown, however, whether this is because clinicians think of separation anxiety as a childhood disorder and so do not inquire about it in

Discussion and preliminary recommendations for DSM-5

This review focused on the evidence for an adult form of separation anxiety disorder (ASAD). Although DSM-IV-TR does allow for a diagnosis of ASAD, this anxiety category generally has been overlooked as it was placed in the “begins in childhood” section. However, studies from three independent research groups in Australia, Italy and the U.S., respectively, provide evidence for the existence of an adult form of this disorder. The U.S. study is the only large community sample to date, whereas

Acknowledgment

The article was commissioned by the DSM-5 Anxiety, Obsessive–Compulsive Spectrum, PostTraumatic, and Dissociative Disorders workgroup. It represents the work of the authors and was reviewed by the workgroup.

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