Separation Anxiety Disorder

What is separation anxiety disorder?

Separation anxiety disorder involves significant fear and worry at the thought of a caregiver leaving. A child with separation anxiety disorder is often fearful of being away from their parent or caregiver, and they may worry that something bad will happen to the caregiver ^[1].

Researchers have determined that 1-4% of children in the general population have separation anxiety disorder, and symptoms usually appear around 6 to 7 years of age. About half of children referred for treatment of anxiety have separation anxiety disorder specifically ^[1].

While separation anxiety disorder commonly begins in childhood, it can have an onset in adolescence or young adulthood as well. In fact, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) recognizes adult separation anxiety disorder ^[1].

Types of separation anxiety disorder

Given the fact that separation anxiety disorder can have an onset in either childhood or adulthood, there are two recognized types of this condition: child separation anxiety disorder and adult separation anxiety disorder ^[1]. These two types are described below:

• Child separation anxiety disorder: Research suggests that separation anxiety disorder in children is more common in girls when compared to boys. Children with separation anxiety disorder typically show distress and feelings of anxiety when separated from a parent, and they will attempt to avoid separation. They may worry that something catastrophic will occur when they are separated from the parent, or they may worry that the parent will never return ^[3].
• Adult separation anxiety disorder: With older editions of the DSM, adult-onset separation anxiety disorder was not recognized, but psychology experts have determined that it is possible for separation anxiety disorder symptoms to appear in adulthood. One survey of Americans found that over three-fourths of cases of separation anxiety disorder have an onset in adulthood. Adults with separation anxiety disorder may worry about losing their parents, partner, or children, which interferes with functioning at work and leads to increased risk of unemployment ^[2].

Symptoms of separation anxiety disorder

The symptoms of separation anxiety disorder are outlined in the DSM 5. The most common symptoms of the condition are described below ^[4]:

• Developmentally inappropriate, excessive levels of fear when separating from someone that a person has a close attachment to
• Worrying about something bad happening to the attachment figure while separated
• Repeated, excessive distress when separating from an attachment figure or thinking about being separated
• Worrying excessively that something terrible will happen, such as being lost or kidnapped, which results in separation from the attachment figure
• Refusal to leave home or attend school or work because of fear of separation
• Worrying about going to sleep or sleeping away from home if it results in separation from the attachment figure
• Significant fear of being home alone without the attachment figure
• Nightmares about being separated from the attachment figure
• Physical symptoms like headaches, nausea, chest pain, and vomiting related to the fear of separating

The symptoms above may appear slightly different for children vs. adults. For instance, children are likely to experience excessive anxiety related to separating from a parent or caregiver, whereas adults may be fearful of separating from a spouse or children. Similarly, children are often fearful of going to school, entering social situations, or spending the night at friends’ homes without their parent or caregiver. Adults may show fear of going to work and being separated from family members.

Causes of separation anxiety disorder

There is not one single cause of separation anxiety disorder; rather, there are several risk factors that increase the likelihood that someone will develop this mental health condition. The risk factors below contribute to the development of separation anxiety disorder ^[4]:

• Genes: Certain genetic factors are believed to make people more vulnerable to separation anxiety disorder, but these factors usually interact with environmental risk factors. Children of parents who have panic disorder are at increased risk of separation anxiety, suggesting a genetic contribution ^[1].
• Parenting: Parenting characteristics, such as lack of warmth and discouragement of independence, have been found to contribute to separation anxiety disorder. Overprotective or highly intrusive parenting practices can make a child more prone to developing separation anxiety disorder symptoms.
• Attachment issues: Children with healthy attachments to their caregivers feel secure and understand that parents will return after a period of separation. On the other hand, unhealthy attachment styles, which are called insecure or anxious attachment, are linked to separation anxiety disorder. Child abuse and neglect have been identified as risk factors for attachment problems ^[5].
• Loss of a parent: Losing a parent to death, divorce, or placement in foster care can increase the risk of separation anxiety disorder ^[1].
• Parental substance misuse: Alcohol use disorders and smoking in parents have been found to be linked to separation anxiety disorder ^[1].

Diagnosing separation anxiety disorder

Separation anxiety disorder is diagnosed using criteria in the DSM. To make a diagnosis, a doctor or mental health professional will perform a psychological evaluation. They will assess a patient’s history, including the history of symptoms as well as family history of anxiety and mental disorders. A clinician making a diagnosis will likely inquire about psychological stressors and rule out any medical explanations of physical symptoms like stomach aches or headaches ^[1].

A clinician may use a diagnostic tool like the Separation Anxiety Avoidance Inventory (SAAI) to assist with identifying symptoms of separation anxiety disorder. Ultimately, the diagnosis is made if a person meets the following DSM criteria ^[1]:

• A person shows at least three signs of excessive, developmentally inappropriate anxiety related to separation from an attachment figure
• These signs can include any of the following:
• Excessive distress when separated from or thinking about separating from the attachment figure
• Ongoing, extreme worry about losing the attachment figure, or about harm to the attachment figure from illness or injury
• Worrying excessively about experiencing an event like a kidnapping that results in separation from the attachment figure
• Continued refusal or hesitation to leave home or separate from the attachment figure to go to work or school
• Excessive fear of being alone without the attachment figure
• Refusing to sleep away from home or without the attachment figure
• Nightmares about separating from the attachment figure
• Physical complaints like headaches, nausea, or vomiting when separating from the attachment figure or thinking about separation
• Fears related to separation are persistent, meaning they last 4 or more weeks in children and 6 or more months in adults
• Anxiety related to separation is so significant that it results in difficulty functioning in major areas of life, such as at work or school

Prevention of separation anxiety disorder

There is no specific way to prevent separation anxiety disorder, but early recognition and treatment can make symptoms more manageable. Children who display significant symptoms of separation anxiety should receive treatment as soon as possible to reduce the risk of complications or the development of other mental health conditions ^[1].

Treatment for separation anxiety disorder

Separation anxiety disorder is usually treated with a combination of therapy and medication. Cognitive-behavioral therapy (CBT) is the most common psychotherapy method used in the treatment of separation anxiety disorder. The combination of SSRI medications and CBT has been found to be effective for treating separation anxiety in both children and adults ^[1].

Therapy

CBT is the most commonly-researched and well-supported treatment for separation anxiety disorder. This therapeutic modality uses cognitive restructuring to help people change irrational or negative thinking patterns and replace them with healthier ways of thinking ^[3].

Other therapy methods may also be effective for treating separation anxiety. For instance, parenting training programs can provide parents with education on the symptoms of separation anxiety and teach them how to reinforce skills in their children. There is some research that suggests that parent training on its own can improve separation anxiety, even if children do not participate in therapy ^[3].

In addition, children may benefit from participating in interpersonal therapy, which teaches them skills for making friends, learning from peers, and talking with friends about challenging situations. Finally, parent-child interaction therapy can be beneficial. This therapeutic method is typically used with younger children, aged 4 to 8, and it teaches parents how to be warm and attentive, which increases children’s feelings of security during separation ^[3].

Medication

There are no approved medications used specifically in the treatment of separation anxiety disorder, but psychotropic medications used for related conditions like depression and generalized anxiety may be useful for treating separation anxiety symptoms. The following medications are used in the treatment of separation anxiety disorder:

• SSRIs: This class of medications is commonly used to treat major depressive disorder, and they can also be effective for treating separation anxiety in both children and adults ^[1]. Medications in this class include sertraline, citalopram, fluoxetine, paroxetine, and escitalopram ^[6].
• Benzodiazepines: This class of drugs is typically used to treat anxiety and panic. They may be used to treat adults with separation anxiety, but they are not safe for use with children ^[1].

Self-care for separation anxiety disorder

If you live with separation anxiety disorder, there are steps you can take to care for yourself and make symptoms more manageable:

• Educate yourself about your condition. Learning about separation anxiety disorder can help you to develop a better understanding of symptoms, triggers, and ways of managing the condition.
• Learn healthy stress management techniques. Managing stress through a healthy diet, regular exercise, and a consistent sleep schedule can alleviate symptoms of anxiety.
• Practice relaxation techniques. Relaxation techniques like yoga, meditation, and deep breathing can calm your nerves and help you to cope with symptoms of separation distress.

Helping someone with separation anxiety disorder

When a loved one lives with a severe anxiety disorder, it’s important to be supportive and compassionate. The following tips can help you to support your loved one:

• Celebrate their successes. For people with separation anxiety, everyday activities like leaving home to go to work or school can be distressing. It’s helpful if you celebrate successes, even if they seem small. This may look like going out to dinner with your spouse on a Friday evening to celebrate a successful week of work, or offering praise to your child for getting on the school bus without a tantrum.
• Be patient. It can be frustrating when a loved one with separation anxiety experiences a panic attack when thinking about leaving home or separating from you, but it’s important to be patient. Remember that your loved one has a legitimate mental health condition that makes it difficult to function. Your patience can go a long way toward helping them recover.
• Encourage treatment. Getting into treatment is one of the best ways to manage separation anxiety disorder. If an adult in your life lives with separation anxiety, reminding them to keep appointments with their therapist or treatment team is helpful. If you are the parent of a child with separation anxiety, it’s important that you engage with treatment providers, as early intervention reduces the risk of long-term complications ^[1].
• Learn about separation anxiety disorder. Educating yourself about the signs and symptoms of separation anxiety disorder can help you to be more understanding of and empathetic toward your loved one. It will also equip you with additional strategies for supporting them.

FAQs about separation anxiety disorder

How common is separation anxiety disorder?

Prevalence estimates show that 1-4% of children in the general population have separation anxiety disorder, and 7.6% of children seen in clinics have the condition. Among adults, the lifetime prevalence of separation anxiety disorder is 6.6% ^[1].

What is the difference between separation anxiety disorder vs. generalized anxiety disorder?

Separation anxiety disorder differs from generalized anxiety disorder. Separation anxiety revolves around fear and distress of separating from attachment figures. Generalized anxiety disorder, on the other hand, is less specific. People with generalized anxiety disorder experience excessive fear and worry over everyday things, such as finances, health, or performance at work or school ^[7].