Day # 72: Separation Anxiety
Today we will continue our current theme of anxiety disorders as we discuss separation anxiety disorder.
Today's Content Level: Beginner, Intermediate
It is apart of normal human development for infants to become distressed when separated from their primary caregiver. This anxiety response likely evolved due to a survival advantage.
Normal development -> Stranger anxiety begins around 6 months and peaks around 9 months. Separation anxiety emerges by 12 months, peaks by 18 months, diminishes by about 3 years old.
Abnormal anxiety -> The anxiety due to separation is considered pathologic when it becomes extreme or developmentally inappropriate.
Diagnostic Criteria 1
Excessive and developmentally inappropriate anxiety regarding separation from attachment figures, as evidenced by ≥ 3 of the following.
Separation (or anticipation) leads to extreme distress.
Persistent worry about loss of or harm to attachment figures (illness, disasters, death).
Excessive worry about experiencing an event that leads to separation (getting lost, kidnapped, accident).
Persistent reluctance to leave home, or attend school or work.
Excessive reluctance/fear to be alone.
Refusal or reluctance to sleep alone or away from home.
Repeated nightmares involving the theme of separation.
Complaints of physical symptoms when separated from major attachment figures.
Duration ≥ 4 weeks in children/adolescents and ≥ 6 months in adults.
Also remember that to make any diagnosis you need to determine that it causes significant distress or impairment, symptoms are not attributable to a substance or medical illness, and symptoms are not better explained by another mental disorder.
Epidemiology/Pathogenesis 2, 3
Prevalence estimated to be ~4-5% in children/adolescents and lifetime prevalence in adults of 6.5%.
More common in younger children than in adolescents with peak incidence around 7-8 years old.
Some studies report occurrence equally in boys and girls while others report higher cases in girls.
Risk factors include: Family history of anxiety disorders, maternal depression and anxiety, poverty, parental overprotection, insecure parent-child attachment, behavioral inhibition (temperament of shyness and withdrawal), may be preceded by a stressful life event (such as severe illness of a primary caregiver).
Examples of screening questions: Do you experience recurrent, excessive distress when expecting to be away from home or from certain family members? Do you worry excessively and frequently about losing family members or about harm that could come to them?
Screen for other anxiety disorders, especially panic, generalized anxiety disorder, and social anxiety disorder. Also screen for depression. Separation anxiety is highly comorbid with these other conditions.
Optional questionnaires: Separation Anxiety Disorder Assessment Tool (SAD); Screen for Child Anxiety Related Disorders (SCARED).
Other important features of the clinical interview include:
Screen for stressful events or trauma.
Family history of anxiety or depressive disorders.
Rule out anxiety/panic due to another medical condition (see day 64).
Treatment for all anxiety disorders are similar, so we have written a detailed post titled "Treatment of Anxiety Disorders" where we discuss treatment options in detail. Please refer to that post for a more thorough discussion.
Psychotherapy: Therapy is the mainstay treatment for anxiety disorders in childhood. Cognitive Behavioral Therapy (CBT) with a focus on gradual independence from parent with positive reinforcement has good evidence of effectiveness. Family therapy is also commonly used where therapists will intervene on parent-child interactions. Play therapy can be used in younger children.
Pharmacotherapy: SSRIs are first-line medications for separation anxiety disorder and have good evidence, particularly when combined with CBT. In the Child/Adolescent Anxiety Multimodal Study (CAMS), treatment with sertraline + CBT had an 81% response rate of "much" or "very much" improved. Response rates for CBT-only and sertraline-only were 60% and 55% respectively. Fluoxetine, sertraline, paroxetine, and fluvoxamine have all been studied and found to be effective.
Other medications can be considered in cases that are refractory to SSRIs + CBT, however we recommend consulting a child/adolescent trained psychiatrist in these cases as other commonly used meds in psychiatry have different considerations in children. For example, TCAs are not currently recommended due to cardiac adverse effects, mixed evidence for benzodiazepines and beta-blockers in this population, etc. If you have expertise in this area feel free to comment below!!
Other notes: Untreated separation anxiety disorder is highly associated with subsequent development of other depressive and anxiety disorders as young adults. It is important to identify and treat as those who receive earlier interventions have a better prognosis.
Next lesson we will discuss selective mutism. If you want more learning resources then check out our recommended resources page.
Resources for today's post include: Kaplan and Sadock's Synopsis of Psychiatry, DSMV, and First Aid for the Psychiatry Clerkship.
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