The relationship between adult separation anxiety disorder and complicated grief in a cohort of 454 outpatients with mood and anxiety disorders

Differential correlates of prolonged grief and depression after bereavement in a population-based sample

Bereavement can lead to prolonged grief disorder (PGD) as well as episodes of major depression. Studies on the prevalence of PGD and its differences from postbereavement depression have not been conclusive. This study compared the correlates of depression and prolonged grief (PG) symptoms in a population-based random sample (N = 535) using the Beck Depression Inventory, Inventory of Complicated Grief-Revised, Anxiety Sensitivity Index (ASI), and Adult Separation Anxiety Questionnaire (ASAQ). Correlates of PG and depressive symptoms were examined using linear regression in 328 bereaved respondents. The prevalence of probable PGD based on PGD-2009 criteria was 3.0% among bereaved respondents and 1.9% in the total sample. PG was related to bereavement-related features including sex of the deceased, β = - .110, p = .026; time since loss, β = - .179, p = .001; the number of lifetime losses experienced, β = .157, p = .016; and perceived closeness with the deceased, β = .214, p < .001. Only lower income of the bereaved predicted depression, β = - .139, p = .018. In women, but not in men, the loss of a male family member (i.e., brother or son) was a significant predictor of PG symptoms, β = - .180, p = .006. The results confirm the qualitative distinction between depression and PG in a nonclinical sample and show that PG is mainly related to the intrinsic and extrinsic characteristics of the deceased or of death, whereas depression relates only to the characteristics of the bereaved person.

Interpersonal psychotherapy for traumatic grief following a loss due to COVID-19: a case report

Interpersonal psychotherapy (IPT) is a highly regarded evidence-based psychotherapy that aims to alleviate the suffering of clients and improve their interpersonal functioning. Research has demonstrated the effectiveness of IPT in depressive, bipolar and eating disorders. IPT also focuses on grief and loss as a problem area to help clients address and process their grief symptoms, leading them to reach a phase of finding meaning. However, traumatic grief which is characterized by someone who has both symptoms of trauma and grief can further complicate treatment. As for Posttraumatic Stress Disorder (PTSD), IPT can be a choice of treatment by addressing perceived isolation and emotional dysregulation through mobilizing adequate social support. This case study highlights the efficacy of IPT in treating complicated grief with traumatic experiences caused by the loss of a loved one during the COVID-19 pandemic, without undergoing exposure-based therapy. The treatment course consisted of 12 sessions scheduled twice weekly, and the client received antidepressant medication augmented with antipsychotic medication. After undergoing IPT, the client experienced an improvement in symptoms, gradual recovery of functional disability, and more meaningful interpersonal relationships. The case study presented provides evidence to suggest that IPT is a promising treatment approach for individuals struggling with trauma related to grief.

The psychological toll of the COVID-19 pandemic on dental care providers in Iran: A multicenter cross-sectional study

Background/Purpose

The COVID-19 pandemic affects social and psychological resources. Healthcare workers, especially dental personnel, are more at risk for mental issues due to anxiety, pressure, and frustration. This study assessed mental health outcomes during the COVID-19 epidemic among Iranian dental care providers, focusing on insomnia, anxiety, depression, and posttraumatic stress disorder (PTSD).

Methods

In this multicenter cross-sectional survey, the Insomnia Severity Index, the Hospital Anxiety and Depression Scale, and the Global Psychotrauma Screening were masured. Six hundred thirty-eight dental care providers (dental specialists, general dentists, dental hygienists, dental assistants, and dental students) from different parts of Iran (Tehran, Shiraz, Tabriz, and Mashhad) were investigated by the stratified sampling method. The univariate analysis was incorporated as independent in binary logistic regression models to analyze the data. In this study, the significance level was set at 0.05.

Results

Among all the participants, 42.8% were dental students or residents, 21.9% were general or specialist dentists, 18.7% were dental assistants, and 16.6% were nonclinicians. The prevalence of insomnia, anxiety, and depression was 31.3%, 40.8%, and 54.9%, respectively. The frequency of participants in the low, moderate, and high levels of PTSD resulting from LCA 56.6%, 33.7%, and 9.7%, respectively.

Conclusions

This study found a significant frequency of mental health issues among Iranian dentists. Females, participants whose relatives have COVID-19, and those with a higher workload were more likely to develop mental health symptoms. As mental problems among dental professionals might affect the quality of patient care, diagnostic, supportive, and therapeutic interventions should be taken.

Relationship Between Adult Separation Anxiety Disorder and Suicide in Patients with Bipolar Disorder

Life expectancy of patients with bipolar disorder (BD) is known to be shorter than the general population. Some of the premature deaths in these patients are attributed to unnatural causes such as suicide, accidents and homicides. Death due to suicide is 15 times more common in patients with GI compared to the general population. The present study aimed to investigate the comorbidity of Adult Separation Anxiety Disorder (ASAD) and the relationship between this comorbidity and suicide in patients with BD. A total of 138 outpatients with BD at remission between the ages of 18-65 years and 63 healthy controls were included in our study. All participants were administered a sociodemographic data form, Hamilton Depression Scale (HMDS), Young Mania Rating Scale (YMRS), Adult Separation Anxiety Questionnaire, and Structured Clinical Interview for Separation Anxiety Symptoms (ASAD-SCI). The age and gender of the participants did not differ significantly between the control group, the BD and BD+ASAD groups. The mean age of the participants was 42.3±11.9 years. When categorized according to gender, 42.3% of the participants were male and 57.7% were female. ASAD was detected in 46.3% of the participants. The suicide attempt rate was significantly higher in the BD and BD+ASAD groups than in the control group. The rate of suicide attempt was significantly higher in the BD+ASAD group than in the BB group. We demonstrated that the comorbidity of ASAD was associated with previous suicide attempts in patients with BD. Recognizing and treating ASAD in patients with BD may reduce suicide attempts in these patients.

Prolonged grief in refugees, parenting behaviour and children's mental health

BACKGROUND

Many refugees experience bereavement, and as a result they suffer elevated rates of prolonged grief disorder. Evidence also indicates that elevated rates of psychological disturbance in refugee children can be associated with parental mental health. This study examined the extent to which prolonged grief disorder in refugees is associated with their parenting behaviour and in turn with their children's mental health.

METHODS

This study recruited participants from the Building a New Life in Australia prospective cohort study of refugees admitted to Australia between October 2013 and February 2014. The current data were collected in 2015-2016 and comprised 1799 adults, as well as 411 children of the adult respondents. Adult refugees were assessed for trauma history, post-migration difficulties, harsh and warm parenting, probable prolonged grief disorder and posttraumatic stress disorder. Children were administered the Strengths and Difficulties Questionnaire. The current analyses on bereaved refugees comprise 110 caregivers and 178 children.

RESULTS

In this cohort, 37% of bereaved refugees reported probable prolonged grief disorder. Path analysis indicated that caregivers' grief was directly associated with children's emotional difficulties. Caregiver warmth was associated with reduced emotional problems in children of refugees with minimal grief but associated with more emotional problems in caregivers with more severe grief. More harsh parenting was associated with children's conduct problems, and this was more evident in those with less severe grief.

CONCLUSION

Severity of prolonged grief disorder is directly linked to refugee children's mental health. The association between parenting style, grief severity and children's mental health highlights that managing grief reactions in refugees can benefit both refugees and their children.

Separation anxiety disorder among outpatients with major depressive disorder: Prevalence and clinical correlates

Prior studies have reported that separation anxiety disorder (SEPAD) can continue into or may begin in adulthood. Association of SEPAD with other psychiatric disorders has been frequently examined, and high rates of comorbidities have been found. The aim of this study was to investigate the prevalence and clinical correlation of SEPAD in adult patients undergoing treatment for major depressive disorder (MDD). The study sample was comprised of 100 outpatients. Participants underwent a DSM-5-based comprehensive assessment. Purposefully-designed semi-structured sociodemographic information and illness history forms were filled out by the researchers, and diagnoses of SEPAD were made using the Structured Clinical Interview for Separation Anxiety Symptoms, Separation Anxiety Symptom Inventory and Adult Separation Anxiety Survey. The frequency of SEPAD was 41% in patients with MDD, three-quarters of whom were adult onset. The use of new-generation antidepressants, adjunctive medications and comorbidity of other anxiety disorders were higher in patients with SEPAD (p < 0.05). SEPAD was highly prevalent, with a majority of cases starting in adulthood among patients with MDD, while SEPAD comorbidity was associated with high levels of anxiety and an increased likelihood of suboptimal response to usual depression treatment. Further studies are required to define the relevance and pathological basis for the comorbidity of SEPAD in people with MDD.

[Separation anxiety disorder]

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) separation anxiety disorder has been included in the chapter on anxiety disorders, thereby removing the age of onset restriction that previously required first onset during childhood or adolescence. Separation anxiety disorder has a lifetime prevalence of 4.8% and onset often occurs after the age of 18 years. Despite the high prevalence, separation anxiety disorder is often underdiagnosed and subsequently remains untreated. This narrative review summarizes the etiology, clinical features, diagnostic criteria as well as important differential diagnostic aspects, common comorbidity profiles and treatment implications of separation anxiety disorder. Furthermore, relevant implications for everyday practice and future perspectives for treatment and research are discussed.

Oxytocin receptor gene variation, behavioural inhibition, and adult separation anxiety: Role in complicated grief

OBJECTIVES

Complicated grief (CG) following bereavement significantly increases the risk for mood and anxiety disorders. The severity of grief reactions may be interactively influenced by temperamental and psychological factors such as behavioural inhibition (BI) and separation anxiety (SA) as well as biological factors. Given its central role in attachment and stress processing, a genetic variant in the oxytocin receptor (OXTR) gene was thus investigated in order to elucidate the direction of association as well as its interaction with BI and SA in the moderation of CG severity.

METHODS

Ninety-three patients with mood and anxiety disorders were evaluated for CG by means of the Inventory of Complicated Grief (ICG), for BI using the Retrospective Self-Report of Inhibition (RSRI), and for symptoms of SA during adulthood using the Adult Separation Anxiety Scale (ASA-27). All patients were genotyped for OXTR rs2254298.

RESULTS

OXTR genotype interacted with BI and, on a trend-level, with adult SA, to increase CG. Specifically, higher levels on the RSRI and ASA-27 scales, respectively, were related to higher ICG scores in GG genotype carriers.

CONCLUSIONS

The present study for the first time suggests a gene-environment interaction effect of an OXTR gene variant with BI and possibly also symptoms of adult SA in the moderation of vulnerability for CG.

A randomized controlled pilot trial of vilazodone for adult separation anxiety disorder

BACKGROUND

Separation anxiety disorder was recently recognized by fifth edition of the Diagnostic and Statistical Manual of Mental Disorders as a diagnosis in adults, but no publications to date have characterized a sample of patients seeking treatment for adult separation anxiety disorder (ASAD) or assessed treatment efficacy. We hypothesized that vilazodone, a selective serotonin reuptake inhibitor (SSRI) and serotonin 1a (5HT1_a ) receptor partial agonist, would have efficacy in ASAD, because SSRIs have appeared efficacious in children with mixed diagnoses including separation anxiety disorder and in animal models of separation anxiety.

METHODS

In this pilot study, 24 adults (ages 18-60) with a principal diagnosis of ASAD were randomized to 12 weeks of double-blind treatment with vilazodone (n = 13) or placebo (n = 11). Outcome was assessed by an independent evaluator and self-ratings, and analyzed with mixed effect models.

RESULTS

This sample was predominantly female (67%), with comorbid psychiatric disorders (58%), and adult onset of separation anxiety disorder (62%). Response rates at week 12 did not differ significantly between groups. Across all time points, the vilazodone group evidenced greater improvement on the Structured Clinical Interview for Separation Anxiety Symptoms (P = .026) and the Quality of Life Enjoyment and Satisfaction Questionnaire (P = .011), and trends toward greater improvement on the Adult Separation Anxiety Questionnaire (P = .054) and the Clinical Global Impression-Change Scale (P = .086), all with large between-group effect sizes.

CONCLUSIONS

Findings demonstrate feasibility of a clinical trial in ASAD, and they suggest that vilazodone may have efficacy in the treatment of ASAD and warrants further study.

Adult separation anxiety disorder in complicated grief: an exploratory study on frequency and correlates

INTRODUCTION

Complicated grief (CG) has been the subject of increasing attention in the past decades but its relationship with separation anxiety disorder (SEPAD) is still controversial. The aim of the current study was to explore the prevalence and clinical significance of adult SEPAD in a sample of help-seeking individuals with CG.

METHODS

151 adults with CG, enrolled in a randomized controlled trial comparing the effectiveness of (CG) treatment to that of interpersonal therapy, were assessed by means of the Inventory of Complicated Grief (ICG), the Structured Clinical Interview for DSM-IV, the Hamilton Rating Scale for Depression (HAM-D), the Work and Social Adjustment Scale (WSAS), the Adult Separation Anxiety Questionnaire (ASA-27), the Grief Related Avoidance Questionnaire (GRAQ), the Peritraumatic Dissociative Experiences Questionnaire (PDEQ), and the Impact of Events Scale (IES).

RESULTS

104 (68.9%) individuals with CG were considered to have SEPAD (ASA-27 score ≥22). Individuals with SEPAD were more likely to have reported a CG related to the loss of another close relative or friend (than a parent, spouse/partner or a child) (p=.02), as well as greater scores on the ICG (p=<.001), PDEQ (p=.004), GRAQ (p<.001), intrusion (p<.001) and avoidance (p=<.001) IES subscales, HAM-D (p<.001) and WSAS (p=.006). ASA-27 total scores correlated with ICG (p<.0001), PDEQ (p<.001) GRAQ (p<.0001) scores and both the IES intrusion (p<.0001) and IES avoidance (p<.0001) subscale scores. People with SEPAD had higher rates of lifetime post-traumatic stress disorder (PTSD) (p=.04) and panic disorder (PD) (p=.01).

CONCLUSIONS

SEPAD is highly prevalent among patients with CG and is associated with greater symptom severity and impairment and greater comorbidity with PTSD and PD. Further studies will help to confirm and generalize our results and to determine whether adult SEPAD responds to CG treatment and/or moderates CG treatment response.

The separation of adult separation anxiety disorder

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) categorization of mental disorders places "separation anxiety disorder" within the broad group of anxiety disorders, and its diagnosis no longer rests on establishing an onset during childhood or adolescence. In previous editions of DSM, it was included within the disorders usually first diagnosed in infancy, childhood, or adolescence, with the requirement for an onset of symptoms before the age of 18 years: symptomatic adults could only receive a retrospective diagnosis, based on establishing this early onset. The new position of separation anxiety disorder is based upon the findings of epidemiological studies that revealed the unexpectedly high prevalence of the condition in adults, often in individuals with an onset of symptoms after the teenage years; its prominent place within the DSM-5 group of anxiety disorders should encourage further research into its epidemiology, etiology, and treatment. This review examines the clinical features and boundaries of the condition, and offers guidance on how it can be distinguished from other anxiety disorders and other mental disorders in which "separation anxiety" may be apparent.

Assessment of Emotional Experience and Emotional Recognition in Complicated Grief

There is substantial evidence of bias in the processing of emotion in people with complicated grief (CG). Previous studies have tended to assess the expression of emotion in CG, but other aspects of emotion (mainly emotion recognition, and the subjective aspects of emotion) have not been addressed, despite their importance for practicing clinicians. A quasi-experimental design with two matched groups (Complicated Grief, N = 24 and Non-Complicated Grief, N = 20) was carried out. The Facial Expression of Emotion Test (emotion recognition), a set of pictures from the International Affective Picture System (subjective experience of emotion) and the Symptom Checklist 90 Revised (psychopathology) were employed. The CG group showed lower scores on the dimension of valence for specific conditions on the IAPS, related to the subjective experience of emotion. In addition, they presented higher values of psychopathology. In contrast, statistically significant results were not found for the recognition of emotion. In conclusion, from a neuropsychological point of view, the subjective aspects of emotion and psychopathology seem central in explaining the experience of those with CG. These results are clinically significant for psychotherapists and psychoanalysts working in the field of grief and loss.

Assessment of co-morbidity of adult separation anxiety in patients with bipolar disorder

OBJECTIVE

The aim of this study was to assess the co-morbidity of adult separation anxiety in bipolar patients and evaluate its effects on the course of disorder and functionality.

METHOD

A total of 70 patients who have been regularly followed in the Bipolar Disorder Unit were included in the study. The Structured Clinical Interview for DSM-IV - Axis I and Axis II disorders and demographic form were used. Separation anxiety was investigated by the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS) and the Hamilton Anxiety Rating Scale (HAM-A) was filled out by an interviewer. In addition, all patients completed the Bipolar Disorder Functioning Questionnaire (BDFQ), Separation Anxiety Symptom Inventory (SASI) and Adult Separation Anxiety Questionnaire (ASA).

RESULTS

The prevalence rate of co-morbid adult separation anxiety disorder (A-SepAD) was 54% (n = 38) in our sample. Age of onset was in adulthood among 36% of patients with a diagnosis of A-SepAD and the others (64%) were childhood-onset. Co-morbidity of personality disorders was more common in bipolar patients with childhood-onset separation anxiety disorder (C-SepAD). The lifetime prevalence of co-morbidity of specific phobias and number of suicide attempts were significantly higher in the group with A-SepAD. Functionality loss due to feeling of stigmatization was higher, and total functionality as measured by the BDFQ was found to be lower in bipolar patients with A-SepAD.

CONCLUSION

The results of this study have shown that 54% of bipolar patients had a diagnosis of A-SepAD. A-SepAD seems to increase the number of suicide attempts and have negative effects on functionality. A-SepAD should be assessed in regular interviews of patients with bipolar disorder.

Pathways involving traumatic losses, worry about family, adult separation anxiety and posttraumatic stress symptoms amongst refugees from West Papua

There is some evidence that adult separation anxiety disorder (ASAD) symptoms are closely associated with posttraumatic stress disorder (PTSD) amongst refugees exposed to traumatic events (TEs), but the pathways involved remain to be elucidated. A recent study suggests that separation anxiety disorder precedes and predicts onset of PTSD. We examined a path model testing whether ASAD symptoms and worry about family mediated the path from traumatic losses to PTSD symptoms amongst 230 refugees from West Papua. Culturally adapted measures were applied to assess TE exposure and symptoms of ASAD and PTSD. A structural equation model indicated that ASAD symptoms played an important role in mediating the effects of traumatic losses and worry about family in the pathway to PTSD symptoms. Although based on cross-sectional data, our findings suggest that ASAD symptoms may play a role in the path from traumatic losses to PTSD amongst refugees. We propose an evolutionary model in which the ASAD and PTSD reactions represent complementary survival responses designed to protect the individual and close attachments from external threats.

Adult separation anxiety differentiates patients with complicated grief and/or major depression and is related to lifetime mood spectrum symptoms

BACKGROUND

Increasing literature has been focused on complicated grief (CG) and its distinctiveness from other potentially loss related mental disorders such as major depression (MD). In this regard, symptoms of separation distress seem to play a key role. The aim of this study was to compare the clinical features of CG to those of MD and of CG+MD, with particular attention to separation anxiety.

METHODS

Fifty patients with CG (26 with and 24 without MD) and 40 with MD were consecutively recruited. Assessments included: SCID-I/P, Inventory of Complicated Grief (ICG), Adult Separation Anxiety Symptom Questionnaire (ASA-27), Work and Social Adjustment Scale (WSAS), Mood Spectrum-Self Report (MOODS-SR)-lifetime version.

RESULTS

Patients with MD reported significantly higher ASA-27 scores than patients with CG either alone or with MD. In all groups, ASA-27 total scores were significantly correlated with the MOODS-SR total scores and with those of its depressive component and rhythmicity domain. No significant differences were reported in the WSAS scores.

LIMITATIONS

Major limitations are the small sample size and the use of lifetime instruments.

CONCLUSIONS

Our results suggest a correlation between adult separation anxiety symptoms and lifetime mood spectrum symptoms both in patients with CG and MD. Further studies are needed to better understand the role of adult separation anxiety in the development of these disorders and for their nosographic autonomy as well.

Treatment of complicated grief in elderly persons: a randomized clinical trial

IMPORTANCE

Complicated grief (CG) is a debilitating condition, most prevalent in elderly persons. However, to our knowledge, no full-scale randomized clinical trial has studied CG in this population.

OBJECTIVE

To determine whether complicated grief treatment (CGT) produces greater improvement in CG and depressive symptoms than grief-focused interpersonal psychotherapy (IPT).

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial enrolling 151 individuals 50 years or older (mean [SD] age, 66.1 [8.9] years) scoring at least 30 on the Inventory of Complicated Grief (ICG). Participants were recruited from the New York metropolitan area from August 20, 2008, through January 7, 2013, and randomized to receive CGT or IPT. The main outcome was assessed at 20 weeks after baseline, with interim measures collected at 8, 12, and 16 weeks after baseline.

INTERVENTIONS

Sixteen sessions of CGT (n = 74) or IPT (n = 77) delivered approximately weekly.

MAIN OUTCOMES AND MEASURES

Rate of treatment response, defined as a rating from an independent evaluator of much or very much improved on the Improvement subscale of the Clinical Global Impression Scale.

RESULTS

Both treatments produced improvement in CG symptoms. Response rate for CGT (52 individuals [70.5%]) was more than twice that for IPT (24 [32.0%]) (relative risk, 2.20 [95% CI, 1.51-3.22]; P < .001), with the number needed to treat at 2.56. Secondary analyses of CG severity and CG symptom and impairment questionnaire measures confirmed that CGT conferred a significantly greater change in illness severity (22 individuals [35.2%] in the CGT group vs 41 [64.1%] in the IPT group were still at least moderately ill [P = .001]), rate of CG symptom reduction (1.05 ICG points per week for CGT vs 0.75 points per week for IPT [t633 = 3.85; P < .001]), and the rate of improvement in CG impairment (0.63 work and Social Adjustment Scale points per week with CGT and 0.39 points per week with IPT [t503 = 2.87; P = .004]). Results were not moderated by participant age.

CONCLUSIONS AND RELEVANCE

Complicated grief treatment produced clinically and statistically significantly greater response rates for CG symptoms than a proven efficacious treatment for depression (IPT). Results strongly support the need for physicians and other health care providers to distinguish CG from depression. Given the growing elderly population, the high prevalence of bereavement in aging individuals, and the marked physical and psychological impact of CG, clinicians need to know how to treat CG in older adults.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01244295.

Bereavement: course, consequences, and care

This paper discusses each of several potential consequences of bereavement. First, we describe ordinary grief, followed by a discussion of grief gone awry, or complicated grief (CG). Then, we cover other potential adverse outcomes of bereavement, each of which may contribute to, but are not identical with, CG: general medical comorbidity, mood disorders, post-traumatic stress disorder, anxiety, and substance use.

Pre-loss symptoms related to risk of complicated grief in caregivers of terminally ill cancer patients

PURPOSE

A number of studies have underlined a 10-20% prevalence of complicated grief (CG) among caregivers of cancer patients. The study aimed at examining the relationship between pre-loss criteria for CG and post-loss diagnosis of CG and at evaluating the validity and factor structure of a predictive tool, the Inventory of Complicated Grief (ICG), in order to identify the risk of developing CG in a sample of Italian caregivers.

METHODS

Sixty family members of terminally ill patients admitted to hospice and receiving a Palliative Prognostic Score (PaP) predictive 30 day survival time <30% completed the Pre-Death ICG (ICG-PL) (T0). Family members were met again 6 months after the death of their loved one (T1) and submitted to the interview for Complicated Grief (Post-loss interview-PLI).

RESULTS

Caseness for CG was shown in 18.3% of caregivers at T1. ICG-PL score (T0) were higher among those who developed CG at T1 than non-cases. A cut off score ≥49 on the ICG-PL (AUC=0.98) maximized sensitivity (92%) and specificity (98%) on caseness at T1. Pre-loss criteria related to traumatic distress, separation distress and emotional symptoms in general were significantly related to a post-loss diagnosis of CG, while no effect was shown on duration of pre-loss distress.

CONCLUSIONS

The use of short screening tools, like the ICG-PL, may help health care professionals to identify subjects at risk for CG.