Prevalence and correlates of estimated DSM-IV child and adult separation anxiety disorder in the National Comorbidity Survey Replication

The Association of Dysfunctional Attitudes and Adult Separation Anxiety in Pregnancy: A Cross-Sectional Study

Background This study aims to examine adult separation anxiety in pregnant women and its relationship with dysfunctional attitudes from the perspective of cognitive theory. Methods The sociodemographic data, Adult Separation Anxiety Questionnaire (ASA-27), and Dysfunctional Attitudes Scale-Revised (DAS-R) questionnaire were utilised to examine the correlation between sociodemographic factors and the ASA and dysfunctional attitudes in women attending antenatal obstetric clinics. Results The study included 190 pregnant women. Of these, 45.8% (n=87) had significant adult separation anxiety disorder (ASAD) symptoms. There was no significant difference between the ASAD (+) and ASAD (-) groups in terms of sociodemographic characteristics (p>0.05). However, a significant association was found between ASAD and the gestational period (p=0.02). DAS-R scores were higher in patients with ASAD symptoms (p<0.001). Positive correlations were observed between DAS-R and perfectionism or achievement and between DAS-R and the need for approval or dependency (p=0.001). DAS-R and gestational week showed potential as predictors of ASAD positivity (Area under the ROC curve (AUC)=0.725 vs. 0.632, respectively). Conclusion Pregnancy can be a sensitive period for the development of separation anxiety in adults. The development and treatment of separation anxiety in adults may benefit from cognitive-behavioural interventions that address dysfunctional attitudes during pregnancy.

COVID-19 and mental health disorders in children and adolescents (Review)

The new coronavirus has been present for two years and has had a widespread and sustained impact worldwide. There is growing evidence in the literature that COVID-19 may have negative effects on mental illness in patients and in healthy populations. The unprecedented changes brought about by COVID-19, such as social isolation, school closures, and family stress, negatively affect people's mental health, especially that of children and adolescents. The purpose of this paper is to review the literature and summarize the impact of COVID-19 disorders on children's and adolescents' mental health, the mechanisms and risk factors, screening tools, and intervention and prevention. We hope that the mental dysfunction caused by the pandemic will be mitigated through appropriate and timely prevention and intervention.

The Relation Between the Paraphilias and Anxiety in Men: A Case-Control Study

Despite a multitude of theoretical views, it is still unclear how individuals develop and sustain paraphilic interests (e.g., sexual attraction to children, interest in non-consensual violence). It is also not clear from these views why many paraphilic interests, and especially many paraphilias and paraphilic disorders, are much more common in men than in women. One possible factor affecting male's higher rate of paraphilias is anxiety, because anxiety can potentiate sexual arousal in men. We speculated that paraphilic interests could develop when feelings of anxiety are recurrently generated by atypical sexual stimuli, and when that anxiety repeatedly potentiates sexual arousal, reinforcing sexual response to atypical stimuli. It follows that men with paraphilic interests are susceptible to anxiety disorders, because an anxiety disorder would facilitate the hypothesized developmental process. We conducted a retrospective file review of 1048 consecutive patients (944 male patients retained for analysis) referred to an outpatient sexual behavior clinic at a psychiatric hospital to investigate the link between paraphilias and anxiety. Male patients with a paraphilia had 1.64 greater odds than male patients without a paraphilia of having been diagnosed with an anxiety disorder, but they also had elevated rates of many other types of disorders. Therefore, there does not seem to be a specific link between paraphilias and anxiety in this sample. The discovery of a general link between the paraphilias and psychological disorders in men opens new avenues for studying the developmental origins and consequences of male paraphilic interests.

Validation of the Children's Separation Anxiety Scale - Parent Version (CSAS-P)

The main objective of this research was to validate the parents’ version of the Children’s Separation Anxiety Scale (CSAS-P), which assesses separation anxiety symptoms in pre-adolescence, the stage with the highest incidence of anxiety disorder due to separation. In Study 1, 1,089 parents, those children aged between 8 and 11 (M = 9.59, SD = 1.11), 51.7% girls, were selected by random cluster sampling, who completed the CSAS-P to obtain the factorial structure. Exploratory factor analysis identified four related factors: Worry, Opposition, Calm, and Distress, which explained 42.93% of the variance. In Study 2, 3,801 parents, those children aged between 8 and 11 (M = 9.50, SD = 1.10), 50.2% girls, completed the CSAS-P, and their children completed the Children’s Separation Anxiety Scale (CSAS). The four related-factor model from Study 1 was validated by confirmatory factor analysis. The CSAS-P had adequate internal consistency (α = 0.84), temporal stability (r = 0.72), and invariance across children’s age and gender and the parent who completed the scale. Age and gender differences were small: older children scored higher on Worry and younger children on Distress; the girls scored higher on all factors. Small differences were also found depending on the parent who completed the scale without finding a clear pattern. Parents scored significantly lower than the child on all four factors of the scale. The results support the reliability and validity of the CSAS-P, an instrument that complements the child’s self-report in the framework of the multi-source assessment.

[Separation anxiety disorder in adults - a new diagnostic category]

Anxiety separation disorder (SAD) became the subject of increased attention of researchers in recent decades. DSM-5 and project of ICD-11 allow us to treat this disorder as an independent nosological unit without attachment to age. The review provides information on the prevalence, clinical manifestations and diagnosis of SAD in adults, summarizes information on the etiopathogenesis, relations to other psychiatric disorders, and highlights the lack of modern therapeutic approaches to SAD. The purpose of this review is to raise the level of knowledge about SAD and its new positioning in classification systems.

Modulation of Fear and Arousal Behavior by Serotonin Transporter (5-HTT) Genotypes in Newly Hatched Chickens

The serotonin transporter (5-HTT) plays a key role in regulating serotonergic transmission via removal of serotonin (5-hydroxytryptamine, 5-HT) from synaptic clefts. Alterations in 5-HTT expression and 5-HT transmission have been shown to cause changes to adult behavior including fear. The objective of the present study was to investigate the 5-HTT role in fear in birds at the very early stages of post-hatching life. Using an avoidance test with an elevated balance beam, which was based on depth perception and the respective fear of heights, we assessed fear-related avoidance behaviors of newly hatched chicks of the three functional 5-HTT genotypes W/W, W/D and D/D. Newly hatched chicks of the genotype D/D, which was linked to high 5-HTT expression, showed less intensive avoidance responses as measured by decreased latency to jump than W/W and W/D chicks. Further, significantly fewer D/D hens than W/W hens showed fear-like behavior that resembled a freezing response. Furthermore, in an arousal test the arousal reaction of the chicks in response to an acute short-term visual social deprivation in the home compartment was assessed 5 weeks after hatching, which also revealed that D/D chicks exhibited decreased arousal reaction, compared to W/W chicks. Thus, the results indicate that fear responses differ in D/D chicks in the early post-hatching periods, possibly due to the different expression of 5-HTT respectively 5-HT levels in this strain.

The diagnostic utility of separation anxiety disorder symptoms: an item response theory analysis

At present, it is not clear whether the current definition of separation anxiety disorder (SAD) is the optimal classification of developmentally inappropriate, severe, and interfering separation anxiety in youth. Much remains to be learned about the relative contributions of individual SAD symptoms for informing diagnosis. Two-parameter logistic Item Response Theory analyses were conducted on the eight core SAD symptoms in an outpatient anxiety sample of treatment-seeking children (N = 359, 59.3 % female, M Age = 11.2) and their parents to determine the diagnostic utility of each of these symptoms. Analyses considered values of item threshold, which characterize the SAD severity level at which each symptom has a 50 % chance of being endorsed, and item discrimination, which characterize how well each symptom distinguishes individuals with higher and lower levels of SAD. Distress related to separation and fear of being alone without major attachment figures showed the strongest discrimination properties and the lowest thresholds for being endorsed. In contrast, worry about harm befalling attachment figures showed the poorest discrimination properties, and nightmares about separation showed the highest threshold for being endorsed. Distress related to separation demonstrated crossing differential item functioning associated with age-at lower separation anxiety levels excessive fear at separation was more likely to be endorsed for children ≥9 years, whereas at higher levels this symptom was more likely to be endorsed by children <9 years. Implications are discussed for optimizing the taxonomy of SAD in youth.

Separation anxiety disorder across the lifespan: DSM-5 lifts age restriction on diagnosis

DSM-5 has lifted the age criterion in the definition of separation anxiety disorder thereby overturning the long-standing convention of restricting the diagnosis to childhood. Previously, adults with separation anxiety symptoms were assigned to other conventional categories such as panic disorder, agoraphobia or generalized anxiety disorder. Over the past two decades, an evolving body of research has identified separation anxiety disorder in adulthood, with 20-40% of adult psychiatric outpatients being assigned that diagnosis. In the US, the lifetime prevalence of the disorder in adulthood is 6.6%. The removal of the age restriction on diagnosis has important implications for clinical practice. Whereas parents (particularly mothers) of children with separation anxiety disorder commonly attracted the diagnosis of agoraphobia, the latter are more likely now to be diagnosed with the adult form of separation anxiety disorder, focusing attention on the importance of intervening with both members of the dyad to overcome mutual reinforcement of symptoms. In addition, adults with separation anxiety disorder have been found to manifest high levels of disability and they tend to show a poor response to conventional psychological and pharmacological treatments. There is an urgent need therefore to devise novel psychological and pharmacological interventions for the adult form of the disorder. The reformulation of separation anxiety disorder in DSM-5 therefore requires a paradigm shift in which clinicians are alerted to identifying and treating the condition in all age groups. Research across countries is needed to examine the new formulation of separation anxiety disorder amongst populations of diverse ethnic and cultural backgrounds.

Adult separation anxiety and TCI-R personality dimensions in patients with anxiety, alcohol use, and gambling: a preliminary report

Background. Nowadays, adult separation anxiety disorder (ASAD) is an established diagnostic category but is little investigated in subjects with addictive behaviours. Objective. To assess the presence of ASAD among patients with addictive disorders in comparison with anxiety patients and measure the personality correlates in all these groups. Methods. 103 outpatients, meeting DSM-IV-TR criteria for anxiety disorders (38 patients), alcohol dependence (30 patients), or pathological gambling (35 patients), were assessed by the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS) and the Adult Separation Anxiety Checklist (ASA-27) for separation anxiety and by the Temperament and Character Inventory-Revised (TCI-R) for personality characteristics. Results. ASAD is detected in 34.2% of anxiety patients, 13.3% of alcoholics, and 11.4% of gamblers. Separation anxiety scores correlate positively with harm avoidance and negatively with self-directedness in all groups; further correlations are seen among addictive patients only, that is, self-transcendence for gamblers and cooperativeness for both alcoholics and gamblers. Conclusions. The prevalence of ASAD is lower among addictive patients than in those with anxiety disorders; correlations are found between separation anxiety and specific TCI-R dimensions, with some matching across the three diagnostic groups.

Male androphilia in the ancestral environment. An ethnological analysis

The kin selection hypothesis posits that male androphilia (male sexual attraction to adult males) evolved because androphilic males invest more in kin, thereby enhancing inclusive fitness. Increased kin-directed altruism has been repeatedly documented among a population of transgendered androphilic males, but never among androphilic males in other cultures who adopt gender identities as men. Thus, the kin selection hypothesis may be viable if male androphilia was expressed in the transgendered form in the ancestral past. Using the Standard Cross-Cultural Sample (SCCS), we examined 46 societies in which male androphilia was expressed in the transgendered form (transgendered societies) and 146 comparison societies (non-transgendered societies). We analyzed SCCS variables pertaining to ancestral sociocultural conditions, access to kin, and societal reactions to homosexuality. Our results show that ancestral sociocultural conditions and bilateral and double descent systems were more common in transgendered than in non-transgendered societies. Across the entire sample, descent systems and residence patterns that would presumably facilitate increased access to kin were associated with the presence of ancestral sociocultural conditions. Among transgendered societies, negative societal attitudes toward homosexuality were unlikely. We conclude that the ancestral human sociocultural environment was likely conducive to the expression of the transgendered form of male androphilia. Descent systems, residence patterns, and societal reactions to homosexuality likely facilitated investments in kin by transgendered males. Given that contemporary transgendered male androphiles appear to exhibit elevated kin-directed altruism, these findings further indicate the viability of the kin selection hypothesis.

Effectiveness of cognitive behavior therapy for severe mood disorders in an acute psychiatric naturalistic setting: a benchmarking study

The current study examined the effectiveness of brief cognitive behavior therapy (CBT) for severe mood disorders in an acute naturalistic setting. The sample included 951 individuals with either major depressive disorder (n = 857) or bipolar disorder with depressed mood (n = 94). Participants completed a battery of self-report measures assessing depression, overall well-being, and a range of secondary outcomes both before and after treatment. We found significant reductions in depressive symptoms, worry, self-harm, emotional lability, and substance abuse, as well as significant improvements in well-being and interpersonal relationships, post-treatment. Comparable to outpatient studies, 30% of the sample evidenced recovery from depression. Comparison of findings to benchmark studies indicated that, although the current sample started treatment with severe depressive symptoms and were in treatment for average of only 10 days, the overall magnitude of symptom improvement was similar to that of randomized controlled trials. Limitations of the study include a lack of control group, a limitation of most naturalistic studies. These findings indicate that interventions developed in controlled research settings on the efficacy of CBT can be transported to naturalistic, "real world" settings, and that brief CBT delivered in a partial hospital program is effective for many patients with severe depressive symptoms.

Preschool anxiety disorders in pediatric primary care: prevalence and comorbidity

OBJECTIVE

We sought to establish prevalence rates and detail patterns of comorbidity for generalized anxiety disorder, separation anxiety disorder, and social phobia in preschool-aged children.

METHOD

The Duke Preschool Anxiety Study, a screen-stratified, cross-sectional study, drew from pediatric primary care and oversampled for children at risk for anxiety. A total of 917 parents of preschool children (aged 2-5 years) completed the Preschool Age Psychiatric Assessment.

RESULTS

Generalized anxiety disorder, separation anxiety disorder, and social phobia are common in preschool-aged children attending pediatric primary care. Three-fourths of preschoolers with an anxiety disorder only had a single anxiety disorder. Generalized anxiety disorder displayed the greatest degree of comorbidity: with separation anxiety disorder (odds ratio [OR] = 4.1, 95% CI = 2.0-8.5), social phobia (OR = 6.4, 95% CI = 3.1-13.4), disruptive behavior disorders (OR = 5.1, 95% CI = 1.6-15.8), and depression (OR = 3.7, 95% CI = 1.1-12.4).

CONCLUSIONS

The weakness of association between generalized anxiety disorder and depression stands in contrast to substantial associations between these 2 disorders reported in older individuals. Attenuated associations in preschool-aged children could translate into clinical opportunities for targeted early interventions, aimed at modifying the developmental trajectory of anxiety disorders.

Separation anxiety avoidance inventory-child and parent version: psychometric properties and clinical utility in a clinical and school sample

The psychometric properties and clinical utility of the Separation Anxiety Avoidance Inventory, child and parent version (SAAI-C/P) were examined in two studies. The aim of the SAAI, a self- and parent-report measure, is to evaluate the avoidance relating to separation anxiety disorder (SAD) situations. In the first study, a school sample of 384 children and their parents (n = 279) participated. In the second study, 102 children with SAD and 35 children with other anxiety disorders (AD) were investigated. In addition, 93 parents of children with SAD, and 35 parents of children with other AD participated. A two-factor structure was confirmed by confirmatory factor analysis. The SAAI-C and SAAI-P demonstrated good internal consistency, test-retest reliability, as well as construct and discriminant validity. Furthermore, the SAAI was sensitive to treatment change. The parent-child agreement was substantial. Overall, these results provide support for the use of the SAAI-C/P version in clinical and research settings.

ADad 3: the epidemiology of Anxiety Disorders among adolescents in a rural community population in India

OBJECTIVES

Despite being the most common mental health concern, there is paucity of literature on the epidemiology of anxiety disorders among the adolescent population in India. This study aimed to estimate the period prevalence of Anxiety Disorders (AD) among 11 to 19 y old adolescents in India.

METHODS

A representative sample of adolescents (N = 500) from a rural community in Southern India was assessed for the period prevalence of all and specific Anxiety Disorders using Screen for Child Anxiety Related Emotional Disorders (SCARED), and confirmed in a subsequent interview with Schedule for Affective Disorders and Schizophrenia for School-Age Children/Present and Lifetime Version (K-SADS-PL).

RESULTS

The prevalence for all AD using the international, Indian SCARED cut-offs and DSM-IV-TR criteria was 8.6 % (boys = 2%; girls = 6.6%), 25.8% (boys = 6.6%; girls = 19.2%) and 14.4 % (boys = 4.8%; girls = 9.6%) respectively. There were significant gender differences in the prevalence for all Anxiety Disorders (χ (2) = 3.61, df = 1; P < 0.05), Separation Anxiety Disorder (χ (2) = 22.27, df = 1; P < 0.001) and Social Anxiety Disorder (χ(2) = 4.29, df = 1; P < 0.03). Significant age difference in the prevalence of Panic Disorder (χ(2) = 10.32; df = 1; P = 0.00) and Generalized Anxiety Disorder (χ(2) = 5.87; df = 1; P = 0.05) was noted.

CONCLUSIONS

The prevalence of Anxiety Disorders in South Indian adolescents was higher than found in the western literature. Prevalence of specific AD was age and gender specific. Adolescent and mental health policies must integrate anxiety disorder of public health significance.

ADad 6: the predictive factors for Anxiety Disorders among adolescents in a rural community population in India

OBJECTIVE

Development of Anxiety Disorders (AD) among adolescents is the interplay of risk and protective factors that have a biological and environmental basis. This study documents the predictive factors associated with the presence of AD among adolescents in India.

METHODS

The authors prospectively collected data for 500 adolescents in a community with independent, trained raters. Data on the dependent variable of AD and its subtypes was collected with Screen for Child Anxiety Related Emotional Disorders (SCARED), Socio-economic status with Modified Kuppuswamy Scale, depression with Beck Depression Inventory and the other independent variables with a specially designed proforma. The predictive factors for the presence of AD were analyzed with univariate and multivariate regression analyses appropriately, and a parsimonious predictive model was built.

RESULTS

Gender (adjusted OR = 1.96), and presence of Depressive Disorder (adjusted OR = 24.14) emerged as independent risk factors. Level of education came-out as a protective factor (adjusted OR = 0.66). Adolescent girls were at risk of developing Separation Anxiety Disorder (SeAD) (adjusted OR = 3.51) and Social Anxiety Disorder (SoAD) (adjusted OR = 1.69). Level of education had a protective influence on SeAD (adjusted OR = 0.39) and SoAD (adjusted OR = 0.59) among those doing high school. This protective effect increased if they were in higher-secondary school for SeAD (adjusted OR = 0.21) and SoAD (adjusted OR = 0.22). In the multivariate model age of the adolescent also gained significance and the 3-factor model had a good model fit. Panic Disorder and Generalized Anxiety Disorder were not related to any specific variable.

CONCLUSIONS

Identifying the factors associated with AD and the subtypes can be used to predict, prevent or treat these disorders in this population. Educating adolescent girls to higher-secondary school level seem to be an important step in this direction.

Responses to voluntary hyperventilation in children with separation anxiety disorder: implications for the link to panic disorder

BACKGROUND

Biological theories on respiratory regulation have linked separation anxiety disorder (SAD) to panic disorder (PD). We tested if SAD children show similarly increased anxious and psychophysiological responding to voluntary hyperventilation and compromised recovery thereafter as has been observed in PD patients.

METHODS

Participants were 49 children (5-14 years old) with SAD, 21 clinical controls with other anxiety disorders, and 39 healthy controls. We assessed cardiac sympathetic and parasympathetic, respiratory (including pCO2), electrodermal, electromyographic, and self-report variables during baseline, paced hyperventilation, and recovery.

RESULTS

SAD children did not react with increased anxiety or panic symptoms and did not show signs of slowed recovery. However, during hyperventilation they exhibited elevated reactivity in respiratory variability, heart rate, and musculus corrugator supercilii activity indicating difficulty with respiratory regulation.

CONCLUSIONS

Reactions to hyperventilation are much less pronounced in children with SAD than in PD patients. SAD children showed voluntary breathing regulation deficits.

Pediatric anxiety disorders

Anxiety disorders are the most common group of psychiatric disorders in children and adolescents. Anxiety disorders in children and adolescents can be chronic and disabling, and they can increase the risk of comorbid disorders. Anxiety is associated with substantial negative effects on children's social, emotional and academic success. Identifying and treating children and adolescents with anxiety disorders would reduce the burden of this disorder and may help in better management of the co-morbid conditions in these patients.

Birth order and avuncular tendencies in Samoan men and fa'afafine

Androphilia refers to sexual attraction and arousal to males whereas gynephilia refers to sexual attraction and arousal to females. In Samoa, transgendered androphilic males are known locally as fa'afafine. Previous research has shown that, compared to Samoan gynephilic men, fa'afafine report greater willingness to invest time and money toward nieces and nephews (i.e., greater avuncular tendencies) and also have greater numbers of older brothers and older sisters. The present study examined whether the Samoan male sexual orientation difference in avuncular tendencies could be accounted for by these parallel differences in numbers of older brothers and older sisters. The sample included 204 fa'afafine and 272 Samoan gynephilic men from our Samoan data archive for whom we had concurrent information on (1) a measure of willingness to invest time and money in nieces and nephews (i.e., avuncular tendencies) and (2) numbers of older and younger biological brothers and sisters. Among fa'afafine, but not Samoan gynephilic men, number of older brothers and number of older sisters were both significantly positively associated with avuncular tendencies. When controlling for number of older brothers, the magnitude of the male sexual orientation difference in avuncular tendencies was lowered, but remained statistically significant. In contrast, when controlling for number of older sisters, the male sexual orientation difference in avuncular tendencies ceased to exist. Discussion detailed how these findings help hone in on the proximate basis of elevated avuncular tendencies among fa'afafine. In addition, discussion focused on how particular evolutionary and cultural factors might relate to the avuncularity of fa'afafine.

Overlap of symptom domains of separation anxiety disorder in adulthood with panic disorder-agoraphobia

There is a need to explain the high level of comorbidity between separation anxiety disorder (SAD) in adulthood and panic disorder with agoraphobia (Pd-Ag). One possibility is that inadequate specification of symptom domains and/or diagnostic questions accounts for some of the comorbidity. The present anxiety clinic study examined responses of adult patients (n = 646) with SAD and/or Pd-Ag on eight symptom domains based on a previous factor analysis of a commonly used separation anxiety measure, the ASA-27, as well as on the Anxiety Sensitivity Index. We also examined questionnaire items that did not load on the factor structure. All separation anxiety domains distinguished strongly between SAD and Pd-Ag. Comparisons across three groups (SAD alone, Pd-Ag alone and comorbid SAD/Pd-Ag) revealed that two symptom domains (anxiety about embarking on trips, and sleep disturbances) showed some overlap between Pd-Ag and SAD. Two of the items of the ASA-27 that did not load with other items in the factor analysis also showed overlap with Pd-Ag, with both referring to anxieties about leaving home. Patients with SAD (with or without Pd-Ag) returned higher scores on anxiety sensitivity than those with Pd-Ag alone. The findings support the distinctiveness of the construct of SAD and the capacity of the ASA-27 to discriminate between that disorder and Pd-Ag. SAD appears to be a more severe form of anxiety than Pd-Ag. There may be a need to refine items to include the reasons for avoiding leaving home, reluctance to sleep alone and to embark on trips, to ensure accurate discrimination between Pd-Ag and SAD in adulthood.

Does the vigilance-avoidance gazing behavior of children with separation anxiety disorder change after cognitive-behavioral therapy?

Cognitive biases are of interest in understanding the development of anxiety disorders. They also play a significant role during psychotherapy, where cognitive biases are modified in order to break the vicious cycle responsible for maintaining anxiety disorders. In a previous study, the vigilance-avoidance pattern was shown in children with separation anxiety disorder (In-Albon et al. Journal of Abnormal Child Psychology 38:225-235, 2010). The exhibited avoidance pattern may be essential for the maintenance of the anxiety disorder. Therefore, in the present study we used eye tracking methodology presenting disorder specific pictures to examine possible changes in the vigilance-avoidance pattern in 18 children with separation anxiety disorder after cognitive-behavioral treatment (CBT) and 13 healthy controls. Results indicated that following treatment, the vigilance pattern of children with separation anxiety disorder reduced significantly. Thus, the vigilance-avoidance pattern can be modified by CBT.

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

BACKGROUND

Recent epidemiological studies indicate that separation anxiety disorder occurs more frequently in adults than children. Data from literature suggest that Adult Separation Anxiety Disorder (ASAD) may develop after a bereavement or threat of loss. Research has demonstrated that bereaved persons may present a clinically significant grief reaction, defined as Complicated Grief (CG) that causes a severe impairment in the quality of life. The aim of this study was to evaluate the relationship between ASAD and CG in a large cohort of outpatients with mood and anxiety disorders.

METHODS

Study participants comprised 454 adult psychiatric outpatients with DSM-IV mood or anxiety disorders diagnoses. Diagnostic assessments were performed using the SCID-I; ASAD was assessed using an adapted version of the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS-adult). Complicated grief symptoms were assessed by the Inventory of Complicated Grief (ICG). Social and work impairments were evaluated using the Sheehan Disability Scale (SDS). Adult attachment styles were assessed by the Relationship Questionnaire (RQ).

RESULTS

The overall frequency of ASAD in our sample was 43% and that of CG was 23%. Individuals with CG had a greater frequency of ASAD (56%) with respect to those without CG (40%). Subjects with CG plus ASAD reported higher scores on ICG and greater impairment on quality of life, as measured with SDS, than CG patients without ASAD.

CONCLUSIONS

Adult separation anxiety disorder occurs in a high proportion of adult psychiatric outpatients with complicated grief. The association between these two conditions should be further investigated in light of their clinical implications.

Hypersensitivity to 35% carbon dioxide in patients with adult separation anxiety disorder

BACKGROUND

Adults with panic disorder (PD) and children with separation anxiety disorder (CSAD) show higher reactivity to CO(2). Our hypothesis was patients with adult separation anxiety disorder (ASAD) would show similar hypersensitivity to CO(2). In the present study, we determined whether sensitivity to CO(2) was enhanced in adult patients with separation anxiety disorder with no history of panic attacks.

METHODS

Patients with PD (n=38), adult separation anxiety disorder (ASAD) patients with no history of panic attacks (n=31), and healthy subjects (n=40) underwent a 35% CO(2) inhalation challenge procedure. Baseline and post-inhalation anxiety were assessed with the Acute Panic Inventory, Visual Analog Scale, and Anxiety Sensitivity Index-3 (ASI-3).

RESULTS

As hypothesized the rate of CO(2)-induced panic attacks was significantly greater in PD and ASAD patient groups (55.3% and 51.6% respectively) than healthy comparison group (17.5%). Nine (69.2%) of 13 patients in PD group who have ASAD concurrent with PD had a CO(2)-induced panic attack. ASI-3 total scores were not different between PD and ASAD groups and both were significantly higher than controls. However, anxiety sensitivity did not predict the occurrence of panic attacks.

LIMITATIONS

The researchers were not blind to the diagnosis and there was no placebo arm for comparison. Besides, parameters of respiratory physiology were not evaluated.

CONCLUSION

ASAD was associated with CO(2) hypersensitivity quite similar to PD. This finding partly unfolds the complex relationship of 'CSAD, PD, and CO(2) hypersensitivity' and indicates that CO(2) hypersensitivity and separation anxiety extend together beyond childhood.

Genetic and environmental contributions to separation anxiety: a meta-analytic approach to twin data

BACKGROUND

Separation anxiety disorder (SAD) and separation anxiety symptoms (SA) have been studied both epidemiologically and genetically; however, large between-studies discrepancies emerge relative to the role of genetic, shared-, and nonshared environmental influences on these conditions.

METHODS

Based upon available literature, 18 cohorts and 31,859 subjects belonging to twin samples in Europe, the United States, and Australia were included in three meta-analytic estimations of: the standardized variance components of etiological influences on SAD/SA, and on the effect of sex and rater.

RESULTS

Meta-analytic estimations carried out on all cohorts showed that within-family (genetic 43% and shared environmental 17%) factors explain most of individual differences for SAD/SA. Meta-heritability estimates were higher among females (.52) than males (.26), whereas nonshared environmental effects were stronger for the latter (.74) than for the former (.41). When SAD/SA was rated by parents, the shared environmental influences were higher than those obtained with self-assessment instruments (.23 versus .05), but this may reflect an age difference between subsamples.

CONCLUSIONS

A shared environmental effect is present and important in SAD/SA. Our results support at an etiological level the involvement of parents in treating SAD/SA in children, and the provision of specific strategies to parents to manage their own anxiety.

Temperament and character dimensions of patients with adult separation anxiety disorder

BACKGROUND

There is growing evidence suggesting that separation anxiety can occur in adults. We aimed to determine temperament and character dimensions in patients with adult separation anxiety disorder (ASAD) compared to patients with panic disorder (PD) and healthy subjects.

METHODS

The study sample included 77 outpatients with ASAD, 44 outpatients with a PD with or without agoraphobia diagnosis, and 35 healthy subjects. ASAD diagnoses were confirmed with Structured Clinical Interview for Separation Anxiety Symptoms. Other measures included Adulthood Separation Anxiety Checklist, Separation Anxiety Symptom Inventory, and Temperament and Character Inventory (TCI). Group comparisons according to presence or absence of PD comorbidity in ASAD were also done.

RESULTS

Patients with ASAD scored higher in harm avoidance (HA) and scored lower in self-directedness (SD) compared to PD and control groups. Moreover, both PD patients and ASAD patients scored higher in RD, and self-transcendence dimensions than control subjects. All subscales of HA (anticipatory worry, fear of uncertainty, shyness, and fatigability) were significantly higher than controls. While HA scores were not different between ASAD and 'ASAD+PD' patients, HA levels of both groups were higher than PD alone and control groups. SD scores of patients with ASAD were lower than PD and control groups.

LIMITATIONS

Cross-sectional design and ASAD group have other anxiety disorders comorbidity which might affect the results.

CONCLUSION

Similar to PD and other anxiety disorders HA and RD was higher, and SD was lower in patients with ASAD compared to healthy subjects. Observed TCI profile is related to the ASAD itself since depression comorbidity was controlled.

Separation anxiety disorder in children: disorder-specific responses to experimental separation from the mother

BACKGROUND

Separation anxiety disorder (SAD) is one of the most common anxiety disorders in childhood and is predictive of adult anxiety disorders, especially panic disorder. However, the disorder has seldom been studied and the attempt to distinguish SAD from other anxiety disorders with regard to psychophysiology has not been made. We expected exaggerated anxiety as well as sympathetic and respiratory reactivity in SAD during separation from the mother.

METHOD

Participants were 49 children with a principal diagnosis of SAD, 21 clinical controls (CC) with a principal diagnosis of anxiety disorder other than SAD, and 39 healthy controls (HC) not meeting criteria for any current diagnosis. Analyses of covariance controlling for age were used to assess sympathetic and parasympathetic activation (preejection period and respiratory sinus arrhythmia) as well as cardiovascular (heart rate, mean arterial pressure, total peripheral resistance), respiratory (total breath time, minute ventilation, tidal volume, end-tidal CO(2) , respiratory variability), electrodermal, and self-report (anxiety, cognitions, symptoms) variables during baseline, 4-min separation from, and reunion with the mother.

RESULTS

Children with a diagnosis of SAD were characterized by elevated self-reported anxiety responses to separation and increased sympathetic reactivity compared with CC and HC groups. The SAD group also displayed greater vagal withdrawal and higher reactivity in multiple cardiovascular, respiratory, and electrodermal measures compared with the HC group, while corresponding responses were less in the CC group and not significantly different from the other groups.

CONCLUSIONS

Separation from the mother elicits greater autonomic, respiratory, and experiential responses in children with SAD. Our findings based on brief experimental separation demonstrate differential subjective and physiological manifestations of specific anxiety diagnoses, thus supporting the validity of the diagnostic category of SAD.

Recalled separation anxiety and gender atypicality in childhood: a study of Canadian heterosexual and homosexual men and women

The current study tested the hypothesis that elevated childhood separation anxiety is associated with female-typical childhood behavior and identity by comparing retrospective reports of heterosexual and homosexual men and women (N = 399). Participants completed measures of recalled childhood separation anxiety and childhood gender-atypical behavior and identity. Heterosexual men reported significantly less childhood separation anxiety relative to all other groups. Childhood gender atypicality was significantly positively correlated with childhood separation anxiety among homosexual men, but not among members of other participant groups. Discussion focused on the implications of these findings for the proposed hypothesis as well as future directions for research examining the bases of developmental associations among sex, sexual orientation, gender atypicality, and childhood separation anxiety.

Trends in psychopathology across the adolescent years: what changes when children become adolescents, and when adolescents become adults?

BACKGROUND

Little is known about changes in the prevalence of psychiatric disorders between childhood and adolescence, and adolescence and adulthood.

METHODS

We reviewed papers reporting prevalence rates of psychiatric disorders separately for childhood, adolescence, and early adulthood. Both longitudinal and cross-sectional papers published in the past 15 years were included.

RESULTS

About one adolescent in five has a psychiatric disorder. From childhood to adolescence there is an increase in rates of depression, panic disorder, agoraphobia, and substance use disorders (SUD), and a decrease in separation anxiety disorder (SAD) and attention-deficit hyperactivity disorder (ADHD). From adolescence to early adulthood there is a further increase in panic disorder, agoraphobia, and SUD, and a further decrease in SAD and ADHD. Other phobias and disruptive behavior disorders also fall.

CONCLUSIONS

Further study of changes in rates of disorder across developmental stages could inform etiological research and guide interventions.

Traits of separation anxiety in childhood: a retrospective study of Samoan men, women, and fa'afafine

Gender Identity Disorder in Childhood (GIDC) and Separation Anxiety Disorder have been found to be co-morbid for boys in Western populations. In a Samoan cultural context, fa'afafine are defined as androphilic males (i.e., biological males who are sexually attracted to and aroused by adult males) who are effeminate or transgendered and occupy an "alternative" gender role category, which is distinct from the gender normative categories of "man" and "woman." Because some Western clinicians would likely conclude that many of the fa'afafine had GIDC, we examined whether adult fa'afafine would also recall traits indicative of elevated separation anxiety in childhood. Given this, the present study compared retrospective reports of childhood separation anxiety for Samoan men, women, and fa'afafine. Our results indicated that Samoan fa'afafine recalled significantly more separation anxiety in childhood compared to Samoan men and women. These findings, coupled with research on U.S. and Canadian boys with GIDC, suggest that separation anxiety in childhood may represent a universal pattern of psychosexual development shared by most gender-atypical, androphilic males, regardless of their cultural milieu. As such, this study adds to a growing body of literature that documents the existence of cross-culturally invariant behavioral and psychological traits in male androphiles.

Children suffering from separation anxiety disorder (SAD) show increased HPA axis activity compared to healthy controls

RESEARCH QUESTIONS

Separation anxiety disorder (SAD) is one of the most common mental disorders in childhood, and one of the earliest emerging. Little is known about the association between SAD and the hypothalamic-pituitary-adrenocortical (HPA) axis activity. Therefore, the present study aimed at investigating this association in children suffering from separation anxiety compared to healthy controls.

METHODS

A total of 31 children with diagnosed SAD (mean age: 8.45; 17 females, 14 males) and 25 healthy controls (HC; mean age: 9.74; 12 females, 13 males) took part in the study. All participants underwent psycho-physiological testing for HPA axis challenge. Testing consisted of a separation and a social exposure paradigm. Saliva samples to assess HPA axis-related cortisol secretion were gathered in parallel.

RESULTS

Compared to healthy controls, children with SAD showed greatly increased HPA axis activity, as reflected by an increased cortisol secretion throughout the entire period of investigation. The rise of cortisol was already observed in anticipation of, but not following the separation paradigm. No gender-related differences of cortisol secretion were observed.

CONCLUSIONS

Separation anxiety disorder (SAD) in children is reflected in greatly increased HPA axis activity. Compared to healthy controls, children with SAD showed increased cortisol values from the beginning of, and throughout, the entire investigation. This pattern of results suggests that both the anticipation of a separation and a persistent hyperactivity of the HPA axis system leads to an increased cortisol secretion.

[How do children with separation anxiety disorder develop after inpatient treatment?]

Separation anxiety in children with severe school refusal evokes often worry about the future with regard to professional career and social integration. This study highlights the native outcome of inpatient children with separation anxiety disorder. 18 of 24 children, who required at the age of 6-13 years between 1996-2002 inpatient treatment because of separation anxiety disorder were assessed at follow up. Diagnostic Interview for Mental Disorders in Children and Adolescents (Unnewehr et al. 2005) was used and academic and social outcome was explored. The follow-up time ranged from 4.3 to 11.1 years (average 7.1 years). Mean age was 18.4 years at time of follow-up. We found at least one clinical psychiatric diagnosis in one third of all patients at follow-up. Even more of the formerly inpatients reported subthreshold psychic symptoms (55%). The mental outcome was strongly related to comorbid diagnosis at time of inpatient care. Estimated remission rate for separation anxiety disorder was high (89%). The results revealed an important shift of diagnosis to social phobia in one third of cases. There was no incidence of agoraphobic or panic disorders. The majority of young people considered academic outcome satisfactory but reported pronounced problems in social integration. The mental stress of young people with a former severe separation anxiety after an average time of seven years was high, especially for social phobic symptoms. The results are discussed in view of further therapeutic implications.

Separation anxiety disorder in OCD

BACKGROUND

A history of separation anxiety disorder (SAD) is frequently reported by patients with obsessive-compulsive disorder (OCD). The purpose of this study was to determine if there are clinical differences between OCD-affected individuals with, versus without, a history of SAD.

METHODS

Using data collected during the OCD Collaborative Genetic Study, we studied 470 adult OCD participants; 80 had a history of SAD, whereas 390 did not. These two groups were compared as to onset and severity of OCD, lifetime prevalence of Axis I disorders, and number of personality disorder traits.

RESULTS

OCD participants with a history of SAD were significantly younger than the non-SAD group (mean, 34.2 versus 42.2 years; P<.001). They had an earlier age of onset of OCD symptoms (mean, 8.0 versus 10.5 years; P<.003) and more severe OCD, as measured by the Yale-Brown Obsessive Compulsive Scale (mean, 27.5 versus 25.0; P<.005). In addition, those with a history of SAD had a significantly greater lifetime prevalence of agoraphobia (odds ratio (OR) = 2.52, 95% confidence interval (CI) = 1.4-4.6, P<.003), panic disorder (OR = 1.84, CI = 1.03-3.3 P<.04), social phobia (OR = 1.69, CI 1.01-2.8, P<.048), after adjusting for age at interview, age at onset of OCD, and OCD severity in logistic regression models. There was a strong relationship between the number of dependent personality disorder traits and SAD (adjusted OR = 1.42, CI = 1.2-1.6, P<.001).

CONCLUSIONS

A history of SAD is associated with anxiety disorders and dependent personality disorder traits in individuals with OCD.

Brief report--associations of personality disorder with early separation anxiety in patients with adult separation anxiety disorder

A recent study has suggested a link between early separation anxiety and personality disorder. It is possible that this relationship is mediated or confounded by the presence of adult separation anxiety disorder (ASAD). In a clinic study of 397 anxiety patients, we found that ASAD patients with heightened early separation anxiety had higher rates of any Cluster C personality disorder compared to ASAD patients without elevated early separation anxiety, and higher rates of any Cluster B or C personality disorder compared to anxiety patients with low early separation anxiety and no ASAD. Although cross-sectional in design, the study supports a direct link between early separation anxiety and some adult personality disorders, irrespective of the type of adult anxiety disorder present, including ASAD.

An evolutionary examination of telemedicine: a health and computer-mediated communication perspective

Telemedicine, the use of advanced communication technologies in the healthcare context, has a rich history and a clear evolutionary course. In this paper, the authors identify telemedicine as operationally defined, the services and technologies it comprises, the direction telemedicine has taken, along with its increased acceptance in the healthcare communities. The authors also describe some of the key pitfalls warred with by researchers and activists to advance telemedicine to its full potential and lead to an unobstructed team of technicians to identify telemedicine's diverse utilities. A discussion and future directions section is included to provide fresh ideas to health communication and computer-mediated scholars wishing to delve into this area and make a difference to enhance public understanding of this field.

Oxytocin receptor polymorphisms and adult attachment style in patients with depression

Much evidence of an association between specific attachment styles and depression prompted us to investigate, in depressive disorders, the potential role of polymorphisms within the gene encoding the receptor of the main neurohormone involved in attachment processes, oxytocin. For this purpose, two single nucleotide polymorphisms (SNPs), 6930G>A (rs53576) and 9073G>A (rs2254298), within the oxytocin receptor gene (OXTR), were studied in a cohort of 185 patients with major depression (50.3%) or bipolar I or II disorders (49.7%) and 192 matched healthy controls. A positive association between the GG genotype of OXTR SNPs (6930G>A or 9073G>A) and unipolar depression was demonstrated. In this group, GG individuals showed high scores on Attachment Style Questionnaire factors that have been previously associated with depression. Moreover, the GG genotype was also associated with high levels of adult separation anxiety. These findings support the involvement of the oxytocinergic system in the mechanisms that underlie depression and specific adult attachment styles.

Development and Preliminary Evaluation of a 1-Week Summer Treatment Program for Separation Anxiety Disorder

Numerous clinical trials have demonstrated the efficacy of cognitive behavior therapy (CBT) for the treatment of childhood Separation Anxiety Disorder (SAD) and other anxiety disorders (Velting, Setzer, & Albano, 2004), yet additional research may still be needed to better access and engage anxious youth (Kendall, Suveg, & Kingery, 2006). In this study, we investigated the acceptability and preliminary utility of a group cognitive-behavioral intervention for school-aged girls with SAD provided within an intensive, 1-week setting. The development of the proposed treatment strategy, a 1-week summer treatment program, was predicated on evidence supporting the need for childhood treatments that are developmentally sensitive, allow for creative application of intervention components, incorporate a child's social context, and ultimately establish new pathways for dissemination to the community. The summer treatment program for SAD was pilot-tested using a case-series design with 5 female children, aged 8 to 11, each with a principal diagnosis of SAD. For 4 of the 5 participants, treatment gains were evidenced by changes in diagnostic status, significant reductions in measures of avoidance, and improvements on self- and parent-report measures of anxiety symptomology. Specifically, severity of SAD symptoms decreased substantially at posttreatment for each participant and, 2 months following treatment, none of the participants met diagnostic criteria for the disorder. A fifth participant experienced substantive improvement in diagnostic status prior to the onset of treatment and, though she evidenced continued improvements following treatment, the role of the intervention in such improvements is less clear.

Mutation analysis of oxytocin gene in individuals with adult separation anxiety

Individuals with a diagnosis of adult separation anxiety (ASAD) have extreme anxiety about separations, actual or imagined, from major attachment figures. ASAD might represent a psychological/behavioral model for research probably involving a dysregulation of those neurobiological mechanisms of attachment, in particular central oxytocin (OT), described in numerous animal studies. As experimental strategy, we chose the nucleotidic sequencing of the human OT gene of patients with ASAD to evaluate whether OT mutations were related to potential alteration of its production. With this aim, mutation scanning of proximal promoter and untranslated and coding regions of the OT gene was carried out in 36 patients with ASAD, 14 patients without ASAD, and 26 controls. No mutations were found in promoter and coding regions of the OT gene in our population. One rare 3'UTR single nucleotide variant (rs17339677) and one intron 2 molecular variant (rs34097556), which showed a high frequency, were evidenced. There was no significant difference in the genotype distribution of this intron 2 polymorphism between patients and healthy individuals. Further research is needed to investigate the association between ASAD and OT peptide and receptor polymorphisms.

Anxiety disorders and posttraumatic stress disorder update

Anxiety disorders are one of the most common categories of psychopathology in children and adolescents. This article provides an overview of several anxiety disorders that are diagnosed often during childhood and adolescence, including separation anxiety disorder, generalized anxiety disorder, social phobia, obsessive-compulsive disorder, and posttraumatic stress disorder. Although anxiety disorders commonly show similar clinical characteristics during childhood and adulthood, this article highlights some of the differences that may present across the life span.

SEPARATION ANXIETY DISORDER IN YOUTH: PHENOMENOLOGY, ASSESSMENT, AND TREATMENT

Separation Anxiety Disorder (SAD) is the most commonly diagnosed and impairing childhood anxiety disorder, accounting for approximately 50% of the referrals for mental health treatment of anxiety disorders. While considered a normative phenomenon in early childhood, SAD has the potential to negatively impact a child's social and emotional functioning when it leads to avoidance of certain places, activities and experiences that are necessary for healthy development. Amongst those with severe symptoms, SAD may result in school refusal and a disruption in educational attainment. This paper provides a comprehensive review of the current literature on SAD etiology, assessment strategies, and empirically supported treatment approaches. New and innovative approaches to the treatment of SAD that also employ empirically supported techniques are highlighted. In addition, future directions and challenges in the assessment and treatment of SAD are addressed.