Reported early separation anxiety symptoms in patients with panic and generalised anxiety disorders

Separation, self‐disclosure, and social evaluation anxiety as facets of trait social anxiety

In the current article, we propose an expansion of the trait anxiety concept to include interpersonal or social facets of trait anxiety involving separation from significant others and disclosing aspects of the self to others, as a supplement to the existing focus on social evaluation anxiety. Participants in three studies completed a modified version of the Endler Multidimensional Anxiety Scales that included a measure of trait social evaluation anxiety, as well as new measures of trait separation anxiety and trait self‐disclosure anxiety (i.e., three measures of trait social anxiety). Results showed that the social evaluation, separation, and self‐disclosure trait anxiety scales have strong psychometric properties and that they represent distinct but related components of trait anxiety. With respect to validity, the facets of trait social anxiety were predictive of related variables including self‐concealment, anxiety sensitivity, and trait worry. The theoretical and practical implications of a multifaceted approach to trait social anxiety are discussed in terms of an expanded multidimensional interaction model of anxiety. Copyright © 2002 John Wiley & Sons, Ltd.

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.

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.

Separation anxiety and panic disorder in clinically referred youth

This study examined whether youngsters with separation anxiety disorder (SAD) and panic disorder (PD) had experienced more separation-related events than youngsters with SAD (without comorbid PD). We also examined whether age of onset of SAD and comorbidity with other psychological disorders was related to the occurrence of PD. We compared youngsters who were diagnosed with SAD and PD (N=31) with youngsters who were diagnosed with SAD without comorbid PD (N=63) for the number of separation-related events, severity of psychopathology, and parent and child CBCL ratings, age of onset of SAD, and the number of comorbid diagnoses. The findings indicate that youngsters with SAD and PD had a later age of onset of SAD and more extensive psychopathology and functional impairment than youngsters with SAD (without comorbid PD). Contrary to hypothesis, there were no differences between the groups in the occurrence or number of separation-related events.

Childhood separation anxiety and the risk of subsequent psychopathology: Results from a community study

OBJECTIVE

To examine the association between separation anxiety disorder (SAD) and mental disorders in a community sample and to evaluate whether separation anxiety is specifically related to panic disorder with and without agoraphobia.

METHOD

The data come from a 4-year, prospective longitudinal study of a representative cohort of adolescents and young adults aged 14-24 years at baseline in Munich, Germany. The present analyses are based on a subsample of the younger cohort that completed baseline and two follow-up investigations (n = 1,090). DSM-IV diagnoses were made using the Munich Composite International Diagnostic Interview. Cox regressions with time-dependent covariates were used to examine whether prior SAD is associated with an increased risk for subsequent mental disorders.

RESULTS

Participants meeting DSM-IV criteria for SAD were at an increased risk of developing subsequent panic disorder with agoraphobia (PDAG) (HR = 18.1, 95% CI = 5.6-58.7), specific phobia (HR = 2.7, 95% CI = 1.001-7.6), generalized anxiety disorder (HR = 9.4, 95% CI = 1.8-48.7), obsessive-compulsive disorder (HR = 10.7, 95% CI = 1.7-66.1), bipolar disorder (HR = 7.7, 95% CI = 2.8-20.8), pain disorder (HR = 3.5, 95% CI = 1.3-9.1), and alcohol dependence (HR = 4.7, 95% CI = 1.7-12.4). Increased hazard rates for PDAG (HR = 4.2, 95% CI = 1.4-12.1), bipolar disorder type II (HR = 8.1, 95% CI = 2.3-27.4), pain disorder (HR = 1.9, 95% CI = 1.01-3.5), and alcohol dependence (HR = 2.1, 95% CI = 1.1-4.) were also found for subjects fulfilling subthreshold SAD.

CONCLUSIONS

Although revealing a strong association between SAD and PDAG, our results argue against a specific SAD-PDAG relationship. PDAG was neither a specific outcome nor a complete mediator variable of SAD.

Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with panic disorder

Traumatic life events during childhood and parental attitudes are discussed as possible etiological factors for panic disorder (PD). Patients with PD (n = 115) and subjects without a history of psychiatric disorders (n = 124) were investigated using a comprehensive retrospective interview with 203 questions regarding childhood traumatic life events, parental attitudes, family history of psychiatric disorders, and birth risk factors. The frequency of reports of some traumatic childhood experiences was significantly different between patients and controls, including death of father, separation from parents, childhood illness, parents' alcohol abuse, violence in the family, sexual abuse, and other factors. On a 0 to 9 "severe trauma scale" patients had significantly more severe traumatic events (mean score, 1.31; SD 1.21) than control subjects (0.52; SD 0.80; P <.0001). Only 31.3% of the panic patients, but 62.9% of the controls, did not report any severe traumatic events at all (P <.0001). Compared to controls, patients described the attitude of their parents as more restricting and providing less loving care and attention. Patients reported significantly higher rates of psychiatric disorders in their families in general, in particular PD and generalized anxiety disorder. Birth risk factors did not differ significantly. In a logistic regression model, the following possible etiological factors showed a significant influence: family history of anxiety disorders, severe traumatic events during childhood, and unfavorable parental attitudes. The present data support the hypothesis that the etiology of PD is multifactorial and that traumatic life events may be a contributing factor. Owing to the retrospective nature of the data, the results have to be interpreted with caution.

Separation anxiety disorder in children and adolescents: epidemiology, diagnosis and management

This paper provides an overview of the phenomenology, longitudinal outcome data, assessment and management of separation anxiety disorder (SAD) in children and adolescents. SAD is qualitatively different from early worries, and is characterised by an abnormal reactivity to real or imagined separation from attachment figures, which significantly interferes with daily activities and developmental tasks. Different epidemiological studies indicate a prevalence of 4 to 5% in children and adolescents. In contrast to other anxiety disorders, 50 to 75% of children with SAD come from homes of low socioeconomic status. The severity of symptomatology ranges from anticipatory uneasiness to full-blown anxiety about separation, but children are usually brought to the clinician when SAD results in school refusal or somatic symptoms. School refusal is reported in about 75% of children with SAD, and SAD is reported to occur in up to 80% of children with school refusal. Longitudinal studies have suggested that childhood SAD may be a risk factor for other anxiety disorders, but whether this link is specific to, for example, panic disorder and agoraphobia, or whether SAD represents a general factor of vulnerability for a broad range of anxiety disorders is still debated. Most relevant data are reported on nonpharmacological treatments (psychoeducational, behavioural, cognitive-behavioural, family and psychodynamic), and these are the first choice approach in SAD. Controlled studies show efficacy of cognitive-behavioural therapy in children with anxiety disorders and specifically in SAD-school phobia, supporting this approach as the best proven treatment. Pharmacotherapy should be used in addition to behavioural or psychotherapeutic intervention when the child's symptoms have failed to respond to those treatments, and he/she is significantly impaired by the symptoms. Selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRI) have a good adverse effect profile and may be considered as first choice drugs in SAD. When different SSRIs fail to improve symptomatology, a trial with a tricyclic antidepressant (TCA) is indicated, with careful monitoring of cardiac functioning. Because of the adverse effect profile and the potential for abuse and dependence, benzodiazepines should be used only when a rapid reduction of symptomatology is needed, until the SSRI or the TCA have begun to be effective (few weeks). Buspirone should be considered in children who have not responded to other treatments. Further research is needed to confirm efficacy of newer antidepressants (venlafaxine, mirtazapine, nefazodone) in childhood anxiety disorders.

Separation anxiety and actual separation experiences during childhood in patients with panic disorder

OBJECTIVE

The association between separation anxiety in childhood and actual separation experiences during childhood has not yet been investigated in patients with panic disorder.

METHODS

In 115 patients with panic disorder with or without agoraphobia and in 124 control subjects without a history of psychiatric illness, we assessed separation anxiety during childhood, retrospectively, using DSM-IV and ICD-10 criteria and the Separation Anxiety Symptom Inventory (SASI). In addition, actual separation experiences from age 0 to 15 years were assessed, retrospectively.

RESULTS

A total of 22.6% of the patients and 4.8% of the control subjects fulfilled both DSM-IV and ICD-10 criteria for childhood separation anxiety (chi 2 = 11.8; P < 0.0001). Further, 57.4% of the patients and 37.9% of the control subjects reported actual separation experiences during their childhood (chi 2 = 9.09, P < 0.003). Separation anxiety and actual separation experiences, however, were independent of each other.

CONCLUSION

These results suggest that separation anxiety during childhood is not a consequence of actual traumatic separation experiences in panic disorder patients.

Continuities of separation anxiety from early life into adulthood

The study investigates whether a putative diagnosis of separation anxiety disorder can be identified in adulthood and whether there are continuities between juvenile and adult forms of the disorder. Seventy patients with conventional adult diagnoses of panic disorder and generalized anxiety disorder attending an anxiety clinic were administered an interview and checklist to assess separation anxiety (SA) symptoms in adulthood. Memories of early SA were assessed using the Separation Anxiety Symptom Inventory (SASI). A subsample (n = 31) was used to calibrate the checklist against assignment to a category of adult separation anxiety disorder (ASAD) based on the structured interview. In an expanded sample (n = 70), patients assigned to the ASAD category returned statistically higher scores on the SASI, with the severity of juvenile SA symptoms accounting for 33% of the variance of adult SA scores (p < .001). Assignment of subjects to the putative ASAD category was not associated with any conventional adult anxiety diagnosis and symptoms of SA appeared to predate the onset of the other anxiety disorders. One possible explanation for the data is that, in some individuals, early onset separation anxiety disorder may persist into adulthood, but the symptoms may either be overlooked or, alternatively, obscured by secondary features such as panic.

Is early separation anxiety a risk factor for adult panic disorder?: a critical review

Heightened levels of early separation anxiety (SA) have long been linked to the risk of adult panic disorder (PD), suggesting that the two types of anxiety arise from a common diathesis--a proposition that has considerably influenced the classification of the anxiety disorders. However, the SA-PD link remains contentious, with some recent studies failing to confirm that putative association. All published research studies investigating the relationship of early SA to PD and/or other anxiety disorders were reviewed. Taken as a whole, the evidence provides support for the SA-PD hypothesis, although the specificity of that relationship needs further clarification. Problems of sample selection, retrospective measurement of early SA and comorbid diagnoses limit the certainty with which inferences can be drawn from existing data. Nevertheless, a recent community-based study provides additional support for the SA-PD hypothesis. Possible developmental pathways linking SA to PD are considered. One possibility that has not received adequate research attention is that early SA disorder (SAD) may persist into adulthood, rendering the sufferer vulnerable to panic and other anxiety symptoms when confronted with salient life stressors. We conclude that it is premature to reject the SA hypothesis of PD. Only well-designed longitudinal studies can map the complex developmental pathways linking early and later manifestations of morbid anxiety.

Genetic factors in early separation anxiety: implications for the genesis of adult anxiety disorders

An important contemporary conceptualization of anxiety has suggested that heightened early separation anxiety is specifically associated with the risk of adult panic disorder, with hereditary factors underlying that cluster of anxiety disorders. Yet there is a dearth of studies examining whether early separation anxiety is inherited. The present twin study, based on a retrospective approach, revealed a substantial genetic contribution to separation anxiety in females but not in males, with unique environmental influences being important in both gender groups. Although speculative, an evolutionary explanation is offered to account for the apparent gender difference in the inheritance of early separation anxiety. It is hypothesized that, in some women, phylogenetic vestiges of separation anxiety may conflict with their need to compete in an individualistic manner in the modern workplace. Whether such an attachment-autonomy conflict accounts for the increased rate of panic disorder and agoraphobia in women is worthy of further study.

Is early separation anxiety a specific precursor of panic disorder-agoraphobia? A community study

The present study aimed to examine memories of early separation anxiety symptoms in a community sample of women at heightened risk to neurotic disorder. The chief finding was that subjects with a lifetime history of panic disorder-agoraphobia (PD-Ag) returned statistically higher scores on a retrospective measure of early separation anxiety compared to subjects with either generalized anxiety or other phobic disorders, a result which was not accounted for by differences in neuroticism or General Health Questionnaire scores. Although limited by its retrospective design and the problem of co-morbidity in subclassifying the anxiety disorders, the present study does provide added support for the hypothesis--endorsed by DSM-III-R--that there is a developmental link between early separation anxiety and panic disorder.