Separation anxiety disorder

Essential (Required) Features:

• Marked and excessive fear or anxiety about separation from those individuals to whom the person is attached (i.e., with whom the individual has a deep emotional bond). In children and adolescents, key attachment figures that are most commonly the focus of separation anxiety include parents, caregivers, and other family members, and the fear or anxiety is beyond what would be considered developmentally normative. In adults, separation anxiety most often involves a spouse, romantic partner, or children. Manifestations of fear or anxiety related to separation depend on the individual’s developmental level, but may include:
• Persistent thoughts that harm or some other untoward event (e.g., being kidnapped) will lead to separation.
• Reluctance or refusal to go to school or work.
• Recurrent excessive distress (e.g., tantrums, social withdrawal) related to being separated from the attachment figure.
• Reluctance or refusal to go to sleep without being near the attachment figure.
• Recurrent nightmares about separation.
• Physical symptoms such as nausea, vomiting, stomachache, headache, on occasions that involve separation from the attachment figure, such as leaving home to go to school or work.
• The symptoms are not transient, that is, they persist for an extended period of time (e.g., at least several months).
• The symptoms are not better accounted for by another mental disorder (e.g., Agoraphobia, Personality Disorder).
• The symptoms result in significant distress about experiencing persistent anxiety symptoms or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Additional Clinical Features:

• Separation Anxiety Disorder frequently co-occurs with other Mental, Behavioural or Neurodevelopmental Disorders. In children and youth, common co-occurring disorders include Generalized Anxiety Disorder and Specific Phobia. In adults, frequently co-occurring disorders include Mood Disorders and Anxiety or Fear-Related Disorders, Post-Traumatic Stress Disorder, and Personality Disorder.
• Although Separation Anxiety Disorder may exhibit a lifelong course with onset in childhood, a significant proportion of adults with Separation Anxiety Disorder do not recall a childhood onset.
• Separation Anxiety Disorder in childhood is frequently associated with a parenting style that interferes with the development of autonomy and self-mastery expected for that person’s cultural context (e.g., parent does not permit child to independently engage in basic activities of daily living such as dressing and bathing).

Boundary with Normality (Threshold):

• Many situations involving separation are associated with other potential stressors or are normal sources of anxiety (e.g., leaving home to start a job or attend university in a new city). Separation Anxiety Disorder is differentiated based on the focus of apprehension being on separation from a key attachment figure rather than on other aspects of adjusting to novel circumstances.
• Strong attachment to loved ones is a normal and healthy part of life and separation from these individuals may be associated with transient sadness or anxiety. Preschool children may show a moderate or even greater degree of anxiety over real or threatened separation from people to whom they are attached. These reactions are considered developmentally appropriate and differentiated from Separation Anxiety Disorder on the basis of the persistence of the symptoms (e.g., lasting for several months) with repeated separations, evidence of excessive preoccupations about the well-being of attachment figures, persistent avoidance, and significant distress or impairment in functioning as a consequence of the symptoms.
• Among children and youth, school refusal is a common occurrence and may be based on transient anxiety about separation from a loved one or be symptomatic of Separation Anxiety Disorder. However, especially in adolescence, anxiety about school or school refusal is not typically related to fear of separation but rather to other factors such as truancy, peer rejection, or bullying.

Course Features:

• The typical onset of Separation Anxiety Disorder is during childhood and the disorder can persist into adulthood. Initial disorder onset during adolescence and adulthood may be less common.
• Separation Anxiety Disorder has been associated with elevated risk of developing a wide range of internalizing disorders including Depressive Disorders, and Bipolar Disorders, and Anxiety or Fear-Related Disorders. There is also evidence of elevated risk of Disruptive Behaviour or Dissocial Disorders, and Attention Deficit Hyperactivity Disorder.

Developmental Presentations:

• Anxiety or Fear-Related Disorders are the most prevalent mental disorders of childhood and adolescence. Among these disorders, Separation Anxiety Disorder is one of the most common in young children.
• In children, the diagnosis of Separation Anxiety Disorder should not be used to describe developmentally normative phenomena.
• The focus of apprehension in Separation Anxiety Disorder may differ across age groups, such that younger children may demonstrate less credible fears (e.g., worrying about sleeping alone for fear they will be kidnapped in the middle of the night) whereas older children and adolescents may have more credible fears (e.g., parents getting into a car accident).
• Symptom presentation varies with age. In younger children, who are less able to express worries or fears, behavioural manifestations of recurrent excessive distress are typically more prominent, such as tantrums or crying when separated from parents and caregivers. When at home, younger children may insist on following caregivers closely, exhibiting distress even when in a different room or on a different floor from parents or caregivers. Older children are usually able to express their preoccupations about separation from attachment figures or fears related to specific dangers (e.g., accidents, kidnapping, mugging, death). Older children and adolescents may be more likely to demonstrate social withdrawal, insisting on staying at home with family members rather than spending time with peers.

Culture-Related Features:

• Cultural variation exists with regard to tolerating separation from attachment figures. In some cultural groups, it would be considered inappropriate to spend time apart from family or loved ones. Distress associated with separation in this sociocultural context should not be considered excessive if it is culturally normative.
• Children in some cultures remain in their parental home longer than in other cultures, and generally this trend is increasing globally, so the assignment of disorder should take into account cultural norms.

Sex- and/or Gender-Related Features:

• Although lifetime prevalence rates for Separation Anxiety Disorder is slightly higher among females (5.6% versus 4%), during childhood, school refusal is equally prevalent for both genders.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Generalized Anxiety Disorder: Individuals with Generalized Anxiety Disorder experience chronic and excessive worry about a variety of everyday life events that can include preoccupation about the safety of key attachment figures. However, these concerns seldom occur without additional worries regarding other domains of everyday life.
• Boundary with Panic Disorder: If an individual with Separation Anxiety Disorder experiences panic attacks exclusively in the context of separation from key attachment figures, an additional diagnosis of Panic Disorder is not warranted and the presence of panic attacks may be indicated using the ‘with panic attacks’ specifier. However, if unexpected panic attacks also occur, an additional diagnosis of Panic Disorder may be assigned.
• Boundary with Agoraphobia: In Agoraphobia, individuals avoid a variety of situations including leaving home alone but the fear or anxiety is centred on the possibility that help will not be available in the event of a panic attack or other incapacitating or embarrassing symptoms rather than concerns about separation from key attachment figures.
• Boundary with Social Anxiety Disorder: In Social Anxiety Disorder, the avoidance of social situations is in response to fear or anxiety about being negatively evaluated by others rather than concerns about being separated from key attachment figures.
• Boundary with Depressive Disorders: Beliefs of social inadequacy, rejection, and failure are common in Depressive Disorders and may be associated with avoidance of leaving the home and being separated from loved ones. However, unlike in Separation Anxiety Disorder, these symptoms occur almost exclusively during a Depressive Episode.
• Boundary with Post-Traumatic Stress Disorder: In Post-Traumatic Stress Disorder, individuals have a history of exposure to a traumatic event that may have involved the loss of a key attachment figure. However, the focus of apprehension is on intrusive re-experiencing of the traumatic event from memory and avoidance of associated stimuli rather than concerns about future loss of or harm coming to the key attachment figure. However, Separation Anxiety Disorder rather than Post-Traumatic Stress Disorder may occur subsequent to the experience of a traumatic event and if all diagnostic requirements are met the diagnosis can be assigned.
• Boundary with Disruptive Behaviour or Dissocial Disorders: Individuals with Oppositional Defiant Disorder can exhibit similar behaviours as those observed in Separation Anxiety Disorder such as anger, irritability, and temper outbursts, or defiant and headstrong behaviour (e.g., refusal to leave home or go to school). However, in Separation Anxiety Disorder these occur exclusively as a result of anticipated or actual separation from a key attachment figure. School refusal or truancy may occur in the context of Conduct Disorder but the behaviour is not related to concerns for the well-being of a key attachment figure.
• Boundary with Personality Disorder: Fear of abandonment or dependency on others can occur as symptoms of an enduring maladaptive pattern of behaviour associated with Personality Disorder. These symptoms tend to occur with other broader disruptions to interpersonal functioning, emotion regulation, as well as identity formation and definition. Personality Disorder may co-occur with Separation Anxiety Disorder and if present, can be diagnosed separately.