Separation anxiety disorder
309.21 Separation Anxiety Disorder
Diagnostic Features
The essential feature of Separation Anxiety Disorder is excessive anxiety concerning separation from the home or from those to whom the person is attached (Criterion A). This anxiety is beyond that which is expected for the individual's developmental level. The disturbance must last for a period of at least 4 weeks (Criterion B), begin before age 18 years (Criterion C), and cause clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning (Criterion D). The diagnosis is not made if the anxiety occurs exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder or, in adolescents or adults, if it is better accounted for by Panic Disorder With Agoraphobia (Criterion E).
Individuals with this disorder may experience recurrent excessive distress on separation from home or major attachment figures (Criterion A1). When separated from attachment figures, they often need to know their whereabouts and need to stay in touch with them (e.g., by telephone calls). Some individuals become extremely homesick and uncomfortable to the point of misery when away from home. They may yearn to return home and be preoccupied with reunion fantasies. When separated from major attachment figures, these individuals are often preoccupied with fears that accidents or illness will befall the attachment figures or themselves (Criterion A2). Children with this disorder often express fear of being lost and never being reunited with their parents (Criterion A3). They are often uncomfortable when traveling independently away from the house or from other familiar areas and may avoid going places by themselves. They may be reluctant or refuse to attend school or camp, to visit or sleep at friends' homes, or to go on errands (Criterion A4). These children may be unable to stay or go in a room by themselves and may display "clinging" behavior, staying close to and "shadowing" the parent around the house or requiring someone to be with them when going to another room in the house (Criterion A5).
Children with this disorder often have difficulty at bedtime and may insist that someone stay with them until they fall asleep (Criterion A6). During the night, they may make their way to their parents' bed (or that of another significant person, such as a sibling); if entry to the parental bedroom is barred, they may sleep outside the parents' door. There may be nightmares whose content expresses the individual's fears (e.g., destruction of the family through fire, murder, or other catastrophe) (Criterion A7). Physical complaints, such as stomachaches, headaches, nausea, and vomiting are common when separation occurs or is anticipated (Criterion A8). Cardiovascular symptoms such as palpitations, dizziness, and feeling faint are rare in younger children but may occur in older individuals.
Specifier
Early Onset. This specifier may be used to indicate onset of the disorder before age 6 years.
Associated Features and Mental Disorders
Children with Separation Anxiety Disorder tend to come from families that are close-knit. When separated from home or major attachment figures, they may recurrently exhibit social withdrawal, apathy, sadness, or difficulty concentrating on work or play. Depending on their age, individuals may have fears of animals, monsters, the dark, muggers, burglars, kidnappers, car accidents, plane travel, and other situations that are perceived as presenting danger to the integrity of the family or themselves. Concerns about death and dying are common. School refusal may lead to academic difficulties and social avoidance. Children may complain that no one loves them or cares about them and that they wish they were dead. When extremely upset at the prospect of separation, they may show anger or occasionally hit out at someone who is forcing separation. When alone, especially in the evening or the dark, young children may report unusual perceptual experiences (e.g., seeing people peering into their room, scary creatures reaching for them, feeling eyes staring at them). Children with this disorder are often described as demanding, intrusive, and in need of constant attention. The child's excessive demands often become a source of parental frustration, leading to resentment and conflict in the family. Sometimes, children with the disorder are described as unusually conscientious, compliant, and eager to please. The children may have somatic complaints that result in physical examinations and medical procedures. Depressed mood is frequently present and may become more persistent over time, justifying an additional diagnosis of Dysthymic Disorder or Major Depressive Disorder in some cases. The disorder may precede the development of Panic Disorder With Agoraphobia. Comorbidity with other Anxiety Disorders may be common, especially in clinical settings.
Specific Culture, Age, and Gender Features
There are cultural variations in the degree to which it is considered desirable to tolerate separation. It is important to differentiate Separation Anxiety Disorder from the high value some cultures place on strong interdependence among family members.
The manifestations of the disorder may vary with age. Younger children may not express specific fears of definite threats to parents, home, or themselves. As children get older, worries or fears are often of specific dangers (e.g., kidnapping, mugging). Anxiety and anticipation of separation become manifest in mid-childhood. Although adolescents with this disorder, especially males, may deny anxiety about separation, it may be reflected in their limited independent activity and reluctance to leave home. In older individuals, the disorder may limit the person's ability to handle changes in circumstances (e.g., moving, getting married). Adults with the disorder are typically overconcerned about their offspring and spouses and experience marked discomfort when separated from them. In clinical samples, the disorder is apparently equally common in males and females. In epidemiological samples, the disorder is more frequent in females.
Prevalence
Separation Anxiety Disorder is not uncommon; prevalence estimates average about 4% in children and young adolescents. Separation Anxiety Disorder decreases in prevalence from childhood through adolescence.
Course
Separation Anxiety Disorder may develop after some life stress (e.g., the death of a relative or pet, an illness of the child or a relative, a change of schools, a move to a new neighborhood, or immigration). Onset may be as early as preschool age and may occur at any time before age 18 years, but onset as late as adolescence is uncommon. Typically there are periods of exacerbation and remission. In some cases, both the anxiety about possible separation and the avoidance of situations involving separation (e.g., going away to college) may persist for many years. However, the majority of children with Separation Anxiety Disorder are free of impairing Anxiety Disorders at extended follow-up.
Familial Pattern
Separation Anxiety Disorder is more common in first-degree biological relatives than in the general population and is relatively more frequent in children of mothers with Panic Disorder.
Differential Diagnosis
Separation anxiety can be an associated feature of Pervasive Developmental Disorders, Schizophrenia, or other Psychotic Disorders. If the symptoms of Separation Anxiety Disorder occur exclusively during the course of one of these disorders, a separate diagnosis of Separation Anxiety Disorder is not given. Separation Anxiety Disorder is distinguished from Generalized Anxiety Disorder in that the anxiety predominantly concerns separation from home and attachment figures. In children or adolescents with Separation Anxiety Disorder, threats of separation may lead to extreme anxiety and even a Panic Attack. In contrast to Panic Disorder, the anxiety concerns separation from attachment figures or from home rather than being incapacitated by an unexpected Panic Attack. In adults, Separation Anxiety Disorder is rare and should not be given as an additional diagnosis if the separation fears are better accounted for by Agoraphobia in Panic Disorder With Agoraphobia or Agoraphobia Without History of Panic Disorder. Truancy is common in Conduct Disorder, but anxiety about separation is not responsible for school absences and the child usually stays away from, rather than returns to, the home. Some cases of school refusal, especially in adolescence, are due to Social Phobia or Mood Disorders rather than separation anxiety. Children with Separation Anxiety Disorder may be oppositional in the context of being forced to separate from attachment figures. Oppositional Defiant Disorder should be diagnosed only if there is oppositional behavior at times other than at times of separation or when separation is anticipated. Similarly, children with Separation Anxiety Disorder may become depressed while being separated or in anticipation of separation. A Depressive Disorder should be diagnosed only if the depression occurs at other times.
Unlike the hallucinations in Psychotic Disorders, the unusual perceptual experiences in Separation Anxiety Disorder are usually based on a misperception of an actual stimulus, occur only in certain situations (e.g., nighttime), and are reversed by the presence of an attachment figure. Clinical judgment must be used in distinguishing developmentally appropriate levels of separation anxiety from the clinically significant concerns about separation seen in Separation Anxiety Disorder.
Diagnostic criteria for 309.21 Separation Anxiety Disorder
- Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:
- recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated
- persistent and excessive worry about losing, or about possible harm befalling, major attachment figures
- persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)
- persistent reluctance or refusal to go to school or elsewhere because of fear of separation
- persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings
- persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
- repeated nightmares involving the theme of separation
- repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated
- The duration of the disturbance is at least 4 weeks.
- The onset is before age 18 years.
- The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
- The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and, in adolescents and adults, is not better accounted for by Panic Disorder With Agoraphobia.
Specify if:
Early Onset: if onset occurs before age 6 years