Keywords

Separation anxiety disorder is a diagnostic category included in the group of anxiety disorders within the DSM 5 classification system [1]. Namely, in the DSM-IV classification, this disorder was placed in the section of childhood disorders and could only be classified in adults when it first occurred before the age of 18 [2]. Within the current DSM 5 classification, this disorder can be classified in adults regardless of first appearance, i.e. even if its beginning is ascertained after the age of 18.

This disorder is characterized by intense anxiety, with its emotional, cognitive, and behavioural manifestations, occurring in situations of separation from significant figures, or loved ones, to whom the person is strongly emotionally attached. In adults, the objects of separation anxiety are, most often, emotional partners [3].

Within the ICD 10 classification, separation anxiety disorder is in the group of disorders that occur in childhood and it is not within the group of neurotic, stress-related and somatoform disorders (F40—F48), i.e. with other anxiety disorders [4]. The proposition of ICD 11 classifies separation anxiety disorder as a part of anxiety disorders, under the code 6B05, similarly to the DSM 5 [5].

Epidemiological Characteristics

Separation anxiety disorder is common in children and adolescents, but there are very few reliable studies that indicate the prevalence of this disorder in the adult population. Nevertheless, some of them indicate that the prevalence of this disorder in the adult population is as high as 6.6% [6]. As with other anxiety disorders, separation anxiety disorder has a higher incidence in the female than in the male population [7].

It occurs much more often in young adulthood—up to the age of 30 and it also occurs frequently in very old population. Socio-epidemiological data further indicate that separation anxiety disorder is more common in: persons who are divorced, widowers and persons who have never married; persons with less education; persons who are not employed and do not work [6].

However, there is still little relevant data that would clearly and unambiguously determine specific epidemiological indicators for separation anxiety disorder. We hope that studies regarding these issues will be performed in the near future, thus evaluating the status of this disorder in the population with greater reliability.

Clinical Characteristics

Separation fears are quite common in children in the early stages of life. They most often occur in situations of separation from family members and those who are their principal caregivers—mother, father, grandmother, etc. Typical situations where the separation anxiety occurs are: going to kindergarten, going to a holiday with kindergarten/school, situations where parents are leaving to go to work, etc. In most children, with maturation, growth and personal development, such fears tend to disappear spontaneously. However, some children continue to experience fear in situations of separation from the people they are attached to. This phenomenon, if it becomes intense and if it persists, takes the form of a psychiatric disorder, and can cause various problems in life [8].

Separation anxiety in adults is most commonly caused by the progression of separation anxiety from childhood, but it may also occur as a de novo phenomenon in some individuals [6, 7].

As in children, separation anxiety in adults can be viewed through three basic components of anxiety [3]:

  • The cognitive component. In adults, separation anxiety cognitively manifests as a strong belief that the person is abandoned, neglected and unable to take care of himself or herself in a situation when he/she is separated from the loved ones. Upon separation, a person might believe that some terrible consequences will befall them –they will become ill, they will not be able to manage everyday activities, they will be lost, etc. The irrational beliefs associated with separation anxiety in those situations, most often, are: “How will I manage alone?”, “I will not be able to cope alone!”, “Being left alone is awful!” ...

  • The emotional component. The onset of separation anxiety is usually accompanied by somatic symptoms of anxiety—tachycardia, rapid respiration, tension headache, tension in the muscles and stomach. As in children, in addition to experiencing fear, there may be other emotional reactions, like anger and rage directed at the person who leaves them.

  • The behavioural component. Due to the consequence of separation anxiety, adults often avoid exposing themselves to situations where they might be separated from the person to whom they are attached. They are usually involved in symbiotic partnerships, and reluctant to leave their place of residence. All of the above results in a poorer lifestyle, stalling in academic and professional advancement, etc. [3]

In addition to the typical clinical presentation of separation anxiety, atypical presentation can occur in some individuals. Atypical presentations of separation anxiety are [3, 5]:

  • Experience and expression of jealousy directed towards the person who is leaving. This phenomenon is different from pathological jealousy because it is fundamentally an expression of fear that he/she will be left alone, that he/she will not be able to cope with being alone, and that he/she will not be able to bear the loneliness. By showing jealousy, the person with a fear of separation can successfully control (i.e. command) his or her emotional partner and keep him/her close.

  • Overly controlling parenting—sometimes referred to as “reverse separation anxiety”. This phenomenon is characterized by hypercontrol of children (who may be adults) because of the fear that the child may leave home at some point, thus abandoning the parent. Therefore, various methods of deception and trickery are used by the parent, whether consciously or unconsciously, in order to keep the child at home for as long as possible, and in close connection with the parent.

  • Pathological relationships. This phenomenon is characterized by remaining in detrimental, inappropriate partner relationships, even though the person might know that the relationship is harmful or damaging, he/she chooses to stay due to the fear of being alone.

  • In the elderly. Although the incidence of separation anxiety disorder in the very old population is lower than in the younger population, there are a large number of older people with this problem. This population is, perhaps, the most exposed to separation from close persons—spouse, friends, family. Any such person might for various reasons, leave. For example, a child might leave home, a friend or spouse might leave for hospital stay or die, etc. Therefore, special attention should be paid to this disorder in the elderly in order to detect and provide adequate care for them.

Specific focus of the fear also varies in relation to age group of the patient. In children, the anxiety might be due to perceived unrealistic consequences of separation (e.g. fear of being kidnapped during the night), while adolescents might have rationalizations for their anxiety which are more realistic (e.g. parents or a significant other might be involved in a traffic accident upon separation). Moreover, behavioural manifestations of anger are more common in children. By comparison, adolescents and adults might manifest a certain degree of social isolation, by staying at home with parents of loved ones, instead of going “out into the world” and maintaining significant relationships with other people [5] .

Presentation of symptoms of anxiety can take many different forms. Personality and temperamental factors, as well as subtle avoidance behaviours may disguise typical symptoms of anxiety. As such, sometimes even prototypical anxiety disorders such as panic disorder may be difficult to diagnose. Lack of epidemiological studies on separation anxiety disorder may be due to some of these factors. Thus, to adequately recognize and diagnose separation anxiety disorder, clinicians must first have a clear understanding of this disorder in mind.

Diagnosis

Two short screening questions can be asked to quickly assess for the presence of separation anxiety:

  1. 1.

    Do you feel intense fear in situations where you are separating from your loved ones?

  2. 2.

    Do you avoid finding yourself in situations without your loved ones?

A positive answer to at least one question may indicate the existence of separation anxiety disorder, and attention needs to be paid to further diagnostic assessment [3].

ICD Classification

The diagnosis of separation anxiety disorder in adults does not exist in the tenth International Classification of Diseases. However, within the ICD 10, there is a diagnosis of “childhood separation anxiety disorder” - F93.0. According to the criteria of that diagnosis, separation anxiety disorder in childhood should be diagnosed when there is an intense fear of separation that appears during the early stages of life [5].

This has been ameliorated in the eleventh revision of International Classification of Diseases. ICD 11 classifies separation anxiety disorder under the code 6B05, and places it in the group of anxiety disorders. In order to make a diagnosis of separation anxiety disorder, the person should have the above-described symptomatology for several months, the symptoms of separation anxiety should be persistent and impact daily functioning in a significant manner [5].

DSM Classification

Within the DSM classification system, the diagnosis of separation anxiety disorder (in adults) first appeared in the 2013 Fifth Revision. Compared to the previous DSM-IV classification, a significant change in the diagnosis of this disorder has occurred. Namely, within the DSM-IV classification, the diagnosis of separation anxiety disorder could be made only in persons with whom it appeared before the age of 18. On the other hand, according to the DSM 5 classification, separation anxiety disorder is not a disorder that occurs exclusively in childhood. It could occur in any period of life—even in adulthood, and in this case, it should be diagnosed in the context of anxiety disorders in adults.

In order to diagnose this disorder according to the DSM 5 classification system, it is necessary to meet the following criteria: a person has to exhibit a strong and long-lasting anxiety, beyond developmental age, in situations of separation from those whom he or she is attached to—such as the carer, family members, etc., and this anxiety is manifested by the presence of some of the symptoms: (1) stress in periods of separation, (2) worry about the people they are attached to, (3) avoiding separation and autonomy, (4) complaints on somatic symptoms in the periods of separation [2].

Assessment instruments can be used to assist in the diagnostic process and evaluation of separation anxiety disorder. To the best of our knowledge, up until now, only one questionnaire has been specifically designed for this issue: the Separation Anxiety Questionnaire for Adults [8]. This instrument assesses the separation anxiety of adults. It consists of 27 statements related to the symptoms of separation anxiety and situations in which such symptoms might be triggered. This instrument has been used in several research studies, but similar instruments are expected to be developed in the future [7, 9, 10].

Aetiology

A little is known yet about the specific aetiology of separation anxiety disorder. It is assumed that the aetiology of this disorder, as in other anxiety disorders, is related to biological factors, hereditary factors, psychological factors that affect the growth and development of personality and many other factors that could be responsible for the manifestation of this psychiatric disorder. Only those factors for which there is a “reasonable doubt and a significant degree of evidence” that there may be aetiological factors in the onset of separation anxiety disorder will be listed [3, 11].

  • Heredity. The research studies indicate that two-thirds of patients with separation anxiety disorder have at least one parent who has separation anxiety problems. This raises the question of the relative risk of transmission of separation anxiety disorder from a parent to children. Unfortunately, there are no published studies that have systematically examined this area in the adult population. The research on child population samples shows that there is a significant risk that separation anxiety will occur within families. However, it is not yet known whether this phenomenon is a specific consequence of genetic inheritance, exposure to particular behaviours in the family, or interplay.

  • Personality. In addition to anxiety disorders and depression, dependent and avoidant personality disorders are often encountered in samples of patients with separation anxiety disorder [12]. However, little is known about whether the personality structure is primarily responsible for the occurrence of separation anxiety disorder, or if the separation anxiety disorder causes the development of (pathological/anxious) personality, since it occurs in the early formative period. Moreover, research has shown high association SAD with Dependent Personality Disorder, but in people with comorbid conditions such as addictions, eating disorders and obsessive compulsive disorder. Previous research has not shown a specific relationship between separation anxiety disorder and dependent personality disorder, but certainly suggest that separation anxiety disorder can predispose to the emergence of dependent personality disorder [12].

    Separation anxiety is also present as a symptom within borderline personality disorder, bearing in mind the presence of similar symptoms such as intense fear of abandonment, hypersensitivity to rejection, insecurity in interpersonal relationships, anxious attachment style to others. Experiencing a current or upcoming broke of the relationship accompanied by anxiety, uncertainty, fear of abandonment and being hurt, regardless of whether their desires and needs can be met by another person is, among other things, characteristic of separation anxiety disorder and borderline personality disorder. It is especially important to emphasize that these two disorders have a partially common etiopathogenic model and that emphasizing separation anxiety is important for potentially new differential diagnostic goals and specific psychotherapeutic and pharmacotherapeutic approaches to the treatment of borderline personality disorder.

  • Information processing. Information processing in patients with anxiety disorders exhibits certain specifics—mostly in the situation where a stimulus is unclear and information are confusing. Studies have shown that, in children with separation anxiety, compared with children who are not anxious, there are certain specificities in the cognitive processes. These children seem to have a greater propensity for fearful interpretations, a greater propensity to make plans for avoiding risky situations, and more frequent beliefs that they are less competent to cope with dangerous situations [11]. It is possible that these findings might be applicable to the separation anxiety in adults as well. However, there are still no data for the adult population to confirm this.

Thus, little is known about the aetiology of separation anxiety disorder in adults. We believe that future research in the fields of genetics, biomarker discovery, cognitive processes analyses and other areas will specify the underlying aetiological factors of the disorder, and that specific therapeutic techniques will be developed to assist patients with the disorder, in line with the results of these studies.

Treatment

An important point in the treatment of patients with separation anxiety disorder is early detection and early initiation of treatment. In this way, the problem of separation anxiety can be efficiently managed, especially in children and young people. If the problem is not detected and not treated in a timely manner, it can be expected that the disorder will progress and eventually enter a chronic phase, resistant to therapeutic interventions.

So far, no studies that adequately addressed the problem of effective treatment of adult patients with separation anxiety disorder have been published. It is therefore very difficult to make evidence-based therapeutic recommendations [3, 11].

Pharmacotherapy

To date, no randomized, placebo-controlled pharmacological studies have been published on a sample of adult patients with separation anxiety disorder. Therefore, no firm recommendation can be made for the pharmacological treatment of these patients. Nevertheless, based on the analogy with other anxiety disorders and pharmacological studies on samples of a paediatric population of patients with separation anxiety disorder, it can be hypothesized that SSRI and SNRI antidepressants could be successful in the treatment of this disorder.

Cognitive-Behavioural Therapy

For now, there is research suggesting that cognitive-behavioural therapy is a viable choice for young patients with this disorder [13]. The problem is that there are no differential treatment protocols, yet that indicate successful techniques for overcoming this problem in the adult population. However, if the general guidelines for cognitive-behavioural treatment of anxiety are applied, and if the problem of separation anxiety disorder is viewed through a model of cognitive-behavioural therapy, it can be assumed that this therapy could be successful in the adult patient population.

Therefore, standard cognitive-behavioural therapy techniques can be expected to be successful with patients with separation anxiety disorder:

Cognitive restructuring consists of discovering irrational (or rigid, i.e. non-flexible) beliefs - “I will not be able to do it alone”, “He/she must not leave me”, “I will not endure without her / him”, which are related to the disorder and their replacement with adaptive, rational (or flexible) beliefs - “It will be difficult but I’ll try, ““ Independence can bring me new success” etc.

Exposure is a basic technique that should be applied in solving the problem of avoiding separation situations. It implies that the patient is exposed to separation from the person whom he or she is attached to for the purpose of learning to function independently.

Modelling is a technique that can be very useful for patients with separation anxiety because anxiety can be overcome by adapting a new behaviour, the behaviour of a role model—a therapist or another symbolic living model.

However, before providing recommendations for treatment of patients with separation anxiety disorder, these techniques need to be verified through adequate methodological studies.

Overall, it is expected that the future studies will provide specific therapeutic guidelines for the treatment of patients with separation anxiety disorder. Until then, the basic principles for treating all anxiety disorders should be followed.

Summary

Although studies of the prevalence and most significant psychopathological phenomena that characterize separation anxiety disorder in adults date back to two or more decades ago [14], there is still a distinctive lack of knowledge about this disorder. Some of the outstanding issues are:

  1. 1.

    its prevalence in the general and clinical population,

  2. 2.

    if there are any specific etiologically factors for the occurrence of this disorder,

  3. 3.

    its relation with other psychiatric disorders, especially anxiety disorders,

  4. 4.

    its specific psychopathological features.

In addition, little (or nothing) is known about effective therapeutic approaches to treating adults with this disorder.

Some outstanding questions remain and there are no clear answers so far regarding the differentiation of “normality” and pathology related to the separation anxiety disorder:

  • Is a strong relationship between family members the consequence of specific cultural and social patterns or a pathological pattern that indicates separation anxiety?

  • Are the pain and suffering resulting from separation from loved ones after wars, natural or other disasters “normal”/common/expected or are they psychopathological manifestations of separation anxiety?

  • What should be “normal”/usual/expected reactions that occur as a result of the loss of a loved one after death or divorce, without the psychopathological manifestations of separation anxiety?

In order to clearly identify separation anxiety disorder as an unambiguous psychopathological category, it is necessary to answer these questions in detail.

Due to all of the above, substantial research is needed/expected in the forthcoming period. We hope that the research will confirm or challenge the justification for the existence of this diagnostic category. In any case, changes to the diagnostic systems are underway. Specifically, this disorder is included in the ICD 11 classification which is expected to be used in 2022 [5].