The video below is the section for Separation Anxiety Disorder from Part 8 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything you need to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 8, click HERE. To watch earlier lectures in this series, or register for our webinar series on DSM-5 and the EPPP, click HERE.
Transcript of DSM-5 EPPP Lecture Video: Separation Anxiety Disorder
Separation Anxiety Disorder occurs when a child has excessive and developmentally inappropriate fear or anxiety related to being separated from his or her home or major attachment figure(s).
To meet diagnostic criteria for Separation Anxiety Disorder, the person must demonstrate at least three of the following symptoms:
1. Extreme distress when the child anticipates or actually is leaving home or being away from a major attachment figure.
2. Persistent and excessive worry that major attachment figures will be harmed or lost to the child.
3. Persistent and excessive worry that an unwanted and unexpected event will separate the child from a major attachment figure.
4. Repeated refusal or reluctance to go to school or other places because of fear of separation.
5. Persistent and excessive fearfulness and reluctance to being alone or away from significant adults at home or in other settings.
6. Persistent refusal to go to sleep, or difficulty with sleep, when not near a major attachment figure or when away from home.
7. Repeated nightmares involving themes of separation.
8. Repeated somatic complaints (e.g., headaches, stomachaches, nausea, or vomiting) when separation from a major attachment figure occurs or is anticipated.
The disturbance must be present for at least four weeks for those under 18 and six months for those over age 18, cause clinically significant distress or impairment in functioning, and not be better explained by another mental disorder.
Some level of separation anxiety is developmentally normal in young children up to age 4, with clinging behavior and mild distress at being separated from a major attachment figure to be expected. This is not pathological and should not be confused with Separation Anxiety Disorder.
Children with Separation Anxiety Disorder often display marked distress when they do not know the whereabouts of major attachment figures and may be fearful that accidents, illness, or even death may occur while they are separated from loved ones.
For children with this disorder, each separation represents an opportunity for major attachment figures to be irretrievably lost to them. Children may respond to separation with sadness, anger, social withdrawal, apathy, and impaired concentration.
Separation Anxiety Disorder manifests itself differently across age groups. Very young children may report unusual perceptual experiences, such as the feeling that they are being stared at by an unknown person or that someone is peering into their bedroom window. Children younger than age 8 typically experience unrealistic worries about catastrophes that may befall major attachment figures. As children grow older, their fears tend to focus on more specific dangers such as kidnapping or being mugged. Between the ages of 9 and 12, children may become inordinately distressed at times of separation (e.g., attending overnight camps, or school trips) as well as during the anticipation of separation. School refusal is present in approximately 75 percent of children with Separation Anxiety Disorder.
Adolescents often deny anxiety about separation and are more likely to complain of physical symptoms (e.g., cardiovascular symptoms such as dizziness and heart palpitations).
Both adolescents and adults with Separation Anxiety Disorder may have difficulty engaging in independent activities. Adults may experience impairment in their ability to cope with major life changes such as getting married or moving. Adults with the disorder are generally concerned with separation from their children or spouses rather than separation from a parental figure. Adults and adolescents may experience cardiovascular symptoms, such as, palpitations, dizziness, and feeling faint.
Although separation anxiety is a predominant cause of school refusal in children between the ages of 5 and 7, school refusal during adolescence may be a sign of depression or other disorders. The prevalence of Separation Anxiety Disorder in the United States is estimated to be 0.9%-1.9%, with children about 4% and adolescents about 1.6% during a 6-12 month time-frame. In most cases, children with Separation Anxiety Disorder do not experience impairing anxiety disorders during adulthood.
In clinical samples, Separation Anxiety Disorder appears to be equally common in males and females. In the community, the disorder is more frequent in females. Separation anxiety disorder in children may be heritable, with one study showing estimated 73% in a community sample of 6-year-old twins. Development of Separation Anxiety Disorder may be associated with parental over-protectiveness, early traumatic separation from caregivers, the presence of anxiety disorders in parents (particularly the presence of Panic Disorder in mothers), and hormonal changes due to stress. Separation Anxiety Disorder is often triggered by trauma or other life stress, such as the death of a pet, moving to a new neighborhood, changing schools, immigration, illness, or divorce.
Treatment for Separation Anxiety Disorder typically involves cognitive-behavioral therapy. In cognitive-behavioral therapy, children learn to recognize their anxious thoughts about separation and are taught strategies to effectively cope with separation. Parental involvement in treatment is recommended, as parents may be inadvertently reinforcing their child’s fears and anxious behavior. When school refusal becomes part of the clinical picture, it is important to get the child to attend school, in order to prevent an escalating pattern of anxiety, reinforced by the avoidance of school. Shaping of lengthier times in school may be effective.
Separation Anxiety Disorder
1. A common anxiety disorder in children, involving inappropriate/excessive anxiety and worry over separation from attachment figures
2. May involve great worry about negative events befalling the attachment figures, school refusal, somatic symptoms, separation from home/caregiver, and/or excessive anxiety over sleep
3. School refusal is present in approximately 75 percent of children with Separation Anxiety Disorder, especially ages 5-7
4. Present for at least four weeks when onset before age 18, and six months for those over age 18
5. Must be differentiated from normative worry over separation in young children
6. Slightly more common in females, in community samples
7. Separation Anxiety: Children: distress when they don’t know whereabouts of attachment figures, fear of irretrievable loss; can respond with sadness, anger, social withdrawal, apathy
8. Separation Anxiety: Adolescents: often deny anxiety about separation, more likely to complain of physical symptoms (e.g., cardiovascular symptoms such as dizziness and heart palpitations); school refusal in adolescence may be sign of depression
9. Separation Anxiety: Adults: impairment in coping with major life events, such as getting married or moving, concerned about separation from their children
10. Both adolescents and adults with Separation Anxiety Disorder may have difficulty engaging in independent activities
11. Associated with parental over-protectiveness, family history of anxiety disorders, immigrant status, moves, family stress, separation/divorce
12. Prevalence: 0.9%-1.9% in US; with children it is 4%; in adolescence it is 1.6%
13. Clinical samples: equally common in males and females; Community: more frequent in females
14. Behavioral/cognitive-behavioral treatments optimal
a. Child must not be reinforced for school refusal; reinstatement in school is crucial
b. Parental involvement in treatment is recommended, as parents may be inadvertently reinforcing their child’s fears and anxious behavior
Lorenzo is a 12 years old middle-schooler who often seems to complain, albeit sometime indirectly, or through somatic ailments, about having to be away from home or his parents, even in situations where distress should not be expected (i.e. leaving for a fun vacation with friends). Sometimes Lorenzo experiences intense distress even when having to leave for school, as he fears that his parents may be involved in a car accident while he is away. Lorenzo was smothered by his father when he was a newborn and he even revealed to his aunt that he was “picked up all the times” by him when he was little. On the other hand, Lorenzo’s mother engages in a cold and strict parenting style, devoid of “excessive” manifestations of affection. She rarely hugs her son and she seems to shrink away from him when he gets physically close to her. Her communication style is direct and authoritarian. When taken to see Dr Bergamaschi, a child psychologist, Lorenzo’s diagnostic description does not include:
A. Excessive distress when thinking of leaving attachment figures and familiar places, anxiety and physical symptoms including dizziness, nausea and vomiting.
B. Excessive need to be taken care of, clinging and submissive behavior, and an extreme fear of separation from the attachment figure.
C. Intense worry about negative events befalling the attachment figures, excessive anxiety over sleep.
D. Early attachment wounds which have lead to developing an anxious-resistant style of attachment.
B is the correct answer: This is the description of Dependent Personality Disorder, a Cluster C Personality Disorder characterized by excessive need to be taken care of, clinging and submissive behavior, along with an extreme fear of separation from the attachment figure. Even though some (but not all) of these indicators may be present, Lorenzo is too young to be diagnosed with a Personality disorder. Both A and C are incorrect, as describing Separation Anxiety and hence appropriately included in the diagnostic impressions. D is incorrect: This is a dynamic, attachment based description which fits well with Lorenzo’s presentation.