A crying infant is always presumed to be calling out for his mother. A slight delay in her availability is seen as a state of acute distress for the child. However, up until what point is this distress appropriate? How can it come back in adulthood? This blog entails an account of “Separation Anxiety Disorder (SAD)” and its manifestations in both childhood and adult life!
The DSM-V TR describes Separation Anxiety disorder as a fear or anxiety about separation from attachment figures, to a degree where it is developmentally inappropriate. Some level of separation anxiety is typically experienced by children during the age of 18 months- 3 years. It manifests when the child becomes temporarily uncomfortable in the absence of the caregiver or throws tantrums in order to stop the caregiver from leaving.
However, the intensity of the fear or anxiety experienced by the child during that time must be kept in check. If on a Monday, the child is throwing a tantrum for not going to daycare, it can be understandable. But, if the behaviours persist and the child ends up going only once a week, it should be looked into. Therefore, if the child’s fear or anxiety levels interfere with its developmental growth as well as routine activities, development of Separation Anxiety Disorder is likely.
Individuals with Separation Anxiety Disorder harbour a persistent fear or anxiety about harm towards attachment figures and events that could lead to loss of or a separation from attachment figures. It results in a reluctance to be away from their attachment figures and persistent nightmares along with physical symptoms of distress.
Children with Separation Anxiety Disorder are often seen avoiding travel away from attachment figures, even if it is for a night. They may even have nightmares about separation (like kidnapping) or experience stomach aches and headaches (Scarpa & Wilson, 2012). They mostly refuse activities which involve them being alone like sleeping in a separate room or playing alone with the toys.
Even though SAD generally has a good prognosis in children, it persists in adulthood for about one-third of children and adolescents (Scarpa & Wilson, 2012). But we don’t see twenty year old’s clinging to a caregiver or do we?
In adults, Separation Anxiety manifests itself in a slightly different way, with the core anxiety being similar. The worries, fear, and anxiety about losing these attachment figures or possible harm to them is significantly heightened. This could be seen as a refusal for things like travel, moving etc. They also experience nightmares about this separation and physical symptoms like nausea, vomiting and even cardiovascular abnormalities can develop. Very commonly you may observe that adults with this disorder are likely to stay in touch (text or call) with their attachment figures all day.
In adulthood, attachment figures might include parents, siblings, children, friends or partners. There is a constant need to know about the whereabouts of their attachment figures often becoming a cause of frustration in relationships. Despite the troublesome impracticalities, adults with this disorder constantly make quite successful efforts to remain in close proximity with their loved ones.
Separation Anxiety in the context of adulting and adulthood is severely under-discussed. Childhood may lay grounds and increase the likelihood for development of this disorder in future but the unique experiences of separation anxiety in adulthood must be understood wholly. Data from WHO World Mental Health Surveys (n= 38,993, from 18 countries) was used by Silove et al. (2015) to examine the prevalence rates of separation anxiety disorder in the general population. The estimates revealed a lifetime SAD prevalence of 4.8% across countries with 43.1% of lifetime onsets occurring after the age of 18 years. Separation Anxiety symptoms were also commonly seen in people with bipolar disorder, complicated grief and post traumatic stress disorder.
Cultural differences may also be at play while mapping the prevalence of this disorder as studies indicate a higher risk of it being associated with collectivistic cultures (Bogels, Knappe & Clark, 2013). Heinrechs et al. (2006) discussed the differences in collectivistic and individualistic cultures, with the former focusing on interdependence and the latter supporting independence. The researchers speculated that the symptoms of separation anxiety may be higher in collectivistic cultures while the diagnoses of SAD may be higher in individualistic cultures, owing to the anxiety being relatively excessive as per the cultural norms.
As we try to trace where this disorder comes from, strong evidence surfaces for genetic heritability, especially in the case of Childhood Separation Anxiety Disorder. It runs in families and is most commonly observed in 1st degree and 2nd degree relatives. Parental anxiety has also been highly correlated with higher levels of separation anxiety in children. Additionally, twin studies are also in support of a strong genetic component as compared to changes in environment (Feriante & Bernstein, 2021; Bogels, Knappe & Clark, 2013).
However, the dualities of nature (genetics) and nurture (environment) play a role in the normal development and pathological manifestation of separation anxiety (Ehrenreich, Santucci & Weiner, 2008). As discussed by Feriante & Bernstein (2021), below mentioned are some potential environmental factors which could have a strong influence:
- Childhood parental loss (by separation, divorce, or death)
- Extended parental absences (e.g., military deployment, incarceration, or immigration for work)
- Diagnosis of an anxiety disorder in a parent (especially panic disorder)
- Parental alcoholism (14% of children of alcoholic parents develop SAD)
- Parental conflict
- Low parental warmth
- Parenting styles that discourage autonomy (e.g., reinforcing avoidance behaviours by removing the child from anxiety-provoking situations)
- Parent co-sleeping with child (demonstrative increased risk of developing childhood anxiety or depressive symptoms)
The changing world with Covid-19 surfaced many of the above mentioned scenarios for children, unexpectedly and unprecedentedly, leaving them predisposed to the development of this disorder. Excessive loss of lives, especially parents, caregivers and loved ones became a routine headline for plenty of people to read, and so many of them to experience first-hand. Children of doctors and other frontline workers also experienced extreme parental absence in a time of distress, which may contribute to potential separation anxiety in children. So far, not a lot of studies have been conducted to understand separation anxiety in the context of the pandemic but researchers do expect an increase in emotional disturbances surfacing as the world reopens completely (Paleaz & Novak, 2020; Jiao et. al. 2020).
Experiences of Separation Anxiety Disorder in both childhood and adulthood can be often seen as ‘annoying’ and ‘clingy’ behaviours which drive the individual even further from seeking the required support. Such misconceptions must not be entertained and rather resolved at an early stage. Individuals may benefit greatly from Cognitive-behaviour therapy and acceptance-commitment therapy for separation anxiety disorders (Feriante & Bernstein, 2021). Thus, it is time we look at this disorder beyond a childish whim!
Author,
Aseess Chadha
Clinical & Research Intern, PsychLine.in
References:
Baldwin, D. S., Gordon, R., Abelli, M., & Pini, S. (2016). The separation of adult separation anxiety disorder. CNS Spectrums, 21(4), 289–294. https://doi.org/10.1017/s1092852916000080
Bögels, S. M., Knappe, S., & Clark, L. A. (2013). Adult separation anxiety disorder in DSM-5. Clinical Psychology Review, 33(5), 663–674. https://doi.org/10.1016/j.cpr.2013.03.006
Ehrenreich, J. T., Santucci, L. C., & Weiner, C. L. (2008). SEPARATION ANXIETY DISORDER IN YOUTH: PHENOMENOLOGY, ASSESSMENT, AND TREATMENT. Psicologia conductual, 16(3), 389–412. https://doi.org/10.1901/jaba.2008.16-389
Feriante J, Bernstein B. Separation Anxiety. [Updated 2021 Nov 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560793/#
Heinrichs, N., Rapee, R. M., Alden, L. A., Bögels, S. M., Hofmann, S. G., Ja Oh, K., et al. (2006). Cultural differences in perceived social norms and social anxiety. Behaviour Research and Therapy, 44, 1187–1197
Jiao, W. Y., Wang, L. N., Liu, J., Fang, S. F., Jiao, F. Y., Pettoello-Mantovani, M., & Somekh, E. (2020). Behavioral and Emotional Disorders in Children during the COVID-19 Epidemic. The Journal of pediatrics, 221, 264–266.e1. https://doi.org/10.1016/j.jpeds.2020.03.013
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Scarpa, A., & Wilson, L. (2012). Childhood mental disorders. Encyclopedia of Human Behavior, 467–475. https://doi.org/10.1016/b978-0-12-375000-6.00088-4
Silove, D., Alonso, J., Bromet, E., Gruber, M., Sampson, N., Scott, K., Andrade, L., Benjet, C., Caldas de Almeida, J. M., De Girolamo, G., de Jonge, P., Demyttenaere, K., Fiestas, F., Florescu, S., Gureje, O., He, Y., Karam, E., Lepine, J.-P., Murphy, S., … Kessler, R. C. (2015). Pediatric-onset and adult-onset separation anxiety disorder across countries in the World Mental Health Survey. American Journal of Psychiatry, 172(7), 647–656. https://doi.org/10.1176/appi.ajp.2015.14091185