Separation anxiety disorder

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The defining feature of separation anxiety disorder is an excessive, unrealistic, and persistent fear of separation from the attachment figure. This level of worry is quantitatively beyond normal, but, as both diagnostic systems indicate, it must be distinguished from formal thought disorder and first-rank symptoms of psychoses and schizophrenia, such as thoughts being inserted into the child's mind. Whilst the former are common, the latter are extremely rare in the prepubertal child.

Severe worries give rise to a typical maladaptive reaction pattern, typically involving some combination of the following:

1. physiological response, such as headaches, nausea, abdominal pain, and (rarely) vomiting;

2. behavioural symptoms, such as avoiding a feared situation, proximity-seeking, tantrums;

3. further escalation of abnormal level of thoughts, such as the notion that there may be a catastrophe, death, or permanent separation may be about to occur.

The diagnostic systems show relatively good agreement on the nature and characteristics of separation anxiety disorder. Both require fear of separation as the focus of the anxiety and at least three symptoms of general worry from eight possibilities:

1. harm might befall a major attachment figure;

2. an event may result in separation;

3. school reluctance because of the above;

4. separation difficulties at night;

5. reluctance to be alone;

6. nightmares involving separation;

7. physical symptoms on separation;

8. distress in anticipation of separations.

In addition, a duration of 4 weeks and the presence of personal impairment in the child's current social function must be present, although the exact nature or level of the latter is not specified. ICD-10 requires the disorder to have its onset before 6 years of age, whereas DSM-IV requires an onset before 18 years, with two subtypes: early (before 6 years) and late (7 to 17 years). This age difference is due to the retention of a childhood-onset generalized anxiety disorder syndrome in ICD-10 for individuals under the age of 18.

Epidemiology

Separation anxiety disorder occurs in an estimated 2 to 4 per cent of children and adolescents, and accounts for approximately 50 per cent of children seen for mental health treatment of anxiety disorders in this age range. (3,4,5,6 and 7) Separation anxiety disorder is most often seen in prepubertal children, with proximity-seeking clinging behaviour being a common presenting complaint. No marked sex differences have been reported to date.

Natural history

Very few systematic data are available on the natural history course and outcome of separation anxiety disorder in childhood. There are no longitudinal prospective studies through into adult life. During childhood, the symptoms tend to wax and wane. Normal events, such as school transitions, as well as undesirable events may lead to a recurrence or exacerbation of symptoms. There is some suggestion of continuities between separation anxiety disorder in childhood and panic disorder and agoraphobia in adults.(89 and19 Identifying which subpopulations of children with separation anxiety disorder are at risk for persistent anxiety disorders into adult life is an important issue for further research. Current preliminary findings suggest that it is the early-onset separation anxiety disorder that may be the most persistent.

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Anxiety and Depression 101

Anxiety and Depression 101

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