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Separation Anxiety Disorder

Separation Anxiety Disorder. An Anxiety Disorder. Anxiety Disorders . Separation Anxiety Disorder Selective Mutism Specific Phobia Social Anxiety Disorder (social phobia) Panic Disorder Agoraphobia Generalized Anxiety Disorder Substance/Medication-Induced Anxiety Disorder

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Separation Anxiety Disorder

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  1. Separation Anxiety Disorder An Anxiety Disorder

  2. Anxiety Disorders • Separation Anxiety Disorder • Selective Mutism • Specific Phobia • Social Anxiety Disorder (social phobia) • Panic Disorder • Agoraphobia • Generalized Anxiety Disorder • Substance/Medication-Induced Anxiety Disorder • Anxiety Disorder Due to Another Medical Condition • Other Specified Anxiety Disorder • Unspecified Anxiety Disorder

  3. Anxiety Disorders • Similarities • Differences

  4. History of Separation Anxiety Disorder in the DSM • Introduced DSM-III, 1980 • 3 of 9 symptoms @ least 2 weeks • Anxiety Disorders of Childhood • DSM-III to DSM-IV • 3 of 8 criteria @ least 4 weeks • No more Anxiety Disorders of Childhood • IV to IV-TR • Prevalence and Course sections were updated • IV-TR to DSM-5 • Anxiety Disorder • Wording • No more specific onset of 18yo • Addition of 6mo or more duration criterion

  5. Separation Anxiety Disorder: DSM-5 • A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by at least three (or more) of the following: • (1) Recurrent excessive distress when separation from home or major attachment figures • (2) Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death • (3) Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) • (4) Persistent reluctance or refusal to go out, away from the home, to school, to work, or elsewhere because of fear of separation • (5) Persistently and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings. • (6) Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. • (7) Repeated nightmares involving the theme of separation • (8) Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated • B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults • C. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. • D. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder • Specify if: Early Onset: if onset occurs before age 6 years

  6. Criterion for Separation Anxiety Disorder • A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by at least three (or more) of the following: • (1) Recurrent excessive distress when separation from home or major attachment figures • (2) Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death • (3) Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) • (4) Persistent reluctance or refusal to go out, away from the home, to school, to work, or elsewhere because of fear of separation • (5) Persistently and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings. • (6) Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. • (7) Repeated nightmares involving the theme of separation • (8) Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated

  7. Criterion for Major Depressive Disorder • B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults • C. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. • D. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder • Specify if: Early Onset: if onset occurs before age 6 years

  8. Prevalence • Little controlled research on SAD • Prevalence rate of 2-4 % • One study did report 2.8% [2.8%, 95% confidence interval (CI) 2.1-3.8, for current disorder] • 15-35% prevalence rate in samples of children with anxiety disorders • Suggestion that SAD occurs more frequently in girls but there is very little support • Prevalence rate does NOT increase with age

  9. Of youth who will develop SAD

  10. Prevalence rate declines with age

  11. Development, Onset, Course, Duration https://www.youtube.com/watch?v=jEkFp0Ux4OQ

  12. Development, Onset, Course, Duration cont… • Course is marked by exacerbation and remission over a period of years • As many as 30-44% of children with SAD show evidence of psychological problems that continue into adult life • May precede the development of conditions such as panic disorder and agoraphobia

  13. Associated Features • Behavioral • Social withdrawal • Difficulty concentrating on work or play • Homesick and Uncomfortable • Anger or Aggression • Emotional • Apathy • Sadness • Physical Symptoms • Nausea/Vomiting • Headaches • Stomaches

  14. Associated Features cont. • Cognitive • Evening or dark perceptual experiences • Fears • Accidents • Illness • Monsters • Of getting lost • Of being kidnapped

  15. What do children with Separation Anxiety Disorder look like? • Demanding • Intrusive • Frustration • Resentment • Conflict

  16. Difference in expression between younger and older children • Younger Children 5-8yo • More symptoms • Unrealistic worry • School refusal • Older Children 9-12yo • Excessive distress • Adolescence • Somatic complaints • School refusal more common

  17. Risk of Subsequent Psychopathology

  18. Models of Separation Anxiety • Environmental Change • Genetic • Parent-Child Attachment • Developmental Considerations • Cognitive Factors • Behavioral Factors • Stress Factors

  19. Environmental Change Environmental Change Separation Anxiety Disorder STRESS

  20. Genetic Influence History of panic disorder, anxiety, or depression Predisposition toward later development of anxiety disorders

  21. Parent-Child Attachment …Emotional distance Behaviors

  22. Developmental Considerations Between and Within Slower rate of development can foster separation anxiety

  23. Cognitive Factors Anxiety & Irrational Behaviors

  24. Behavioral Factors Crying and Clinging Behavior = distract attention away Nurtures anxiety and fear

  25. Stress Factors Change (stress factor) Feel uncomfortable Anxious Response

  26. Neurobiology of Separation Anxiety Disorder • Research done on the neurobiology of SAD has not been exclusively conducted on SAD. Literature has included SAD when analyzing all anxiety disorders in groups of children. • They amygdala has been one of the most prominent structures identified as being involved in anxiety disorders. • Until more research has been conducted solely on SAD any conclusions drawn would be an extrapolation of the findings from the other anxiety disorders

  27. Accounting for Variance: Genetics Bolton D, Eley TC, O’Connor TG, et al. • Twin pair study of 6-6.5yo • N = 854 • MZ and DZ

  28. Accounting for Variance: Genetics cont.

  29. Accounting for Variance: HPA-Axis

  30. Accounting for Variance: HPA-Axis and hormonal influences during pregnancy Maternal endocrine activation during pregnancy and/or early separation or loss Lower cortisol levels Anxiety, learned helplessness, depression

  31. Accounting for Variance: HPA-Axis and Cognitive Appraisal • Cognitive processes may trigger the stimulation of the HPA axis activity • The interpretation of a situation as being stressful or not • Separation anxiety disorder is derived from theories of anxiety disorders generally, which are predominately cognitive theories

  32. Accounting for Variance: HPA-Axis and Cognitive Appraisal and Gender • The pattern of results from the previous findings suggests there may be some gender-related differences with regard to the cognitive appraisal and anticipation of threat

  33. Accounting for Variance: Family DynamicCronk, N. J., Slutske, W. S., Madden, P. a F., Bucholz, K. K., & Heath, A. C. (2004). Risk for separation anxiety disorder among girls: paternal absence, socioeconomic disadvantage, and genetic vulnerability. Journal of abnormal psychology, 113(2), 237–47. doi:10.1037/0021-843X.113.2.237 • N=1,887 • Female MZ and DZ twin pairs • Looking across 4 SAD Categories @ • Attachment • Paternal Absence • Socioeconomic Disadvantage

  34. 4 Categories of SAD • SAD-Symptoms • Presence of 3 or more symptoms • SAD-Cluster • Presence of 3 or more symptoms occuring together for a period of at least 1 month • SAD-Impair • Presence of 3 or more symptoms causing impairment in functioning and/or treatment seeking • SAD-Full • Presence of 3 or more symptoms with clustering and impairment/treatment seeking, consistent with DSM-IV

  35. RaceIncomePaternal Absence

  36. a=additive genetic factorc=shared environmental factorp=paternal absence effects=socioeconomic disadvantage effect

  37. What this study says… • Effects of paternal absence on SAD are rather robust. • As predicted, paternal absence appears to be an important predictor of all categories of SAD • Suggesting that the loss or threat of loss of a father figure has important consequences for separation anxiety in girls. • Attachment theory, suggest that the loss of a parent (or attachment figure) in the preschool years or younger would be most detrimental to subsequent development.

  38. What this means… • Socioeconomic disadvantage • 0.1%-1.0% total variance • 0.4%-2.7% shared environmental effects • Paternal Absence • 1.0%-3.0% total variance • 4.3%-8.7% shared environmental effects • “Important role for genes” • High Heritability estimates for parent-reported symptoms of SAD in girls

  39. Maddie Marks’ Model

  40. References

  41. References cont.

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