Why are we still missing adult separation anxiety disorder in clinical practice?

Separation anxiety disorder (SEPAD) was first described among adults in the 1990s (Manicavasagar et al., 1997; Manicavasagar and Silove, 1997). Subsequently, the criteria for SEPAD (309.21; F93.0) in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) allows assignment of the diagnosis to persons of all ages, the wording of items being altered to encompass variation in symptom manifestations across the life course. This change represents a significant departure from the conceptualization of SEPAD embodied in previous editions of the DSM where onset of the disorder was restricted to persons below 18 years of age. The prevailing view that SEPAD was linked developmentally to panic disorder and agoraphobia in adulthood further discouraged clinicians from assigning the former diagnosis to adults. For these reasons, until recently, SEPAD has been excluded from epidemiological studies focusing on anxiety subtypes among adults. A recent transnational study was the first to include the category, reporting a lifetime prevalence of SEPAD of approximately 5% across countries (Silove et al., 2015). Clinical studies have indicated that 20–40% of adult outpatients meet criteria for SEPAD, depending on the type of clinic (specialized anxiety or general outpatient) and measures used (Pini et al., 2010). In almost all instances, these patients were referred for comorbid disorders. Importantly, two-fifths of adult cases report experiencing first onset of the disorder after 18 years of age (Silove et al., 2015).

In our experience, it is unusual for adult patients to be diagnosed with or referred for SEPAD in clinical practice. We suggest that a combination of clinician and patient factors contributes to the disorder being overlooked or misdiagnosed. Some of the reasons why clinicians may overlook the diagnosis include the following:

• Unfamiliarity with recent research and the diagnostic changes to SEPAD introduced by DSM-5 and/or a general resistance to the expansion of diagnostic categories to include larger segments of the population.

• Adherence to psycho-analytic or attachment models that regard severe separation anxiety as arising during and restricted to early development. There is a tendency, therefore, to regard separation anxiety symptoms in adults (if identified) as normative, adaptive or reactive to other (primary) disorders with which the response is commonly comorbid.

• High levels of comorbidity with other anxiety and mood disorders and lack of clear guidelines concerning the determination of which category is primary or secondary.

• Confusion created in existing phenomenological criteria for diagnosing anxiety subtypes in general, particularly because the generic symptoms of SEPAD overlap with more familiar forms of anxiety particularly panic disorder, agoraphobia and generalized anxiety disorder.

• Misdiagnosis of separation anxiety as a feature of personality problems or disorder (such as dependency) or attribution of the response to chronic stressors and/or dysfunctional relationships.

• Lack of confidence in treating SEPAD in adults given that there are no standard or tested approaches to treat the adult form of the disorder.

• Mistaking SEPAD for other disorders that mimic some of the symptoms, such as pathological jealousy, rejection sensitivity, grief, extreme homesickness and adjustment disorders.

Patients, in turn, may not reveal symptoms of adult SEPAD because

• They have become habituated to living with their fears, believe they are justified and/or minimize the impact of symptoms and associated behaviours on themselves and others. Alternately, they may attribute the problem to lack of availability or adequacy of support from close attachments.

• Families and networks may have adapted to and continue to reinforce the person’s fear structures, security seeking and/or protective behaviours. This may be particularly relevant where there are mutual social or psychological gains in ensuring a tight and dependent network.

• Persons may be embarrassed to acknowledge or divulge SEPAD symptoms to others or to mental health professionals for fear of being regarded as immature, dependent or inadequate.

In summary, because separation anxiety derives from a universal adaptive response aimed at affording protection to the self and close attachments, and always occurs in an interpersonal context, patients, families and even mental health professionals are at risk of minimizing the pathological nature of symptoms even when they are extreme and disabling, Yet, there is some evidence that interventions (psychological or pharmacological) that focus solely on other anxiety or depressive disorders but not on comorbid SEPAD in adulthood may result in a poor overall clinical outcome (Miniati et al., 2012)

The first step in addressing this issue is to increase awareness that SEPAD is a common and potentially disabling condition in adulthood, a change in the conceptualization of the disorder that will require a cultural and conceptual shift among mental health professionals. In an epoch when it seems fashionable to criticize DSM-5, we find cause, in this instance, to offer some praise to its architects in recognizing that SEPAD can occur in adulthood, the first step in ensuring that effective treatments are developed to address this neglected subtype of anxiety.

See Case Report by Manicavasagar and Silove 31(2): 299–303.