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SEPARATION ANXIETY DISORDER





  • Starting from before age 18, displayed excessive anxiety when away from home or from significant others.

  • Must last at least 4 weeks in children and adolescents and 6 months or more in adults.

  • Not due to a more serious mental disorder.

Prediction

    Childhood onset; sometimes lasts years but most grow out of it.

Problems

    Occupational-Economic Problems:

    • Causes significant social or academic functioning (e.g., school refusal).

    • School refusal may lead to academic difficulties and social avoidance.

    Reserved, Quiet (Low Extraversion):

    • Social withdrawal, apathy when separated from major attachment figures.

    Worried, Easily Upset (Low Emotional Stability):

    • Developmentally inappropriate and excessive anxiety on separation from home or major attachment figures (e.g., extreme homesickness).

    • Demanding, intrusive, and in need of constant attention which can cause parental frustration and conflict in the family.

    • Depressed mood may develop into Persistent Depressive Disorder or Major Depressive Disorder.

    • Sadness, inability to concentrate when separated from major attachment figures.

    • Anger at the person who is forcing the separation.

    • Separation Anxiety Disorder may precede the development of Panic Disorder.

    • Increased rates of other Anxiety Disorders.

    Medical:

    • Fear of separation causes stomachaches, headaches, nausea, and vomiting; adolescents and adults may develop palpitations, dizziness, and feeling faint.



Explanation Of Terms And Symbols

Internet Mental Health Quality of Life Scale

Fear, Phobia, Obsession, Compulsion

Fearful avoidance is part of our instinctual "flight" response to adversity.

Our ancestors learned to fear dangerous things (e.g., snakes), and this harm avoidance saved their lives.

However, fear can spiral out of control. For example, an individual can develop a phobia to snakes in which the fear becomes excessive. This phobia can develop into an obsession in which the individual spends much of the time thinking about snakes, and how to avoid them. The obsession can develop into a compulsion in which the individual spends much of the time doing superstitious, compulsive, ritual behaviors aimed at avoiding snakes.

There are stages in the escalation of fear:

  • Fear:
    Fear is normal if it is in proportion to the actual danger posed by the specific object or situation, and this fear doesn't cause significant distress or disability.

  • Phobia:
    If fear about about a specific object or situation becomes excessive, it is defined as a phobia. This phobic fear is out of proportion to the actual danger posed by the specific object or situation, and this phobic fear causes significant distress or disability. In separation anxiety disorder, there is developmentally inappropriate and excessive anxiety when away from home or from loved ones. This excessive separation anxiety is the equivalent of a phobia.

  • Obsession:
    If the individual develops persistent, unwanted thoughts about the phobia; this is defined as an obsession. An obsession is a fear-provoking intrusive thought. In severe cases of separation anxiety disorder, the persistent and excessive worry about losing loved ones or about possible harm to them can actually reach obsessional proportions.

  • Compulsion:
    If the individual develops a superstitious ritual aimed at reducing the anxiety associated with the obsession; this is defined as a compulsion. A compulsion is a fear-relieving avoidance behavior. The individual feels driven to perform these compulsions. Unlike in obsessive-compulsive disorder, individuals with separation anxiety disorder do not develop a compulsion in response to their phobic separation anxiety.

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Separation Anxiety Disorder of Childhood F93.0 - ICD10 Description, World Health Organization

Should be diagnosed when fear of separation constitutes the focus of the anxiety and when such anxiety first arose during the early years of childhood. It is differentiated from normal separation anxiety when it is of a degree (severity) that is statistically unusual (including an abnormal persistence beyond the usual age period), and when it is associated with significant problems in social functioning.
Separation Anxiety Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with separation anxiety disorder needs to meet all of the following criteria:

  • Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:

    • Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.

    • Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.

    • Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.

    • Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.

    • Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.

    • Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.

    • Repeated nightmares involving the theme of separation.

    • Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated.

  • The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.

  • The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.

  • 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.


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Diagnostic Features

In this disorder, individuals display excessive anxiety when away from home or from those to whom they are emotionally attached. This separation anxiety has to be developmentally inappropriate and excessive; with onset before age 18. It must last at least 4 weeks in children and adolescents and 6 months or more in adults. This disorder must cause significant distress or life impairment. This disorder does not occur exclusively during the course of a more serious disorder like autistic spectrum disorder, schizophrenia, other psychotic disorder, agoraphobia, generalized anxiety disorder, or illness anxiety disorder.

Effective Therapies

The first-line treatment for this disorder is Cognitive Behavioral Therapy (CBT) [exposure with prevention of avoidance behavior]. If this fails, treatment with SSRI antidepressant medication is often effective.

Ineffective therapies

Tricyclic antidepressants and benzodiazepines are ineffective. Vitamins and dietary supplements are ineffective for this disorder.

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Videos

Stories

Which Behavioral Dimensions Are Involved?

The ancient Greek civilization lasted approximately 3,000 years (16th century BC to 15th century AD).

The ancient Greek philosophers taught that the pillars of their civilization were: (1) cooperation, (2) justice, (3) wisdom, (4) self-control, and (5) courage.

Research has shown that these ancient themes form 5 basic dimensions of personality disorders and other mental disorders. There are two free online personality tests that assess your personality in terms of the "Big 5" dimensions of personality.

This website uses these 5 major dimensions of human behavior to describe all mental disorders. (This website adds 2 more dimensions, "Physical Health" and "Socioeconomic", but our discussion will focus on the first 5 major dimensions.) The following discussion of Big-5 personality dimensions is based on John Oliver's excellent Big Five Inventory (BFI), and Sam Gosling's ingenious Ten Item Personality Measure (TIPI).

These 5 major dimensions of human behavior seem to represent 5 major dimensions whereby our early ancestors chose their hunting companions or spouse. To maximize their chance for survival, our ancestors wanted companions who were agreeable, conscientious, intelligent, sociable, and calm. Their chance for survival was decreased if their companions were disagreeable, disorganized, close-minded, reserved, or nervous.

Which Dimensions of Human Behavior are Impaired in Separation Anxiety Disorder?

ANCIENT GREEK CONCEPT "BIG 5" PERSONALITY DIMENSIONS DESCRIPTION
Love Agreeableness       Sympathetic, Kind vs. Critical, Quarrelsome
Justice (Responsibility) Conscientiousness       Careful, Responsible vs. Careless, Irresponsible
Wisdom Intellect (also termed Openness)       Open-Minded, Creative vs. Easily Distracted
Self-Control Extraversion       Sociable, Enthusiastic vs. Reserved, Quiet
Courage Emotional Stability       Calm, Emotionally Stable vs. Worried, Easily Upset


The 5 Major Dimensions of Mental Illness













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Improving Positive Behavior

Philosophers for the past 2,500 years have taught that it is very beneficial to start the day with goal-setting, and end the day with a brief review.

This habit of planning the day in the morning, then assessing these plans in the evening has been shown to increase health and happiness. There is an additional benefit from doing a weekly review of your life satisfaction.

Note: When each of the following videos finishes; you must exit YouTube (by manually closing the window) in order to return to this webpage.



Morning Planning (Video)



Evening Review (Video)



Life Satisfaction Scale (Video)



Healthy Social Behaviors Scale (Video)



Mental Health Scale (Video)

Click Here For More Self-Help



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  • Criteria For High Quality Research Studies

  • It is imperative that medical researchers conduct high quality research studies, otherwise the US Food and Drug Administration (FDA) refuses to licence their new drug or therapy. In 2009, the cost of successfully licensing one new drug or therapy under the FDA scheme was estimated to be US$1,000 million. Thus psychiatric research which leads to FDA approval of a new drug or therapy has to be of the highest quality; however the majority of psychological research studies on new therapies fail to reach these high standards for research. This could explain why two-thirds of psychological research studies can't be replicated. High quality research must meet the following criteria:

    • Randomized Controlled Trial:
      Ask: Was the trial randomized? Was the randomization procedure described and was it appropriate? The best research design is to have research subjects randomly assigned to an experimental or control group. It is essential that confounding factors be controlled for by having a control group or comparator condition (no intervention, placebo, care as usual etc.).

    • Representative Sample:
      Ask: Do the research subjects represent a normal cross-section of the population being studied? Many psychological research studies using university students are flawed because their subjects are not representative of the normal population since they are all W.E.I.R.D. (White, Educated, Intelligent, Rich, and living in a Democracy).

    • Single Blind Trial:
      Ask: Was the treatment allocation concealed? It is essential that the research subjects are kept "blind" as to whether they are in the experimental or control group (in order to control for any placebo effects).

    • Double Blind Trial (Better Than Single Blind Trial):
      Ask: Were blind outcome assessments conducted? In a double blind study, neither the research subjects nor the outcome assessors know if the research subject is in the experimental or control group. This controls for both the placebo effect and assessor bias.

    • Baseline Comparability:
      Ask: Were groups similar at baseline on prognostic indicators? The experimental and control groups must be shown to be comparable at the beginning of the study.

    • Confounding Factors:
      Ask: Were there factors, that weren't controlled for, that could have seriously distorted the study's results? For example, research studies on the effectiveness of mindfulness cognitive therapy in preventing depressive relapse forgot to control for whether the research subjects were also simultaneously receiving antidepressant medication or other psychological treatments for depression.

    • Intervention Integrity:
      Ask: Was the research study protocal strictly followed? The research subjects must be shown to be compliant (e.g., taking their pills, attending therapy) and the therapists must be shown to be reliably delivering the intervention (e.g., staying on the research protocol).

    • Statistical analysis:
      Ask: Was a statistical power calculation described? The study should discuss its statistical power analysis; that is whether the study size is large enough to statistically detect a difference between the experimental and control group (should it occur) and usually this requires at least 50 research subjects in the study.

      Ask: Are the results both statistically significant and clinically significant? The results should be both statistically significant (with a p-value <0.05) and clinically significant using some measure of Effect Size such as Standardized Mean Difference (e.g., Cohen's d >= 0.33). The summary statistics should report what percentage of the total variance of the dependent variable (e.g., outcome) can be explained by the independent variable (e.g., intervention). In clinical studies, the study should report the number needed to treat for an additional beneficial outcome (NNTB), and the number needed to treat for an additional harmful outcome (NNTH).

      Ask: Does the researcher accept full responsibility for the study's statistical analysis? The researcher should not just hand over the study's raw data to a corporation (that may have $1,000 million invested in the study) to do the statistical analysis.

    • Completeness of follow-up data:
      Ask: Was the number of withdrawals or dropouts in each group mentioned, and were reasons given for these withdrawals or dropouts? Less than 20% of the research subjects should drop out of the study. The intervention effect should persist over an adequate length of time.

    • Handling of missing data:
      Ask: Was the statistical analysis conducted on the intention-to-treat sample? There must be use of intention-to-treat analysis (as opposed to a completers-only analysis). In this way, all of the research subjects that started the study are included in the final statistical analysis. A completers-only analysis would disregard those research subjects that dropped out.

    • Replication of Findings:
      Ask: Can other researchers replicate this study's results? The research study's methodology should be clearly described so that the study can be easily replicated. The researcher's raw data should be available to other researchers to review (in order to detect errors or fraud).

    • Fraud:
      Ask: Is there a suspicion of fraud? In a research study, examine the independent and dependent variables that are always measured as a positive whole number (e.g., a variable measured on a 5-point Likert-type scale ranging from "1 = definitely false to 5 = definitely true" etc.). For each of these variables, look at their sample size (n), mean (M) and standard deviation (SD) before they undergo statistical analysis. There is a high suspicion of fraud in a study's statistics:

      • If the M is mathematically impossible (online calculator): This is one of the easiest ways to mathematically detect fraud. The mean (M) is defined as "the sum (Sum) of the values of each observation divided by the total number (n) of observations". So: M = Sum/n. Thus: (Sum) = (M) multiplied by (n). We know that, if a variable is always measured as a positive whole number, the sum of these observations always has to be a whole number. For these variables to test for fraud: calculate (M) multiplied by (n). This calculates the Sum which MUST be a positive whole number. If the calculated Sum isn't a positive whole number; the reported mean (M) is mathematically impossible - thus the researcher either cooked the data or made a mistake. A recent study of 260 research papers published in highly reputable psychological journals found that 1 in 2 of these research papers reported at least one impossible value, and 1 in 5 of these research papers reported multiple impossible values. When the authors of the 21 worst offending research papers were asked for their raw data (so that its reliability could be checked) - 57% angrily refused. Yet such release of raw data to other researchers is required by most scientific journals. (Here is an example of a research paper filled with mathematically impossible means.)

      • If the SD is mathematically impossible (online calculator): When researchers fraudulently "cook" their data, they may accidently give their data a mean and standard deviation that is mathematically impossible for a (normally distributed) strictly positive variable (because the "cooked" M and SD would mathematically require the strictly positive variable's range of data to include negative numbers). For a normally distributed sample of size of 25-70, this occurs when the SD is greater than one-half of the M; for a sample size of 70+, this occurs when the SD is greater than one-third of the M [using these formulas].

      • If the SD/M is very small (i.e., the variable's standard deviation is very small compared to the mean suggesting data smoothing).

      • If the SD's are almost identical (i.e., the variables have different means but almost identical standard deviations).

      • If the 4th digit of the values of the variables aren't uniformly distributed - since each should occur 10% of the time (Benford's Law).

      • If the researcher is legally prevented from publishing negative findings about a drug or therapy because that would violate the "nondisclosure of trade secrets" clause in the research contract (i.e., it is a "trade secret" that the drug or therapy is ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical trials fail to publish their results.

      • If the researcher refuses to release his raw data to fellow researchers (so that they can check its validity). In order to be published in most scientific journals, a researcher must promise to share his raw data with fellow researchers. Thus a researcher's refusal to do so is almost a sure indicator of fraud.

      • If the research study's data contradicts the study's own conclusions - surprisingly, this often occurs.

  • Calling Bullshit In The Age of Big Data - "Bullshit is language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence." Reading the syllabus of this university course should be required reading for every student of mental health. This syllabus is absolutely fantastic!

  • Statistical Methods in Psychology Journals: Guidelines and Explanations - American Psychologist 1999

  • Not All Scientific Studies Are Created Equal - video

  • The efficacy of psychological, educational, and behavioral treatment

  • Estimating the reproducibility of psychological science

  • Psychologists grapple with validity of research

  • Industry sponsorship and research outcome (Review) - Cochrane Library

  • 'We've been deceived': Many clinical trial results are never published - (text and video)

  • Junk science misleading doctors and researchers

  • Junk science under spotlight after controversial firm buys Canadian journals

  • Medicine with a side of mysticism: Top hospitals promote unproven therapies - Are some doctors becoming modern witchdoctors?

  • When Evidence Says No, But Doctors Say Yes


  • Cochrane Reviews (the best evidence-based, standardized reviews available)

Research Topics


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