Separation Anxiety Disorder
DSM-IV-TR Diagnostic Criteria
Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:
recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated
persistent and excessive worry about losing, or about possible harm befalling, major attachment figures
persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)
persistent reluctance or refusal to go to school or elsewhere because of fear of separation
persistently and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings
persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
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 duration of the disturbance is at least 4 weeks.
The onset is before age 18 years.
The disturbance causes clinically significant distress or impairment in social, academic (occupation), or other important areas of functioning.
The disturbance does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and, in adolescents and adults, is not better accounted for by panic disorder with agoraphobia.
Specify if:
Early onset: if onset occurs before age 6 years.
(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000, Washington, DC: American Psychiatric Association.)
Separation anxiety disorder (SAD) occurs in 2–4% of children and adolescents. It represents about 50% of all referrals for evaluation of anxiety disorder at this age. SAD may be slightly more prevalent in girls and in families of lower socioeconomic status. School refusal is equally common in all socioeconomic groups. Its incidence is 1–2% in school-aged children, and it may be more common in boys.
SAD is linked to insecure attachment (see Chapter 45). It may be precipitated by loss, separation, or the threat of either. Parental anxiety and an enmeshed mother–child relationship is commonly associated with this condition. The combination of parental anxiety and depression is an additional risk factor. The prevalence of anxiety disorders in other family members might indicate a genetic factor.
A psychodynamic theory concerning the etiology of SAD postulates the following: (1) The mother has a hostile-dependent relationship with her own mother, (2) the mother is lonely and unsatisfied in her marriage, (3) following a threat to security, the child responds to an overly dependent relationship with the mother, (4) the mother is gratified by the child’s overdependence, (5) the mother and child develop a mutually ambivalent hostile-dependent relationship, (6) the child responds to the normal stresses of school with fear and avoidance, (7) the mother is pleased by having the child at home, while at the same time annoyed by it, and (8) both mother and child focus on the somatic symptoms of anxiety and become convinced that the child has a physical disorder.
SAD, like other many other neurodevelopmental disorders of childhood onset, is likely to be associated with multiple vulnerability genes. Twin studies suggest that different genes may be playing a role in mediating this condition in males versus females. It also appears that the heritability of SAD is greater for girls than for boys.
The average age at onset is 8–9 years. Children with SAD exhibit severe distress when separated or threatened with separation from their parent, usually the mother. Fearing that harm will befall the attachment figure or themselves, they typically want to sleep in the parental bed, refuse to be alone, plead not to go to school, have nightmares about separation, and exhibit numerous somatic symptoms when threatened with separation. For example, when it is time to go to school these children complain of abdominal pain, nausea, vomiting, diarrhea, urinary frequency, and palpitations. Sometimes they have to be forced to leave the house. They may run away and hide near the home.
Generalized Anxiety Disorder
DSM-IV-TR Diagnostic Criteria
Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
The person finds it difficult to control the worry.
The anxiety and worry are associated with one of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months).
restlessness or feeling keyed up or on edge
being easily fatigued
difficulty concentrating or mind going blank
irritability
muscle tension med
sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive–Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.
The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The disturbance is not true to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.
(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000, Washington, DC: American Psychiatric Association.)
Generalized anxiety disorder (GAD) involves excessive anxiety and worry about a number of events or activities (e.g., school performance, social relationships, clothes), causing significant impairment or distress, manifested by somatic symptoms, self-consciousness, and social inhibition.
GAD occurs in about 3% of children and in 6–7% of adolescents. The sex ratio is equal. GAD is more prevalent among children of higher socioeconomic status.
As with SAD, GAD is associated with a familial concentration of anxiety disorders. Parents of children with GAD have been described as anxious and hypercritical, with high expectations for their children’s performance. Children with GAD are more likely to have exhibited behavioral inhibition when younger, a temperamental trait involving shyness and withdrawal from unfamiliar situations. Behavioral inhibition is probably genetically determined.
Twin studies suggest that genetic factors appear to play only a modest role in the etiology of GAD.
The average age at onset of GAD is 10 years. Children with GAD worry about their clothes, schoolwork, social relationships, and sporting performance—past, present, and future. They are exceedingly self-conscious, have low self-esteem, and complain of many somatic symptoms (particularly abdominal pain and headaches).
See end of Chapter.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
