Accepted Manuscript Title: The relationships among separation anxiety disorder, adult attachment style and agoraphobia in patients with panic disorder Author: Stefano Pini Marianna Abelli Alfonso Troisi Alberto Siracusano Giovanni B. Cassano Katherine M. Shear David Baldwin PII: DOI: Reference:
S0887-6185(14)00094-2 http://dx.doi.org/doi:10.1016/j.janxdis.2014.06.010 ANXDIS 1622
To appear in:
Journal of Anxiety Disorders
Received date: Revised date: Accepted date:
19-5-2012 20-6-2014 30-6-2014
Please cite this article as: Pini, S., Abelli, M., Troisi, A., Siracusano, A., Cassano, G. B., Shear, K. M., and Baldwin, D.,The relationships among separation anxiety disorder, adult attachment style and agoraphobia in patients with panic disorder, Journal of Anxiety Disorders (2014), http://dx.doi.org/10.1016/j.janxdis.2014.06.010 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
The relationships among separation anxiety disorder, adult attachment style
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and agoraphobia in patients with panic disorder
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Stefano Pini1a, Marianna Abelli1, Alfonso Troisi3, Alberto Siracusano3, Giovanni B. Cassano1 , Katherine M. Shear2, and David Baldwin4
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From: 1
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Columbia University, Department of Social Work, School of Social Work Columbia University, New York, NY, USA
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2
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Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, via Roma 65, I-56100 Pisa, Italy
Department of Neurosciences, University of Rome Tor Vergata, Via Montpellier 1,
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00133 Rome, Italy.
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Department of Psychiatry University of Southampton Faculty of Medicine Academic Centre, College Keep 4-12 Terminus Terrace, Southampton SO14 3DT
Key words: panic disorder, separation anxiety disorder, adult attachment style, agoraphobia
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Corresponding author: Prof. Stefano Pini Department of Psychiatry, University of Pisa Via Roma 67, 56100 Pisa, Italy Phone +39 050 993559 Fax +39 050 21581 e-mail: [email protected]
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ABSTRACT
Epidemiological studies indicate that separation anxiety disorder occurs more frequently in adults than children. It is unclear whether the presence of adult separation anxiety
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disorder (ASAD) is a manifestation of anxious attachment, or a form of agoraphobia, or a specific condition with clinically significant consequences. We conducted a study to
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examine these questions. A sample of 141 adult outpatients with panic disorder
participated in the study. Participants completed standardized measures of separation
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anxiety, attachment style, agoraphobia, panic disorder severity and quality of life. Patients with ASAD (49.5% of our sample) had greater panic symptom severity and more
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impairment in quality of life than those without separation anxiety. We found a greater rate of symptoms suggestive of anxious attachment among panic patients with ASAD compared to those without ASAD. However, the relationship between ASAD and
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attachment style is not strong, and adult ASAD occurs in some patients who report secure attachment style. Similarly, there is little evidence for the idea that separation anxiety
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disorder is a form of agoraphobia. Factor analysis shows clear differentiation of agoraphobic and separation anxiety symptoms. Our data corroborate the notion that
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ASAD is a distinct condition associated with impairment in quality of life and needs to be
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better recognized and treated in patients with panic disorder.
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1. Introduction Separation anxiety disorder is a well-established diagnostic category in the psychiatric nomenclature (Shear et al., 2006) . However, most studies of this condition pertain to childhood. By contrast, little attention has been paid to the occurrence of adult
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separation anxiety disorder (ASAD). Although in DSM-IV, separation anxiety disorder was classified in the section “Disorders Usually First Diagnosed in Infancy, Childhood,
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or Adolescence,” criteria for the disorder are now described in the DSM-5 section on
anxiety disorders (APA, 2013). The core features remain mostly unchanged, although the
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wording of the criteria has been modified to more adequately represent the expression of separation anxiety symptoms in adulthood. For example, attachment figures may include
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the children of adults with separation anxiety disorder, and avoidance behaviors may occur in the workplace as well as at school. Also, in contrast to DSM-IV, the diagnostic criteria no longer specify that age at onset must be before 18 years, because a substantial
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number of adults report onset of separation anxiety after age 18 (Marnane & Silove, 2013). The disturbance must cause clinically significant distress or impairment in social,
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academic, or other important areas of functioning. Adults with a diagnosis of ASAD report extreme anxiety about separations from major attachment figures (partner,
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children, or parents), fear that harm would befall those close to them and need to
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maintain proximity to them. These symptoms may affect the individual’s behavior and lead to severe impairment in social relationships. It is important to distinguish between symptoms of ASAD and dependent personality traits. Dependency is a pervasive and indiscriminate tendency to rely excessively on others, whereas ASAD refers to a limited array of concern about the proximity and safety of key attachment figures. Initially, Manicavasagar, Silove and Curtis (1997) highlighted the clinical
significance of ASAD as a distinct diagnosis. This group raised the possibility that the most common pathological outcome for children with separation anxiety may be adult separation anxiety disorder (Manicavasagar et al., 2000, 1998) and documented the occurrence of ASAD in adults (Wijeratne and Manicavasagar, 2003). Our group (Fagiolini et al., 1998; Cyranowski et al., 2002; Pini et al., 2010, 2005) also found ASAD to be surprisingly common in a large clinical population of outpatients with anxiety and
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mood disorders. The high prevalence of ASAD in the general population (6.6%) was also confirmed in the NCS-R data (Shear et al., 2006). Another unresolved question is the nature of the relationship linking separation anxiety disorder to insecure attachment in general and to anxious attachment in
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particular (Troisi et al., 2004). Theoretically, it is possible that not all individuals with
anxious attachment meet criteria for separation anxiety disorder. It is also possible that
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separation anxiety disorder occurs even in the context of secure attachment. In other words, it is not known whether all individuals with separation anxiety disorder also
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engage in other anxious attachment behaviours. To our knowledge, no empirical study has been undertaken to answer this question.
Manicavasagar et al. (2009) tried to clarify the link between attachment styles and
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panic disorder/agoraphobia (PD-Ag). They studied 83 patients with PD-Ag and ASAD, highlighting that the style of anxious attachment, using the Attachment Style
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Questionnaire (ASQ) (Feeney et al., 1994), was more prevalent in patients with separation anxiety and panic disorder than in patients with only panic attacks. Similarly, the relationship between adult separation anxiety disorder, panic
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disorder (PD) and agoraphobia has not been well clarified (Mian et al., 2012; Wittchen et
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al., 2010, 2008). A prominent theme in the literature pertains to the relationship between childhood separation anxiety and adult PD (Brueckl et al., 2007). Some investigators
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found evidence that childhood separation anxiety disorder is associated with an increased risk of PD, with or without agoraphobia, in adulthood (Klein, 1964, 1980; DeRuiter & VanIjzendoorm, 1992). However, other studies have not supported this association (Warner et al., 1995; Aschenbrand et al., 2003). Lipsitz et al. (1994) found a high rate of childhood separation anxiety among adults with different anxiety disorders and questioned whether childhood separation anxiety disorder is selectively linked to adult PD or, alternatively, constitutes a risk factor for adult anxiety disorders more generally. Findings from the NCS-R supported the latter hypothesis. In the NCS-R, ASAD was highly comorbid with PD, but such a comorbidity rate was not different from the rates with other anxiety or mood disorders. Thus, neither childhood nor adult ASAD was preferentially associated with PD.
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This hypothesis has been further corroborated by findings arguing against the notion that separation anxiety and anxious attachment are relevant to panic disorder with agoraphobia in general, suggesting instead that that constellation is confined to a separate group, namely that of adult separation anxiety disorder.
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Preter & Klein (2008) proposed a model that amplified the original suffocation
false alarm theory (Klein, 1993). The observation of respiratory abnormalities in patients
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with PD was in line with the hypothesis that panic may be provoked by indicators of potential suffocation, such as fluctuations in pCO2 and brain lactate, as well as
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environmental circumstances. However, the fact that sudden loss, bereavement and childhood separation anxiety are also antecedents of “spontaneous” panic required an
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integrative explanation. Within this framework, the authors reappraised a developmental pathophysiological link between separation anxiety and PD and subsequent agoraphobia, coupled with attachment theory and ethological views of anxiety. Central opioid system
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dysfunction has been claimed to play a key role in both disordered breathing and separation distress in decreasing the suffocation alarm threshold.
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Given the dearth of research concerning ASAD, we have undertaken a series of investigations to better understand this condition among help-seeking individuals
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diagnosed with other DSM IV diagnoses (Pini et al., 2010, 2005, 2005a; Costa et al.,
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2009). In the current paper, we report the results of a clinical study aimed at ascertaining whether adult separation anxiety can be distinguished from agoraphobia and from anxious attachment style. In addition, we aimed at clarifying whether the occurrence of ASAD is associated with distinctive features of the PD clinical picture. These data may contribute to the current debate whether ASAD is a distinct clinical entity or merely a variant/subtype of PD. In addition, differential assessment of ASAD, agoraphobia or anxious attachment style may have important therapeutical implications for patients with panic disorder (Milrod et al., 2014).
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2. Methods The study sample included 141 consecutive adult psychiatric outpatients with a diagnosis of panic disorder with or without agoraphobia as a primary diagnosis. Participants were recruited from the adult psychiatric outpatient clinics of the Department
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of Psychiatry, University of Pisa. Patients with psychotic disorders or substance use
disorder prior to the index assessment were excluded. This investigation was carried out
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in accordance with the Declaration of Helsinki. The University of Pisa Ethical Committee reviewed the study design and all subjects were informed of the nature of study
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procedures and provided written informed consent prior to participation. Experienced residents in psychiatry performed interviews. Subjects completed self-report
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questionnaires and structured clinical interviews over 2 days.
2.1. Panic Disorder Diagnosis
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All subjects were assessed with the Structured Clinical Interview for the DSM-IV (SCID-I) (First et al., 2002) to establish DSM IV axis I primary diagnosis and
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comorbidity. We used the Panic Disorder Severity Scale (PDSS) to assess current severity of PD (Shear et al., 1997, 2001a). We also examined current severity of
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depression using the Hamilton Depression Rating Scale (Hamilton, 1960). Quality of life
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was assessed by the Medical Outcomes Study Short Form (SF-36) (Ware & Gandek, 1998).
2.2. Separation Anxiety
We conducted clinical interviews for adult and childhood history of separation anxiety disorder. To do this, we used the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS) (Cyranowski et al., 2002). This semi-structured interview evaluates each of the 8 DSM IV criterion symptoms of separation anxiety, separately for childhood and adult symptoms. Each question was scored as 0 (not at all), 1 (sometimes), 2 (often) or ? (don’t recall). In keeping with the DSM-IV guidelines, endorsement of three or more of the eight criterion symptoms (symptoms rated as “2 (often)”) was used as a threshold to determine categorical (yes/no) diagnosis of separation anxiety disorder in childhood and adulthood. In addition, criterion B (i.e.,
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duration of at least 4 weeks) and C (i.e., the disturbance causes clinically significant distress or impairment in social, academic, occupational), or other important areas of functioning were required. Scores on the 8 items of each subscale were also summed to produce a continuous measure of separation anxiety symptoms (range for each subscale =
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0–16).
We further assessed separation anxiety using the Adult Separation Anxiety
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Questionnaire (ASA-27), a 27-item inventory, which rates symptoms of ASAD. This
scale has been shown to display good internal reliability as well as concurrent validity
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with clinical assessments of ASAD (Manicavasagar et al., 2003, 1997).
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2.3. Attachment Style
Attachment style was assessed using two different self-report instruments. The Relationship Questionnaire (RQ) (Bartholomew & Horowitz, 1991) is a single-item
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measure made up of four short paragraphs, each describing a prototypical attachment pattern as it applies in close adult peer relationships. Participants are asked to rate degree
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of fit for each prototype on a 7-point scale. The RQ was designed to obtain continuous ratings of each of the four attachment patterns, and can also be used to categorize
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individuals into their best fitting attachment pattern. The highest of the four attachment
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prototype ratings can be used to classify participants into an attachment category designated A (secure), B ( fearful-avoidant attachment), C (preoccupied) and D (dismissing-avoidant) (Griffin & Bartholomew, 1994). The instrument has shown good psychometric properties (Picardi et al. 2002). In this study, the RQ data were used to assign each participant to an attachment style category. Attachment style was determined by assigning each subject to the category with the maximum score among the four items described by the RQ (data available for 107 subjects). In addition, we used the Attachment Style Questionnaire (ASQ) (Feeney et al.,
1994) as a dimensional measure of attachment style (data available for 104 subjects). The ASQ is a 40-item self-report questionnaire in which items are rated on a 6-point scale from 1 (totally disagree) to 6 (totally agree). Based on both theoretical expectations and principal components analysis, the 40 items can be assigned to five scales: Confidence, Discomfort with Closeness, Need for Approval, Preoccupation with Relationships, and
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Relationships as Secondary. Discomfort with Closeness maps onto conceptualizations of avoidant attachment (Hazan & Shaver, 1987). Need for Approval reflects respondents’ need for acceptance and confirmation from others that characterizes fearful avoidant and anxious preoccupied groups. Preoccupation with Relationships also maps to anxious
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attachment (sometimes also called anxious/ambivalent attachment). The Relationships as Secondary scale identifies dismissing attachment (Bartholomew, 1990). Confidence (in
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Self and Others) reflects a secure attachment orientation. When the ASQ was
administered to a large sample of university students, the five scales showed good
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internal consistency, with Cronbach’s alpha coefficients ranging from .76 to .84; further, the 10-week retest reliability coefficients of the scales ranged from .67 to .78 (Feeney et
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al., 1994).
2.4. Agoraphobia
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Agoraphobia was assessed using the Panic-Agoraphobic Spectrum Self-Report ( PASSR) (Cassano et al., 1999). This 114-item questionnaire was developed to assess lifetime
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panic-agoraphobic spectrum symptoms and displays good psychometric properties (Shear et al., 2001; Frank et al., 2002). Items are organized into eight panic-agoraphobic
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symptom domains including a domain comprising 25 items for assessing agoraphobia.
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Items are rated dichotomously (yes/no). Domain scores are obtained by counting the number of positive responses.
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3. Statistical Analyses
The mean values of continuous variables such as age and scale scores were
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compared between subjects with and without ASAD using the t-test for independent samples. Comparisons of categorical variables between groups were conducted using the chi-square test. In particular, rates of Axis I psychiatric comorbidity were compared
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between the two groups with or without ASAD, before proceeding to factor analysis and
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attachment comparisons. The p-value was set at 0.05. The association of demographic and clinical variables with ASAD was estimated using crude odds ratios (ORs) with 95% confidence intervals (CIs). The factor structure of the adult SCI-SAS scale and PAS-SR
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‘agoraphobia’ subscale was evaluated by using a generalized least square factor analysis. For this analysis the SCI-SAS items were dichotomized (0,1=absent, 2=present) to have
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the same measurement level as PAS-SR items.
Statistical analyses were conducted using IBM SPSS Statistics, version 20.0 (IBM
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SPSS, 2011).
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4. Results
4.1. Characteristics of sub-groups with and without adult separation anxiety disorder (ASAD)
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Overall, ASAD was diagnosed in 70/141 (49.5%) of our sample, and was more
likely to occur in females (52/91; 57.1%) compared with males (18/50; 36%) (OR=2.37,
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95% CI: 1.17-4.83.) Age, educational level and marital status were similar between
subjects with or without ASAD (age: 39.45±12.60 with ASAD and 41.65±13.07 without
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ASAD; t-test= 1.013, p=0.313; educational level: 10.76±3.71 with ASAD and
11.20±4.36 without ASAD, t-test=-0.652, p=0.516; married: 31 (45.6%) and 33 (46.5%),
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in each group respectively, chi-square=0.11, p= .916). Subjects with ASAD were less likely to be employed (58.8% vs. 72.9%) although this difference did not reach statistical significance (chi-square=3.03, p=0.082).
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Thirty-eight (54.3%) of the 70 participants with ASAD also reported a history of childhood separation anxiety disorder, while only 13/71 (18.3%) of those without ASAD
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recalled these symptoms in childhood (OR = 5.30, CI 2.47-11.37 for those with ASAD compared with those without). Overall, 58/141 (41%) of the sample did not meet criteria
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for child or adult separation anxiety disorder.
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4.2. Clinical correlates of adult separation anxiety disorder (ASAD) As shown in Table 1, ASAD was associated with higher frequency of
agoraphobia (p=.046), more panic attacks during last month (p=.008), greater severity of panic disorder symptoms (p=.008), and earlier age of onset of agoraphobia (p=.018). Patients with ASAD endorsed lower scores on quality of life as assessed by SF-36 in terms of ‘physical functioning’ (p=.007), ‘role emotional’ (p=.048), ‘mental health’ (p=.003) and ‘general health’ (p=.008.)
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4.3. Adult separation anxiety and agoraphobia ASA-27 total score significantly correlated with SCI-PAS agoraphobia subscale score (r=0.31.) Factor analysis including items from both scales revealed that a two-factor model fits the data well (chi-square=163.6, df=151, p=0.228). The factor loadings are
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shown in Table 2. Two items from the agoraphobia scale load on the ‘separation anxiety’ factor. These items rate feeling nervous or uncomfortable when alone outside home or
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somewhere far from home or when home alone.
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4.4. Adult separation anxiety disorder and attachment style
The relationship between ASAD and attachment style has been investigated by
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the RQ and the ASQ. About 20% of the sample was not willing to complete the attachment evaluation. However, these individuals did not differ from those who
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completed the assessment on socio-demographic or clinical characteristics.
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There were no significant differences in the distribution of the four RQ-rated attachment styles among panic disorder patients with vs without ASAD (‘Anxious’, 35.8% vs 26.8%; ‘Avoidant’ 26.4% vs 22.2%; ‘Dismissing’ 26.4% vs 25.9%, ‘Secure’ 11.3% vs 24.1%).
The dimensional measure ASQ revealed that the group with ASAD scored
significantly higher on preoccupation with relationships (32.22±8.43 vs 28.56±7.40; t =2.308, p=.023) and showed a trend toward greater need for approval (25.00±7.89 vs 22.40±7.44, t =-1.702, p=.092), i.e. on both the scales indicative of anxious attachment.
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5. Discussion Our study of panic disorder patients examined questions related to the
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distinctiveness of the syndrome of adult separation anxiety disorder. Results of our study support the idea that adult separation anxiety disorder is different from anxious
attachment or agoraphobia. We found a greater rate of symptoms suggestive of anxious
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attachment among panic patients with ASAD compared to those without ASAD.
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However, the relationship between ASAD and attachment style is not strong, and ASAD occurs in some patients who report secure attachment style. Similarly, there is little evidence for the idea that separation anxiety disorder is a form of agoraphobia. Factor
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analysis shows clear differentiation of agoraphobic and separation anxiety symptoms. Previous studies reported that ASAD is an impairing condition that leads to long
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term difficulties in different areas of functioning (Shear et al., 2006; Pini et al., 2010; Milrod et al., 2014). We found that panic disorder patients with ASAD had greater severity of panic disorder and more impairment in quality of life than those without.
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These findings corroborate the notion that it is important for clinicians and researchers to
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focus on ASAD, when co-occurring with other psychiatric disorders, as an independent source of disability. We highlight the importance of distinguishing between separation
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anxiety as a symptom and separation anxiety as a disorder. Both ASAD and anxious attachment share separation anxiety symptoms (Shear, 1996; Dozier et al., 1999). However, our results suggest that separation anxiety, as a symptom, is not necessarily indicative of separation anxiety disorder. The latter is a specific constellation of symptoms in adults, resembling the well-described childhood condition, to which it is often related. In this case, patients have profound sensitivity to transitions and losses, including those experienced in therapeutic relationships (Milrod et al., 2014). Patients and clinicians may not recognize its presence or potency given that it tends to normalize, so that separation anxiety fuels chronic anxiety and a global sense of inadequacy and incompetence that can undermine either psychological or pharmacological treatments. In particular, separation anxiety disorder has been found to predict medication nonresponse
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to SSRIs and tricyclic antidepressants in subjects with panic disorder with agoraphobia (Miniati et al., 2012).
Fear of being alone and unable to get help is a form of separation anxiety and also a
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criterion symptom for agoraphobia (Pollack et al., 1996; Bandelow et al., 2001; BeesdoBaum et al., 2009). However, agoraphobic fear is usually related to the possibility of
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having a panic attack, whereas the core fear in separation anxiety disorder is that of harm pending on a close attachment figure. The resulting pattern of avoidance associated with
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agoraphobia differs from that found with adult separation anxiety disorder. The
distinctiveness of ASAD and agoraphobia is supported by our factor analysis findings.
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However, agoraphobic fear of being alone did load with ASAD. This suggests that some individuals diagnosed with agoraphobia based on such fear may have co-occurring ASAD and/or may be better characterized as ASAD.
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5.1. Limitations
The limitations of this study need to be acknowledged. We used only self-report
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instruments to evaluate attachment style. However, these scales have been well validated and used by many other investigators. Our sample included PD patients recruited from a
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psychiatric outpatient clinic with a reputation for the treatment of anxiety and mood
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disorders. Thus, although panic disorder was the primary diagnosis in our sample, the high prevalence of comorbid mood disorders could have affected the relationship between separation anxiety and attachment styles. The frequency of ASAD may be elevated in this tertiary care setting (Pini et al., 2005). However, there is no reason to expect that the lack of correspondence between ASAD and attachment style or between ASAD and agoraphobia was specific to this sample. Our study is also limited by the cross-sectional nature of our data. We found some potentially important associations between separation anxiety disorder, panic disorder severity, impairment in quality of life and anxious-preoccupied attachment style. However, we cannot determine the direction of causality nor whether impact of quality of life was, at least in part, mediated by severity of PD .
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5.2. Conclusions In summary, we found a high frequency of adult separation anxiety disorder in a group of psychiatric outpatients who met DSM-IV criteria for panic disorder. We found more differences than similarities between anxious attachment, agoraphobia and ASAD.
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We further corroborate indications of clinical significance of this condition (Silove &
Marnane, 2013). We urge clinicians and researchers to be aware of separation anxiety
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disorder in adults and consider the possibility that specific treatment strategies may be
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needed.
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Acknowledgements
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This work was supported by grants from the Italian Ministry of University and Scientific Research ( prot. 2005069159) and Fondazione IDEA (Institute for Research and Prevention of Depression and Anxiety).
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Declaration of interest statement
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All authors declare that they have no conflicts of interest and the manuscript has
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not been published elsewhere.
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questionnaire for measuring separation anxiety in adulthood. Comprehensive Psychiatry 44, 146–153.
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Manicavasagar, V., Silove, D., Marnane, C., Wagner, R. 2009. Adult attachment styles in panic disorder with and without comorbid adult separation anxiety disorder. Australian and New Zealand Journal of Psychiatry, 43(2), 167-72. Marnane, C. & Silove, D. 2013. DSM-5 allows separation anxiety disorder to grow up. Australian and New Zealan Journal of Psychiatry, 47(1), 12-5. Mian, N.D., Godoy, L., Briggs-Gowan, M.J. & Carter, A.S. (2012). Patterns of anxiety symptoms in toddlers and preschool-age children: evidence of early differentiation. Journal of Anxiety Disorders, 26(1), 102-110. Milrod, B., Markowitz, J.C., Gerber, A.J., Cyranowski, J., Altemus, M., Shapiro, T., Hofer, M., Glatt, C. 2014. Childhood separation anxiety and the pathogenesis and treatment of adult anxiety. American Journal of Psychiatry, 171, 34-43. Miniati M, Calugi S, Rucci P, Shear MK, Benvenuti A, Santoro D, Mauri M, Cassano GB. 2012. Predictors of response among patients with panic disorder treated with
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Pini, S., Abelli, M., Mauri, M., Muti, M., Iazzetta, P., Banti, S. & Cassano, GB. (2005). Clinical correlates and significance of separation anxiety in patients with bipolar
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Pini, S., Abelli, M., Shear, K.M., Cardini, A., Lari, L., Gesi, C., Muti, M., Calugi, S., Galderisi, S., Troisi, A., Bertolino, A. & Cassano, G.B. (2010). Frequency and
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clinical correlates of adult separation anxiety in a sample of 508 outpatients with mood and anxiety disorders. Acta Psychiatrica Scandinavica, 122(1), 40-46
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Pollack, M.H., Otto, M.W., Sabatino, S., Majcher, D., Worthington, J.J., McArdle, E.T.
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Shear M.K. (1996) Factors in the etiology and pathogenesis of panic disorder: revisiting the attachment–separation paradigm. American Journal of Psychiatry, 153, 125–135. Shear M.K., Brown T.A., Barlow D.H., Money R., Sholomskas D.E., Woods S.W., Gorman J.M., Papp L.A. (1997) Multicenter collaborative panic disorder severity scale. American Journal of Psychiatry, 154, 1571-1575. Shear, M.K., Frank, E., Rucci, P., Fagiolini, A., Grochocinski, V., Houck, P., Cassano, G.B., Kupfer, D.J., Endicott, J., Maser, J., Mauri, M. & Banti, S. (2001). Panic-
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(1993). The development of the Separation Anxiety Symptom Inventory (SASI). Australian and New Zealand Journal of Psychiatry, 27, 477–488.
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IBM SPSS Inc. 2011. SPSS Statistics, Rel. 20.0., IBM, USA. Troisi, A. & D'Argenio, A. (2004). The relationship between anger and depression in a clinical sample of young men: the role of insecure attachment. Journal of Affective Disorders, 79(1-3), 269-272.
Ware, J.E. Jr. & Gandek, B. (1998). Overview of the SF-36 Health Survey and the International Quality of Life Assessment (IQOLA) Project. Journal of Clinical Epidemiology, 51, 903-912.
Warner, V., Mufson, L. & Weissman, M.M. (1995). Offspring at high and low risk for depression and anxiety: mechanisms of psychiatric disorder. Journal of the American Academy of Child and Adolescence Psychiatry, 34, 786-797. Wijeratne, C. & Manicavasagar, V. (2003). Separation anxiety in the elderly. Journal of Anxiety Disorders, 17, 695–702. Wittchen H.U., Nocon A., Beesdo K., Pine D.S., Hofler M., Lieb R., Gloster A.T. (2008).
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Agoraphobia and panic. Prospective-longitudinal relations suggest a rethinking of diagnostic concepts. Psychotherapy & Psychosomatics, 77(3), 147-57. Wittchen, H.U., Gloster, A.T., Beesdo-Baum, K., Fava, G.A. & Craske, M.G. (2010) Agoraphobia: a review of the diagnostic classificatory position and criteria.
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Psychiatry, 63(4), 406-414.
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Table 1. Clinical and Quality of Life (QOL) characteristics in subjects with panic disorder (PD) 1 with and without adult separation anxiety disorder (ASAD )
Patients with PD with ASAD (n=70)
Chisquare
Lifetime comorbidity Agoraphobia Social phobia OCD Specific phobia Bipolar I Bipolar II Major depression
37 (52.1%) 14 (19.7%) 13 (18.3%) 18 (25.4%) 8 (11.3%) 19 (26.8%) 23 (32.4%)
48 (68.6%) 10 (14.3%) 10 (14.3%) 22 (31.4%) 11 (15.7%) 18 (25.7%) 17 (24.3%)
3.988 .737 .418 .640 .598 .020 1.140 t-test
.046 .391 .518 .424 .439 .888 .286
Severity of PD Past month panic attacks Number of panic symptoms ASA-27 SASI-tot Age at onset of PD Tot Hamilton Age at onset of Agoraphobia
3.98±7.95 7.55±2.83 20.82±11.61 11.445±7.90 29.76±12.37 12.23±7.43 33.97±14.14
9.62±14.74 10.09±2.43 45.31±12.23 18.81±9.82 28.20±12.22 13.50±9.35 27.28±11.17
-2.695 -5.709 -12.197 -4.918 .723 -,897 2.411
.008 .008 .0001 .0001 .471 .371 .018
SF36 QOL Physical Functioning Role Physical Role Emotional Mental Health General Health Social Functioning Vitality Bodily Pain
88.57±16.76 58.33±45.12 36.50±42.63 48.17±23.52 61.16±22.18 49.40±12.38 43.22±23.54 71.77±30.91
77.58±26.43 59.16±45.55 22.22±36.13 35.58±22.08 49.68±25.12 49.16±9.45 35.97±23.95 68.79±32.93
t-test 2.767 -.102 2.000 3.018 2.690 .119 1.671 .511
p .007 .919 .048 .003 .008 .905 .097 .610
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Patients with PD with no ASAD (n=71)
ASAD = 3 or more items scored “2” (often) at Structured Clinical Interview for Separation Anxiety
Disorder – Adult (SCI-SAS)
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Table 2. Rotated Factor Matrix of PAS-SR1 ‘typical agoraphobia” subscale and the 8 SCI-SAS2 adult section items.
Factor 2 (separation anxiety)
.382 .394 .462 .421 .578
.416 .415 .056 .318 .385
cr .508 .692 .651 .590 .510
.215 -.035 .150 -.200 .132
.587 .330
.181 .089
.089
.664
.139
.689
.194
.454
.071
.352
-.011
.538
.003
.505
.015 .201
.262 .207
1 2
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Did you avoid, feel nervous or uncomfortable...1 ...when you were alone outside your home or somewhere far from home? ...when home alone? ...when you were in a crowded place? ...when on a bridge or in a ski gondola? ...when you were in closed places (such as tunnels, subways, underground, or in a theater)? ...when you were in an elevator? ...driving a car other than on a highway? ❏I never drove. ...driving a car on the highway? ❏I never drove. ...being in an open place like a town square or a wide street? ...traveling as a passenger by car, bus, train or plane? Note: Not because of fear of crashing. ...standing in line? ...in situations or places in which you thought you might be embarrassed by the symptoms previously described? As a child or an adult, did you ever experience ...2 A lot of distress if you were separated or anticipated separation from home or loved ones. A lot of distress because of thoughts that you might lose someone close to you or some harm might come to them 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
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1 (agoraphobia)
PAS-SR: Panic-agoraphic Spectrum self-report Questionnaire SCI-SAS: Structured Clinical Interview for Separation Anxiety Disorder
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Highlights We found adult separation anxiety disorder in 49.5% of our panic disorder patients sample. Patients with adult separation anxiety had greater panic symptom severity and more impairment in quality of life than those without separation anxiety. Separation anxiety is distinct from agoraphobia. Adult separation anxiety is associated with insecure attachment style.
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S0887-6185(14)00094-2 http://dx.doi.org/doi:10.1016/j.janxdis.2014.06.010 ANXDIS 1622
To appear in:
Journal of Anxiety Disorders
Received date: Revised date: Accepted date:
19-5-2012 20-6-2014 30-6-2014
Please cite this article as: Pini, S., Abelli, M., Troisi, A., Siracusano, A., Cassano, G. B., Shear, K. M., and Baldwin, D.,The relationships among separation anxiety disorder, adult attachment style and agoraphobia in patients with panic disorder, Journal of Anxiety Disorders (2014), http://dx.doi.org/10.1016/j.janxdis.2014.06.010 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
The relationships among separation anxiety disorder, adult attachment style
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and agoraphobia in patients with panic disorder
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Stefano Pini1a, Marianna Abelli1, Alfonso Troisi3, Alberto Siracusano3, Giovanni B. Cassano1 , Katherine M. Shear2, and David Baldwin4
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From: 1
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Columbia University, Department of Social Work, School of Social Work Columbia University, New York, NY, USA
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2
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Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, via Roma 65, I-56100 Pisa, Italy
Department of Neurosciences, University of Rome Tor Vergata, Via Montpellier 1,
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00133 Rome, Italy.
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Department of Psychiatry University of Southampton Faculty of Medicine Academic Centre, College Keep 4-12 Terminus Terrace, Southampton SO14 3DT
Key words: panic disorder, separation anxiety disorder, adult attachment style, agoraphobia
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Corresponding author: Prof. Stefano Pini Department of Psychiatry, University of Pisa Via Roma 67, 56100 Pisa, Italy Phone +39 050 993559 Fax +39 050 21581 e-mail: [email protected]
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ABSTRACT
Epidemiological studies indicate that separation anxiety disorder occurs more frequently in adults than children. It is unclear whether the presence of adult separation anxiety
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disorder (ASAD) is a manifestation of anxious attachment, or a form of agoraphobia, or a specific condition with clinically significant consequences. We conducted a study to
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examine these questions. A sample of 141 adult outpatients with panic disorder
participated in the study. Participants completed standardized measures of separation
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anxiety, attachment style, agoraphobia, panic disorder severity and quality of life. Patients with ASAD (49.5% of our sample) had greater panic symptom severity and more
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impairment in quality of life than those without separation anxiety. We found a greater rate of symptoms suggestive of anxious attachment among panic patients with ASAD compared to those without ASAD. However, the relationship between ASAD and
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attachment style is not strong, and adult ASAD occurs in some patients who report secure attachment style. Similarly, there is little evidence for the idea that separation anxiety
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disorder is a form of agoraphobia. Factor analysis shows clear differentiation of agoraphobic and separation anxiety symptoms. Our data corroborate the notion that
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ASAD is a distinct condition associated with impairment in quality of life and needs to be
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better recognized and treated in patients with panic disorder.
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1. Introduction Separation anxiety disorder is a well-established diagnostic category in the psychiatric nomenclature (Shear et al., 2006) . However, most studies of this condition pertain to childhood. By contrast, little attention has been paid to the occurrence of adult
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separation anxiety disorder (ASAD). Although in DSM-IV, separation anxiety disorder was classified in the section “Disorders Usually First Diagnosed in Infancy, Childhood,
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or Adolescence,” criteria for the disorder are now described in the DSM-5 section on
anxiety disorders (APA, 2013). The core features remain mostly unchanged, although the
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wording of the criteria has been modified to more adequately represent the expression of separation anxiety symptoms in adulthood. For example, attachment figures may include
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the children of adults with separation anxiety disorder, and avoidance behaviors may occur in the workplace as well as at school. Also, in contrast to DSM-IV, the diagnostic criteria no longer specify that age at onset must be before 18 years, because a substantial
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number of adults report onset of separation anxiety after age 18 (Marnane & Silove, 2013). The disturbance must cause clinically significant distress or impairment in social,
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academic, or other important areas of functioning. Adults with a diagnosis of ASAD report extreme anxiety about separations from major attachment figures (partner,
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children, or parents), fear that harm would befall those close to them and need to
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maintain proximity to them. These symptoms may affect the individual’s behavior and lead to severe impairment in social relationships. It is important to distinguish between symptoms of ASAD and dependent personality traits. Dependency is a pervasive and indiscriminate tendency to rely excessively on others, whereas ASAD refers to a limited array of concern about the proximity and safety of key attachment figures. Initially, Manicavasagar, Silove and Curtis (1997) highlighted the clinical
significance of ASAD as a distinct diagnosis. This group raised the possibility that the most common pathological outcome for children with separation anxiety may be adult separation anxiety disorder (Manicavasagar et al., 2000, 1998) and documented the occurrence of ASAD in adults (Wijeratne and Manicavasagar, 2003). Our group (Fagiolini et al., 1998; Cyranowski et al., 2002; Pini et al., 2010, 2005) also found ASAD to be surprisingly common in a large clinical population of outpatients with anxiety and
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mood disorders. The high prevalence of ASAD in the general population (6.6%) was also confirmed in the NCS-R data (Shear et al., 2006). Another unresolved question is the nature of the relationship linking separation anxiety disorder to insecure attachment in general and to anxious attachment in
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particular (Troisi et al., 2004). Theoretically, it is possible that not all individuals with
anxious attachment meet criteria for separation anxiety disorder. It is also possible that
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separation anxiety disorder occurs even in the context of secure attachment. In other words, it is not known whether all individuals with separation anxiety disorder also
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engage in other anxious attachment behaviours. To our knowledge, no empirical study has been undertaken to answer this question.
Manicavasagar et al. (2009) tried to clarify the link between attachment styles and
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panic disorder/agoraphobia (PD-Ag). They studied 83 patients with PD-Ag and ASAD, highlighting that the style of anxious attachment, using the Attachment Style
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Questionnaire (ASQ) (Feeney et al., 1994), was more prevalent in patients with separation anxiety and panic disorder than in patients with only panic attacks. Similarly, the relationship between adult separation anxiety disorder, panic
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disorder (PD) and agoraphobia has not been well clarified (Mian et al., 2012; Wittchen et
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al., 2010, 2008). A prominent theme in the literature pertains to the relationship between childhood separation anxiety and adult PD (Brueckl et al., 2007). Some investigators
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found evidence that childhood separation anxiety disorder is associated with an increased risk of PD, with or without agoraphobia, in adulthood (Klein, 1964, 1980; DeRuiter & VanIjzendoorm, 1992). However, other studies have not supported this association (Warner et al., 1995; Aschenbrand et al., 2003). Lipsitz et al. (1994) found a high rate of childhood separation anxiety among adults with different anxiety disorders and questioned whether childhood separation anxiety disorder is selectively linked to adult PD or, alternatively, constitutes a risk factor for adult anxiety disorders more generally. Findings from the NCS-R supported the latter hypothesis. In the NCS-R, ASAD was highly comorbid with PD, but such a comorbidity rate was not different from the rates with other anxiety or mood disorders. Thus, neither childhood nor adult ASAD was preferentially associated with PD.
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This hypothesis has been further corroborated by findings arguing against the notion that separation anxiety and anxious attachment are relevant to panic disorder with agoraphobia in general, suggesting instead that that constellation is confined to a separate group, namely that of adult separation anxiety disorder.
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Preter & Klein (2008) proposed a model that amplified the original suffocation
false alarm theory (Klein, 1993). The observation of respiratory abnormalities in patients
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with PD was in line with the hypothesis that panic may be provoked by indicators of potential suffocation, such as fluctuations in pCO2 and brain lactate, as well as
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environmental circumstances. However, the fact that sudden loss, bereavement and childhood separation anxiety are also antecedents of “spontaneous” panic required an
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integrative explanation. Within this framework, the authors reappraised a developmental pathophysiological link between separation anxiety and PD and subsequent agoraphobia, coupled with attachment theory and ethological views of anxiety. Central opioid system
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dysfunction has been claimed to play a key role in both disordered breathing and separation distress in decreasing the suffocation alarm threshold.
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Given the dearth of research concerning ASAD, we have undertaken a series of investigations to better understand this condition among help-seeking individuals
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diagnosed with other DSM IV diagnoses (Pini et al., 2010, 2005, 2005a; Costa et al.,
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2009). In the current paper, we report the results of a clinical study aimed at ascertaining whether adult separation anxiety can be distinguished from agoraphobia and from anxious attachment style. In addition, we aimed at clarifying whether the occurrence of ASAD is associated with distinctive features of the PD clinical picture. These data may contribute to the current debate whether ASAD is a distinct clinical entity or merely a variant/subtype of PD. In addition, differential assessment of ASAD, agoraphobia or anxious attachment style may have important therapeutical implications for patients with panic disorder (Milrod et al., 2014).
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2. Methods The study sample included 141 consecutive adult psychiatric outpatients with a diagnosis of panic disorder with or without agoraphobia as a primary diagnosis. Participants were recruited from the adult psychiatric outpatient clinics of the Department
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of Psychiatry, University of Pisa. Patients with psychotic disorders or substance use
disorder prior to the index assessment were excluded. This investigation was carried out
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in accordance with the Declaration of Helsinki. The University of Pisa Ethical Committee reviewed the study design and all subjects were informed of the nature of study
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procedures and provided written informed consent prior to participation. Experienced residents in psychiatry performed interviews. Subjects completed self-report
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questionnaires and structured clinical interviews over 2 days.
2.1. Panic Disorder Diagnosis
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All subjects were assessed with the Structured Clinical Interview for the DSM-IV (SCID-I) (First et al., 2002) to establish DSM IV axis I primary diagnosis and
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comorbidity. We used the Panic Disorder Severity Scale (PDSS) to assess current severity of PD (Shear et al., 1997, 2001a). We also examined current severity of
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depression using the Hamilton Depression Rating Scale (Hamilton, 1960). Quality of life
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was assessed by the Medical Outcomes Study Short Form (SF-36) (Ware & Gandek, 1998).
2.2. Separation Anxiety
We conducted clinical interviews for adult and childhood history of separation anxiety disorder. To do this, we used the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS) (Cyranowski et al., 2002). This semi-structured interview evaluates each of the 8 DSM IV criterion symptoms of separation anxiety, separately for childhood and adult symptoms. Each question was scored as 0 (not at all), 1 (sometimes), 2 (often) or ? (don’t recall). In keeping with the DSM-IV guidelines, endorsement of three or more of the eight criterion symptoms (symptoms rated as “2 (often)”) was used as a threshold to determine categorical (yes/no) diagnosis of separation anxiety disorder in childhood and adulthood. In addition, criterion B (i.e.,
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duration of at least 4 weeks) and C (i.e., the disturbance causes clinically significant distress or impairment in social, academic, occupational), or other important areas of functioning were required. Scores on the 8 items of each subscale were also summed to produce a continuous measure of separation anxiety symptoms (range for each subscale =
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0–16).
We further assessed separation anxiety using the Adult Separation Anxiety
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Questionnaire (ASA-27), a 27-item inventory, which rates symptoms of ASAD. This
scale has been shown to display good internal reliability as well as concurrent validity
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with clinical assessments of ASAD (Manicavasagar et al., 2003, 1997).
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2.3. Attachment Style
Attachment style was assessed using two different self-report instruments. The Relationship Questionnaire (RQ) (Bartholomew & Horowitz, 1991) is a single-item
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measure made up of four short paragraphs, each describing a prototypical attachment pattern as it applies in close adult peer relationships. Participants are asked to rate degree
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of fit for each prototype on a 7-point scale. The RQ was designed to obtain continuous ratings of each of the four attachment patterns, and can also be used to categorize
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individuals into their best fitting attachment pattern. The highest of the four attachment
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prototype ratings can be used to classify participants into an attachment category designated A (secure), B ( fearful-avoidant attachment), C (preoccupied) and D (dismissing-avoidant) (Griffin & Bartholomew, 1994). The instrument has shown good psychometric properties (Picardi et al. 2002). In this study, the RQ data were used to assign each participant to an attachment style category. Attachment style was determined by assigning each subject to the category with the maximum score among the four items described by the RQ (data available for 107 subjects). In addition, we used the Attachment Style Questionnaire (ASQ) (Feeney et al.,
1994) as a dimensional measure of attachment style (data available for 104 subjects). The ASQ is a 40-item self-report questionnaire in which items are rated on a 6-point scale from 1 (totally disagree) to 6 (totally agree). Based on both theoretical expectations and principal components analysis, the 40 items can be assigned to five scales: Confidence, Discomfort with Closeness, Need for Approval, Preoccupation with Relationships, and
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Relationships as Secondary. Discomfort with Closeness maps onto conceptualizations of avoidant attachment (Hazan & Shaver, 1987). Need for Approval reflects respondents’ need for acceptance and confirmation from others that characterizes fearful avoidant and anxious preoccupied groups. Preoccupation with Relationships also maps to anxious
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attachment (sometimes also called anxious/ambivalent attachment). The Relationships as Secondary scale identifies dismissing attachment (Bartholomew, 1990). Confidence (in
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Self and Others) reflects a secure attachment orientation. When the ASQ was
administered to a large sample of university students, the five scales showed good
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internal consistency, with Cronbach’s alpha coefficients ranging from .76 to .84; further, the 10-week retest reliability coefficients of the scales ranged from .67 to .78 (Feeney et
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al., 1994).
2.4. Agoraphobia
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Agoraphobia was assessed using the Panic-Agoraphobic Spectrum Self-Report ( PASSR) (Cassano et al., 1999). This 114-item questionnaire was developed to assess lifetime
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panic-agoraphobic spectrum symptoms and displays good psychometric properties (Shear et al., 2001; Frank et al., 2002). Items are organized into eight panic-agoraphobic
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symptom domains including a domain comprising 25 items for assessing agoraphobia.
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Items are rated dichotomously (yes/no). Domain scores are obtained by counting the number of positive responses.
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3. Statistical Analyses
The mean values of continuous variables such as age and scale scores were
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compared between subjects with and without ASAD using the t-test for independent samples. Comparisons of categorical variables between groups were conducted using the chi-square test. In particular, rates of Axis I psychiatric comorbidity were compared
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between the two groups with or without ASAD, before proceeding to factor analysis and
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attachment comparisons. The p-value was set at 0.05. The association of demographic and clinical variables with ASAD was estimated using crude odds ratios (ORs) with 95% confidence intervals (CIs). The factor structure of the adult SCI-SAS scale and PAS-SR
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‘agoraphobia’ subscale was evaluated by using a generalized least square factor analysis. For this analysis the SCI-SAS items were dichotomized (0,1=absent, 2=present) to have
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the same measurement level as PAS-SR items.
Statistical analyses were conducted using IBM SPSS Statistics, version 20.0 (IBM
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4. Results
4.1. Characteristics of sub-groups with and without adult separation anxiety disorder (ASAD)
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Overall, ASAD was diagnosed in 70/141 (49.5%) of our sample, and was more
likely to occur in females (52/91; 57.1%) compared with males (18/50; 36%) (OR=2.37,
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95% CI: 1.17-4.83.) Age, educational level and marital status were similar between
subjects with or without ASAD (age: 39.45±12.60 with ASAD and 41.65±13.07 without
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ASAD; t-test= 1.013, p=0.313; educational level: 10.76±3.71 with ASAD and
11.20±4.36 without ASAD, t-test=-0.652, p=0.516; married: 31 (45.6%) and 33 (46.5%),
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in each group respectively, chi-square=0.11, p= .916). Subjects with ASAD were less likely to be employed (58.8% vs. 72.9%) although this difference did not reach statistical significance (chi-square=3.03, p=0.082).
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Thirty-eight (54.3%) of the 70 participants with ASAD also reported a history of childhood separation anxiety disorder, while only 13/71 (18.3%) of those without ASAD
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recalled these symptoms in childhood (OR = 5.30, CI 2.47-11.37 for those with ASAD compared with those without). Overall, 58/141 (41%) of the sample did not meet criteria
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for child or adult separation anxiety disorder.
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4.2. Clinical correlates of adult separation anxiety disorder (ASAD) As shown in Table 1, ASAD was associated with higher frequency of
agoraphobia (p=.046), more panic attacks during last month (p=.008), greater severity of panic disorder symptoms (p=.008), and earlier age of onset of agoraphobia (p=.018). Patients with ASAD endorsed lower scores on quality of life as assessed by SF-36 in terms of ‘physical functioning’ (p=.007), ‘role emotional’ (p=.048), ‘mental health’ (p=.003) and ‘general health’ (p=.008.)
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4.3. Adult separation anxiety and agoraphobia ASA-27 total score significantly correlated with SCI-PAS agoraphobia subscale score (r=0.31.) Factor analysis including items from both scales revealed that a two-factor model fits the data well (chi-square=163.6, df=151, p=0.228). The factor loadings are
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shown in Table 2. Two items from the agoraphobia scale load on the ‘separation anxiety’ factor. These items rate feeling nervous or uncomfortable when alone outside home or
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somewhere far from home or when home alone.
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4.4. Adult separation anxiety disorder and attachment style
The relationship between ASAD and attachment style has been investigated by
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the RQ and the ASQ. About 20% of the sample was not willing to complete the attachment evaluation. However, these individuals did not differ from those who
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completed the assessment on socio-demographic or clinical characteristics.
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There were no significant differences in the distribution of the four RQ-rated attachment styles among panic disorder patients with vs without ASAD (‘Anxious’, 35.8% vs 26.8%; ‘Avoidant’ 26.4% vs 22.2%; ‘Dismissing’ 26.4% vs 25.9%, ‘Secure’ 11.3% vs 24.1%).
The dimensional measure ASQ revealed that the group with ASAD scored
significantly higher on preoccupation with relationships (32.22±8.43 vs 28.56±7.40; t =2.308, p=.023) and showed a trend toward greater need for approval (25.00±7.89 vs 22.40±7.44, t =-1.702, p=.092), i.e. on both the scales indicative of anxious attachment.
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5. Discussion Our study of panic disorder patients examined questions related to the
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distinctiveness of the syndrome of adult separation anxiety disorder. Results of our study support the idea that adult separation anxiety disorder is different from anxious
attachment or agoraphobia. We found a greater rate of symptoms suggestive of anxious
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attachment among panic patients with ASAD compared to those without ASAD.
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However, the relationship between ASAD and attachment style is not strong, and ASAD occurs in some patients who report secure attachment style. Similarly, there is little evidence for the idea that separation anxiety disorder is a form of agoraphobia. Factor
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analysis shows clear differentiation of agoraphobic and separation anxiety symptoms. Previous studies reported that ASAD is an impairing condition that leads to long
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term difficulties in different areas of functioning (Shear et al., 2006; Pini et al., 2010; Milrod et al., 2014). We found that panic disorder patients with ASAD had greater severity of panic disorder and more impairment in quality of life than those without.
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These findings corroborate the notion that it is important for clinicians and researchers to
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focus on ASAD, when co-occurring with other psychiatric disorders, as an independent source of disability. We highlight the importance of distinguishing between separation
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anxiety as a symptom and separation anxiety as a disorder. Both ASAD and anxious attachment share separation anxiety symptoms (Shear, 1996; Dozier et al., 1999). However, our results suggest that separation anxiety, as a symptom, is not necessarily indicative of separation anxiety disorder. The latter is a specific constellation of symptoms in adults, resembling the well-described childhood condition, to which it is often related. In this case, patients have profound sensitivity to transitions and losses, including those experienced in therapeutic relationships (Milrod et al., 2014). Patients and clinicians may not recognize its presence or potency given that it tends to normalize, so that separation anxiety fuels chronic anxiety and a global sense of inadequacy and incompetence that can undermine either psychological or pharmacological treatments. In particular, separation anxiety disorder has been found to predict medication nonresponse
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to SSRIs and tricyclic antidepressants in subjects with panic disorder with agoraphobia (Miniati et al., 2012).
Fear of being alone and unable to get help is a form of separation anxiety and also a
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criterion symptom for agoraphobia (Pollack et al., 1996; Bandelow et al., 2001; BeesdoBaum et al., 2009). However, agoraphobic fear is usually related to the possibility of
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having a panic attack, whereas the core fear in separation anxiety disorder is that of harm pending on a close attachment figure. The resulting pattern of avoidance associated with
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agoraphobia differs from that found with adult separation anxiety disorder. The
distinctiveness of ASAD and agoraphobia is supported by our factor analysis findings.
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However, agoraphobic fear of being alone did load with ASAD. This suggests that some individuals diagnosed with agoraphobia based on such fear may have co-occurring ASAD and/or may be better characterized as ASAD.
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5.1. Limitations
The limitations of this study need to be acknowledged. We used only self-report
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instruments to evaluate attachment style. However, these scales have been well validated and used by many other investigators. Our sample included PD patients recruited from a
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psychiatric outpatient clinic with a reputation for the treatment of anxiety and mood
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disorders. Thus, although panic disorder was the primary diagnosis in our sample, the high prevalence of comorbid mood disorders could have affected the relationship between separation anxiety and attachment styles. The frequency of ASAD may be elevated in this tertiary care setting (Pini et al., 2005). However, there is no reason to expect that the lack of correspondence between ASAD and attachment style or between ASAD and agoraphobia was specific to this sample. Our study is also limited by the cross-sectional nature of our data. We found some potentially important associations between separation anxiety disorder, panic disorder severity, impairment in quality of life and anxious-preoccupied attachment style. However, we cannot determine the direction of causality nor whether impact of quality of life was, at least in part, mediated by severity of PD .
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5.2. Conclusions In summary, we found a high frequency of adult separation anxiety disorder in a group of psychiatric outpatients who met DSM-IV criteria for panic disorder. We found more differences than similarities between anxious attachment, agoraphobia and ASAD.
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We further corroborate indications of clinical significance of this condition (Silove &
Marnane, 2013). We urge clinicians and researchers to be aware of separation anxiety
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disorder in adults and consider the possibility that specific treatment strategies may be
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needed.
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Acknowledgements
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This work was supported by grants from the Italian Ministry of University and Scientific Research ( prot. 2005069159) and Fondazione IDEA (Institute for Research and Prevention of Depression and Anxiety).
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Declaration of interest statement
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All authors declare that they have no conflicts of interest and the manuscript has
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not been published elsewhere.
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Table 1. Clinical and Quality of Life (QOL) characteristics in subjects with panic disorder (PD) 1 with and without adult separation anxiety disorder (ASAD )
Patients with PD with ASAD (n=70)
Chisquare
Lifetime comorbidity Agoraphobia Social phobia OCD Specific phobia Bipolar I Bipolar II Major depression
37 (52.1%) 14 (19.7%) 13 (18.3%) 18 (25.4%) 8 (11.3%) 19 (26.8%) 23 (32.4%)
48 (68.6%) 10 (14.3%) 10 (14.3%) 22 (31.4%) 11 (15.7%) 18 (25.7%) 17 (24.3%)
3.988 .737 .418 .640 .598 .020 1.140 t-test
.046 .391 .518 .424 .439 .888 .286
Severity of PD Past month panic attacks Number of panic symptoms ASA-27 SASI-tot Age at onset of PD Tot Hamilton Age at onset of Agoraphobia
3.98±7.95 7.55±2.83 20.82±11.61 11.445±7.90 29.76±12.37 12.23±7.43 33.97±14.14
9.62±14.74 10.09±2.43 45.31±12.23 18.81±9.82 28.20±12.22 13.50±9.35 27.28±11.17
-2.695 -5.709 -12.197 -4.918 .723 -,897 2.411
.008 .008 .0001 .0001 .471 .371 .018
SF36 QOL Physical Functioning Role Physical Role Emotional Mental Health General Health Social Functioning Vitality Bodily Pain
88.57±16.76 58.33±45.12 36.50±42.63 48.17±23.52 61.16±22.18 49.40±12.38 43.22±23.54 71.77±30.91
77.58±26.43 59.16±45.55 22.22±36.13 35.58±22.08 49.68±25.12 49.16±9.45 35.97±23.95 68.79±32.93
t-test 2.767 -.102 2.000 3.018 2.690 .119 1.671 .511
p .007 .919 .048 .003 .008 .905 .097 .610
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Patients with PD with no ASAD (n=71)
ASAD = 3 or more items scored “2” (often) at Structured Clinical Interview for Separation Anxiety
Disorder – Adult (SCI-SAS)
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Table 2. Rotated Factor Matrix of PAS-SR1 ‘typical agoraphobia” subscale and the 8 SCI-SAS2 adult section items.
Factor 2 (separation anxiety)
.382 .394 .462 .421 .578
.416 .415 .056 .318 .385
cr .508 .692 .651 .590 .510
.215 -.035 .150 -.200 .132
.587 .330
.181 .089
.089
.664
.139
.689
.194
.454
.071
.352
-.011
.538
.003
.505
.015 .201
.262 .207
1 2
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Did you avoid, feel nervous or uncomfortable...1 ...when you were alone outside your home or somewhere far from home? ...when home alone? ...when you were in a crowded place? ...when on a bridge or in a ski gondola? ...when you were in closed places (such as tunnels, subways, underground, or in a theater)? ...when you were in an elevator? ...driving a car other than on a highway? ❏I never drove. ...driving a car on the highway? ❏I never drove. ...being in an open place like a town square or a wide street? ...traveling as a passenger by car, bus, train or plane? Note: Not because of fear of crashing. ...standing in line? ...in situations or places in which you thought you might be embarrassed by the symptoms previously described? As a child or an adult, did you ever experience ...2 A lot of distress if you were separated or anticipated separation from home or loved ones. A lot of distress because of thoughts that you might lose someone close to you or some harm might come to them 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
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1 (agoraphobia)
PAS-SR: Panic-agoraphic Spectrum self-report Questionnaire SCI-SAS: Structured Clinical Interview for Separation Anxiety Disorder
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Highlights We found adult separation anxiety disorder in 49.5% of our panic disorder patients sample. Patients with adult separation anxiety had greater panic symptom severity and more impairment in quality of life than those without separation anxiety. Separation anxiety is distinct from agoraphobia. Adult separation anxiety is associated with insecure attachment style.
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