Sam came into couple’s therapy with his wife Leah kicking and screaming all the way. “I’m fed up,” Leah said. “We may be home together all day, and if I’m watching television or doing something around the house without him, he pops in to say he misses me. If I go out to run errands for a couple of hours, he calls me two to three times to find out how I am. And, if I don’t come home in a time frame that he thinks is reasonable, he calls to say he’s worried about me. 

But, what really gets me riled is when he calls to ask if something’s wrong that he thought I’d be home by now. You’d think I was gone for a day rather than 2 hours. Heck, even the police won’t begin to look for you unless you are gone for over 24 hours. My friends think he’s just being attentive and sweet and wish their husbands were like Sam. If it is just this, then why do I feel suffocated by him? ” 

Leah and Sam have been married for 35 years. Sam’s “changed” Leah says, since their youngest son died in a motorcycle accident seven years ago. Sam was never very social, a little neurotic, and always preferred being with Leah than other people. But, the meaning of being-with-her has taken on new meaning in their relationship. Leah described Sam as becoming more needy over the past few years than her children when they were 2-years of age.

What’s wrong with Sam?

Sam has adult separation anxiety disorder (ASAD). To most of us, separation anxiety is what happens to young children separating from their parents on the first day of school. They cry, cling and voice strong opposition to having to separate from their parents for a short while.

But some adults also experience anxiety and fear of being separated from their loved ones. Bereavement and other traumatic situations that cause loss and separation (illness, marital or partnership breakup, prolonged military service) seems to activate the disorder in adults, as it did in Sam (Relationship between separation anxiety disorder and complicated grief;  Separation-Anxiety?). People with ASAD become anxious, worried and afraid that something bad might happen to themselves, and the people they love, just like young children do. But, now, the ghosts and monsters of childhood have become vehicular accidents, illness, or any other threatening event that may take away the people they depend on most for their happiness, support and well being.

Additionally, some studies show that adulthood separation anxiety is an extension of a dysfunctional style of the attachment bond (Anxious or Avoidant Attachment Style) to primary caregivers established in early childhood that makes one vulnerable to adult separation issues as adults, especially in times of high stress (Attachment, Panic Disorder and ASAD; Adult Separation Anxiety & Attachment Style). This connection between early attachment style and adulthood separation disorder may explain its high rate of occurrence in the United States (6.6% or 20 million people).

Childhood experiences that raise children’s fear of the unknown, potential for harm, and uncertainty of circumstance can make them anxious and fearful. This is especially the case in families that have a high level of financial and social stress, emotional difficulties, or drug or alcohol addiction. These types of stressful preoccupations can lead parents to neglect their children, which makes children anxious about the stability of their parents’ attention, care and love. In contrast, parents may overprotect their children, as a result of such pressures that increases children’s anxieties about all of the bad things that can happen to them.

Take Sam, for example. Sam was the youngest, only male child of three. His parents came from Greece to the United States through Ellis Island, when Sam was just 2-years-old. They didn’t speak English and lived with relatives until they had enough money to live on their own.

Sam doesn’t recall many childhood times that he wasn’t with family and relatives. He was not allowed to go on school camping trips or slumber parties with friends and playing outdoors was ill-advised, as the family lived in a rough neighborhood. Although his childhood was happy, there was always an undercurrent of fear related to financial and social stress. His parents, especially his mother, had a heightened concern about negative consequences of the family separating. On family outings, she’d continually shout out, “Stay together.” She was preoccupied with worst-case scenarios that Sam carried forward into his adult life.

ASAD FACTS

People vary in terms of how adult separation anxiety disorder presents in their lives and in the intensity of symptoms. But, research shows that:

• ASAD tends to present more in female than male adults.
• Cultures that have a lower tolerance for physical and emotional separation of family members may have higher rates of ASAD within their populations.
• The most common co-occurring mental disorders that appear with ASAD include major depressive disorder (40.8%), generalized anxiety disorder (16.1%), specific phobias (35.8%), social anxiety disorder (34.5%), post-traumatic stress disorder (23.7%), panic disorder (14.8%), agoraphobia without panic (5.8%), and obsessive-compulsive disorder (9.9%).
• For some persons, early childhood separation anxiety disorder can extend into adulthood.
• Symptoms of ASAD most usually show up after bereavement (especially of the complicated type)  and traumatic loss. But, positive and negative life transitions (e.g., change in relationship, job or lifestyle status) can also activate symptoms in some people.
• ASAD has periods of activation and remission.
• Symptoms of ASAD include a persistent worry about losing loved ones to death, illness, accidents or some other disaster; nightmares stemming from these fears; grieving-related behaviors that include social withdrawal, sadness, nervousness and an inability to concentrate, avoidance of sleeping away from loved ones, also
• The rates of the disorder in the population show that separation disorder occurs more frequently in adults than in children. (DSM V Changes in Anxiety Disorders and Phobias).

Recent changes in the leading psychiatric diagnostic manual (Diagnostic Statistical Psychiatric Manual, DSM V) now includes adults as well as children as capable of having a separation anxiety disorder  (ASAD). In the past, patients presenting with separation anxiety difficulties tended to be misdiagnosed as having either an adjustment, depression, agoraphobia, generalized anxiety or social anxiety disorder.

I’ve treated adults throughout the years who present with symptoms of ASAD. It is not easy to spot, at first, as ASAD shares some of the symptoms of the above-mentioned mental health conditions. Studies that have shown bereavement and traumatic loss as main precipitants of ASAD are helpful in establishing the diagnosis and its treatment.

Treatment of ASAD

The treatment of ASAD is only in its infancy. At this time, treatment for ASAD relies on treatments for the other Anxiety Disorders, as well as the expertise of psychiatrists and psychologists to tailor treatment approaches to the individual needs of their patients.

ASAD is a serious disorder. The symptoms of ASAD can be quite disabling, negatively affecting people’s work, social, and relationship life.  Antidepressant and anxiety medication in combination with cognitive behavioral therapy and support groups are the main focus of treatment.

1. Medication. The selective serotonin reuptake inhibitors (SSRI’s) are the first line of medication treatment. They increase the feel good nerve transmitter (serotonin) throughout the brain and body, which lowers depression, anxiety, and fear-related behaviors. Patients feel more calm and overall happiness and stop avoiding situations that have led to their dysfunction. The SSRI medications include:  Fluoxtine (Prozac®), Fluvoxamine (Luvox®), Paroxetine (Paxil®), Sertraline (Zoloft®), Citalopram (Celexa®), and Escitalopram (Lexapram®).

Many people would like to avoid taking medication, if possible. But, with conditions like ASAD, physiology cannot be ignored, especially at first. People with anxiety conditions tend to have overly sensitive nervous systems that sensitize them to perceiving harm and threat.  To adequately treat the symptoms of ASAD, the body has to become desensitized to separation threat. Only then, can persons with the disorder learn that their worst separation fears will not be confirmed. A calm mind and body also allows patients to benefit more from the coping skills and support that they get in psychotherapy.  Additionally, medication benefits more than symptom reduction. A large body of genetic research shows that sufficient levels of brain serotonin helps the brain to repair and regenerate its neurons. SSRI medications increase the brain’s serotonin level to normal levels.

2.Cognitive Behavioral Treatment. ASAD cognitive behavioral psychotherapy should emphasize a restructuring of thinking that increases separation anxiety and fears, like the thought, separation always brings disaster. Sam’s son left the house and never returned home again, for example. To him, leaving home equated with actual death. His disaster-type thoughts excited his body, which worsened his symptoms. Psychotherapy helped Sam to become aware of the relationship between his negative thoughts and his anxiety and to counter these extreme ideas with rational thinking.

Additionally, cognitive-behavioral techniques increase patients awareness of their bodies. They learn to sense subtle increases in body tension that can lead to anxiety and fear. Through techniques, like muscle relaxation, deep breathing and mindfulness, they learn how to lower brain and body arousal to stop their anxieties from taking them over. With enough practice, people can retrain their bodies to be less responsive to threat and harm, which can help them to lower their medication or completely get off it.

3. Support Groups. Attending an ASAD support group is a very important aspect of treatment. It helps to know that other people have walked in your shoes and appreciate first-hand your anxieties and fears. Support systems should always include a licensed professional who is able to work with the individual with ASAD to develop coping tools to reduce their burden upon their loved one. It is also important for each person in the relationship to have their own support system of family and friends.

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