CNS Spectrums (2016), 21, 289–294.

© Cambridge University Press 2016

doi:10.1017/S1092852916000080

REVIEW ARTICLE

The separation of adult separation anxiety disorder

David S. Baldwin,1,2 Robert Gordon,1* Marianna Abelli,3 and Stefano Pini3

1
Clinical and Experimental Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
2
Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
3
Department of Psychiatry, University of Pisa, Pisa, Italy

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) categorization of mental disorders
places “separation anxiety disorder” within the broad group of anxiety disorders, and its diagnosis no longer rests on
establishing an onset during childhood or adolescence. In previous editions of DSM, it was included within the
disorders usually first diagnosed in infancy, childhood, or adolescence, with the requirement for an onset of symptoms
before the age of 18 years: symptomatic adults could only receive a retrospective diagnosis, based on establishing this
early onset. The new position of separation anxiety disorder is based upon the findings of epidemiological studies that
revealed the unexpectedly high prevalence of the condition in adults, often in individuals with an onset of symptoms
after the teenage years; its prominent place within the DSM-5 group of anxiety disorders should encourage further
research into its epidemiology, etiology, and treatment. This review examines the clinical features and boundaries of
the condition, and offers guidance on how it can be distinguished from other anxiety disorders and other mental
disorders in which “separation anxiety” may be apparent.

Received 20 October 2015; Accepted 14 March 2016

Key words: attachment, comorbidity, epidemiology, psychopathology, separation anxiety disorder.

Diagnosing Separation Anxiety Disorder in Adults
“Adult-onset” adult separation anxiety disorder includes
those individuals whose separation anxiety symptoms
first appeared in adulthood, without a documented
history of related symptoms during childhood, whereas
“childhood-onset” adult separation anxiety disorder
connotes those individuals whose symptoms had a
childhood onset and which persisted into adulthood.1
A large proportion of adult patients with anxiety
disorders have problems that can be traced back to
childhood experiences and environments, but which only
become manifest in clinical symptoms during adult life,
and separation anxiety disorder is considered in the same
way as other anxiety conditions. Removing the age of
onset stipulation in the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5)
* Address for correspondence: Robert Gordon, University Department
of Psychiatry, University of Southampton, College Keep, 4-12 Terminus
Terrace, Southampton, SO14 3DT, UK.
(Email: rpg1822@gmail.com)
RG is supported by the NIHR Clinical Academic Fellow training pro-
gramme and by the Research Management Committee of the Faculty of
Medicine at the University of Southampton. Secretarial support was
provided by Magda Nowak, herself supported by the European College of
Neuropsychopharmacology Network Initiative (ECNP-NI).
aligns separation anxiety disorder with all other anxiety
disorders and so removes the need for separate adult and
juvenile anxiety groups.2
In the DSM-5,3 separation anxiety disorder is
characterized by the presence of developmentally inap-
propriate and excessive fear or anxiety concerning
separation from attachment figures. To meet the
diagnostic threshold, the fear, anxiety, or avoidance of
separation must have been present for at least 4 weeks in
a child or adolescent, and typically for at least 6 months
in an adult. Diagnosis also requires the presence of at
least 3 of 8 features, including recurrent excessive
distress when anticipating or experiencing separation,
and persistent and excessive worry about losing major
attachment figures; this can be problematic, as it seems
difficult to distinguish fear and anxiety concerning
separation from attachment figures (the characteristic
feature) from excessive distress when anticipating or
experiencing separation, or from excessive worry about
losing attachment figures (2 of the supporting features).
Furthermore, another 2 of the supporting features
include a persistent reluctance or refusal to go out, away
from home, to school or to work because of fear of
separation, and a persistent fear or reluctance about
being alone or without major attachment figures at home
or in other settings, which seems a rather nuanced

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 290 D. S. BALDWIN ET AL.
distinction. In addition, the criterion of “persistent and
excessive worry about experiencing an untoward event
that causes separation from an attachment figure” is
hard to distinguish from the persistent and excessive
worrying about family members, which is common in
patients with generalized anxiety disorder (GAD). Also,
the features of troubled sleep while being away from
attachment figures and repeated nightmares about
separation seem difficult to delineate from posttraumatic
sleep disturbances in patients whose trauma involved
significant threats to family members. The capacity of
diagnostic tools to delineate between separation anxiety
disorder and panic disorder has been validated,4
although panic disorder itself is important in the
differential diagnosis of separation anxiety disorder.
But these problems are not restricted to DSM-5
criteria: similar problems are seen in the diagnostic
criteria for separation anxiety disorder in childhood
included within ICD-10.5 At least 3 of 8 features must be
present, including persistent and excessive worry
about possible harm befalling major attachment figures,
and persistent and excessive worry that some untoward
event will separate the child from an attachment figure.
But if the worrisome and anticipated untoward event
involves harm, should both features count? It also
seems difficult to distinguish anxiety and worry
about harm potentially befalling an attachment figure
(the first listed feature) from distress (for example
manifest by anxiety, crying, and misery) in anticipation
of separation from an attachment figure (another listed
feature). The ICD-10 criteria stipulate that “the criteria
for generalized anxiety disorder of childhood are not
met,” implying that when they are present, GAD should
be diagnosed in preference to separation anxiety
disorder. But, again, it could be hard to distinguish 2
other features relating to sleep disturbance, namely
insomnia marked by persistent reluctance or refusal to
go to sleep without being near an attachment figure,
from the presence of repeated nightmares involving
themes of separation.
In separation anxiety disorder in childhood, parents
are the major attachment figures, and common separa-
tion behaviors include crying, tantrums, and school
refusal. By contrast, adults with separation anxiety have
strong fears that their attachment figures (usually a
spouse or child) will come to harm, and so make
strenuous efforts to remain in close contact with them,
despite troublesome impracticalities.6 Childhood
separation anxiety can be the first step along a pathway
of a mental disorder that may manifest either as
separation anxiety or as other forms of mental disorder
in young adults.7 Early separation anxiety symptoms and
behaviors may act as a “general vulnerability factor,”
conferring an increased risk for anxiety and mood
disorders.8,9
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Appreciating the Burden of Separation Anxiety
Disorder in Adults
Separation anxiety symptoms are not uncommon, across
the lifespan: a prospective longitudinal study in adoles-
cents and young adults (aged 14–24 years) found a 7.8%
“lifetime prevalence” of separation anxiety symptoms,10
and an opportunity sample in first-semester college
students found that 21% met or exceeded the symptom
threshold on a checklist of separation anxiety
symptoms.11 This threshold was exceeded by 3.5% of
elderly (60 years or older) primary care patients12; supra-
threshold levels of separation anxiety were present in
24.5% of women attending a hospital ante-natal clinic13
and in 35% of primiparous women with unsettled infants
admitted to a parent/child residential unit.14 But the
presence of separation anxiety symptoms does not
necessarily equate to the presence of separation anxiety
disorder, which is characterized by significant personal
distress and associated impairment.
The findings of the large (n = 5692) U.S. National
Co-morbidity Survey Replication (NCS-R) epidemiologi-
cal study, in which the estimated lifetime prevalence was
6.6%, provided substantial data on the existence of
separation anxiety in adults. Although 36.1% of cases
with an onset of separation anxiety symptoms in child-
hood persisted into adult life, the majority (77.5%) of
“cases” in adults had a reported onset in adulthood. The
prevalence was higher in females than in males, this
difference being more marked in the sub-group of
individuals in which separation anxiety started in child-
hood.15 Adult separation anxiety disorder markedly
impairs social and work function: more than 40% of
respondents classified as having the condition reported
severe impairment in at least one life domain, most
commonly in the domains of social and personal life, with
impairment being more marked in those with comorbid
conditions, which were present in more than half
the cases in the NCS-R study.15 Silove et al8 have
re-examined prevalence rates of separation anxiety
disorder in the general population (n = 38,993 adults)
in 18 countries using data from the World Health
Organization (WHO) World Mental Health Surveys.
Analyses focused on prevalence, age at onset, comorbid-
ity, predictors of onset and persistence, and separation
anxiety–related role impairment. In this analysis, the
lifetime separation anxiety disorder prevalence averaged
4.8% across countries, and 43.1% of lifetime onsets
occurred after the age of 18 years. Rates of comorbidity
with other psychiatric disorders were similar to those
found in previous large-scale epidemiological studies.
Significant predictors of lifetime separation anxiety
disorder included female gender, retrospectively
reported childhood adversities, and lifetime traumatic
events. These predictors were largely comparable for

separation anxiety disorder onsets in childhood, adoles-
cence, and adulthood and across country income groups.
The extensive comorbidity of separation anxiety
disorder has been confirmed in a number of clinical
samples. Separation anxiety symptoms, of both
childhood-onset and adult-onset, are common in patients
with bipolar disorder, particularly in those patients with
an early onset of bipolar disorder16 and in outpatients
with eating disorders.17 Separation anxiety symptoms are
common in outpatients with “complicated grief”18 and
posttraumatic stress disorder,19 and separation anxiety
disorder was diagnosed in 56% of outpatients with
affective disorders and complicated grief.20 Also,
features of prolonged grief, depression, and separation
anxiety disorder were found to correlate in an
opportunity sample of bereaved individuals.21
Observational studies in patients with obsessive-
compulsive disorder have found a point prevalence of
separation anxiety disorder of 27.2%22 and a lifetime
prevalence of 17%.23 The relationship between
separation anxiety and “obsessivity” (as an abnormal
trait rather than a diagnosis of OCD) is intriguing.
Unfortunately, the few data in the literature arise from a
focus on the relationship with insecure attachment, with
the observation of an association between obsessiveness
and high scores on the attachment fearful dimension
style.24 However, it is a common impression among
clinicians working with adult individuals with separation
anxiety that, in some cases, they have excessive inter-
personal control over significant figures (a core feature
of obsessive personality), characterized by over-thinking
or rumination on attachment figures, with reticence
toward unplanned changes in routine movements and
trips. Future research in this direction is recommended
to clarify the extent to which the trait of obsessiveness
impacts on separation anxiety (and vice versa).
Separation anxiety disorder or high separation anxiety
was found to be associated with the presence of comorbid
personality disorders (Clusters B and C) in patients
attending an anxiety clinic.25 Meta-analytic findings
indicate that childhood separation anxiety disorder
increases the risk of panic disorder in later life.9
Comorbidity of separation anxiety disorder with panic
disorder and agoraphobia in adults is common, but the
two disorders can be distinguished.4 Childhood
separation anxiety disorder, adult panic disorder, and
hypersensitivity to a 35% carbon dioxide challenge may
share a common latent intervening variable.26–28
The presence of comorbid separation anxiety disorder
confers a generally worse prognosis for other conditions.
Successful outcomes in patients with social anxiety
disorder, panic disorder, or GAD were found to be less
likely in the presence of comorbid adult separation anxiety
disorder.29 A successful outcome for cognitive behavior
therapy (CBT) in patients with panic disorder was 4 times
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ADULT SEPARATION ANXIETY DISORDER 291
less likely in the presence of comorbid separation anxiety
disorder,30 possibly because CBT undertaken for other
anxiety disorders does not reduce the intensity of
separation anxiety symptoms.31 A more recent study
indicates that patients undergoing CBT for panic disorder,
GAD, or social phobia all have worse outcomes if they also
have adult separation anxiety disorder.1
Measuring Separation Anxiety Symptoms
A number of diagnostic interviews and rating scales have
been developed to facilitate the diagnosis and assessment
of severity of adult separation anxiety disorder. The Adult
Separation Anxiety Structured Interview (ASA-SI) is
derived from Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV) criteria for
the childhood-onset condition, with items modified for
adulthood.32 The Structured Clinical Interview for
Separation Anxiety Symptoms (SCI-SAS) assesses
childhood-onset and adult-onset conditions, with items
based on DSM-IV criteria.33 The NCS-R study involved
the development of a new module for adult separation
anxiety disorder for addition to the Composite Interna-
tional Diagnostic Interview, based on the SCI-SAS.
Symptom severity can be assessed through completion
of the self-report Adult Separation Anxiety-27 (ASA-27),
which contains the same items as the ASA-SI: it has an
established threshold for “caseness,”32 adequate internal
consistency and test–retest reliability, and, as expected,
high concordance with the ASA-SI.34
Distinguishing Separation Anxiety Disorder from Other
Conditions
It seems reasonable to suppose that separation anxiety in
adults was previously often construed as a form of panic
disorder with or without agoraphobia,35 while for many
individuals a diagnosis of adult separation anxiety
disorder may have been more appropriate, with panic
attacks being regarded as a feature of separation anxiety,
rather than of panic disorder. Differential diagnosis
between separation anxiety disorder and panic disorder
rests on establishing that the fear of having a panic attack
does not drive separation anxiety, whereas it does in
agoraphobia: patients with separation anxiety disorder
may experience “panic” that manifests as extreme stress
or distress,4 but the primary fear is the fear of separation
rather than the fear of having a panic attack.1 In
addition, patients with panic disorder are preoccupied
with their own personal health and safety, whereas
individuals with separation anxiety disorder are con-
cerned for the well-being of their attachment figures.
The distinction from agoraphobia is potentially trouble-
some: though agoraphobic situations are defined as
 292 D. S. BALDWIN ET AL.
places and situations from which escape might be
difficult or in which help might not be available to the
affected person, conversely in separation anxiety
disorder, the primary fear is that something untoward
will happen to someone else (loved ones and other major
attachment figures).1
Differential diagnosis between separation anxiety
disorder and GAD can also be troublesome, as worrying
about something bad happening to loved ones is a feature
that is common to the 2 conditions. Approximately half
of children and adolescents with separation anxiety
disorder worry about harm befalling their parents when
not with them,36 and the majority of children with the
diagnosis of separation anxiety disorder also have the
diagnosis of comorbid GAD.37 The distinction between
the 2 disorders in adults is often difficult, but largely
rests on establishing that the fear and worry of losing
loved ones is just one of a wide range of worrisome
themes in patients with GAD (in which other common
themes include personal health, financial concerns, and
interpersonal difficulties), whereas in separation anxiety
disorder, the central and often only concern is the fear of
and worry about losing a major attachment figure.1
The distinction of separation anxiety disorder from
“dependent personality disorder” is also difficult.
Dependent personality disorder is characterized by a
persistent, pervasive, and indiscriminate tendency to
rely excessively on other individuals, particularly when
making decisions. By contrast, separation anxiety
disorder is characterized by a limited array of concerns
about the proximity and safety of major attachment
figures.6 Adults with separation anxiety disorder
typically perceive no difficulty in caring for themselves.
Although frantic efforts to avoid real or imagined
abandonment are a feature of “borderline personality
disorder,” the distinction between the 2 conditions is
helped by identifying the pervasive mood instability and
uncertainty with regard to self and the majority of
relationships in borderline personality disorder, which is
not a typical feature of separation anxiety disorder.2
Finally, a concern regarding the misbehavior of romanti-
cally attached figures is a feature of morbid jealousy, and
this condition should be included within the differential
diagnosis, particularly when the worries and concerns
about attachment figures in patients with separation
anxiety disorder have acquired a persistently preoccupy-
ing and obsessive quality.
Linking Separation Anxiety Disorder and Adult
Attachment Style
According to attachment theory, securely attached
children exhibit less anxious behavior toward attachment
figures, while insecurely attached children display more
symptoms of separation anxiety.38 From this perspective,
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a link between insecure attachment and separation
anxiety revealed that insecure attachment constituted a
general risk factor in the development of anxiety.
Bowlby38 explained that attachment, separation, and
reunion responses are learned as infants develop.
Anxiety and the fear of abandonment are the driving
forces behind attachment formation. Insecure attach-
ment can often result when an attachment relationship is
threatened, or the attachment figure is not consistently
available. Bowlby39 proposed that children’s levels of
anxiety might be affected by the way in which they are
attached to their caregivers: ambivalently attached
children were constantly afraid of being alone and in
danger, because their caregivers were unreliable con-
cerning their needs.39
Clinical studies have revealed the association between
specific adult attachment styles and depressive disor-
ders.40 Attachment anxiety, which concerns apprehen-
sion over rejection and abandonment, has been associated
with increased rates of psychopathology. Attachment
anxiety represents 1 of the 2 primary dimensions involved
in self-report measures of adult attachment style. The
second dimension, namely attachment avoidance, con-
cerns the degree to which a person feels uncomfortable
depending on and being emotionally close to others.
Hypothesized explanations for the association between
attachment anxiety and depression include anxious
peoples’ negative models of self (eg, believing they are
unlovable41), low self-esteem, self-criticism, and dysfunc-
tional attributions to partners’ behavior that increase the
likelihood of separation anxiety.42 People high in avoid-
ance generally invest less in relationships, are less upset
when they end, and are relatively low in commitment and
relationship satisfaction.43
Separating Adult Separation Anxiety Disorder
Although anxious attachment style and separation
anxiety were found to be highly correlated in patients
with panic disorder or separation anxiety disorder,44 not
all individuals with separation anxiety disorder have an
insecure attachment style.45 The condition is, however,
associated with the temperament and character dimen-
sions of high “harm avoidance” and low “self-directed-
ness,”46 but is not especially linked to “intolerance of
uncertainty.”47
There have been few attempts to identify the possible
biological basis of separation anxiety symptoms in adults.
The role of environmental and genetic factors and the
extent to which they interact is unclear.48 Peripheral-type
benzodiazepine binding site receptors, which have a role
in the biosynthesis of steroids during stress and anxiety
states, were found to have a significantly lower density in
the sub-group of panic disorder patients in which
coexisting separation anxiety was a prominent feature.49

Separation anxiety disorder appears to be associated with
hypersensitivity to inhaled carbon dioxide, with a similar
pattern to that in patients with panic disorder, suggest-
ing the 2 diagnoses may have a shared pathophysiological
basis.28,50
Complex perturbations of the hypothalamic neuropep-
tide oxytocin may be involved in disordered attachment,
as it is known to play a part in trust, reducing distress, and
helping “read” the mental and emotional states of others.
Extensive research using animal models and human
volunteers has established a significant role for oxytocin
in mother–infant interactions. Peripheral oxytocin levels
are potential markers of social responsivity and the
capacity for attachment.51 However, mutation analysis of
the oxytocin gene has shown no consistent disturbance in
patients with adult separation anxiety disorder, although
single nucleotide and intron 2 molecular variants have
been detected,52 and the GG genotype single nucleotide
polymorphism within the oxytocin receptor gene is linked
to high levels of separation anxiety in patients with major
depression.53 Attachment anxiety is linked to higher
plasma cortisol levels, and further exploration of the links
between cortisol and oxytocin may clarify mechanisms
underlying the stress response.54
Fear of separation is one of the basic fears of humans; it
is readily observable in children, and generally becomes
less prominent with maturity. It is presumed that marked
separation anxiety represents a psychopathological phe-
nomenon, but diagnostic criteria for separation anxiety
disorder would benefit from being conceptually tightened.
It has been argued by analogy that extreme versions of
normal “death anxiety” could lead to the unnecessary
category of “death anxiety disorder,” as fears of severe
illness and dying are common across many psychopatho-
logical conditions.55 But the inclusion of separation
anxiety disorder within the DSM-5 group of anxiety
disorders diagnosable in adults certainly provides impetus
for further research into its distinguishing psychopatho-
logical phenotypic features, and also identifying possible
endophenotypes, which might help delineate it from
frequent comorbid conditions, such as panic disorder,
agoraphobia, and social anxiety disorder. Studies, such as
the sensitivity of separation anxiety symptoms to carbon
dioxide challenge, and also of the potential role of oxytocin
in dysfunctional attachment, may provide fruitful lines of
enquiry in helping separate this common and burdensome
condition from apparently similar conditions.
Disclosures
David S. Baldwin reports “other” from NIHR Clinical
Academic Fellow training programme, grants from
Research Management Committee of the Faculty of
Medicine at the University of Southampton, during the
conduct of the study; grants from Pfizer Ltd, grants from
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ADULT SEPARATION ANXIETY DISORDER 293
H. Lundbeck A/S, outside the submitted work. Robert
Gordon reports “other” from NIHR Clinical Academic
Fellow training programme and grants from Research
Management Committee of the Faculty of Medicine at
the University of Southampton during the conduct of the
study. Marianna Abelli and Stefano Pini have nothing to
disclose.
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