Separation anxiety disorder

The etiology of social anxiety remains unclear however, evidence suggests that developmental and genetic factors may predispose some individuals to social anxiety disorder. Adults with social anxiety disorder are more likely to report a history of childhood shyness and separation anxiety, limited social interaction during adolescence, and having had parents who placed great emphasis on the importance of the opinion of others. 

Avoidant Personality Disorder (APD). APD is virtually indistinguishable from the generalized subtype of social anxiety disorder. APD is typically diagnosed when the social inhibition pervades almost all social interaction and has been present since childhood. Some have suggested that it is, in fact, the most severe manifestation of generalized social anxiety disorder and does not warrant inclusion as a separate diagnostic entity. 

In this chapter, we consider categorical anxiety disorders as defined by the standardized diagnostic criteria of American Psychiatric Association s Diagnostic and Statistical Manual for Psychiatric Disorders [i.e., DSM-III (1980), DSM-III-R (1987), DSM-IV (1994)]. The subtypes of anxiety states included are panic disorder, agoraphobia, specific phobia, social phobia, generahzed anxiety/overanxious disorder, separation anxiety, and obsessive-compulsive disorder. 

DSM-IV specifies a total of 12 anxiety disorders, but starts by defining panic attacks. Panic attacks are defined separately but are not considered as a separate diagnostic category because they may occur in many of the other anxiety disorders. Likewise, agoraphobia and panic disorder are not considered as specific anxiety diagnoses but rather their combination. In the following, a description of the clinical presentation will be given ... 

Some suggest that childhood separation anxiety disorder and adult panic disorder share a biological substrate, based at least in part on commonalities in res-... 

Among both children and adults, panic attacks are associated with a set of respiratory abnormalities (Klein, 1993 Pine et ah, 2000). These abnormalities are found not only in panic disorder but also in a range of other conditions, such as separation anxiety disorder and isolated panic attacks, which show strong familial associations with panic disorder. It has been suggested that parents with panic disorder transmit a diathesis for certain forms of anxiety that is apparent in the respiratory system (Pine, 1999), may remain latent (Coryell, 1997), or may vary across development, manifested as separation distress during childhood or as panic attacks after puberty (Klein, 1993 Pine et ah, 2000). 

Ventilatory abnormalities have been identified in first-degree relatives of patients with panic disorder (Perna et ah, 1995 Coryell, 1997), as well as in patients with possible precursors for panic disorders, such as separation anxiety disorder (Pine et ah, 2000) or isolated panic attacks (Perna et ah, 1995). Additionally, studies have found family loading for panic disorder in the relatives of panic patients with respiratory abnormalities (Perna et al., 1996), suggesting that hypersensitivity to CO2 inhalation may be a trait marker for panic disorder rather than a state marker. These data suggest that parents with panic disorder may transmit a diathesis for certain forms of anxiety (e.g., separation anxiety disorder) that is observable in the respiratory... 

Effects of early environmental adversity on HPA mediation of neurodevelopment have also been demonstrated in non-human primates (Coplan et al., 1995). Corticotropin-releasing hormone (CRH) intracerebro-ventricular administration in rhesus monkeys that had been separated from their mothers produced behavioral inhibition and increases in ACTH and cortisol. Coplan et al (1995) presented evidence for persistently elevated cerebrospinal fluid concentrations of corticotropin-releasing factor (CRF) in grown macaques that had been reared by mothers in unpredictable environmental conditions. Further studies in adversely reared adult monkeys demonstrated an inverse relationship between mean CRF concentrations and GH response to clonidine (Coplan et al., 2000). In light of evidence that reduced GH response to clonidine has been shown in other anxiety disorders (Charney and Bremner, 1999), Coplan et al. (2000) hypothesize that GH response to clonidine may inversely reflect trait-like increases of central nervous system CRF activity. Data linking childhood anxiety to growth deficits are consistent with this view (Pine et al., 1996). Activity, of the HPA axis, as related to early environmental... 

Approximately three-quarters of children with OCD have comorbid diagnoses. These include tic disorders (24%-30%) and mood disorders, especially major depression (26%-29%). Riddle and colleagues (1990) found that 38% of children with OCD have other anxiety disorders, while Swedo (1989) more specifically identified increased rates of simple phobias (17%), overanxious disorder (16%), and separation anxiety disorder (7%). Other reported comorbidities include specific developmental disabilities, adjustment disorder with depressed mood, oppositional defiant disorder, attention-deficit hyperactivity disorder (ADHD), conduct disorder, and enuresis/encopresis (Swedo et ah, 1989b Riddle et ah, 1990). 

Studies at the National Institutes of Health (NIH) have detailed the clinical characteristics of patients in the PANDAS subgroup (Swedo et al., 1998). The rate of neuropsychiatric comorbidity in this population is quite striking. Twenty of the 50 children (40%) met DSM-IV criteria for ADHD and/or oppositional defiant disorder (ODD), 18 (36%) for major depressive disorder, 14 (28%) for overanxious disorder, and 10 (20%) for separation anxiety disorder. Six children (12%) were enuretic, often episodically and closely correlated with periods of OCD and tic exacerbations. Depressive symptoms, ADHD, and separation anxiety disorder also waxed and waned in concert with the OCD/ tic symptoms. In addition, exacerbations of OCD and tics were accompanied frequently by the acute onset of choreiform movements (clinically distinct from chorea), emotional lability and irritability, tactile/sensory defensiveness, motoric hyperactivity, messy handwriting, and symptoms of separation anxiety (Perlmutter et al., 1998 Becker et al., 2000). 

Because of the hesitancy to use normal anxiolytic substances (benzodiazepines) in children, TCAs were first studied in the use of school refusal and separation anxiety disorder in the 1970s. There have been both positive (Gittleman-Klein and Klein, 1973, Bernstein et al., 2000, 2001) and negative studies for this indication (Berney et al., 1981 Klein et ah, 1992). 

Klein, R.G., Koplewicz, H.S., and Kanner, A. (1992) Imipramine treatment of children with separation anxiety disorder. J Am Acad Child Adolesc Psychiatry 31 21—28. 

The section for emotional disorders in children spans across the following diagnoses separation anxiety disorder social anxiety disorder of childhood phobic anxiety disorder of childhood generalized anxiety disorder of childhood other emotional disorders (with onset specific to childhood) and sibling rivalry disorder. 

Through the use of psychopharmacotherapy, it thus appears that bipolar, unipolar, and atypical depressions are discrete entities. They are also separate from dysthymia, which may be the bridging condition to the anxiety disorders. 

G. The fear or avoidance is not due to the direct physiological effects of a substance [e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder [e.g., panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, a pervasive developmental disorder, or schizoid personality disorder). 

Klein PS, Melton DA A molecular mechanism for the effect of lithium on development. Proc Natl Acad Sci U S A 93 8455-8459, 1996 Klein RG Is panic disorder associated with childhood separation anxiety disorder ... 

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