Kossowsky, J., Pfaltz, M., Schneider, S., Taeymans, J., Locher, C., & Gaab, J. (2013). The separation anxiety hypothesis of panic disorder: A meta-analysis. American Journal of Psychiatry, 170, 768-781.
The concept of separation anxiety is intimately tied to attachment theory. Problematic early attachments have negative consequences for adults’ ability to experience and internalize positive relationships which help to develop mental capacities to self sooth, tolerate anxiety, and modulate affect. Separation anxiety is the persistent, excessive, and developmentally inappropriate fear of separation from major attachment figures, like parents. It is one of the most frequently diagnosed childhood anxiety disorders, with a lifetime prevalence of 4.1% to 5.1%. If we knew that separation anxiety is truly related to or causes adult psychopathology, then we would have a better understanding of the development of adult mental disorders and greater reason to quickly and aggressively treat childhood separation anxiety. A meta analysis by Kossowsky and colleagues (2013) begins to address this relationship between separation anxiety and adult disorders. They looked at case-control, prospective, and retrospective studies comparing children with and without separation anxiety disorder with regard to future panic disorder, major depressive disorder, any anxiety disorder, and substance use disorders. The meta analysis included 25 studies of 14, 855 participants. Children with separation anxiety were 3.45 times more likely to develop a panic disorder later on; and 5 studies suggested that children with separation anxiety were 2.19 times more likely to develop future anxiety disorders. Childhood separation anxiety disorder did not increase the risk of future depressive disorders or of future substance use disorders. In a subsequent paper, Milrod and colleagues (2014) reviewed the literature on separation anxiety and psychotherapy outcomes of adult anxiety and mood disorders. Separation anxiety is associated with poor response to treatment of adult anxiety and mood disorders possibly because separation anxiety disrupts the therapeutic relationship. Separation anxiety also predicted non-response to antidepressant medications.
As Kossowsky and colleagues (2013) indicate, it is possible that children suffering from separation anxiety disorder may be hindered early on in developing skills to help cope with anxiety and strong emotions. Nevertheless, the findings draw our attention to the importance of recognizing and treating separation anxiety as early as possible. A few psychological treatment studies show that disorder-specific parent-child cognitive behavioral therapy is successful in treating separation anxiety in children. For adults, poorer treatment response may reflect difficulty forming and maintaining attachments, including the therapeutic relationship. Milrod and colleagues (2014) suggest that psychotherapies that focus on relationships and separation anxiety by using the dyadic therapist-patient relationship to revisit earlier problematic parent-child relationships may benefit adults with separation anxiety.