Predictors of response among patients with panic disorder treated with medications in a naturalistic follow-up: the role of adult separation anxiety

Is adult separation anxiety associated with offspring risk for internalizing psychiatric problems?

BACKGROUND

Awareness of adult separation anxiety (ASA) is growing, but there is a dearth of knowledge about how separation anxiety aggregates in families. We examined the intergenerational associations of separation anxiety and other forms of internalizing problems in an American community sample of 515 predominantly white children and their parents.

METHODS

Children's separation anxiety (CSA), depression, and other anxiety disorders were modeled as latent factors using diagnoses from interviews and symptom scores from questionnaires completed by mothers, fathers, and children when children were 9 years old and again 3 years later. Parents' separation anxiety was assessed via a questionnaire and parents' other anxiety, depressive, and substance use disorders were assessed with a diagnostic interview when children were nine. Relationships between parents' and children's psychopathology were modeled using s.e.m.

RESULTS

Mothers' and fathers' ASA were related to all three psychopathology factors in offspring, over and above other parental disorders, in concurrent and prospective analyses. CSA was also related to maternal depression concurrently and prospectively and to maternal anxiety prospectively. Of all paternal psychopathology variables, only ASA was significantly related to children's psychopathology in either model.

CONCLUSIONS

Results indicate that parental separation anxiety is an important, but non-specific, risk factor for children's psychopathology. The pathway by which this risk is transmitted may be genetic or environmental, and the observed statistical associations likely also encompass child-to-parent effects.

Initial white matter connectivity differences between remitters and non-remitters of patients with panic disorder after 6 months of pharmacotherapy

Panic disorder (PD) is a harmful mental condition that causes relapsed and persistent impairment. In the treatment of PD, the prognosis for PD should be considered. However, the relationship between pharmacotherapy and biomarkers, for predicting a better response through neuroimaging, is a little known. The purpose of the present study was to examine whether there would be the initial white matter (WM) regions associated with the remission in 6 months. A total of 104 patients with PD were investigated in the study. After six months, there were 17 remission patients with PD and 81 non-remission patients. The Panic Disorder Severity Scale, Albany Panic and Phobia Questionnaire, Anxiety Sensitivity Inventory-Revised, Beck Anxiety Inventory, and Beck Depression Inventory were assessed for all patients at baseline. We compared the diffusion indices between remission and non-remission group at 6 months using Tract-Based Spatial Statistics. The results showed that the fractional anisotropy (FA) values were significantly higher in the non-remitter group compared with those in the remitter group in the WM regions, such as the posterior corona radiata and superior longitudinal fasciculus, at the 6 month evaluation. The logistic regression analysis with clinical symptom severity and FA values of the WM regions as covariates showed that FA values in those regions and the Beck Depression Inventory-II predicted poor remission. This study suggests that posterior corona radiata and superior longitudinal fasciculus are related to potential predictive factors of 6-month remission in patients with PD. WM regions associated with the long-term remission should be verified with further investigations.

Separation anxiety disorder among outpatients with major depressive disorder: Prevalence and clinical correlates

Prior studies have reported that separation anxiety disorder (SEPAD) can continue into or may begin in adulthood. Association of SEPAD with other psychiatric disorders has been frequently examined, and high rates of comorbidities have been found. The aim of this study was to investigate the prevalence and clinical correlation of SEPAD in adult patients undergoing treatment for major depressive disorder (MDD). The study sample was comprised of 100 outpatients. Participants underwent a DSM-5-based comprehensive assessment. Purposefully-designed semi-structured sociodemographic information and illness history forms were filled out by the researchers, and diagnoses of SEPAD were made using the Structured Clinical Interview for Separation Anxiety Symptoms, Separation Anxiety Symptom Inventory and Adult Separation Anxiety Survey. The frequency of SEPAD was 41% in patients with MDD, three-quarters of whom were adult onset. The use of new-generation antidepressants, adjunctive medications and comorbidity of other anxiety disorders were higher in patients with SEPAD (p < 0.05). SEPAD was highly prevalent, with a majority of cases starting in adulthood among patients with MDD, while SEPAD comorbidity was associated with high levels of anxiety and an increased likelihood of suboptimal response to usual depression treatment. Further studies are required to define the relevance and pathological basis for the comorbidity of SEPAD in people with MDD.

Adult separation anxiety disorder: The human-animal bond

BACKGROUND

The introduction of an adult onset Separation Anxiety Disorder in the DSM-V recognises that separation anxiety can occur at any stage across the lifespan. In this paper, we examine whether adult separation anxiety, which is known to occur when people are apart from other people close to them, can also develop when people are separated from animal companions. The social and individual psychological correlates of this reported phenomenon are examined.

METHODS

Participants (N = 313, aged 18-76, M = 41.89 years), completed demographic information and questionnaires measuring separation anxiety from companion animals and humans, attachment towards companion animals and humans, and social support.

RESULTS

Significant positive relationships were observed between separation anxiety from humans, people substitution and separation anxiety from animals. Participants with greater separation anxiety from animals also reported less social support and greater attachment anxiety involving humans. People substitution was also positively related to greater animal-related separation anxiety. Associations were generally weaker when cats were identified as the principal companion animal. Participants without children reported significantly less attachment-related avoidance (human); less perceived social support; greater people substitution; and, greater separation anxiety towards companion animals. Separation anxiety from humans, attachment avoidance, and attachment anxiety accounted for 41% of variance in separation anxiety from animals.

LIMITATIONS

The correlational design does not allow the investigation of causal associations.

CONCLUSIONS

A strong, positive relationship was observed between human-related separation anxiety and animal-related separation anxiety, which was significantly stronger for people with lower levels of social support.

Psychometric analysis of the adult separation anxiety symptom questionnaire: Item functioning and invariance across gender and time

The Adult Separation Anxiety Symptom Questionnaire (ASA-27) is the most widely used self-report assessment of adult separation anxiety (ASA). Despite its widespread use, relatively little is known about its psychometric properties, specifically whether it is unidimensional, its degree of precision (or information) across latent levels of ASA, the functioning of individual items in general and of DSM-derived versus non-DSM-derived items in particular, and whether the measure is invariant across gender and time. We addressed these issues in a sample of 509 adult women and 407 adult men from the local community participating in a longitudinal study of temperament and psychopathology in children. Two items from the ASA-27 were removed so that the measure met the item response theory (IRT) assumption of unidimensionality. Findings from a graded response model for categorical items suggested that the ASA-27 assesses ASA most reliably at moderate to high levels and that the DSM-derived items were more closely related to latent ASA than the non-DSM-derived items. Invariance tests employing single-factor confirmatory factor analysis models suggested that the measure is partially invariant across gender and time at the unique factor level, with fewer than 7% of parameters freed in both cases; this implies that the means and variances of the latent factors and differences in the observed responses are attributable to true differences in ASA. Future work should replicate these findings in a sample that includes individuals with a wider range of ASA severity and may consider removing additional items that provide little or redundant information. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

[Separation anxiety disorder in adults - a new diagnostic category]

Anxiety separation disorder (SAD) became the subject of increased attention of researchers in recent decades. DSM-5 and project of ICD-11 allow us to treat this disorder as an independent nosological unit without attachment to age. The review provides information on the prevalence, clinical manifestations and diagnosis of SAD in adults, summarizes information on the etiopathogenesis, relations to other psychiatric disorders, and highlights the lack of modern therapeutic approaches to SAD. The purpose of this review is to raise the level of knowledge about SAD and its new positioning in classification systems.

A randomized controlled pilot trial of vilazodone for adult separation anxiety disorder

BACKGROUND

Separation anxiety disorder was recently recognized by fifth edition of the Diagnostic and Statistical Manual of Mental Disorders as a diagnosis in adults, but no publications to date have characterized a sample of patients seeking treatment for adult separation anxiety disorder (ASAD) or assessed treatment efficacy. We hypothesized that vilazodone, a selective serotonin reuptake inhibitor (SSRI) and serotonin 1a (5HT1_a ) receptor partial agonist, would have efficacy in ASAD, because SSRIs have appeared efficacious in children with mixed diagnoses including separation anxiety disorder and in animal models of separation anxiety.

METHODS

In this pilot study, 24 adults (ages 18-60) with a principal diagnosis of ASAD were randomized to 12 weeks of double-blind treatment with vilazodone (n = 13) or placebo (n = 11). Outcome was assessed by an independent evaluator and self-ratings, and analyzed with mixed effect models.

RESULTS

This sample was predominantly female (67%), with comorbid psychiatric disorders (58%), and adult onset of separation anxiety disorder (62%). Response rates at week 12 did not differ significantly between groups. Across all time points, the vilazodone group evidenced greater improvement on the Structured Clinical Interview for Separation Anxiety Symptoms (P = .026) and the Quality of Life Enjoyment and Satisfaction Questionnaire (P = .011), and trends toward greater improvement on the Adult Separation Anxiety Questionnaire (P = .054) and the Clinical Global Impression-Change Scale (P = .086), all with large between-group effect sizes.

CONCLUSIONS

Findings demonstrate feasibility of a clinical trial in ASAD, and they suggest that vilazodone may have efficacy in the treatment of ASAD and warrants further study.

Adult separation anxiety disorder in complicated grief: an exploratory study on frequency and correlates

INTRODUCTION

Complicated grief (CG) has been the subject of increasing attention in the past decades but its relationship with separation anxiety disorder (SEPAD) is still controversial. The aim of the current study was to explore the prevalence and clinical significance of adult SEPAD in a sample of help-seeking individuals with CG.

METHODS

151 adults with CG, enrolled in a randomized controlled trial comparing the effectiveness of (CG) treatment to that of interpersonal therapy, were assessed by means of the Inventory of Complicated Grief (ICG), the Structured Clinical Interview for DSM-IV, the Hamilton Rating Scale for Depression (HAM-D), the Work and Social Adjustment Scale (WSAS), the Adult Separation Anxiety Questionnaire (ASA-27), the Grief Related Avoidance Questionnaire (GRAQ), the Peritraumatic Dissociative Experiences Questionnaire (PDEQ), and the Impact of Events Scale (IES).

RESULTS

104 (68.9%) individuals with CG were considered to have SEPAD (ASA-27 score ≥22). Individuals with SEPAD were more likely to have reported a CG related to the loss of another close relative or friend (than a parent, spouse/partner or a child) (p=.02), as well as greater scores on the ICG (p=<.001), PDEQ (p=.004), GRAQ (p<.001), intrusion (p<.001) and avoidance (p=<.001) IES subscales, HAM-D (p<.001) and WSAS (p=.006). ASA-27 total scores correlated with ICG (p<.0001), PDEQ (p<.001) GRAQ (p<.0001) scores and both the IES intrusion (p<.0001) and IES avoidance (p<.0001) subscale scores. People with SEPAD had higher rates of lifetime post-traumatic stress disorder (PTSD) (p=.04) and panic disorder (PD) (p=.01).

CONCLUSIONS

SEPAD is highly prevalent among patients with CG and is associated with greater symptom severity and impairment and greater comorbidity with PTSD and PD. Further studies will help to confirm and generalize our results and to determine whether adult SEPAD responds to CG treatment and/or moderates CG treatment response.

Adult separation anxiety in treatment nonresponders with anxiety disorders: delineation of the syndrome and exploration of attachment-based psychotherapy and biomarkers

Clinically significant separation anxiety [SA] has been identified as being common among patients who do not respond to psychiatric interventions, regardless of intervention type (pharmacological or psychotherapeutic), across anxiety and mood disorders. An attachment formation and maintenance domain has been proposed as contributing to anxiety disorders. We therefore directly determined prevalence of SA in a population of adult treatment non-responders suffering from primary anxiety. In these separation anxious nonresponders, we pilot-tested an SA-focused, attachment-based psychotherapy for anxiety, Panic-Focused Psychodynamic Psychotherapy-eXtended Range [PFPP-XR], and assessed whether hypothesized biomarkers of attachment were engaged. We studied separation anxiety [SA] in 46 adults (ages 23-70 [mean 43.9 (14.9)]) with clinically significant anxiety symptoms (Hamilton Anxiety Rating Scale [HARS]≥15), and reporting a history of past non-response to psychotherapy and/or medication treatments. Thirty-seven (80%) had clinically significant symptoms of separation anxiety (Structured Clinical Interview for Separation Anxiety Symptoms [SCI-SAS] score≥8). Five of these subjects completed an open clinical trial of Panic Focused Psychodynamic Psychotherapy eXtended Range [PFPP-XR], a 21-24 session, 12-week manualized attachment-focused anxiolytic psychodynamic psychotherapy for anxiety. Patients improved on "adult threshold" SCI-SAS (current separation anxiety) (p=.016), HARS (p=0.002), and global severity, assessed by the Clinical Global Impression Scale (p=.0006), at treatment termination. Salivary oxytocin levels decreased 67% after treatment (p=.12). There was no significant change in high or low frequency HRV after treatment, but change in high frequency HRV inversely correlated with treatment change in oxytocin (p<.02), and change in low frequency HRV was positively associated with change in oxytocin (p<.02). SA is surprisingly prevalent among non-responders to standard anti-anxiety treatments, and it may represent a novel transdiagnostic target for treatment intervention in this population. Anxiety and global function improved in a small trial of a brief, manualized, attachment-focused psychodynamic psychotherapy, potentially supporting the clinical relevance of attachment dysfunction in this sample. The large decrease in oxytocin levels with treatment, although not statistically significant in this very small sample, suggests the need for further study of oxytocin as a putative biomarker or mediator of SA response. These pilot data generate testable hypotheses supporting an attachment domain underlying treatment-resistant anxiety, and new treatment strategies.

Long-Term Pharmacological Treatments of Anxiety Disorders: An Updated Systematic Review

Many aspects of long-term pharmacological treatments for anxiety disorders (AnxDs) are still debated. We undertook an updated systematic review of long-term pharmacological studies on panic disorder (PD), generalized anxiety disorder (GAD), and social anxiety disorder (SAD). Relevant studies dating from January 1, 2012 to August 31, 2015 were identified using the PubMed database and a review of bibliographies. Of 372 records identified in the search, five studies on PD and 15 on GAD were included in the review. No studies on SAD were found. Our review confirms the usefulness of long-term pharmacological treatments for PD and GAD and suggests that they can provide further improvement over that obtained during short-term therapy. Paroxetine, escitalopram, and clonazepam can be effective for long-term treatment of PD. However, further studies are needed to draw conclusions about the long-term benzodiazepine use in PD, particularly for the possible cognitive side-effects over time. Pregabalin and quetiapine can be effective for long-term treatment of GAD, while preliminary suggestions emerged for agomelatine and vortioxetine. We did not find any evidence for determining the optimal length and/or dosage of medications to minimize the relapse risk. Few investigations have attempted to identify potential predictors of long-term treatment response. Personalized treatments for AnxDs can be implemented using predictive tools to explore those factors affecting treatment response/tolerability heterogeneity, including neurobiological functions/clinical profiles, comorbidity, biomarkers, and genetic features, and to tailor medications according to each patient's unique features.

Separation anxiety disorder from the perspective of DSM-5: clinical investigation among subjects with panic disorder and associations with mood disorders spectrum

OBJECTIVE/INTRODUCTION

High levels of comorbidity between separation anxiety disorder (SEPAD) and panic disorder (PD) have been found in clinical settings. In addition, there is some evidence for a relationship involving bipolar disorder (BD) and combined PD and SEPAD. We aim to investigate the prevalence and correlates of SEPAD among patients with PD and whether the presence of SEPAD is associated with frank diagnoses of mood disorders or with mood spectrum symptoms.

METHODS

Adult outpatients (235) with PD were assessed by the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), the Panic Disorder Severity Scale (PDSS), the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS), and the Mood Spectrum Self-Report Instrument (MOODS-SR, lifetime version).

RESULTS

Of ther 235 subjects, 125 (53.2%) were categorized as having SEPAD and 110 (46.8%) as not. Groups did not differ regarding onset of PD, lifetime prevalence of obsessive compulsive disorder (OCD), social phobia, simple phobia, BD I and II, or major depressive disorder (MDD). SEPAD subjects were more likely to be female and younger; they showed higher rates of childhood SEPAD, higher PDSS scores, and higher MOODS-SR total and manic component scores than subjects without SEPAD. Discussion SEPAD is highly prevalent among PD subjects. Patients with both PD and SEPAD show higher lifetime mood spectrum symptoms than patients with PD alone. Specifically, SEPAD is correlated with the manic/hypomanic spectrum component.

CONCLUSION

Our data confirm the high prevalence of SEPAD in clinical settings. Moreover, our findings corroborate a relationship between mood disorders and SEPAD, highlighting a relationship between lifetime mood spectrum symptoms and SEPAD.

Pathways involving traumatic losses, worry about family, adult separation anxiety and posttraumatic stress symptoms amongst refugees from West Papua

There is some evidence that adult separation anxiety disorder (ASAD) symptoms are closely associated with posttraumatic stress disorder (PTSD) amongst refugees exposed to traumatic events (TEs), but the pathways involved remain to be elucidated. A recent study suggests that separation anxiety disorder precedes and predicts onset of PTSD. We examined a path model testing whether ASAD symptoms and worry about family mediated the path from traumatic losses to PTSD symptoms amongst 230 refugees from West Papua. Culturally adapted measures were applied to assess TE exposure and symptoms of ASAD and PTSD. A structural equation model indicated that ASAD symptoms played an important role in mediating the effects of traumatic losses and worry about family in the pathway to PTSD symptoms. Although based on cross-sectional data, our findings suggest that ASAD symptoms may play a role in the path from traumatic losses to PTSD amongst refugees. We propose an evolutionary model in which the ASAD and PTSD reactions represent complementary survival responses designed to protect the individual and close attachments from external threats.

Pediatric-Onset and Adult-Onset Separation Anxiety Disorder Across Countries in the World Mental Health Survey

OBJECTIVE

The age-at-onset criterion for separation anxiety disorder was removed in DSM-5, making it timely to examine the epidemiology of separation anxiety disorder as a disorder with onsets spanning the life course, using cross-country data.

METHOD

The sample included 38,993 adults in 18 countries in the World Health Organization (WHO) World Mental Health Surveys. The WHO Composite International Diagnostic Interview was used to assess a range of DSM-IV disorders that included an expanded definition of separation anxiety disorder allowing onsets in adulthood. Analyses focused on prevalence, age at onset, comorbidity, predictors of onset and persistence, and separation anxiety-related role impairment.

RESULTS

Lifetime separation anxiety disorder prevalence averaged 4.8% across countries (interquartile range [25th-75th percentiles]=1.4%-6.4%), with 43.1% of lifetime onsets occurring after age 18. Significant time-lagged associations were found between earlier separation anxiety disorder and subsequent onset of internalizing and externalizing DSM-IV disorders and conversely between these disorders and subsequent onset of separation anxiety disorder. Other consistently 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, adolescence, and adulthood and across country income groups. Twelve-month separation anxiety disorder prevalence was considerably lower than lifetime prevalence (1.0% of the total sample; interquartile range=0.2%-1.2%). Severe separation anxiety-related 12-month role impairment was significantly more common in the presence (42.4%) than absence (18.3%) of 12-month comorbidity.

CONCLUSIONS

Separation anxiety disorder is a common and highly comorbid disorder that can have onset across the lifespan. Childhood adversity and lifetime trauma are important antecedents, and adverse effects on role function make it a significant target for treatment.

Open-longitudinal study of the effect of dissociative symptoms on the response of patients with panic disorder to venlafaxine

The relationship between Panic Disorder (PD) and dissociation is well known. In this study we aimed to investigate whether or not dissociative experiences affect the response to PD drug treatment. For this purpose, standart dose of venlafaxine was preferred for treatment. 63 patients with PD were included in the study. Venlafaxine treatment with increasing dose was administered to each patient during a 10-week period. The Panic Disorder Severity Scale (PDSS) and the Dissociation Questionnaire (DIS-Q) were applied to the patients at the beginning of the study. Patients were divided into two groups based on DIS-Q scores. PDSS was applied again to both groups at the end of 10-week treatment. No difference between sociodemographic data and PDSS scores of two groups - patients with low DIS-Q scores (<2.5) and high DIS-Q scores (>2.5) - was found at the beginning. At the end of the study, a significant decrease in PDSS scores measured in both groups was detected. However, the decrease in PDSS score for the group with lower DIS-Q score was at a higher percentage (z=-3.822, p=0.0001). These results depict that dissociative symptoms accompanying PD affect psychopharmacological treatment in a negative way. Reevaluation of dissociative symptoms at the beginning and end of treatment would help in planning personal therapy.

The relationships among separation anxiety disorder, adult attachment style and agoraphobia in patients with panic disorder

Epidemiological studies indicate that separation anxiety disorder occurs more frequently in adults than children. It is unclear whether the presence of adult separation anxiety 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 examine these questions. A sample of 141 adult outpatients with panic disorder participated in the study. Participants completed standardized measures of separation 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 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 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 disorder is a form of agoraphobia. Factor analysis shows clear differentiation of agoraphobic and separation anxiety symptoms. Our data corroborate the notion that ASAD is a distinct condition associated with impairment in quality of life and needs to be better recognized and treated in patients with panic disorder.

Separation anxiety disorder across the lifespan: DSM-5 lifts age restriction on diagnosis

DSM-5 has lifted the age criterion in the definition of separation anxiety disorder thereby overturning the long-standing convention of restricting the diagnosis to childhood. Previously, adults with separation anxiety symptoms were assigned to other conventional categories such as panic disorder, agoraphobia or generalized anxiety disorder. Over the past two decades, an evolving body of research has identified separation anxiety disorder in adulthood, with 20-40% of adult psychiatric outpatients being assigned that diagnosis. In the US, the lifetime prevalence of the disorder in adulthood is 6.6%. The removal of the age restriction on diagnosis has important implications for clinical practice. Whereas parents (particularly mothers) of children with separation anxiety disorder commonly attracted the diagnosis of agoraphobia, the latter are more likely now to be diagnosed with the adult form of separation anxiety disorder, focusing attention on the importance of intervening with both members of the dyad to overcome mutual reinforcement of symptoms. In addition, adults with separation anxiety disorder have been found to manifest high levels of disability and they tend to show a poor response to conventional psychological and pharmacological treatments. There is an urgent need therefore to devise novel psychological and pharmacological interventions for the adult form of the disorder. The reformulation of separation anxiety disorder in DSM-5 therefore requires a paradigm shift in which clinicians are alerted to identifying and treating the condition in all age groups. Research across countries is needed to examine the new formulation of separation anxiety disorder amongst populations of diverse ethnic and cultural backgrounds.