Journal of Anxiety Disorders 28 (2014) 741746

Contents lists available at ScienceDirect

Journal of Anxiety Disorders

The relationships among separation anxiety disorder, adult

attachment style and agoraphobia in patients with panic disorder
Stefano Pini a, , Marianna Abelli a , Alfonso Troisi c , Alberto Siracusano c ,
Giovanni B. Cassano a , Katherine M. Shear b , David Baldwin d
a
Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, via Roma 65, I-56100 Pisa, Italy
b
Columbia University, Department of Social Work, School of Social Work, Columbia University, New York, NY, USA
c
Department of Neurosciences, University of Rome Tor Vergata, Via Montpellier 1, 00133 Rome, Italy
d
Department of Psychiatry, University of Southampton, Faculty of Medicine, Academic Centre, College Keep, 4-12 Terminus Terrace, Southampton SO14
3DT, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Epidemiological studies indicate that separation anxiety disorder occurs more frequently in adults than
Received 19 May 2012 children. It is unclear whether the presence of adult separation anxiety disorder (ASAD) is a manifestation
Received in revised form 20 June 2014 of anxious attachment, or a form of agoraphobia, or a specic condition with clinically signicant con-
Accepted 30 June 2014
sequences. We conducted a study to examine these questions. A sample of 141 adult outpatients with
Available online 11 July 2014
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
Keywords:
(49.5% of our sample) had greater panic symptom severity and more impairment in quality of life than
Panic disorder
Separation anxiety disorder
those without separation anxiety. We found a greater rate of symptoms suggestive of anxious attachment
Adult attachment style among panic patients with ASAD compared to those without ASAD. However, the relationship between
Agoraphobia 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 symp-
toms. 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.
2014 Published by Elsevier Ltd.

1. Introduction disorder, and avoidance behaviors may occur in the workplace as

Separation anxiety disorder is a well-established diagnostic cat-
egory in the psychiatric nomenclature (Shear, Jin, Ruscio, Walters,
& Kessler, 2006). However, most studies of this condition pertain to
childhood. By contrast, little attention has been paid to the occur-
rence of adult separation anxiety disorder (ASAD). Although in
DSM-IV, separation anxiety disorder was classied in the section
Disorders Usually First Diagnosed in Infancy, Childhood, or Ado-
lescence, criteria for the disorder are now described in the DSM-5
section on anxiety disorders (APA, 2013). The core features remain
mostly unchanged, although the wording of the criteria has been
modied to more adequately represent the expression of sepa-
ration anxiety symptoms in adulthood. For example, attachment
gures may include the children of adults with separation anxiety
Corresponding author at: Department of Psychiatry, University of Pisa, Via Roma
67, 56100 Pisa, Italy. Tel.: +39 050 993559; fax: +39 050 21581.
E-mail address: stefano.pini@med.unipi.it (S. Pini).
well as at school. Also, in contrast to DSM-IV, the diagnostic criteria
no longer specify that age at onset must be before 18 years, because
a substantial number of adults report onset of separation anxiety
after age 18 (Marnane & Silove, 2013). The disturbance must cause
clinically signicant distress or impairment in social, academic, or
other important areas of functioning. Adults with a diagnosis of
ASAD report extreme anxiety about separations from major attach-
ment gures (partner, children, or parents), fear that harm would
befall those close to them and need to maintain proximity to them.
These symptoms may affect the individuals behavior and lead to
severe impairment in social relationships. It is important to dis-
tinguish between symptoms of ASAD and dependent personality
traits. Dependency is a pervasive and indiscriminate tendency to
rely excessively on others, whereas ASAD refers to a limited array of
concern about the proximity and safety of key attachment gures.
Initially, Manicavasagar, Silove, and Curtis (1997) highlighted
the clinical signicance of ASAD as a distinct diagnosis. This group
raised the possibility that the most common pathological out-
come for children with separation anxiety may be adult separation

http://dx.doi.org/10.1016/j.janxdis.2014.06.010
0887-6185/ 2014 Published by Elsevier Ltd.
742 S. Pini et al. / Journal of Anxiety Disorders 28 (2014) 741746
anxiety disorder (Manicavasagar, Silove, Curtis, & Wagner, 2000;
Manicavasagar, Silove, & Hadzi-Pavlovic, 1998) and documented
the occurrence of ASAD in adults (Wijeratne & Manicavasagar,
2003). Our group (Cyranowski et al., 2002; Fagiolini, Shear, Cassano,
& Frank, 1998; Pini, Abelli, et al., 2005; Pini et al., 2010) also found
ASAD to be surprisingly common in a large clinical population of
outpatients with anxiety and mood disorders. The high prevalence
of ASAD in the general population (6.6%) was also conrmed in the
NCS-R data (Shear et al., 2006).
Another unresolved question is the nature of the relationship
linking separation anxiety disorder to insecure attachment in gen-
eral and to anxious attachment in particular (Troisi & DArgenio,
2004). Theoretically, it is possible that not all individuals with
anxious attachment meet criteria for separation anxiety disor-
der. It is also possible that separation anxiety disorder occurs
even in the context of secure attachment. In other words, it is
not known whether all individuals with separation anxiety dis-
order also engage in other anxious attachment behaviors. To our
knowledge, no empirical study has been undertaken to answer this
question.
Manicavasagar, Silove, Marnane, and Wagner (2009) tried
to clarify the link between attachment styles and panic disor-
der/agoraphobia (PD-Ag). They studied 83 patients with PD-Ag and
ASAD, highlighting that the style of anxious attachment, using the
Attachment Style Questionnaire (ASQ) (Feeney, Noller, & Hanrahan,
1994), was more prevalent in patients with separation anxiety and
panic disorder than in patients with only panic attacks.
Similarly, the relationship between adult separation anxiety
disorder, panic disorder (PD) and agoraphobia has not been well
claried (Mian, Godoy, Briggs-Gowan, & Carter, 2012; Wittchen
et al., 2008; Wittchen, Gloster, Beesdo-Baum, Fava, & Craske, 2010).
A prominent theme in the literature pertains to the relationship
between childhood separation anxiety and adult PD (Bruckl et al.,
2007). Some investigators found evidence that childhood separa-
tion anxiety disorder is associated with an increased risk of PD, with
or without agoraphobia, in adulthood (De Ruiter & Van Ijzendoorn,
1992; Klein, 1964, 1980). However, other studies have not sup-
ported this association (Aschenbrand, Kendall, Webb, Safford, &
Flannery-Schroeder, 2003; Warner, Mufson, & Weissman, 1995).
Lipsitz et al. (1994) found a high rate of childhood separation anx-
iety among adults with different anxiety disorders and questioned
whether childhood separation anxiety disorder is selectively linked
to adult PD or, alternatively, constitutes a risk factor for adult anx-
iety disorders more generally. Findings from the NCS-R supported
the latter hypothesis. In the NCS-R, ASAD was highly comorbid with
PD, but such a comorbidity rate was not different from the rates
with other anxiety or mood disorders. Thus, neither childhood nor
adult ASAD was preferentially associated with PD.
This hypothesis has been further corroborated by ndings
arguing against the notion that separation anxiety and anxious
attachment are relevant to panic disorder with agoraphobia in
general, suggesting instead that that constellation is conned to
a separate group, namely that of adult separation anxiety disorder.
Preter and Klein (2008) proposed a model that amplied the
original suffocation false alarm theory (Klein, 1993). The observa-
tion of respiratory abnormalities in patients with PD was in line
with the hypothesis that panic may be provoked by indicators of
potential suffocation, such as uctuations in pCO2 and brain lac-
tate, as well as environmental circumstances. However, the fact
that sudden loss, bereavement and childhood separation anxiety
are also antecedents of spontaneous panic required an integra-
tive explanation. Within this framework, the authors reappraised
a developmental pathophysiological link between separation anxi-
ety and PD and subsequent agoraphobia, coupled with attachment
theory and ethological views of anxiety. Central opioid system dys-
function has been claimed to play a key role in both disordered
breathing and separation distress in decreasing the suffocation
alarm threshold.
Given the dearth of research concerning ASAD, we have under-
taken a series of investigations to better understand this condition
among help-seeking individuals diagnosed with other DSM IV diag-
noses (Costa et al., 2009; Pini, Abelli, et al., 2005; Pini, Martini,
et al., 2005; Pini et al., 2010). In the current paper, we report
the results of a clinical study aimed at ascertaining whether adult
separation anxiety can be distinguished from agoraphobia and
from anxious attachment style. In addition, we aimed at clarify-
ing whether the occurrence of ASAD is associated with distinctive
features of the PD clinical picture. These data may contribute to
the current debate whether ASAD is a distinct clinical entity or
merely a variant/subtype of PD. In addition, differential assessment
of ASAD, agoraphobia or anxious attachment style may have impor-
tant therapeutical implications for patients with panic disorder
(Milrod et al., 2014).
2. Methods
The study sample included 141 consecutive adult psychiatric
outpatients with a diagnosis of panic disorder with or without
agoraphobia as a primary diagnosis. Participants were recruited
from the adult psychiatric outpatient clinics of the Department
of Psychiatry, University of Pisa. Patients with psychotic disor-
ders or substance use disorder prior to the index assessment were
excluded. This investigation was carried out in accordance with
the Declaration of Helsinki. The University of Pisa Ethical Commit-
tee reviewed the study design and all subjects were informed of the
nature of study procedures and provided written informed consent
prior to participation. Experienced residents in psychiatry per-
formed interviews. Subjects completed self-report questionnaires
and structured clinical interviews over 2 days.
2.1. Panic disorder diagnosis
All subjects were assessed with the Structured Clinical Inter-
view for the DSM-IV (SCID-I) (First, Spitzer, Gibbon, & Williams,
2002) to establish DSM IV axis I primary diagnosis and comorbidity.
We used the Panic Disorder Severity Scale (PDSS) to assess cur-
rent severity of PD (Shear et al., 1997; Shear, Rucci, et al., 2001).
We also examined current severity of depression using the Hamil-
ton Depression Rating Scale (Hamilton, 1960). Quality of life was
assessed by the Medical Outcomes Study Short Form (SF-36) (Ware
& Gandek, 1998).
2.2. Separation anxiety
We conducted clinical interviews for adult and childhood his-
tory of separation anxiety disorder. To do this, we used the
Structured Clinical Interview for Separation Anxiety Symptoms
(SCI-SAS) (Cyranowski et al., 2002). This semi-structured interview
evaluates each of the 8 DSM IV criterion symptoms of separation
anxiety, separately for childhood and adult symptoms. Each ques-
tion was scored as 0 (not at all), 1 (sometimes), 2 (often) or ? (dont
recall). In keeping with the DSM-IV guidelines, endorsement of
three or more of the eight criterion symptoms (symptoms rated
as 2 (often)) was used as a threshold to determine categorical
(yes/no) diagnosis of separation anxiety disorder in childhood and
adulthood. In addition, criterion B (i.e., duration of at least 4 weeks)
and C (i.e., the disturbance causes clinically signicant distress or
impairment in social, academic, occupational), or other important
areas of functioning were required. Scores on the 8 items of each
subscale were also summed to produce a continuous measure of
separation anxiety symptoms (range for each subscale = 016).
 S. Pini et al. / Journal of Anxiety Disorders 28 (2014) 741746
We further assessed separation anxiety using the Adult Separa-
tion Anxiety Questionnaire (ASA-27), a 27-item inventory, which
rates symptoms of ASAD. This scale has been shown to display
good internal reliability as well as concurrent validity with clinical
assessments of ASAD (Manicavasagar et al., 1997; Manicavasagar,
Silove, Wagner, & Drobny, 2003).
2.3. Attachment style
Attachment style was assessed using two different self-report
instruments. The Relationship Questionnaire (RQ) (Bartholomew
& Horowitz, 1991) is a single-item measure made up of four short
paragraphs, each describing a prototypical attachment pattern as it
applies in close adult peer relationships. Participants are asked to
rate degree of t for each prototype on a 7-point scale. The RQ was
designed to obtain continuous ratings of each of the four attach-
ment patterns, and can also be used to categorize individuals into
their best tting attachment pattern. The highest of the four attach-
ment prototype ratings can be used to classify participants into
an attachment category designated A (secure), B (fearful-avoidant
attachment), C (preoccupied) and D (dismissing-avoidant) (Grifn
& Bartholomew, 1994). The instrument has shown good psycho-
metric properties (Picardi et al., 2002). In this study, the RQ data
were used to assign each participant to an attachment style cate-
gory. Attachment style was determined by assigning each subject
to the category with the maximum score among the four items
described by the RQ (data available for 107 subjects).
In addition, we used the Attachment Style Questionnaire (ASQ)
(Feeney et al., 1994) as a dimensional measure of attachment
style (data available for 104 subjects). The ASQ is a 40-item self-
report questionnaire in which items are rated on a 6-point scale
from 1 (totally disagree) to 6 (totally agree). Based on both the-
oretical expectations and principal components analysis, the 40
items can be assigned to ve scales: Condence, Discomfort with
Closeness, Need for Approval, Preoccupation with Relationships,
and Relationships as Secondary. Discomfort with Closeness maps
onto conceptualizations of avoidant attachment (Hazan & Shaver,
1987). Need for Approval reects respondents need for acceptance
and conrmation from others that characterizes fearful avoidant
and anxious preoccupied groups. Preoccupation with Relation-
ships also maps to anxious attachment (sometimes also called
anxious/ambivalent attachment). The Relationships as Secondary
scale identies dismissing attachment (Bartholomew, 1990). Con-
dence (in Self and Others) reects a secure attachment orientation.
When the ASQ was administered to a large sample of university
students, the ve scales showed good internal consistency, with
Cronbachs alpha coefcients ranging from .76 to .84; further, the
10-week retest reliability coefcients of the scales ranged from .67
to .78 (Feeney et al., 1994).
2.4. Agoraphobia
Agoraphobia was assessed using the Panic-Agoraphobic Spec-
trum Self-Report (PAS-SR) (Cassano et al., 1999). This 114-item
questionnaire was developed to assess lifetime panic-agoraphobic
spectrum symptoms and displays good psychometric properties
(Frank et al., 2002; Shear, Frank, et al., 2001). Items are orga-
nized into eight panic-agoraphobic symptom domains including
a domain comprising 25 items for assessing agoraphobia. Items
are rated dichotomously (yes/no). Domain scores are obtained by
counting the number of positive responses.
3. Statistical analyses
The mean values of continuous variables such as age and scale
scores were compared between subjects with and without ASAD
743
using the t-test for independent samples. Comparisons of categori-
cal variables between groups were conducted using the chi-square
test. In particular, rates of Axis I psychiatric comorbidity were
compared between the two groups with or without ASAD, before
proceeding to factor analysis and attachment comparisons. The p-
value was set at .05. The association of demographic and clinical
variables with ASAD was estimated using crude odds ratios (ORs)
with 95% condence intervals (CIs). The factor structure of the adult
SCI-SAS scale and PAS-SR agoraphobia subscale was evaluated by
using a generalized least square factor analysis. For this analysis
the SCI-SAS items were dichotomized (0, 1 = absent, 2 = present) to
have the same measurement level as PAS-SR items.
Statistical analyses were conducted using IBM SPSS Statistics,
version 20.0 (IBM SPSS Inc., 2011).
4. Results
4.1. Characteristics of sub-groups with and without adult
separation anxiety disorder (ASAD)
Overall, ASAD was diagnosed in 70/141 (49.5%) of our sample,
and was more likely to occur in females (52/91; 57.1%) com-
pared with males (18/50; 36%) (OR = 2.37, 95% CI: 1.174.83.) Age,
educational level and marital status were similar between sub-
jects with or without ASAD (age: 39.45 12.60 with ASAD and
41.65 13.07 without ASAD; t-test = 1.013, p = .313; educational
level: 10.76 3.71 with ASAD and 11.20 4.36 without ASAD, t-
test = .652, p = .516; married: 31 (45.6%) and 33 (46.5%), in each
group respectively, chi-square = .11, p = .916). Subjects with ASAD
were less likely to be employed (58.8% vs. 72.9%) although this
difference did not reach statistical signicance (chi-square = 3.03,
p = .082).
Thirty-eight (54.3%) of the 70 participants with ASAD also
reported a history of childhood separation anxiety disorder, while
only 13/71 (18.3%) of those without ASAD recalled these symptoms
in childhood (OR = 5.30, CI 2.4711.37 for those with ASAD com-
pared with those without). Overall, 58/141 (41%) of the sample did
not meet criteria for child or adult separation anxiety disorder.
4.2. Clinical correlates of adult separation anxiety disorder
(ASAD)
As shown in Table 1, ASAD was associated with higher frequency
of agoraphobia (p = .046), more panic attacks during last month
(p = .008), greater severity of panic disorder symptoms (p = .008),
and earlier age of onset of agoraphobia (p = .018). Patients with
ASAD endorsed lower scores on quality of life as assessed by SF-
36 in terms of physical functioning (p = .007), role emotional
(p = .048), mental health (p = .003) and general health (p = .008.)
4.3. Adult separation anxiety and agoraphobia
ASA-27 total score signicantly correlated with SCI-PAS ago-
raphobia subscale score (r = .31.) Factor analysis including items
from both scales revealed that a two-factor model ts the data
well (chi-square = 163.6, df = 151, p = .228). The factor loadings are
shown in Table 2. Two items from the agoraphobia scale load on
the separation anxiety factor. These items rate feeling nervous or
uncomfortable when alone outside home or somewhere far from
home or when home alone.
4.4. Adult separation anxiety disorder and attachment style
The relationship between ASAD and attachment style has been
investigated by the RQ and the ASQ. About 20% of the sample was
not willing to complete the attachment evaluation. However, these
744 S. Pini et al. / Journal of Anxiety Disorders 28 (2014) 741746

Table 1 Table 2
Clinical and quality of life (QOL) characteristics in subjects with panic disorder (PD) Rotated factor matrix of PAS-SRa typical agoraphobia subscale and the 8 SCI-SASb
with and without adult separation anxiety disorder (ASADa ). adult section items.

Patients Patients Chi-square p Factor

with PD with with PD
no ASAD with ASAD 1 (agoraphobia) 2 (separation
(n = 71) (n = 70) anxiety)

Lifetime comorbidity Did you avoid, feel nervous or

Agoraphobia 37 (52.1%) 48 (68.6%) 3.988 .046 uncomfortable. . .a
Social phobia 14 (19.7%) 10 (14.3%) .737 .391 . . .when you were alone outside your .382 .416
OCD 13 (18.3%) 10 (14.3%) .418 .518 home or somewhere far from home?
Specic phobia 18 (25.4%) 22 (31.4%) .640 .424 . . .when home alone? .394 .415
Bipolar I 8 (11.3%) 11 (15.7%) .598 .439 . . .when you were in a crowded place? .462 .056
Bipolar II 19 (26.8%) 18 (25.7%) .020 .888 . . .when on a bridge or in a ski .421 .318
Major depression 23 (32.4%) 17 (24.3%) 1.140 .286 gondola?
. . .when you were in closed places .578 .385
(such as tunnels, subways,
Patients Patients t-Test p
underground, or in a theater)?
with PD with PD
. . .when you were in an elevator? .508 .215
with no with
. . .driving a car other than on a .692 .035
ASAD ASAD
highway? I never drove
(n = 71) (n = 70)
. . .driving a car on the highway? I .651 .150
Severity of PD never drove
Past month panic 3.98 7.95 9.62 14.74 2.695 .008 . . .being in an open place like a town .590 .200
attacks square or a wide street?
Number of panic 7.55 2.83 10.09 2.43 5.709 .008 . . .traveling as a passenger by car, bus, .510 .132
symptoms train or plane? Note: Not because of
ASA-27 20.82 11.61 45.31 12.23 12.197 .0001 fear of crashing
SASI-tot 11.445 7.90 18.81 9.82 4.918 .0001 . . .standing in line? .587 .181
Age at onset of PD 29.76 12.37 28.20 12.22 .723 .471 . . .in situations or places in which you .330 .089
Tot Hamilton 12.23 7.43 13.50 9.35 .897 .371 thought you might be embarrassed
Age at onset of 33.97 14.14 27.28 11.17 2.411 .018 by the symptoms previously
agoraphobia described?
As a child or an adult, did you ever
SF36 QOL
experience. . .b
Physical 88.57 16.76 77.58 26.43 2.767 .007
A lot of distress if you were separated .089 .664
Functioning or anticipated separation from home
Role physical 58.33 45.12 59.16 45.55 .102 .919
or loved ones
Role emotional 36.50 42.63 22.22 36.13 2.000 .048 A lot of distress because of thoughts .139 .689
Mental health 48.17 23.52 35.58 22.08 3.018 .003
that you might lose someone close to
General health 61.16 22.18 49.68 25.12 2.690 .008
you or some harm might come to
Social functioning 49.40 12.38 49.16 9.45 .119 .905
them
Vitality 43.22 23.54 35.97 23.95 1.671 .097
Persistent and excessive worry that an .194 .454
Bodily pain 71.77 30.91 68.79 32.93 .511 .610
untoward event will lead to
a
ASAD = 3 or more items scored 2 (often) at structured clinical interview for separation from a major attachment
separation anxiety disorder adult (SCI-SAS). gure (e.g., getting lost or being
kidnapped)
Persistent reluctance or refusal to go to .071 .352
school or elsewhere because of fear
individuals did not differ from those who completed the assess- of separation
ment on socio-demographic or clinical characteristics. Persistently and excessively fearful or .011 .538
There were no signicant differences in the distribution of the reluctant to be alone or without
major attachment gures at home or
four RQ-rated attachment styles among panic disorder patients
without signicant adults in other
with vs without ASAD (Anxious, 35.8% vs 26.8%; Avoidant 26.4% settings
vs 22.2%; Dismissing 26.4% vs 25.9%, Secure 11.3% vs 24.1%). Persistent reluctance or refusal to go to .003 .505
The dimensional measure ASQ revealed that the group with sleep without being near a major
ASAD scored signicantly higher on preoccupation with rela- attachment gure or to sleep away
from home
tionships (32.22 8.43 vs 28.56 7.40; t = 2.308, p = .023) and
Repeated nightmares involving the .015 .262
showed a trend toward greater need for approval (25.00 7.89 vs theme of separation
22.40 7.44, t = 1.702, p = .092), i.e. on both the scales indicative Repeated complaints of physical .201 .207
of anxious attachment. symptoms (such as headaches,
stomachaches, nausea, or vomiting)
when separation from major
5. Discussion attachment gures occurs or is
anticipated

Our study of panic disorder patients examined questions related
to the distinctiveness of the syndrome of adult separation anxiety
disorder. Results of our study support the idea that adult sepa-
ration anxiety disorder is different from anxious attachment or
agoraphobia. 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 ASAD occurs in some patients
who report secure attachment style. Similarly, there is little evi-
dence for the idea that separation anxiety disorder is a form of
Bold values dene items tting in the same factor.
a
PAS-SR: panic-agoraphic Spectrum self-report questionnaire.
b
SCI-SAS: structured Clinical Interview for Separation Anxiety Disorder.
agoraphobia. Factor analysis shows clear differentiation of agora-
phobic and separation anxiety symptoms.
Previous studies reported that ASAD is an impairing condition
that leads to long term difculties in different areas of functioning
(Milrod et al., 2014; Pini et al., 2010; Shear et al., 2006). We found
that panic disorder patients with ASAD had greater severity of panic
 S. Pini et al. / Journal of Anxiety Disorders 28 (2014) 741746
disorder and more impairment in quality of life than those without.
These ndings corroborate the notion that it is important for clini-
cians and researchers to focus on ASAD, when co-occurring with
other psychiatric disorders, as an independent source of disability.
We highlight the importance of distinguishing between separation
anxiety as a symptom and separation anxiety as a disorder. Both
ASAD and anxious attachment share separation anxiety symptoms
(Shear, 1996; Dozie, Chase Stovall, & Albus, 1999). However, our
results suggest that separation anxiety, as a symptom, is not nec-
essarily indicative of separation anxiety disorder. The latter is a
specic constellation of symptoms in adults, resembling the well-
described childhood condition, to which it is often related. In this
case, patients have profound sensitivity to transitions and losses,
including those experienced in therapeutic relationships (Milrod
et al., 2014). Patients and clinicians may not recognize its pres-
ence or potency given that it tends to normalize, so that separation
anxiety fuels chronic anxiety and a global sense of inadequacy and
incompetence that can undermine either psychological or pharma-
cological treatments. In particular, separation anxiety disorder has
been found to predict medication nonresponse to SSRIs and tricyclic
antidepressants in subjects with panic disorder with agoraphobia
(Miniati et al., 2012).
Fear of being alone and unable to get help is a form of separation
anxiety and also a criterion symptom for agoraphobia (Bandelow
et al., 2001; Beesdo-Baum et al., 2009; Pollack et al., 1996). How-
ever, agoraphobic fear is usually related to the possibility of having
a panic attack, whereas the core fear in separation anxiety disorder
is that of harm pending on a close attachment gure. The resulting
pattern of avoidance associated with agoraphobia differs from that
found with adult separation anxiety disorder. The distinctiveness of
ASAD and agoraphobia is supported by our factor analysis ndings.
However, agoraphobic fear of being alone did load with ASAD. This
suggests that some individuals diagnosed with agoraphobia based
on such fear may have co-occurring ASAD and/or may be better
characterized as ASAD.
5.1. Limitations
The limitations of this study need to be acknowledged. We used
only self-report instruments to evaluate attachment style. How-
ever, these scales have been well validated and used by many other
investigators. Our sample included PD patients recruited from a
psychiatric outpatient clinic with a reputation for the treatment of
anxiety and mood disorders. Thus, although panic disorder was the
primary diagnosis in our sample, the high prevalence of comorbid
mood disorders could have affected the relationship between sep-
aration anxiety and attachment styles. The frequency of ASAD may
be elevated in this tertiary care setting (Pini, Abelli, et al., 2005).
However, there is no reason to expect that the lack of correspon-
dence between ASAD and attachment style or between ASAD and
agoraphobia was specic to this sample. Our study is also limited
by the cross-sectional nature of our data. We found some poten-
tially important associations between separation anxiety disorder,
panic disorder severity, impairment in quality of life and anxious-
preoccupied attachment style. However, we cannot determine the
direction of causality nor whether impact of quality of life was, at
least in part, mediated by severity of PD.
5.2. Conclusions
In summary, we found a high frequency of adult separation anx-
iety disorder in a group of psychiatric outpatients who met DSM-IV
criteria for panic disorder. We found more differences than simi-
larities between anxious attachment, agoraphobia and ASAD. We
further corroborate indications of clinical signicance of this condi-
tion (Silove & Marnane, 2013). We urge clinicians and researchers
745
to be aware of separation anxiety disorder in adults and consider
the possibility that specic treatment strategies may be needed.
Acknowledgements
This work was supported by grants from the Italian Ministry
of University and Scientic Research (prot. 2005069159) and Fon-
dazione IDEA (Institute for Research and Prevention of Depression
and Anxiety).
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