ORIGINAL RESEARCH
Separation Anxiety and Actual Separation Experiences During Childhood in Patients with Panic Disorder Borwin Bandelow, MD\ Gabriel Alvarez Tichauer, MD^, Corinna Spath, MD^, Andreas Broocks, MD", Goran Hajak, MD^, Stefan Bleich, MD«, Eckart Ruther, MD'
Objective: The association between separation anxiety in childhood and actual separation experiences during childhood has not yet been investigated in patients with panic disorder. Methods: In 115 patients with panic disorder with or without agoraphobia and in 124 control subjects without a history of psychiatric illness, we assessed separation anxiety during childhood, retrospectively, using DSM-IV and ICD-10 criteria and the Separation Anxiety Symptom Inventory (SASI). In addition, actual separation experiences from age 0 to 15 years were assessed, retrospectively. Resutts: A total of22.6% ofthe patients and 4.8% ofthe control subjectsfulfilled both DSM-IV and ICD-10 criteriafor childhood separation anxiety (x^ =11.8; P < 0.0001). Further, 57.4% of the patients and 37.9% ofthe control subjects reported actual separation experiences during their childhood (y^ = 9.09, P < 0.003). Separation anxiety and actual separation experiences, however, were independent of each other. Conctusion: These results suggest that separation anxiety during childhood is not a consequence of actual traumatic separation experiences in panic disorder patients. (Can J Psychiatry 2001 ;948-952) Key Words: panic disorder, agoraphobia, separation anxiety disorder tion anxiety and its severity were significantly higher for panic disorder patients than for healthy control subjects (7-11) or surgical outpatients (12,13). Taken as a whole, the evidence provides support for the hypothesis that early separation anxiety is an antecedent of adult panic disorder (14). We see higher rates of separation anxiety in more severely ill patients (for example, those with agoraphobia or with eomorbid conditions) (3,5,6,9,11,15,16).
F
or the first time in 1964, Donald F Klein observed that 16 out of a group of 32 persons with agoraphobia had suffered from separation anxiety during childhood (1). Likewise, in other studies which did not use a healthy control group, high rates of 18% to 54% of separation anxiety were reported (2-6). In most studies that compared patients with panic disorder with a control group, the incidence of separa-
Even so, separation anxiety during childhood does not seem to be specific for panic disorder. The rates for separation anxiety for patients with panic disorder were found to be similar to the rates in patients with depression (11,17), generalized anxiety disorder (10,11,18), social phobia (5,11), obsessive-compulsive disorder (5), or specific phobia (19,20). One study found higher rates in panic disorder than in generalized anxiety disorder or other phobic disorders (21).
Manuscript received June 2001 and accepted October 2001. 'Professor, Department of Psychiatry and Psychotherapy, University of Gottingen, Germany. ^Research Assistant, Department of Psychiatry and Psychotherapy, University of Gottingen, Germany. ^Research Assistant, Department of Psychiatry and Psychotherapy, University of Gcjttingen, Germany. ''Assistant Professor, Department of Psychiatry and Psychotherapy, University of Liibeck, Germany. ^Professor, Department of Psychiatry and Psychotherapy, University of Regensburg, Germany. "Research Assistant, Department of Psychiatry and Psychotherapy, University of Erlangen, Germany. 'Professor, Head, Department of Psychiatry and Psychotherapy, University of Gottingen, Germany. Addressfor correspondence: Prof Dr Borwin Bandelow, Department of Psychiatry, University of Gottingen, von-Siebold-Str, D-37075 Gottingen, Germany e-mail:
[email protected]
Can J Psychiatry, Vol 46, December 2001
These retrospective data have their limitations. Prospective studies that investigate the association between childhood separation anxiety and adult panic disorder, however, are unavailable. As higher rates of actual separation experiences have also been found in persons with panic disorder and agoraphobia 948
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Separation Anxiety and Actual Separation Experiences During Childhood in Patients with Panic Disorder
when compared with control subjects (22-25), it seems possible that separation anxiety during childhood may be a consequence of actual separation experiences. Some authors found elevated rates of both separation anxiety and actual separation trauma but did not report the correlation between both (1,2,16,18).
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Table 1. Actual separation experiences during age 0 to 15 years Separation from the natural mother, due to death of the mother long absence of the mother due to illness (> 100 days) adoption upbringing in a foster home
This paper investigates the association between separation anxiety and actual separation experiences during childhood, which, to our knowledge, has not been done.
upbringing by other family kin or nonrelated persons long absence due to divorce or separation of parents Separation from the natural father, due to
Methods The study was approved by the local ethical committee. Patients with panic disorder, with or without agoraphobia, who had been treated at the Anxiety Disorders Unit of the Department of Psychiatry at the University of Gottingen were contacted personally, by telephone or by mail. A total of 151 outpatients were asked to participate in the survey. Of these, 15 patients had moved and were untraceable, and 21 refused to take part in the study. The remaining 115 patients participated in the study after giving informed consent. In using the Structured Clinical Interview for DSM-IV (SCID) (26), a lifetime diagnosis of panic disorder was reconfirmed, and in control subjects, psychiatric disorders were excluded. Control subjects (« = 124) were matched for age, sex, social class, and school education. The mean age of patients was 38.1 (SD 10.6) years, the mean age of control subjects was 36.8 (SD 11.6) years. The difference was not significant (/ = 1.2, P = 0.22). The percentage of women was 59.1% in the patient group and 57.3% in the control group; the difference was not statistically significant (x^ = 0.086, f = 0.79). Among the persons with panic disorder, 50% had concomitant agoraphobia. Separation anxiety during childhood was assessed retrospectively by using 1) the DSM-IV criteria for Separation Anxiety Disorder (309.21)(27); 2) the ICD-10 criteria for Separation Anxiety Disorder of Childhood (F93.0) (28); and 3) the Separation Anxiety Symptom Inventory (SASI) (29). To fulfill DSM or ICD criteria for separation anxiety, 3 out of 8 items concerning separation anxiety before age 18 years are confirmed. The mean sums of all 8 DSM or ICD items were calculated. The SASI is a self-rated questionnaire with 15 items concerning separation anxiety before age 18 years, each with a 0 to 3 Likert scale from "never" to "very often".
death of the father long absence of the father due to illness ( > 100 days) adoption, upbringing in a foster home upbringing by other family members or nonrelated persons absence due to parents' separation or divorce long absence of the father due to war service or war imprisonment long absence of the father due to imprisonment Separation from parents due to the proband's hospitalization ( > 100 days).
Table 2. Separation anxiety measures (mean total scores) in patients and controls (Wilcoxon-Mann-Whitney Test). Patients (n=115) DSM-IV
lCD-10
SASI
Control subjects («=124)
P
Men
1.24 (SD 1.73) 0.27 (SD 0.72)
