اضطراب جدایی و اختلال پانیک در جوانان مراجعه کننده بالینی

This study examined whether youngsters with separation anxiety disorder (SAD) and panic disorder (PD) had experienced more separation-related events than youngsters with SAD (without comorbid PD). We also examined whether age of onset of SAD and comorbidity with other psychological disorders was related to the occurrence of PD. We compared youngsters who were diagnosed with SAD and PD (N = 31) with youngsters who were diagnosed with SAD without comorbid PD (N = 63) for the number of separation-related events, severity of psychopathology, and parent and child CBCL ratings, age of onset of SAD, and the number of comorbid diagnoses. The findings indicate that youngsters with SAD and PD had a later age of onset of SAD and more extensive psychopathology and functional impairment than youngsters with SAD (without comorbid PD). Contrary to hypothesis, there were no differences between the groups in the occurrence or number of separation-related events.

An emerging body of research suggests that separation anxiety or experiences of separation from significant attachment figures in childhood may be linked to the development of panic disorder (Mattis & Ollendick, 1997). One line of research was stimulated by Klein's (Gittelman & Klein, 1985; Klein, 1964 and Klein, 1980) proposal that separation anxiety during childhood is a precursor of panic disorder (PD) and agoraphobia. This “separation anxiety hypothesis” was based on observations that some adults with PD reported a history of separation anxiety as a child. Research on the separation anxiety hypothesis suggests that separation anxiety disorder (SAD) and (PD) may be related in a number of ways (Black, 1995; Gittelman & Klein, 1985; Shear, 1996). Several studies have confirmed that a history of separation anxiety is present in a significant number of adults with PD and agoraphobia (Breier, Charney, & Heninger, 1986; Klein, Zitrin, Woerner, & Ross, 1983; Pollock et al., 1996). However, other studies have found that rates of separation anxiety for adults with PD were comparable to the rates in adults with generalized anxiety disorder (Raskin, Peeke, Dickman, & Pinsker, 1982; Silove, Manicavasagar, O’Connell, & Blaszczynski, 1993), social phobia (Lipsitz et al., 1994), obsessive-compulsive disorder (Lipsitz et al., 1994), specific phobia (Thyer, Nesse, Cameron, & Curtis, 1985; Thyer, Nesse, Curtis, & Cameron, 1986), and depression (Yeragani, Meiri, Balon, Patel, & Pohl, 1989). Overall, these findings raise doubts about whether SAD is selectively linked to PD in adults (Barlow, 2002 and Thyer, 1992). Instead, SAD during childhood may represent a general vulnerability factor that increases the likelihood of developing a variety of anxiety disorders later in life (Aschenbrand, Kendall, Webb, Safford, & Flannery-Schroeder, 2003; Last, Perrin, Hersen, & Kazdin, 1996; Lipsitz et al., 1994). Even if it is not linked specifically to PD and agoraphobia in adults, SAD or marked distress when separated from significant attachment figures may be one pathway in the development of PD in children and adolescents (Mattis & Ollendick, 1997; Ollendick, 1998). For example, separation anxiety may represent the early symptoms of PD in some children (Gittelman & Klein, 1985; Klein, 1980). When children with SAD are separated from their parents or other important attachment figures, they become very anxious and may experience a panic attack (Kaplan & Sadock, 1998). Examination of clinical descriptions of youngsters with PD or SAD reveals many similarities in these disorders. PD (with agoraphobia) and SAD are both characterized by extreme anxiety when the child is away from parents, home, or other familiar settings. In addition, children with these disorders exhibit marked avoidance behaviors that can take the form of reluctance or refusal to play outside or to travel away from home. “In fact, it is not uncommon for individuals with PD at any age to fear and avoid separation from attachment figures” (Black, 1995, p. 226). For children with either disorder, distress is markedly reduced when the child is accompanied by a parent (or significant attachment figure). The finding that a significant proportion of children and adolescents with PD present with comorbid SAD (Alessi & Magen, 1988; Biederman et al., 1997; Bradley & Hood, 1993; Doerfler, Connor, Volungis, & Toscano, 2007; Masi, Favilla, Mucci, & Millepiedi, 2000; Moreau, Weissman, & Warner, 1989; but see Last & Strauss, 1989 for an exception) suggests that SAD may be a risk factor for the development of PD in youngsters. Building on the emerging evidence regarding PD in children and adolescents, Mattis and Ollendick (1997) offered a model for the development of PD in youngsters. “In this model, panic attacks and panic disorder are viewed as emanating from biological and psychological vulnerabilities that are potentiated by separation-related stressors and mediated by important learning processes” (Ollendick, 1998, p. 243). One element of this model is the proposal that repeated experiences of separation from important attachment figures will be frightening for children who are predisposed to experience intense distress by such separation. Thus, according to this model, separation experiences will have important implications for the development of PD in children and adolescents (Mattis & Ollendick, 1997; Ollendick, 1998). Separation experiences or disruptions in attachment play an important role in other etiological models of PD (e.g., Gittelman & Klein, 1985; Shear, 1996). Only a few studies have investigated whether separation from significant attachment figures is associated with panic attacks or panic disorder in youngsters, but these studies provide tentative evidence that such experiences could play a role in the development of childhood PD. All of these studies focused on the occurrence of life-disrupting events, such as removal of the child or parent from the home or prolonged illness in the child or parent (Gittelman & Klein, 1985). For example, two surveys of high school students indicated that over 50% of students who experienced at least one panic attack reported loss-related events like parental separation or divorce (Hayward, Killen, & Taylor, 1989; Warren & Zgourides, 1988). Similar findings were obtained for a sample of 28 adolescents who met criteria for clinically significant panic attacks (Bradley & Hood, 1993); 26 adolescents in this sample reported significant psychosocial stressors that included death of a relative, family conflict, peer problems, and school pressures. Ollendick (1998) and Mattis and Ollendick (1997) noted that youngsters who are prone to respond with high levels of distress when separated from significant attachment figures will be at heightened risk of developing PD when they are exposed to repeated separation-related experiences. Youngsters with SAD, who experience great distress when they are separated from their parents or other attachment figures, may go on to develop PD if they experience multiple, highly disruptive or prolonged separation-related events. From a developmental psychopathology perspective, it is unlikely that there is a single pathway to the development of PD (Ollendick & Hirshfeld-Becker, 2002). As a result, it is likely that other factors, in addition to the number or type of separation-related events, are important for the development of PD in youngsters. SAD could be related to PD in children in a different way, however. Instead of the frequency of separation-related experiences, characteristics like age of onset of separation anxiety or co-occurrence of other psychiatric disorders may affect the risk of developing PD in childhood (Black, 1995). Separation anxiety is very common in young children and many children who exhibit intense distress when separated from attachment figures recover without any lingering impairment (Perwien & Bernstein, 2004). Some children, however, experience episodes of separation anxiety that are developmentally inappropriate. Based on clinical observation, Black (1995) suggested that children who develop SAD at a later age may experience a more chronic course of the disorder. When separation anxiety develops at a later age, it may represent the early symptoms of PD and agoraphobia (Gittelman & Klein, 1985; Klein, 1980). Some children with SAD exhibit other psychological problems, and the occurrence of these other problems could be related to the development of PD. Multiple diagnoses could reflect more severe psychopathology. The diagnosis of comorbid SAD and PD could reflect a more generalized level of dysfunction. An alternative possibility is that these children are more generally anxious. There are very high rates of comorbidity among the anxiety disorders (Barlow, 2002) and children who receive multiple anxiety disorder diagnoses may experience more intense or pervasive levels of anxiety. The present study was designed to investigate the link between SAD and PD in an outpatient clinical sample of youngsters. In a previous study of 35 children and adolescents with PD, we found that 31 youths (89% of the sample) had comorbid SAD (Doerfler et al., 2007). In the present study, the 31 children and adolescents with PD and SAD were compared to a group of youngsters with SAD (without comorbid PD). Based on the empirical literature regarding the possible link between SAD and PD, as well as Mattis and Ollendick's (1997) model, we hypothesized that youths with both PD and SAD would have experienced more separation-related events than youths with SAD (without comorbid PD). We also examined Black's (1995) proposal that age of onset of SAD and comorbidity with other psychological disorders may be associated with the course and outcome of SAD. We hypothesized that children with SAD and PD would have a later age of onset for SAD than children with SAD (without PD). We also hypothesized that children with PD with comorbid SAD would exhibit more severe disturbance (e.g., severity of separation symptoms, total number of diagnoses, functional impairment) compared to youths with SAD (without comorbid PD).