اضطراب جدایی بزرگسالان: ویژگی های روان سنجی از یک مصاحبه بالینی ساختار یافته جدید

Separation anxiety has traditionally been characterized and assessed as a disorder that is unique to childhood. Yet the core symptoms of separation anxiety, i.e. excessive and often disabling distress when faced with actual or perceived separation from major attachment figures, may persist or even arise during adulthood. We report on the psychometric properties of a new structured clinical interview designed to assess symptoms of separation anxiety as experienced both during childhood and adulthood. This instrument, called the Structured Clinical Interview for Separation Anxiety Symptoms (or SCI-SAS), was administered as part of an assessment battery to 91 adult psychiatric outpatients and 20 non-psychiatric controls. Results indicate that this instrument displays excellent psychometric properties, including good internal consistency, a clear factor structure, and exceptional levels of convergent and discriminate validity. These results highlight the feasibility and potential clinical utility of assessing age-appropriate symptoms of separation anxiety experienced during adulthood.

Separation anxiety disorder has traditionally been defined as a childhood phenomenon. This disorder is conceptually rooted in both developmental research and attachment theory. Distress upon separation from one’s mother (or like attachment figure) is the developmental norm during early childhood (Ainsworth, 1963, Bowlby, 1969 and Bowlby, 1973), and is considered to be an evolutionarily adaptive mechanism designed to keep the defenseless child in close proximity to its adult caregiver (Bowlby, 1969 and Bowlby, 1973). Only when separation distress becomes prolonged, excessive, developmentally inappropriate or impairing is a psychiatric diagnosis typically made. The estimated prevalence of childhood separation anxiety disorder is 4% (DSM-IV, American Psychiatric Association, 1994). The implied age restriction on the diagnosis of separation anxiety disorder raises two important questions. First, what happens when individuals with childhood separation anxiety reach adulthood? Second, do symptoms of excessive separation distress ever arise in adulthood? An adult form of this syndrome is listed in neither the DSM-IV nor the ICD-10, nor is adult separation anxiety rated in any of the commonly used structured diagnostic interviews. Although the DSM-IV indicates that symptoms of childhood separation anxiety disorder may persist for years and technically allows for a separation anxiety diagnosis in an adult whose symptoms originated prior to age 18, the manual explicitly states that “onset as late as adolescence is uncommon” (p. 112), and, moreover, provides no appropriate criteria for an adult expression of the disorder. Listed among the mental disorders first diagnosed in infancy, childhood, or adolescence, separation anxiety disorder is defined in the DSM-IV as “excessive anxiety concerning separation from the home or from those to whom the person is attached” (p. 110). Eight diagnostic criteria are listed, with endorsement of any three required for a diagnosis. These criteria include: distress about actual or anticipated separation; worries about losing attachment figures; worries that an untoward event will lead to separation; reluctance or refusal to go to school or elsewhere because of fears of separation; reluctance to be alone or without attachment figures at home or in other settings; reluctance or refusal to sleep away from home or to go to sleep without an attachment figure near; repeated nightmares involving the theme of separation; and, repeated complaints or physical symptoms when faced with actual or anticipated separation. Although the core concepts underlying each of these criterion are not themselves age-limited, the language used and examples provided in the DSM-IV description of this disorder are clearly child oriented (e.g. references to school refusal behaviors, fears of being kidnapped, desire to sleep in parental bed, etc.). Silove, Manicavasagar and colleagues recently proposed that the core symptoms of separation anxiety—i.e. excessive and often disabling distress in the face of actual or perceived separation from major attachment figures—may indeed persist or arise throughout adulthood (Silove et al., 1996, Manicavasagar et al., 1997 and Manicavasagar et al., 1998). Indeed, clinical case studies indicate that adult separation anxiety represents a discrete diagnostic entity worthy of clinical attention (Manicavasagar and Silove, 1997). This being the case, a conservative approach to identifying an adult variant of separation anxiety that parallels the described childhood syndrome would be to develop age-appropriate adult descriptions of the separation anxiety criteria included in the DSM-IV. Shear and colleagues developed a structured clinical interview designed to assess each of the eight DSM-IV separation anxiety criterion as experienced both during childhood and adulthood. For each criterion, a set of age-appropriate queries is provided, responses to which are rated by the clinical interviewer. In the current paper, we report results of psychometric testing of this structured clinical interview. We call this instrument the Structured Clinical Interview for Separation Anxiety Symptoms or SCI-SAS. The SCI-SAS, developed for use in adult populations, includes two 8-item scales, one that retrospectively assesses symptoms of childhood separation anxiety disorder, and one that assesses adult separation anxiety disorder. See the Appendix for a list of queries included in the SCI-SAS to assess both child and adult separation anxiety symptoms. (The full SCI-SAS instrument is available from Dr. Shear upon request.) In order to obtain descriptive and psychometric information on the SCI-SAS instrument, self-report and interview assessment data were obtained on a mixed sample of adult psychiatric outpatients and non-psychiatric control subjects. Aims of the study were threefold: (1) to provide information regarding the structure and internal consistency of the SCI-SAS scales; (2) to test the convergent and discriminant validity of the SCI-SAS scales; and (3) to examine the potential effects of age and gender on reports of child and adult separation anxiety.