Clinical Vignette
Patient: "Mrs. R," 41-year-old real estate agent, referred by her therapist after her husband's 2-week business trip precipitated severe anxiety, daily panic-like episodes, and inability to work.
Chief Concern: "When my husband is away, I can't function. I'm terrified something terrible will happen to him. I call him 15-20 times a day. I can't sleep alone. I've canceled all my real estate showings because I can't leave the house without him."
History of Present Illness: Mrs. R reports a 3-year pattern of excessive anxiety specifically related to separation from her husband. The pattern began after her mother was diagnosed with cancer 3 years ago (her mother recovered). Symptoms include: (1) recurrent excessive distress when separation occurs or is anticipated, (2) persistent worry about losing her husband to accident, illness, or catastrophe (checks his location on phone every 30 minutes), (3) reluctance to leave home without him, (4) difficulty sleeping without him (moves to the couch with all lights on), (5) physical symptoms when separation occurs (stomach pain, headaches, nausea). When her husband is home, she functions normally: attends showings, socializes, sleeps well, and has no anxiety symptoms. She can leave the house alone during her husband's work hours IF she can reach him by phone. Her distress is specifically about HIS safety, not about being alone in general. She has no fear of public spaces, crowds, or situations where escape might be difficult (ruling out agoraphobia).
Past Psychiatric History: No prior psychiatric history before age 38. No childhood separation anxiety. Secure childhood attachment described.
Family History: Mother: GAD. No other relevant psychiatric history.
Mental Status Exam: Anxious when discussing husband's upcoming trip. Speech rapid. Mood 'anxious.' Affect congruently anxious, tearful. Thought content: catastrophic worry focused specifically on husband's safety. No psychotic symptoms. No depressive symptoms. Insight partial.
Step 1: Separation Anxiety Disorder DSM-5-TR Criteria (Adults ≥18)
Criterion A (1): Recurrent excessive distress when anticipating or experiencing separation from major attachment figures.
Severe distress when husband is away. Calls 15-20 times daily. Cries, cannot function. PRESENT.
Criterion A (2): Persistent worry about losing major attachment figures to illness, injury, disaster, or death.
Persistent catastrophic worry about husband dying in accident. Checks his phone location every 30 minutes. PRESENT.
Criterion A (3): Persistent worry about experiencing an untoward event that causes separation from attachment figure.
Worries about being in an accident herself that would prevent her from being with her husband. PRESENT.
Criterion A (4): Reluctance or refusal to go out because of fear of separation.
Cannot leave household when husband is traveling. Canceled work appointments during his trips. PRESENT.
Criterion A (5): Excessive fear or reluctance about being alone.
Cannot sleep alone. Sleeps on couch with all lights on when husband travels. PRESENT.
Criterion A (6): Reluctance or refusal to sleep away from home or without major attachment figure.
Has refused all overnight invitations and trips for 3 years. PRESENT.
Criterion A (7): Repeated nightmares involving the theme of separation.
Mrs. R does not report nightmares about separation. Sleep difficulty is limited to inability to sleep alone. NOT PRESENT.
Criterion A (8): Physical complaints when separation occurs or is anticipated.
Stomach pain, headaches, nausea specifically triggered by separation. PRESENT.
Criterion A: 7 of 8 criteria present (≥3 required for adults).
Far exceeds threshold. CRITERIA MET.
Criterion B: Duration ≥6 months in adults.
Three-year duration. MET.
Criterion C: Clinically significant distress or impairment.
Unable to work during husband's trips. Severe subjective distress. Interpersonal strain. MET.
Step 2: Differentiating from Agoraphobia and Dependent PD
| Feature | Separation Anxiety Disorder | Agoraphobia | Dependent PD | This Patient |
|---|---|---|---|---|
| Core fear | Harm to/loss of attachment figure | Being in situations where escape is difficult | Being unable to care for self alone | SAD: fear is about husband's safety |
| With attachment figure present | Fully functional | May still be anxious in feared situations | Seeks reassurance continuously | Fully functional when husband is home |
| Can leave home? | Yes, if attachment figure is reachable | Avoids specific situations regardless | Dependent on others for decisions | Can leave if she can reach husband by phone |
| Focus of worry | Something happening TO the other person | Something happening to SELF in public | Being unable to function independently | Husband being in an accident or dying |
| Onset pattern | Often after a threatening event | Variable | Lifelong pattern | After mother's cancer diagnosis (3 years ago) |
Differential Summary
The anxiety is specifically attachment-focused (husband's safety), resolves completely when the attachment figure is present, and does not generalize to public spaces or situations. Agoraphobia is excluded (no fear of public spaces or escape-constrained situations). Dependent PD is excluded (functions independently when husband is accessible; the fear is not about her own helplessness but about his safety).
Diagnostic Formulation
Diagnostic Conclusion
Separation Anxiety Disorder, Adult Onset (F93.0): Seven of 8 DSM-5-TR criteria met with 3-year duration. Anxiety is exclusively attachment-focused (husband's safety). Precipitant: mother's cancer diagnosis (sensitizing event). Normal functioning when attachment figure is accessible. Agoraphobia and Dependent PD excluded. Treatment: CBT with focus on catastrophic cognitions about attachment figure safety, graduated exposure to toleration of separation, and possible SSRI augmentation.
Teaching Points
- DSM-5-TR recognizes that Separation Anxiety Disorder can have onset in adulthood and is not limited to children. Adult SAD was only fully recognized as a disorder in DSM-5 (2013). Previously, the diagnosis required onset before age 18.
- The core differentiator between adult SAD and Agoraphobia is the focus of fear. In SAD, the fear is about the ATTACHMENT FIGURE's safety. In Agoraphobia, the fear is about the SELF being in situations where escape or help is unavailable. Both can produce home confinement, but for different reasons.
- Adult-onset SAD often follows a sensitizing event involving actual or threatened loss of an attachment figure (illness, death threat, near-miss accident). Mrs. R's onset after her mother's cancer diagnosis illustrates this pattern.
- The duration requirement for adults is 6 months (vs. 4 weeks for children), reflecting the expectation that transient separation anxiety in adults should resolve more quickly without meeting disorder criteria.
- Treatment for adult SAD mirrors that for other anxiety disorders: CBT (cognitive restructuring of catastrophic beliefs + behavioral exposure to tolerated separation durations) is first-line. SSRIs (sertraline, fluoxetine) are evidence-supported pharmacological options.