Separation Anxiety: History, Treatment & Considerations

This is an edited version of an assignment I wrote for the AUT graduate diploma in Psychotherapy on Separation Anxiety. I hope it shines some light on a dark place.

Introduction

Imagine being in a relationship (intimate or familial) where, even the thought of being apart from your loved one roots you to the spot in terror. You live in an inner world of constant degrees of anxiety and panic attacks every time he or she leaves as your brain hijacks your physical and mental functions. You want to run, or hide, and often are frozen to the spot. Welcome to separation anxiety. Where the fear of losing that one person who loves you, or you love like no other, is greater than your needs, life and well-being. Before you judge, look at the underlying research around the origins, biology and development of this disorder. 

History of Anxiety

Humans have been nervous, and quite rightly so, as far back as when we were worried about saber tooth tigers and woolly mammoths. Under such stressful conditions, the natural and logical response is to attack, defend, run or freeze and play dead, like possums do under threat. In stressful situations, the autonomic nervous system (ANS), more specifically the component of the ANS called the sympathetic nervous system (SNS) becomes activated, readying the body chemically and biologically to respond accordingly (fight, flight or freeze). Being nervous under fearful conditions is therefore normal and healthy. As long as one can self soothe and down-regulate the autonomic response once the threat has passed, bringing the body back to homeostasis; calm, centered and ‘business as usual’ so to speak.

Anxiety however is an extreme reaction to a perceived fearful situation. As discussed, being afraid and nervous is a normal response to stress or danger and is a core part of the evolutionary process. However anxiety goes beyond a normal nervous reaction and is considered by the American Psychiatric Association (2013) as a mental disorder due to it presenting as a:

…clinically significant disturbance in an individual’s cognition, emotion regulation, or behaviour that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning… (p. 4).

When normal nervousness becomes an anxiety disorder, the SNS is activated, when no real threat is present or by thought alone. This fight and flight response is able to switch on by numerous conscious or unconscious cues and essentially malfunctions, as the anxious organism (person, animal etc), is unable to self regulate and switch the SNS’s fight and flight response off, as would normally happen once the threat has passed. This is often because the threat is not real but imagined or perceived and arises from implicit and often traumatic memories buried in the subconscious which are unavailable for logical processing and resolution. As an adaptive process, anxiety can sharpen our senses and keep us safe in potentially dangerous situations, however as a maladaptive response, anxiety stops one’s ability to have a quality of life where new behaviours and experiences are a welcomed part of daily living.  

Separation Anxiety 

Separation anxiety disorder is defined by the American Psychiatric Association (APA) (2013), in their Diagnostic and Statistical Manual of Mental Disorders (DSM)  as “developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached…” (p. 115). If never experienced, it would be easy to judge this disorder as irrational and the person as being labeled ‘needy’. However ‘needy’ is far from an adept description of the utter panic and despair that separation from significant others can trigger in those with this disorder. 

When experiencing separation anxiety, there may be a combination of physiological and psychological symptoms present, such as the acceleration of heart rate, shortness of breath, shaking and sleep disturbances. Psychologically there may be an inability to regulate emotions, resulting in maladaptive defence mechanisms such as withdrawal, extreme idealisation, somatisation, sexualisation and acting out. These may be both conscious responses and unconscious reactions to the panic attacks that often come with anxiety disorders. When an anxious state is present, one may also feel out of control and have a fear of going crazy as the body’s executive function switches off and maladaptive, habitual ways of responding kick in and old subconscious behaviours take control.

Work is often affected and the anxious person suffers socially as they find it impossible at times to leave the house or engage with others, especially when triggered. This relates back to the SNS kicking in, shutting down the prefrontal cortex’s regulating function, leaving the anxious person engaging in life through the fight and flight stress hormones and old unhealthy patterns learned in childhood, which is often the case for those with childhood trauma.

From a neuroscientific approach we can understand the biological processes in play, such as the triggering of the SNS and the corresponding increase of energy due to the heart rate increasing and the enhancement of muscular tone in response to stress. Corresponding to this is the inhibition of the immune system, growth and digestion and the impact on cognition, attention and memory from the increased levels of epinephrine, glucocorticoids and endogenous opioids that are released into the system. 

Neuroscience has helped us understand  how neural pathways are formed and adapted throughout life and how the brain has the ability to rewire its neural networks and change its structure through deleting “…specific unwanted emotional learning, including core non conscious beliefs and schemas at the level of the physical, neural synapses…” (neuroplasticity) (Dahliz, 2015, p.53) which helps the neuropsychotherapists understand the change process better, at least from a neurobiological perspective.

How neuropsychotherapists add to our understanding of separation anxiety is their explanation of how infantile trauma affects the neural wiring in the brain. How infantile brain development is impeded by unfavorable conditions such as abuse, neglect, or other parental psychopathology. Furthermore, because of early interpersonal trauma, the distressed child’s brain forms patterns of behaviour that serve them well as they navigate traumatic childhood experiences. However, they are survival mechanisms that become maladaptive or unhealthy and debilitating later in life. Continuing from this, that early development of psychic structures and attachment schemas that evolve from these early interpersonal interactions, influence how a person behaves, regulates their emotions and sees the world as a whole. 

Researchers such as Allan Schore further claim that insecure attachment schemas formed from traumatic interpersonal relationships in early development stages, play a central role in “…the psychoneuropathogenesis of all psychiatric disorders’ “ (2014, p. 390). 

The attachment schemas formed in early childhood may therefore explain what has happened in the neural wiring of the person suffering separation anxiety. Further explaining why the anxious person becomes so physically and psychologically disturbed and afraid, or feels abandoned by a significant other (child, parent, spouse, lover), even in the most loving, committed and seemingly secure relationships. 

Current Treatment Recommendations

Current treatment recommendations depend on the therapist’s approach and may be treated from a Cognitive Behavioural Therapy (CBT) perspective, neuroscientific or psychoanalytic approach (among others). From this author’s perspective, taking into consideration research around separation anxiety’s roots in interpersonal relationship breakdown and the subsequent development of unhealthy attachment schemas, it seems that a reversal of this disorder may be found in the therapeutic relationship. That in the process of therapy, the therapist replicates to some degree the parent or primary caregiver role, holding and containing the space for the client to explore their fears and emotional responses. The client learns affect (emotional) regulation through gentle exposure to anxiety inducing implicit memories and perceived fears “…allowing for ongoing cognitive flexibility, learning and neural integration…” (Cozolino, 2017, p. 23). The result is a shift in the client from experiencing anxiety as an avoidant defense trigger to seeing anxiety as something curious (biologically and intrapersonally) and something worthy of deeper exploration. Further allowing the client to cultivate a secure relationship schema and new narratives around past and present anxiety inducing situations, paving the way for new responses and more life conducive future outcomes. 

CBT techniques, such as those found in ancient yogic texts (mindfulness and meditation), are often employed to keep the client present to the physical and emotional responses arising in therapy. Further using these techniques to teach self soothing and downregulating of stress responses in the client’s day to day existence and when triggered. 

From a personal perspective, the above treatment is highly effective and in addition to this, the interpersonal relationships outside of therapy also hold significant importance in the healing process. That being in a relationship with a secure other who is able to hold and contain the anxious person in a loving, understanding and patient way, helps further heal the unhealthy attachment schema. However an important note must be made; the significant other must also have some understanding of what is going on. Interpersonal communication techniques must be learnt and employed and the significant attachment figure must hold his or her space so as not to fall into an enabling role and therefore hinder growth and development.   

Conclusion and Considerations Moving Forward

There is so much more to explore here. Separation anxiety is such a debilitating disorder as it affects every aspect of one’s existence. If not recognised and treated, a person may never live up to their fullest potential. They may miss out on so many experiences that will later be regretted and too late to revisit. Treatments will vary depending on the individual, their past and present experiences however, one thing is clear; running away and avoiding situations which may induce anxiety and panic attacks is not the answer. That exposure, albeit gently and the support of a compassionate therapist and, if possible, the support of a loving significant other, are important elements in the healing process. 

References

Abraham, M. (2018). A brief history of Anxiety. Calm Clinic. Retrieved October 3, 2019 from https://www.calmclinic.com/brief-history-of-anxiety

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Bowlby, J. (1969). Attachment and loss. (OKS Print.) New York: Basic Books. 

Bowlby, J. (1973). Attachment and loss:  Separation: anxiety and anger (Vol. 2). New York, NY: Basic Books.

Cozolino, L. (2017). The neuroscience of psychotherapy: Healing the social brain (3rd ed.). New York: W. W. Norton & Company.

Cozolino, L. (2014). The neuroscience of relationships: Attachment and the developing social brain. New York: W. W. Norton & Company. 

Dahlitz, M. (2015). Neuropsychotherapy: Defining the emerging paradigm of neurobiology informed psychotherapy. International Journal of Neuropsychotherapy. 3(1). 47-69. Retrieved September 26, 2019, from http://www.thescienceofpsychotherapy.com/wp-content/uploads/2015/08/IJNPT_Vol3_issue1.pdf#page=50

Fraser, T., & Tilyard, M. (2010). Recognising and managing mental health disorders in Māori. Best Practice Journal, 28. Retrieved September 1, 2019 from https://bpac.org.nz/BPJ/2010/June/docs/BPJ_28_june2010.pdf

Fonagy, P. (2001). Attachment theory and psychoanalysis. New York: Other Press. 

Fonagy, P., Gregely, G., Jurist,e., & Target, M. (2002). Affect regulation, mentalization and the development of the self. New York: Other Press.

Gordon, R. M. (2010). The Psychodynamic Diagnostic manual (PDM). In I. weiner and E. Craighead, (Eds.). Corsini’s Encyclopedia of psychology (4)3. 1312-1315. Hoboken, NJ: John Wiley and Sons.

Kaplan-Solms, K., & Solms, M. (2002). Clinical studies in neuro-psychoanalysis (2ond ed.). 1-320. New York London.

Lingiardi, V., & McWilliams, N. (Eds.). (2017). Psychodynamic diagnostic manual: PDM-2 (2nd ed.). New York, NY, US: Guilford Press.

McLeod, S. (2017). Bowlby’s attachment theory. Simply Psychology. Retrieved October 10, 2019, from https://www.simplypsychology.org/bowlby.html

McNeill, H. (2009). Maori models of mental wellness. Te Kharoa, 2. Retrieved September 1, 2019, from https://openrepository.aut.ac.nz/bitstream/handle/10292/3325/47-134-1-PB%5B2%5D.pdf?sequence=2&isAllowed=y

McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding the personality structure in the clinical process (2ond ed.). New York, NY: The Guilford Press.

Schore, A. N. (2008). Paradigm shift: The right brain and the relational unconscious. Psychologist-Psychoanalyst. 20 – 26. Retrieved September 3, 2019 from https://www.yellowbrickprogram.com/Papers-By-Yellowbrick/paradigm-shift.html  

Schore, A. N. (2011). The right brain implicit self lies at the core of psychoanalysis. Psychoanalytic Dialogue. 21. 75 – 100. 

Schore, A. N. (2014). The right brain is dominant in psychotherapy. Psychotherapy. 51(3). 388-397.

Williams, R. B. (1995). Somatic consequences of stress. In M. J. Friedman, D. S. 

Charney, & A. Y. Deutch (Eds.), Neurobiological and clinical consequences of stress: From normal adaptation to post-traumatic stress disorder (pp. 403-412). Philadelphia, PA, US: Lippincott Williams & Wilkins Publishers.

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