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Reviews and Overviews   |    
Childhood Separation Anxiety and the Pathogenesis and Treatment of Adult Anxiety
Barbara Milrod, M.D.; John C. Markowitz, M.D.; Andrew J. Gerber, M.D., Ph.D.; Jill Cyranowski, Ph.D.; Margaret Altemus, M.D.; Theodore Shapiro, M.D.; Myron Hofer, M.D.; Charles Glatt, M.D.
Am J Psychiatry 2014;171:34-43. doi:10.1176/appi.ajp.2013.13060781
View Author and Article Information

Dr. Milrod receives royalties from Taylor & Francis for an academic book. Dr. Markowitz receives research funding support from NIMH and salary support from New York State Psychiatric Institute; minor book royalties from American Psychiatric Publishing, Basic Books, and Oxford University Press; and an editorial stipend from Elsevier Press; none of these constitutes a conflict of interest with the current article. Dr. Altemus has received payment for consultation from Ironwood Pharmaceuticals and Corcept Pharmaceuticals; she has also received research support from Fisher-Wallace Corporation. The other authors report no financial relationships with commercial interests.

Supported in part by a fund in the New York Community Trust established by DeWitt Wallace (Dr. Milrod), by NIMH grants R01 MH70918-01A2 (Dr. Milrod) and R01 MH-079078 (Dr. Markowitz), by the Brain and Behavior Research Foundation (Dr. Milrod), and New York State Psychiatric Institute (Dr. Markowitz).

The authors thank biostatistician Eva Petkova, Ph.D.

From the Department of Psychiatry, Weill Cornell Medical College, New York; New York State Psychiatric Institute, New York; and the Department of Psychiatry, University of Pittsburgh School of Medicine.

Address correspondence to Dr. Milrod (bmilrod@med.cornell.edu).

Copyright © 2014 by the American Psychiatric Association

Received June 14, 2013; Accepted August 26, 2013.

Abstract

Clinically significant separation anxiety disorder in childhood leads to adult panic disorder and other anxiety disorders. The prevailing pathophysiological model of anxiety disorders, which emphasizes extinction deficits of fear-conditioned responses, does not fully consider the role of separation anxiety. Pathological early childhood attachments have far-reaching consequences for the later adult ability to experience and internalize positive relationships in order to develop mental capacities for self-soothing, anxiety tolerance, affect modulation, and individuation. Initially identified in attachment research, the phenomenon of separation anxiety is supported by animal model, neuroimaging, and genetic studies. A role of oxytocin is postulated. Adults, inured to their anxiety, often do not identify separation anxiety as problematic, but those who develop anxiety and mood disorders respond more poorly to both pharmacological and psychotherapeutic interventions. This poorer response may reflect patients’ difficulty in forming and maintaining attachments, including therapeutic relationships. Psychotherapies that focus on relationships and separation anxiety may benefit patients with separation anxiety by using the dyadic therapist-patient relationship to recapture and better understand important elements of earlier pathological parent-child relationships.

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TABLE 1.Comparison of Fear Extinction and Potential Separation/Attachment Models of Anxiety
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