Introduction

Anxiety
According to the American Psychological Association, “Anxiety is an emotion
characterized by feelings of tension, worried thoughts, and physical changes like
increased blood pressure”. Anxiety is a normal stress reaction. Mild levels of
anxiety can be beneficial in some situations. It can alert us to dangers and help us
prepare and pay attention. Anxiety disorders differ from normal feelings of
nervousness or anxiousness and involve excessive fear or anxiety. Anxiety disorders
are the most common mental disorders. They affect nearly 30% of adults at some
point in their lives. However, anxiety disorders are treatable with several
psychotherapeutic treatments. Treatment helps most people lead normal productive
lives. Anxiety refers to the anticipation of a future concern and is more associated
with muscle tension and avoidance behavior (American Psychiatric Association).
Anxiety is a feeling of fear, dread, and uneasiness. It might cause one person to sweat,
feel restless and tense, and have a rapid heartbeat. It can be a normal stress reaction.
For example, one might feel anxious when faced with a difficult problem at work,
before taking a test, or before making an important decision and it helps to cope. The
anxiety may give a boost of energy or help to focus. But for people with anxiety
disorders, the fear is not temporary and can be overwhelming. Anxiety disorders are
conditions in which anxiety does not go away and can get worse over time. The
symptoms can interfere with daily activities such as job performance, schoolwork,
and relationships. The cause of anxiety is unknown. Factors such as genetics, brain
biology and chemistry, stress and your environment may play a role. (National library
of medicine n. d)
Anxiety disorders are like other forms of mental illness. They don’t come from
personal weakness, character flaws or problems with upbringing. But researchers
don’t know exactly what causes anxiety disorders. They suspect a combination of
factors plays a role:
 Chemical imbalance: Severe or long-lasting stress can change the chemical
balance that controls your mood. Experiencing a lot of stress over a long
period can lead to an anxiety disorder.
 Environmental factors: Experiencing a trauma might trigger an anxiety
disorder, especially in someone who has inherited a higher risk to start.
 Heredity: Anxiety disorders tend to run in families. It may inherit them from
one or both parents, like eye color. (Cleveland Clinic,2024)
Types of Anxiety Disorder
Generalized Anxiety Disorder: Generalized anxiety disorder involves persistent and
excessive worry that interferes with daily activities. This ongoing worry and tension
may be accompanied by physical symptoms, such as restlessness, feeling on edge or
easily fatigued, difficulty concentrating, muscle tension or problems sleeping. Often
the worries focus on everyday things such as job responsibilities, family health or
minor matters such as chores, car repairs, or appointments.
Panic Disorder: The core symptom of panic disorder is recurrent panic attacks, an
overwhelming combination of physical and psychological distress.
Phobias, Specific Phobia: A specific phobia is excessive and persistent fear of a
specific object, situation or activity that is generally not harmful. Patients know their
fear is excessive, but they can't overcome it. These fears cause such distress that some
people go to extreme lengths to avoid what they fear. Examples are public speaking,
fear of flying or fear of spiders.
Agoraphobia: Agoraphobia is the fear of being in situations where escape may be
difficult or embarrassing, or help might not be available in the event of panic
symptoms. The fear is out of proportion to the actual situation and lasts generally six
months or more and causes problems in functioning.
Social Anxiety Disorder: A person with social anxiety disorder has significant
anxiety and discomfort about being embarrassed, humiliated, rejected or looked down
on in social interactions. People with this disorder will try to avoid the situation or
endure it with great anxiety. Common examples are extreme fear of public speaking,
meeting new people or eating/drinking in public. The fear or anxiety causes problems
with daily functioning and lasts at least six months.
Separation Anxiety Disorder: A person with separation anxiety disorder is
excessively fearful or anxious about separation from those with whom he or she is
attached. The feeling is beyond what is appropriate for the person's age, persists (at
least four weeks in children and six months in adults) and causes problems
functioning. A person with separation anxiety disorder may be persistently worried
about losing the person closest to him or her, may be reluctant or refuse to go out or
sleep away from home or without that person, or may experience nightmares about
separation. Physical symptoms of distress often develop in childhood, but symptoms
can carry through adulthood. (American Psychiatric Association).
Separation anxiety
Separation anxiety is characterized by stress and fear that occurs when a person is
separated from a particular person, or even an object, to which they have become
attached. Many people associate separation anxiety with children. However, adults
can also experience this condition. A person with separation anxiety usually develops
extreme anxiety when faced with the idea of separation. Separation anxiety disorder is
a type of anxiety disorder wherein the affected individual experiences intense worry,
fear, and panic when being separated from the attachment person. Even anticipation
of separation can induce symptoms of this mental illness. The disorder usually affects
children, and their attachment person is a parent or caregiver. Adolescents and adults
can develop separation anxiety disorder as well. Their attachment person can be a
love interest. It is not the same as separation anxiety, which is a normal part of a
child’s development. (Feriante, Torrico and Bernstein 2023)
Definitions
Separation anxiety disorder (SAD) is one of the most common childhood anxiety
disorders. SAD is an exaggeration of otherwise developmentally typical anxiety
manifested by excessive concern, worry, and even dread of the actual or anticipated
separation from an attachment figure. (Feriante, Torrico and Bernstein 2023)
Meaning of Separation Anxiety
Separation anxiety disorder is an intense fear of being separated from a loved one or
caregiver. It can affect children and adults. Separation anxiety is a normal
emotion in babies and toddlers. When anxiety interferes with age-appropriate
behavior, it becomes a disorder that needs to be treated. An adult’s separation
anxiety can trusted Source from many life events, such as the loss of an attachment
figure, either from moving away or being separated even for a relatively short amount
of time. Their anxiety may also be related to another underlying mental health
condition. For example, anxiety conditions are common in autistic people. On
occasion, people may categorized trusted Source an adult with separation anxiety
disorder as controlling or overprotective. However, their actions are often an adult’s
way of expressing their fears regarding separation.
Clinical features
According to ICD 10, it involves:

Recurrent excessive distress when anticipating or experiencing separation from home

or major attachment figures.

Persistent and excessive worry about losing major attachment figures or about
possible harm to them, such as illness, injury, disasters, or death.

Persistent and excessive worry about experiencing an untoward event (eg, getting lost,
being kidnapped, having an accident, becoming ill) that causes separation from a
major attachment figure.

● Persistent reluctance or refusal to go out, away from home, to school, to work,

or elsewhere because of fear of separation.

● Persistent and excessive fear of or reluctance about being alone or without

major attachment figures at home or in other settings.

● Persistent reluctance or refusal to sleep away from home or to go to sleep

without being near a major attachment figure.

 Repeated nightmares involving the theme of separation.

 Repeated complaints of physical symptoms (eg, headaches, stomachaches,

nausea, vomiting) when separation from major attachment figures occurs or is
anticipated.

To meet the criteria for this disorder, it must cause clinically significant distress or
impairment in social, academic, occupational, or other important areas of functioning
and is not better explained by another mental disorder such as refusing to leave home
because of excessive reluctance to change in autism spectrum disorder, delusions or
hallucinations concerning separation in psychotic disorders, refusal to go outside
without a trusted companion in agoraphobia, worries about ill health or other harm
befalling significant others in generalized anxiety disorder, or concerns about having
an illness in illness anxiety disorder.

Separation anxiety is often the precursor to school refusal, which occurs in

approximately three-fourths of children who are present with separation anxiety
disorder. It is important to screen for selective mutism because some children may
have school refusal as a symptom of selective mutism. The diagnosis of selective
mutism involves a comprehensive evaluation, including ruling in or out of comorbid
conditions such as expressive and receptive language delays and other communication
disorders.

Separation Anxiety Among Elderly

Ageing population is increasing very rapidly across the globe. A growing elderly
portion of the population will probably present new societal challenges in the form of
medical service provisions, financial support, social and passionate help etc.
Urbanization, modernization and globalization have changed the traditional concept
of family in India, which used to provide social support to ill, dependent and older
family members. Over the years, urbanization has lead to change in the economic
structure, diminishing societal values, weakening the importance of joint family. As a
result, elderly adults are forced to take an alternative living arrangement in old age
homes. Separation anxiety have been mainly confined to children and adolescents,
recent case studies and other studies of adult outpatients with anxiety disorders have
suggested that fears typical of juvenile separation anxiety disorder (SAD) may persist
into early and middle adulthood. Such fears have included anxiety when separated
from close attachment figures, preoccupation that loved ones will be harmed and
avoidance of being alone. Both genetic factors and environmental stressors such as
the loss of, or separation from, loved ones and physical ill health have been implicated
in the development of heightened separation anxiety. While the elderly are
particularly vulnerable to the experiences of loneliness, separation and grief, there has
been no previous study of separation anxiety in this age group. Indeed, there have
been relatively few studies of anxiety disorders across the adult age span, and which
have included people aged 65 years and over. Reported prevalence rates have varied
depending on the use of hierarchical diagnostic criteria and case threshold criteria.
Phobic disorders, obsessive–compulsive disorder and panic disorder all appear to be
commoner in younger life and in females when hierarchical diagnostic methods were
used. The same trends were reported for generalized anxiety disorder, but there was
no decline in prevalence with age when only threshold criteria were used. Further,
apart from agoraphobia, anxiety disorders in old age have tended to persist from early
life. Possible reasons for the decline in the rates of anxiety disorders in the elderly
include changes in biological vulnerability, cohort effects, increased mortality in
people with early onset anxiety disorders, and misattribution of anxiety symptoms to
medical illness.

Prevalence of separation anxiety among elderly

According to a prevalence study conducted by Silove et al., approximately 10% of

patients developed SEPAD after 40 years of age. In another study, the frequency of
SEPAD-A was 6% in the geriatric group between the ages of 62 and 87, and it was
associated with a past psychiatric history of mood and anxiety disorders. Although we
did not inquire about the exact age of onset of SEPAD, our results support the finding
that SEPAD continues to exist in the middle age group.
Separation anxiety has been studied in children and young adults, but little is known
about this form of anxiety in older people. The aim of it is to examine socio-
demographic, psychological and physical health correlates of separation anxiety in the
elderly. Eighty-six ambulatory subjects aged 62–87 years were recruited from primary
medical care practices to participate in it. The presence of lifetime DSM-IV affective
and anxiety disorders was determined by structured clinical interview. Subjects also
completed a battery of self-report questionnaires measuring levels of state and trait
anxiety, juvenile and adult separation anxiety. (Wijeratnea and Manicavasagarb,2002)

Causes of Separation Anxiety among Elderly

Genetic Factors: Most of the patients who are diagnosed with separation anxiety
disorder are found to have a history of other psychiatric conditions themselves, or in
their family. Therefore, researchers believe separation anxiety disorder to be a
heritable disorder and of genetic origin. The first-degree relatives of patients with a
history of mental illness are usually at a higher risk of developing separation anxiety
disorder, albeit the precise genetic trigger has not been identified yet.

Biological Factors: Like other psychiatric disorders, separation anxiety disorder also
involves imbalances in neurotransmitter levels. In the patients with separation anxiety
disorder, the regulation mechanism that controls the optimal level of such brain
chemicals is impaired. Serotonin and norepinephrine levels are believed to be majorly
affected in such patients. This results in poor central regulation of emotions, and
amplified stress responses to low-level triggers of danger.
Environmental Factors: While genetic and biological factors are believed to be the
causal triggers of separation anxiety disorder, environmental factors also form a major
set of contributors. And unlike the above two, environmental factors can be
pinpointed relatively easily by closely observing the surroundings and events of the
patient’s life.

There exists a panoply of environmental stressors. The most basic one is an abrupt
change in the surroundings of a person who is prone to the disorder, such as work
commitments. neighbourhood, and locality altogether can get too much for the person
to handle. Additionally, elderly subconsciously imbibe a habit of worrying
extensively from the mere observation of their surroundings, and eventually fail to see
anything abnormal in that habit. Stress and trauma are other important triggers of
anxiety. Major losses such as the unexpected death of a family member to whom the
patient was closely attached can render the person very lonely and traumatized.
Separation from a caregiver, a close friend, or a pet may all have similar impacts with
varying severities according to the given situation. Partners with an emotionally
interdependent romantic relationship also find it difficult to cope if faced with
separation or divorce. The extreme unfamiliarity with the new emotional space and
unpreparedness to deal with the change can contribute heavily to separation anxiety
disorder.

Therapies for Separation Anxiety: The good news is that separation anxiety
disorder is highly treatable. Typical interventions include cognitive behavioral therapy
(CBT), family therapy, medication, or a combination of these treatments. When
designing a treatment strategy, clinicians will often consider the client’s temperament,
thought patterns, family system, social support, and any acute or chronic life stressors.
Developmental stage and parental anxiety/depression might also be assessed when
treating children.
Separation anxiety disorder treatments typically include:

 Therapy-Evidence-based interventions for separation anxiety disorder- include

CBT, family therapy, and pharmacological treatments, or a combination.
Given the role that attachment figures (e.g., caregivers) play with separation
anxiety disorder, it is essential that they are integrally involved in both
treatment planning and implementation.

 Cognitive behavioral therapy CBT- the treatment of choice for separation

anxiety disorder. CBT Therapy teaches clients to better understand the links
between their thoughts, behaviors and actions. They are taught to identify and
challenge irrational beliefs, (e.g., “I need to know where my spouse is at all
times,” or, “my mother may never come home”). Client’s practice generating
more realistic thoughts and develop healthier, less anxious thought patterns.
 Family Therapy- family therapies help clients and families to assess their
interactions, behaviors, and ways individuals or the entire system might be
contributing to and maintaining the client’s separation anxiety. Since anxiety is
often inherited, families are often encouraged to use the same emotion
regulation techniques on themselves.
 Medication-When symptoms fail to respond to therapy alone, medication might
be added to the regimen. While medication does not cure anxiety disorders, it
can alleviate anxiety and allow for more full participation in therapy.
Medication for anxiety may be prescribed by psychiatrists, primary care
providers, and in some states by specially trained psychologists.

 Selective serotonin reuptake inhibitors are considered the first-choice drugs in

separation anxiety disorder. SSRIs are believed to work by promoting
neuroplasticity in the brain. Simply put, higher levels of serotonin promote
increased brain flexibility, and may allow more ability for the brain to be
modified. This means it can help make therapy more success Starte If SSRIs do
not improve symptoms, then a tricyclic antidepressant might be tried. Tricyclic
 antidepressants work by preventing the reabsorption of serotonin and
norepinephrine, two different neurotransmitters in the brain. If there is too
much of either, anxiety symptoms can occur.

Management of Separation Anxiety

Appropriate treatment and management of SAD often depends on the symptom

severity. In the case of mild symptoms, patient and parent education, support, and
encouragement may be sufficient to help the patient resume normal
activities. Maintaining regular eating, sleeping, and exercise schedules with
removing inconsistent routines should be encouraged. Anxiety symptoms should be
reassessed with validated screening tools to monitor for changes. When treatment
is required, the recommended first-line therapy is cognitive behavioral therapy.
Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed and are
known to be successful at managing anxiety disorders; however, there are no
medications with an FDA-labelled indication for SAD.

Cognitive Behavioral Therapy (CBT): CBT is considered the first-line

treatment for SAD and is an optimal choice for its efficacy and low risk of adverse
effects. CBT should include techniques involving psychoeducation, changing
maladaptive thought patterns, and gradual exposure to anxiety-provoking
situations. Effective CBT typically requires 10 to 15 outpatient sessions (60-90
minutes each) with the practice of newly acquired skills at home. The treatment
regime may be shortened or prolonged depending on the severity of symptoms and
comorbid factors. Notably, up to 44% of the pediatric population treated with CBT
for anxiety disorders do not improve. Exposure therapy effectiveness is postulated
to help increase the treatment response rate. Subjective reporting and heart rate
measurements are unreliable indices of distress or emotional arousal during
exposure. A reliable and alternate method of accurately measuring distress during
exposure therapy is electrodermal activity (EDA). EDA is specific to sympathetic
arousal and measures the activity of the eccrine sweat glands. Higher EDA
indicates greater emotional and physiological arousal. Physiological arousal during
exposure therapy is the strongest predictor of treatment response. Physiological
arousal negatively predicts the response rate, with one study reporting that high
physiological arousal predicted poorer treatment response to brief CBT.

Combination Therapy with CBT and an SSRI: Although various reports

describe improvement in SAD with pharmacotherapy, there are no medications
with FDA-labelled indications to treat SAD, and high-quality (double-blind,
placebo-controlled) studies are lacking. Some studies report CBT and SSRIs as
equally efficacious for children with anxiety disorders; others report CBT to be
superior to pharmacotherapy on some indices. More recent data suggest that
combination treatment with CBT and SSRIs is more efficacious than either
treatment alone, with as many as 81% of children with anxiety disorders who
received sertraline and CBT being classified as responders compared to a 60%
response rate for CBT alone and 55% response rate for sertraline
alone. Interestingly, patients receiving placebo pharmacotherapy had a 23%
response rate.

A randomized control trial published in 2008 reported the superiority of

combination CBT and SSRI therapy, attributed to the synergistic effects of the 2
therapies. The study included children with moderate-to-severe anxiety and did not
report any significant adverse effects using SSRIs. They concluded that CBT and
sertraline, either in combination or as monotherapy, were effective for treating
childhood anxiety disorders, including SAD; however, combination therapy was
superior to either alone. Authors of a recent systematic review evaluating the
comparative effectiveness and safety of CBT and various pharmacotherapies for
childhood anxiety disorders reported that SSRIs and serotonin and norepinephrine
reuptake inhibitors (SNRIs) improved anxiety symptoms when compared to
placebo. The efficacy of benzodiazepines and tricyclic antidepressants (TCAs) was
supported by insufficient or low-quality evidence for treating these
disorders. Benzodiazepines and TCAs disorders. (Feriante, Torrico and
Bernstein,2023)

Social Work with Elderly

According to the National Association of Social Workers (NASW), geriatric social
workers are professionals who specialize in addressing the various challenges
within the aging process, promoting independence, autonomy and dignity later in
life. The elderly face many of the same obstacles as younger individuals, but their
issues can become further exacerbated by pervasive attitudes related to ageism and
ableism. Geriatric social work also offers the chance to address the holistic needs
of older adults. It involves considering not only the physical health of older
individuals but also their psychological, social, and environmental well-being. By
taking a comprehensive approach, you can help older adults navigate various
challenges, such as managing chronic illnesses, addressing mental health concerns,
connecting with community resources, and fostering social connections. Healthcare
social services for the elderly is a specialized area within geriatric social work that
specifically focuses on addressing the healthcare needs of older adults. Healthcare
geriatric social workers collaborate with healthcare professionals, older adults, and
their families to ensure that older adults receive comprehensive and coordinated
care. This aspect of geriatric social work is crucial especially since the Pan
American Health Organization and World Health Organization estimate that the
number of elderly suffering from mental disorders will be doubled by 2030.
(Bouchrika,n.d)