By: Khomotso Fredah Matlala
Epilepsy and Separation Anxiety
What is Separation Anxiety?
Separation anxiety refers to the experience of excessive fear or distress when separated from individuals to whom one feels strongly attached. While some level of discomfort during separation is developmentally appropriate, separation anxiety becomes clinically significant when it is disproportionate to the person’s developmental stage, persistent, and disruptive to functioning.
In children, separation anxiety often manifests as clinginess, refusal to attend school, nightmares about separation, or somatic symptoms such as stomach aches or headaches when separation is anticipated. In adults, it can present as preoccupation with the safety of loved ones, resistance to travel or work that requires time apart, and difficulty living independently (American Psychiatric Association [APA], 2022). Separation anxiety is therefore best understood as a disorder of attachment regulation, where the individual struggles to tolerate physical or perceived distance from attachment figures.
Diagnostic Criteria of Separation Anxiety
The DSM-5-TR outlines the criteria for Separation Anxiety Disorder (SAD). These include:
- Recurrent excessive distress when anticipating or experiencing separation from home or major attachment figures.
- Persistent and excessive worry about losing attachment figures or possible harm to them.
- Worry about untoward events that might cause separation.
- Reluctance or refusal to go to school, work, or other places because of fear of separation.
- Fear of being alone without attachment figures.
- Refusal to sleep away from home or without being near attachment figures.
- Repeated nightmares involving the theme of separation.
- Repeated physical complaints when separation occurs or is anticipated.
For children, the symptoms must last at least four weeks, while in adults the duration is typically six months or more. The disturbance must cause clinically significant distress or impairment and cannot be better explained by another disorder (APA, 2022).
Prevalence, Causes, and Risk Factors
Prevalence:
Separation Anxiety Disorder is one of the most common childhood anxiety disorders, with prevalence estimates between 3 and 5 percent in children (Beesdo et al., 2009). In adults, prevalence is lower but still clinically significant, with lifetime rates estimated around 6 percent in epidemiological studies (Silove et al., 2015).
Causes:
The development of SAD is multifactorial. Genetic predisposition plays a role, with heritability estimates for anxiety disorders in general ranging from 30 to 40 percent. Dysregulation in neurobiological systems related to stress, such as the hypothalamic-pituitary-adrenal axis, is also implicated (Beesdo et al., 2009). Psychological factors such as behavioral inhibition and insecure attachment styles contribute to vulnerability. Environmental stressors, including parental loss, divorce, or exposure to illness, can act as triggers (Silove et al., 2015).
Risk Factors:
Key risk factors include:
- A family history of anxiety or mood disorders.
- Overprotective or controlling parenting practices.
- Childhood adversity, such as parental conflict or inconsistent caregiving.
- Chronic medical conditions, such as epilepsy, that heighten dependency on caregivers and amplify fears about safety (Yetkin et al., 2024).
Anxiety disorders are highly prevalent in people with epilepsy, affecting an estimated 20 to 30 percent of patients (Scott et al., 2020). Separation anxiety specifically has received less research attention, but evidence suggests that it is more common in both children and adults with epilepsy than in the general population (Yetkin et al., 2024).
Several mechanisms may explain the heightened presence of separation anxiety in individuals with epilepsy:
- Neurological overlap: The temporal lobe and limbic system, areas implicated in seizure activity, also regulate fear and attachment. Dysfunction here may predispose to anxiety symptoms (Scott et al., 2020).
- Seizure unpredictability: The uncertainty of when a seizure will occur can make individuals feel unsafe without caregivers present, reinforcing dependence.
- Caregiving dynamics: Families often respond to epilepsy with protective or overprotective behaviors. While protective care is understandable, it can inadvertently reinforce a patient’s anxiety and fear of separation (Yavlal & Cetin, 2023).
- Stigma and social limitations: Epilepsy is often stigmatized, leading to reduced participation in peer activities, which further increases reliance on attachment figures (Scott et al., 2020).
A study by Yetkin et al. (2024) found that adults with epilepsy had significantly higher rates of separation anxiety disorder compared to healthy controls. They also reported that separation anxiety correlated with lower quality of life and higher levels of perceived parental overprotection and depression. Yavlal and Cetin (2023) further demonstrated that caregivers of people with epilepsy also show elevated levels of separation anxiety and depression, suggesting that anxiety dynamics around separation affect not only patients but also their families.
The relationship between separation anxiety and epilepsy highlights the need for routine anxiety screening to become a standard component of epilepsy care. Too often, clinical management focuses narrowly on seizure control, overlooking the emotional and behavioural challenges that accompany the condition. By including validated screening tools for separation anxiety and related disorders, clinicians can identify vulnerable patients earlier and intervene before anxiety symptoms escalate into chronic impairment.
Cognitive-behavioural therapy (CBT) remains the most evidence-based treatment for separation anxiety, and adaptations of this approach can be made for individuals with epilepsy. For example, CBT interventions can be tailored to account for seizure unpredictability and health-related fears, helping patients develop more flexible coping strategies. In non-epilepsy populations, CBT has consistently demonstrated strong efficacy in reducing separation fears, suggesting that its integration into epilepsy care is both feasible and promising.
Family-based interventions are equally important. Parents of children with epilepsy often adopt protective or restrictive caregiving styles out of concern for seizure safety. While understandable, this overprotection can unintentionally reinforce dependence and intensify separation-related fears. Structured family therapy and psychoeducation can help caregivers strike a balance between ensuring safety and fostering independence. This not only reduces anxiety symptoms but also promotes healthier family dynamics and resilience (Scott et al., 2020).
Integrating seizure management with psychological support is therefore key to improving both psychiatric and neurological outcomes. When separation anxiety is left unaddressed, it can reduce adherence to medication, limit participation in social or educational activities, and increase overall caregiver burden. Conversely, when epilepsy care incorporates psychological interventions, patients benefit from more holistic support that targets both seizure activity and the psychological vulnerabilities associated with chronic illness. Ultimately, this integrated approach can enhance quality of life and reduce the long-term burden of epilepsy for both patients and their families.
Conclusion
Separation Anxiety Disorder is a clinically significant condition that extends beyond childhood. It involves intense, developmentally inappropriate fear of separation and has well-established diagnostic criteria. Its prevalence and risk factors show it to be a disorder influenced by genetic, psychological, and environmental factors. In epilepsy populations, separation anxiety appears particularly salient, driven by neurological vulnerabilities, unpredictable seizures, and family dynamics. Recognizing and addressing this link through integrated medical and psychological care is essential for improving both mental health and overall quality of life in people with epilepsy.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing.
Beesdo, K., Knappe, S., & Pine, D. S. (2009). Anxiety and anxiety disorders in children and adolescents: Developmental issues and implications for DSM-V. Psychiatric Clinics of North America, 32(3), 483–524. https://doi.org/10.1016/j.psc.2009.06.002
Scott, A. J., Sharpe, L., Thayer, Z., & Miller, L. A. (2020). Anxiety and epilepsy: A review of clinical and neurobiological relations. Clinical Psychology Review, 78, 101859. https://doi.org/10.1016/j.cpr.2020.101859
Silove, D., Manicavasagar, V., O’Connell, D., & Morris-Yates, A. (2015). Separation anxiety in adulthood: Clinical presentation, associations and epidemiology. Journal of Affective Disorders, 174, 64–71. https://doi.org/10.1016/j.jad.2014.11.044
Yavlal, F., & Cetin, A. (2023). Separation anxiety and depression in caregivers of epileptic patients. European Review for Medical and Pharmacological Sciences, 27(3), 859–866. https://doi.org/10.26355/eurrev_202302_31163
Yetkin, S., Ayhan, M. G., & Hacimusalar, Y. (2024). Separation anxiety disorder, perceived overprotection and quality of life in epilepsy patients. Epilepsy & Behavior, 152, 109244. https://doi.org/10.1016/j.yebeh.2024.109244
