Separation Anxiety Disorder

Becca_H · Jul 24, 2011

One of my characters suffers from separation anxiety disorder. She's had it all her life, and is very attached to her parents and brother. She was uncomfortable leaving her parents and going to school, didn't like sleeping alone, and had nightmares about losing her parents. Symptoms eased a bit as she hit her teens. This is all backstory, so I have room to change this if necessary.

In the story, at age 17, she loses her parents suddenly, in a car crash. She's in the car and witnesses it. What I'm trying to figure out is how her grieving process would differ from a teenager who didn't suffer from this disorder. It's basically her worst nightmare come true.

She still has her brother, and she becomes even closer to him as a result. Some of the adjectives he uses to describe her to his friends are: clingy, emotionally unstable, manipulative, and controlling. Do these traits sound typical of a girl in this situation? Over the course of the story, the girl becomes so dependent on her brother, that he has to significantly adapt his life to keep her comfortable and as happy as possible.

I know there's individual differences to consider, but am I on the right track with this?

Also: are there any other disorders that tend to accompany social anxiety disorder, that may be relevant to their situation?

shelleyo · Jul 24, 2011

Becca_H said:
One of my characters suffers from separation anxiety disorder. She's had it all her life, and is very attached to her parents and brother. She was uncomfortable leaving her parents and going to school, didn't like sleeping alone, and had nightmares about losing her parents. Symptoms eased a bit as she hit her teens. This is all backstory, so I have room to change this if necessary.

In the story, at age 17, she loses her parents suddenly, in a car crash. She's in the car and witnesses it. What I'm trying to figure out is how her grieving process would differ from a teenager who didn't suffer from this disorder. It's basically her worst nightmare come true.

She still has her brother, and she becomes even closer to him as a result. Some of the adjectives he uses to describe her to his friends are: clingy, emotionally unstable, manipulative, and controlling. Do these traits sound typical of a girl in this situation? Over the course of the story, the girl becomes so dependent on her brother, that he has to significantly adapt his life to keep her comfortable and as happy as possible.

I know there's individual differences to consider, but am I on the right track with this?

Also: are there any other disorders that tend to accompany social anxiety disorder, that may be relevant to their situation?

I don't have answers for every question, but post-traumatic stress a little while after a loss like that might be reasonable.

Shelley

Psychomacologist · Jul 24, 2011

I'd disagree with the manipulative and controlling bit. I suffer from an anxiety disorder, and when you're in the midst of a severe anxiety attack you simply aren't rational enough to manipulate or control anyone. Rather, I'd imagine her crying hysterically and begging her brother not to leave; and her brother giving in because he doesn't know how to deal with her and is scared of what she'll do.

Typical anxiety emotions: a sense of prolonged, inescapable panic; fear, hostility to others and desperation. Typical behaviours include crying, lashing out at people, anger, withdrawing, giving up.

I'd imagine that in this scenario, she'd be constantly tense and will keep tipping over into outright panic. She would probably start having panic attacks if she wasn't already. The constant tension and panic will make her exhausted. She might sleep a lot and/or have trouble sleeping without medication (I have terrible problems getting to sleep when my anxiety is high, but when I do sleep I will often sleep for twelve hours or more at a time). She will probably have a lot of emotionally charged dreams, full of anxiety and terror; she'd probably also have nightmares. I imagine restless nights and waking up in cold sweats.

The anxiety could make her alternate between being snappish, telling people off, pushing people away etc. and being really weepy and depressed. She will cry a lot but won't be able to go through healthy grieving (i.e. cycling through denial, anger, bargaining, depression and finally accepting it and moving on) Instead she will just cycle endlessly through denial, panic, depression and despair. She might become suicidal or start harming herself because she isn't thinking straight. The key thing is, anxiety makes you irrational and slave to emotional turmoil.

Anxiety disorders often cluster together, so as well as her SAD she might suffer with generalised anxiety (GAD), social anxiety, phobias or panic attacks. I could imagine even prior to the accident she might have panic attacks if her parents left her for any length of time. After the accident, they'd get much worse. Depression is commonly comorbid with anxiety as well.

I hope this is helpful. I don't have SAD specifically and I've never had panic attacks (thank GOD) so I wouldn't be able to help you on those fronts. But this is from my own experience of GAD and what anxiety feels like and makes you do.

PinkAmy · Jul 25, 2011

Becca_H said:
One of my characters suffers from separation anxiety disorder. She's had it all her life, and is very attached to her parents and brother. She was uncomfortable leaving her parents and going to school, didn't like sleeping alone, and had nightmares about losing her parents. Symptoms eased a bit as she hit her teens. This is all backstory, so I have room to change this if necessary.

In the story, at age 17, she loses her parents suddenly, in a car crash. She's in the car and witnesses it. What I'm trying to figure out is how her grieving process would differ from a teenager who didn't suffer from this disorder. It's basically her worst nightmare come true.

She still has her brother, and she becomes even closer to him as a result. Some of the adjectives he uses to describe her to his friends are: clingy, emotionally unstable, manipulative, and controlling. Do these traits sound typical of a girl in this situation? Over the course of the story, the girl becomes so dependent on her brother, that he has to significantly adapt his life to keep her comfortable and as happy as possible.

I know there's individual differences to consider, but am I on the right track with this?

Also: are there any other disorders that tend to accompany social anxiety disorder, that may be relevant to their situation?

Anxiety disorders aren't usually piled on--clients are usually only given one diagnosis.

Separation anxiety disorder isn't the correct diagnosis for your MC. She's likely be diagnosed with borderline personality disorder (which is a lot more interesting to write for anyway,) although at 17 she's on the low age range for diagnosis. Borderlines are often nightmares for therapists and the people who try to love them, because they have extreme reactions to perceived rejection.

True separation anxiety disorder often has it's roots from anxiety a parents feels, that a child picks up, at leaving that child, so it's a function of the relationship rather than pathology of the child. It's a very specific diagnosis and not part of an overall anxiety disorder.

Your MC would likely have PTSD, which is an anxiety disorder. In the case of PTSD, you can also have a generalized or social anxiety, because PTSD has a specific root cause(s.)

I think you're trying to get too complicated with the diagnoses here.

There's no such thing as a "normal" grief process. Elizabeth Kubler-Ross's five stages of loss http://grief.com/the-five-stages-of-grief/ is a skeleton for what people experience with loss. People don't go thru the stages sequentially--they go in and out of stages and don't always hit all the stages. The Kubler-Ross model is just one way to understand grief and not absolute.

Your MC seems emotionally unstable to begin with, so she might take longer to develop her "new normal"-- a life without her parents. Since your MC didn't have a lot of ego strength before the accident, she could attempt suicide or more likely a attempt a pseudo-suicidal act in order to get people to "take care of her" since her parents can no longer fulfill that role. But---she's at the age where she should have been further separating and individuating from her parents, preparing herself for adulthood (the same thing happens during toddlerhood, but in a more primitive manner.) Psychiatric intervention, probably hospitalization, might help, but could also further her dependence on outsiders taking care of her.

Her prognosis for having healthy relationships is precarious, unless she realizes she's been too dependent on her parents and that she has to work to move forward as an independent woman (which therapeutic intervention to help her develop the skills she's lacking,) not a clingy child.

Everything you've said so far about this girl would scream to healthy folks, RUN, don't walk away from her. If you want her to be likable and for readers to root for her, you'll have to make her less extreme, including her history.

PinkAmy · Jul 25, 2011

Psychomacologist said:
I'd disagree with the manipulative and controlling bit. Exactly. anxiety disorders aren't manipulative. Personality disorders are.

Anxiety disorders often cluster together, so as well as her SAD she might suffer with generalised anxiety (GAD), social anxiety, phobias or panic attacks. I could imagine even prior to the accident she might have panic attacks if her parents left her for any length of time. After the accident, they'd get much worse. Depression is commonly comorbid with anxiety as well. symptoms cluster together, but people are usually only given 1 anxiety disorder as a diagnosis. As you say symptoms often overlap

Your excellent points are why people can't just look up diagnosis and understand them. People are unique individuals, not DSM diagnostic criteria and the understanding from a disorder on paper is different than seeing it manifested in a person with that disorder.

Becca_H · Jul 25, 2011

Thanks for your replies. Psychomacologist, I read your post and a lot of what you described fits the character, but then, after reading Amy's, it clicked: borderline personality disorder seems to fit her much, much better. And yeah, it definitely seems a lot more interesting to write for, and better suited to her behaviour.

With BPD, would this likely be diagnosed at an early age, or would this be more likely to come through after bereavement (or maybe just before, say 15-16 years old)?

Would she also still develop an unhealthy emotional attachment to her brother, similar to separation anxiety disorder? A lot of the story focuses on the brother-sister relationship, and the lengths he goes to, and sacrifices he makes, to look after her.

PinkAmy · Jul 26, 2011

Technically personality disorders aren't supposed to be diagnosed before the age of 18, because many of the traits are developmentally appropriate. I never diagnosed anyone under the age of 18, but in the back of my mind, I knew which teens would had characterological disorders and which were within the limits of expected behavior.

Clinginess is a big red-flag for borderlines. People are only given diagnoses when their behaviors interfere with their relationships or level of functioning. Diagnosis are used primarily for insurance reimbursement, not treatment.

Separation anxiety disorder isn't necessarily an unhealthy attachment. It's more like a fear of being apart from a primary caregiver. I saw a little girl who missed a lot of school for what was previously attributed to school phobia. Digging deeper, she loved school, but her mom made such a huge deal about her poor baby going off to school and what was she (mom) going to do all day all alone. The girl's fears were about whether the mom would be okay. Yes, it was interfering with the girl's functioning, but the root source was external, not internal.
Your MC would probably be diagnosed with GAD (generalized anxiety disorder.) If she was borderline, chances are she's show some of those features at a younger age like either loving/hating people, putting them on a pedestal only to be disappointed when they aren't perfect. Cutting off relationships. Attention seeking behavior like self injury (look how bad you made me feel,) blaming others etc.
Usually personality disorders like borderline develop from anxious or insecure attachment with primary caregiver(s.) Infants who can predict that their needs will be met develop more secure attachment. When they cry, they will be fed, changed or comforted. Infants who can predict that their needs will not be met actually develop less anxiety than those who have their needs sometimes met, sometimes not met. If a child sometimes gets fed, changed, comforted when crying but other times does not, they can become overwhelmed and anxious, because they can't predict what will happen next. Fear of the unknown. This isn't about "blaming the mother." It can happen if there is perpetual change in caregivers, like attending a day care with a high turnover rate or if the primary caregiver has emotional or substance abuse problems that interfere with meeting the infant's needs.

After your MC's parents die, she would likely try to attach to one or more other people as replacement(s.) Since she experienced the worst possible loss, probably worse than her darkest fears, she's likely to be clingy with her brother. Part of that is a "normal" reaction, but your MC will cling harder than what's healthy. The more he tries to pull away and establish healthy boundaries, the more symptomatic she will become. If the bro gives in to her manipulative behavior, she learns the more drama she causes, the more she gets what she thinks she needs and wants. Like a toddler who's told no, he can't have a cookie only to receive one after having a tantrum, the boy learns no means cry tantrum harder. The bro could quite easily unwittingly feed into your MC's disorder as he sacrifices thinking he's doing what she needs.

Becca_H · Jul 26, 2011

PinkAmy said:
Technically personality disorders aren't supposed to be diagnosed before the age of 18, because many of the traits are developmentally appropriate. I never diagnosed anyone under the age of 18, but in the back of my mind, I knew which teens would had characterological disorders and which were within the limits of expected behavior.

Clinginess is a big red-flag for borderlines. People are only given diagnoses when their behaviors interfere with their relationships or level of functioning. Diagnosis are used primarily for insurance reimbursement, not treatment.

Separation anxiety disorder isn't necessarily an unhealthy attachment. It's more like a fear of being apart from a primary caregiver. I saw a little girl who missed a lot of school for what was previously attributed to school phobia. Digging deeper, she loved school, but her mom made such a huge deal about her poor baby going off to school and what was she (mom) going to do all day all alone. The girl's fears were about whether the mom would be okay. Yes, it was interfering with the girl's functioning, but the root source was external, not internal.
Your MC would probably be diagnosed with GAD (generalized anxiety disorder.) If she was borderline, chances are she's show some of those features at a younger age like either loving/hating people, putting them on a pedestal only to be disappointed when they aren't perfect. Cutting off relationships. Attention seeking behavior like self injury (look how bad you made me feel,) blaming others etc.
Usually personality disorders like borderline develop from anxious or insecure attachment with primary caregiver(s.) Infants who can predict that their needs will be met develop more secure attachment. When they cry, they will be fed, changed or comforted. Infants who can predict that their needs will not be met actually develop less anxiety than those who have their needs sometimes met, sometimes not met. If a child sometimes gets fed, changed, comforted when crying but other times does not, they can become overwhelmed and anxious, because they can't predict what will happen next. Fear of the unknown. This isn't about "blaming the mother." It can happen if there is perpetual change in caregivers, like attending a day care with a high turnover rate or if the primary caregiver has emotional or substance abuse problems that interfere with meeting the infant's needs.

After your MC's parents die, she would likely try to attach to one or more other people as replacement(s.) Since she experienced the worst possible loss, probably worse than her darkest fears, she's likely to be clingy with her brother. Part of that is a "normal" reaction, but your MC will cling harder than what's healthy. The more he tries to pull away and establish healthy boundaries, the more symptomatic she will become. If the bro gives in to her manipulative behavior, she learns the more drama she causes, the more she gets what she thinks she needs and wants. Like a toddler who's told no, he can't have a cookie only to receive one after having a tantrum, the boy learns no means cry tantrum harder. The bro could quite easily unwittingly feed into your MC's disorder as he sacrifices thinking he's doing what she needs.

Amy, you are amazing. Thank you so much!

Separation Anxiety Disorder

Becca_H

Where am I again?

shelleyo

Just another face in a red jumpsuit

Psychomacologist

The Sarcasm Fairy

PinkAmy

New kid, be gentle!

PinkAmy

New kid, be gentle!

Becca_H

Where am I again?

PinkAmy

New kid, be gentle!

Becca_H

Where am I again?