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Am J Psychiatry. 2015 Jul;172(7):647-56. Epub 2015 Jun 5.

Pediatric-Onset and Adult-Onset Separation Anxiety Disorder Across Countries in the World Mental Health Survey.

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From the Psychiatry Research and Teaching Unit and Ingham Institute, School of Psychiatry, University of New South Wales, Randwick, NSW, Australia; IMIM-Hospital del Mar Research Institute, Parc de Salut Mar, Pompeu Fabra University (UPF) and CIBER en Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain; Department of Psychiatry, Stony Brook University School of Medicine, Stony Brook, N.Y..; Department of Health Care Policy, Harvard Medical School, Boston; Department of Psychological Medicine, University of Otago, Otago, New Zealand; Department/Institute of Psychiatry, University of São Paulo Medical School, São Paulo, Brazil; Department of Epidemiologic and Psychosocial Research, National Institute of Psychiatry Ramón de la Fuente, Mexico City, Mexico; Chronic Diseases Research Center (CEDOC) and Department of Mental Health, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portgual; IRCCS St. John of God Clinical Research Centre and IRCCS Centro S. Giovanni di Dio Fatebenefratelli, Brescia, Italy; University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Psychiatry, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium; Unit of Analysis and Generation of Evidence for Public Health, Peruvian National Institutes of Health, Lima, Peru; National School of Public Health, Management and Professional Development, Bucharest, Romania; Department of Psychiatry, University College Hospital, Ibadan, Nigeria; Shanghai Mental Health Center, Shanghai, the People's Republic of China; Department of Psychiatry and Clinical Psychology, Faculty of Medicine, Balamand University, Beirut, Lebanon; Department of Psychiatry and Clinical Psychology, St. George Hospital University Medical Center, Beirut, Lebanon; Institute for Development Research Advocacy and Applied Care (IDRAAC), Beirut, Lebanon; Hôpital Lariboisière Fernand Widal, Assistance Publique Hôpitaux de Paris, University



The age-at-onset criterion for separation anxiety disorder was removed in DSM-5, making it timely to examine the epidemiology of separation anxiety disorder as a disorder with onsets spanning the life course, using cross-country data.


The sample included 38,993 adults in 18 countries in the World Health Organization (WHO) World Mental Health Surveys. The WHO Composite International Diagnostic Interview was used to assess a range of DSM-IV disorders that included an expanded definition of separation anxiety disorder allowing onsets in adulthood. Analyses focused on prevalence, age at onset, comorbidity, predictors of onset and persistence, and separation anxiety-related role impairment.


Lifetime separation anxiety disorder prevalence averaged 4.8% across countries (interquartile range [25th-75th percentiles]=1.4%-6.4%), with 43.1% of lifetime onsets occurring after age 18. Significant time-lagged associations were found between earlier separation anxiety disorder and subsequent onset of internalizing and externalizing DSM-IV disorders and conversely between these disorders and subsequent onset of separation anxiety disorder. Other consistently significant predictors of lifetime separation anxiety disorder included female gender, retrospectively reported childhood adversities, and lifetime traumatic events. These predictors were largely comparable for separation anxiety disorder onsets in childhood, adolescence, and adulthood and across country income groups. Twelve-month separation anxiety disorder prevalence was considerably lower than lifetime prevalence (1.0% of the total sample; interquartile range=0.2%-1.2%). Severe separation anxiety-related 12-month role impairment was significantly more common in the presence (42.4%) than absence (18.3%) of 12-month comorbidity.


Separation anxiety disorder is a common and highly comorbid disorder that can have onset across the lifespan. Childhood adversity and lifetime trauma are important antecedents, and adverse effects on role function make it a significant target for treatment.

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