Adult separation anxiety and insomnia symptoms in individuals with mood and anxiety disorders

Stefano Pini; Daniela Tramontano; Benedetta Nardi; Laura Palagini; Barbara Milrod; David S Baldwin; Katharina Domschke; Miriam Schiele; Chiara Bonelli; Federico Giovannoni; Gabriele Massimetti; Liliana Dell'Osso; Barbara Carpita

doi:10.1016/j.nsa.2025.106877

Adult separation anxiety and insomnia symptoms in individuals with mood and anxiety disorders

Neurosci Appl. 2025 Dec 1:5:106877. doi: 10.1016/j.nsa.2025.106877. eCollection 2026.

Affiliations

¹ Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
² Albert Einstein College of Medicine, Director of Psychotherapy Research, PRIME (Psychiatric Research Institute of Montefiore Einstein), New York, NY, USA.
³ Clinical and Experimental Sciences, University of Southampton Faculty of Medicine, Academic Centre, College Keep, Southampton, SO14 3DT, UK.
⁴ University Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa.
⁵ Department of Psychiatry and Psychotherapy, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.

Abstract

The Diagnostic and Statistical Manual for Mental disorder (DSM-5) identifies severe sleep disruption as one of the clinical features and diagnostic criteria for Separation Anxiety Disorder (SAD), with one diagnostic criterion being a persistent reluctance or refusal to sleep away from home or to go to sleep without being near a central attachment figure. While SAD is commonly associated with childhood, it can also present in adulthood (A-SAD), especially in individuals with mood and anxiety disorders. During this phase of an individual's life, A-SAD may prominently interfere with daily activities, as well as with sleep. This study aims to evaluate the impact of symptoms of SAD on sleep in a large cohort of patients with mood and anxiety disorders. A total of 404 consecutively recruited outpatients with mood or anxiety disorders were assessed with the Structured Clinical Interview for Separation Anxiety Disorder (SCI-SAS), the Adult Separation Anxiety (ASA-27), and the Hamilton Rating Scales for Depression (HAM-D) and Anxiety (HAM-A). Insomnia symptom scores were calculated using nine items that encompass the definition of sleep disturbances from the Mood Spectrum-Self Report (MOODS-SR). Overall, 91 patients were diagnosed with A-SAD only, 33 with childhood-onset SAD (C-SAD), 79 with both A-SAD and C-SAD, and 201 had no history of SAD. No significant differences were found in HAM-A and HAM-D scores between the four groups, nor in the frequency of their primary diagnosis (anxiety disorders, major depression, or bipolar disorder). However, sleep disturbance scores were significantly higher in participants with A-SAD, with or without C-SAD, compared to only C-SAD or no SAD. Regression analyses revealed that ASA-27 total score was a significant predictor of sleep disturbances (p < .002), while HAM-A and HAM-D scores were not. While sleep disturbances are often linked to anxiety and depressive symptoms, these findings suggest that adult separation anxiety contributes independently to sleep impairment in individuals with mood and anxiety disorders. This highlights the importance of assessing and addressing separation anxiety in clinical practice when treating sleep-related complaints in this population.

Keywords: Anxiety; Insomnia; Mood disorders; Separation anxiety; Sleep disorders.