Hindawi Publishing Corporation

BioMed Research International

Volume 2014, Article ID 680985, 6 pages
http://dx.doi.org/10.1155/2014/680985

Research Article
Adult Separation Anxiety and TCI-R Personality
Dimensions in Patients with Anxiety, Alcohol Use, and
Gambling: A Preliminary Report

Gino Pozzi,1 Angelo Bruschi,1 Andrea De Angelis,1 Marco Pascucci,1

Daniele Stavros Hatzigiakoumis,1 Paolo Grandinetti,1 Marco Di Nicola,1
Stefano Pini,2 and Luigi Janiri1
1
Institute of Psychiatry and Psychology, Catholic University of the Sacred Heart, Rome, Italy
2
Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Pisa, Italy

Correspondence should be addressed to Angelo Bruschi; [email protected]

Received 13 March 2014; Accepted 19 June 2014; Published 3 July 2014

Academic Editor: Sophia Achab

Copyright © 2014 Gino Pozzi et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Nowadays, adult separation anxiety disorder (ASAD) is an established diagnostic category but is little investigated
in subjects with addictive behaviours. Objective. To assess the presence of ASAD among patients with addictive disorders in
comparison with anxiety patients and measure the personality correlates in all these groups. Methods. 103 outpatients, meeting
DSM-IV-TR criteria for anxiety disorders (38 patients), alcohol dependence (30 patients), or pathological gambling (35 patients),
were assessed by the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS) and the Adult Separation Anxiety
Checklist (ASA-27) for separation anxiety and by the Temperament and Character Inventory-Revised (TCI-R) for personality
characteristics. Results. ASAD is detected in 34.2% of anxiety patients, 13.3% of alcoholics, and 11.4% of gamblers. Separation
anxiety scores correlate positively with harm avoidance and negatively with self-directedness in all groups; further correlations are
seen among addictive patients only, that is, self-transcendence for gamblers and cooperativeness for both alcoholics and gamblers.
Conclusions. The prevalence of ASAD is lower among addictive patients than in those with anxiety disorders; correlations are found
between separation anxiety and specific TCI-R dimensions, with some matching across the three diagnostic groups.

1. Introduction Although this disorder has been classically defined as

a childhood phenomenon, growing evidence exists that
Separation anxiety can be defined as a condition burdened separation anxiety may have an adult onset (adult separation
by an excessive and inappropriate display of fear and distress anxiety disorder, ASAD), regardless of history of childhood
when the individual is faced with situations of separation separation anxiety disorder (CSAD) [4].
from home or from a specific attachment figure. As is well Many studies have been conducted to evaluate the clinical
known, the discomfort arisen by the separation from an and epidemiological characteristics of this disease [5, 6],
attachment figure is related to the ordinary childhood devel- the prevalence and gender differences [7], the impairment
opment [1, 2], with a probable evolutionary purpose: the of functioning [5], the correlation with specific biomarkers
retention of the human offspring, still inept, near its main [8, 9], and the temperament and character dimensions
caregiver [3]. [10].
Only if the sensitivity to the separation becomes excessive Apart from general population studies [5], the ASAD
and prolonged, with intense anxiety and interference in daily comorbidity has been investigated mainly in patients with
life activities or normal development, it can be diagnosed as mood disorders [11], anxiety disorders [7], posttraumatic
separation anxiety disorder (SAD). stress disorder [12], and personality disorders [4, 7].
2 BioMed Research International

Recently, the American Psychiatric Association, in its payment. In order to ensure anonymity all the acquired data
DSM-5, decided to create a brand new specific ASAD cate- were deidentified before any further manipulation, ensuring
gory within the general section of the anxiety disorders [13]. an adequate level of protection, using a double level of data
Apart of the seminal study of Loas et al. [14], to the best encryption.
of our knowledge, no clinical study has further investigated
the presence of ASAD among patients with addictive disor- 2.3. Separation Anxiety Assessment. The categorical assess-
ders, with particular reference to gambling. ment of CSAD and ASAD was conducted using the SCI-SAS
The objective of this study is to assess the presence of adult [17]. This semistructured interview contains items derived
separation anxiety in patients with chemical or behavioral from the DSM-IV-TR criteria for CSAD with symptoms
addictions, in comparison with a clinical sample of anxiety modified for adulthood. According to the DSM-IV, endorse-
patients, and to measure the personality correlates in all the ment of three or more of the eight criterion symptoms
groups using the Temperament and Character Inventory- was used as a threshold to determine a diagnosis of CSAD
Revised (TCI-R) [15]. and of ASAD. For the diagnosis were required a symptom
duration of at least 4 weeks and clinically significant distress
2. Materials and Methods or impairment in social, academic, occupational, or other
important areas of functioning.
2.1. Participants. Subjects were recruited, during the year The dimensional measure of ASAD was performed by
2012 and in a consecutive manner, among clients referring administering a self-report questionnaire, the ASA-27 [18].
to the adult psychiatric outpatient clinic of the “A. Gemelli” The ASA-27 is a 27-item inventory which rates symptoms of
University General Hospital in Rome. adult separation anxiety after the age of 18, having high levels
Inclusion criteria were (1) currently meeting DSM- IV-TR of internal consistency (Cronbach’s 𝛼 = 0.89) and test-retest
[16] criteria for anxiety disorder (38 patients), alcohol depen- reliability (𝑟 = 0.86; 𝑃 < 0.001); moreover it has shown
dence (30 patients), or pathological gambling (35 patients); concurrent validity with clinical assessments of ASAD, with
(2) having an age of 18 to 65 years; (3) for the anxious a cut-off score of twenty-two.
patients, spending at least one month of integrated treatments
including benzodiazepines and/or selective serotonin reup- 2.4. Personality Assessment. Personality was investigated by
take inhibitors-serotonin norepinephrine reuptake inhibitors means of the TCI-R [20]. This is a 240-item, five-point Likert
(SSRI-SNRI); (4) for the alcoholics and gamblers, spending at scale, a reliable and valid questionnaire that measures seven
least one month of a specific rehabilitation program requiring dimensions of personality: four dimensions of temperament
total abstinence from the addictive behavior (alcohol abuse (i.e. harm avoidance (HA), novelty seeking (NS), reward
or pathological gambling) and the possibility, upon the dependence (RD), and persistence (P)) and three character
clinician’s advice, of a maintenance treatment with mood traits (i.e. self-directedness (SD), cooperativeness (CO), and
stabilizers (valproate, gabapentin, and pregabalin). self-transcendence (ST)) [15]. Internal consistency of the
Subjects were excluded if any of the following condi- different personality dimensions in the Italian adaptation
tions were present: (1) a diagnosis of mental retardation or ranged between 𝛼 = 0.78 and 𝛼 = 0.89 [8].
documented IQ < 70; (2) any other current axis I DSM-
IV-TR diagnosis; (3) unstable general medical conditions;
2.5. Statistical Analysis. Statistical analysis was conducted
(4) clinically significant prestudy physical exam, electrocar-
using SPSS for Windows, Version 15 (SPSS Inc., Chicago,
diogram, laboratory, or urinalysis abnormalities indicating
Illinois). Dichotomous data were compared by chi-square
serious medical disease impairing evaluation; (5) pregnant or
test using the Fisher or the Yates corrections as appropri-
breast-feeding women; (6) recent use of not prescribed drugs.
ate. Continuous data were expressed as means ± standard
deviation and compared by one-way ANOVA. The principal
2.2. Procedures. DSM-IV-TR current diagnosis was prelimi-
outcome analysis consisted of nonparametric Kruskal-Wallis
narily established by trained psychiatrists (G. P. and A. B.).
H test for comparison between the three groups. Spearman’s
Then an anamnestic interview was administered in order
rank correlation coefficient was employed to examine the
to obtain sociodemographic information and psychiatric
relationship between continuous variables. All tests were 2-
history.
tailed, with statistical significance set at 𝑃 < 0.05.
All participants were interviewed by specifically trained
interviewers (M. P., P. G., and A. D. A.) using the Structured
Clinical Interview for Separation Anxiety Symptoms (SCI- 3. Results
SAS) [17] and the Adult Separation Anxiety Checklist (ASA-
The study group included 38 patients with anxiety disorders
27) [18].
(mostly generalized anxiety disorder and panic disorder),
Moreover they were administered the TCI-R, the Italian
30 patients with an alcohol use disorder (mostly alcohol
version [19, 20].
dependence), and 35 patients with a gambling disorder (i.e.,
The study was conducted in accordance with the latest
pathological gambling). The demographic characteristics are
revision of the Declaration of Helsinki and the rules of Good
summarized in Table 1.
Clinical Practice (ICH-GCP): all subjects provided written
informed consent after a complete description of the study Separation Anxiety in the Three Study Groups. No statistically
procedures and participated without receiving any form of significant difference was found in the frequency of CSAD
BioMed Research International 3

Table 1: Demographic characteristics.

Characteristics of patients ANX (𝑁 = 38) ALC (𝑁 = 30) PG (𝑁 = 35)

Age (mean ± SD) 39.82 ± 11.97 51.03 ± 8.68 50.63 ± 13.07
Gender
Male 8 (21.1%) 13 (43.3%) 28 (80.0%)
Female 30 (78.9%) 17 (56.7%) 7 (20.0%)
Marital status
Single 20 (52.6%) 15 (50.0%) 9 (25.7%)
Married 16 (42.1%) 11 (36.7%) 18 (51.4%)
Divorced/widowed 2 (5.3%) 4 (13.3%) 8 (22.9%)
Education
Middle school 7 (18.4%) 7 (23.3%) 12 (34.3%)
High school 22 (57.9%) 15 (50.0%) 18 (51.4%)
University degree 9 (23.7%) 8 (26.7%) 5 (14.3%)
Occupation
Employed 21 (55.3%) 13 (43.3%) 20 (57.1%)
Unemployed 3 (7.9%) 13 (43.3%) 3 (8.6%)
Other 14 (36.8%) 4 (13.3%) 12 (34.3%)
ANX: anxiety disorders; ALC: alcohol use disorders; PG: pathological gamblers.
Other: student, retired, and housewife.

Table 2: Separation anxiety across the three study groups.

ANX (𝑁 = 38) ALC (𝑁 = 30) PG (𝑁 = 35) 𝑃 value

CSAD 8 (21.1%) 3 (10.0%) 2 (5.7%) 0.227
ASAD 13 (34.2%) 4 (13.3%) 4 (11.4%) 0.028
ASA-27 (mean value ± SD) 23.45 ± 16.75 22.50 ± 12.92 20.66 ± 12.78 0.777
ASA-27 (score ≥ 22) 17 (44.7%) 9 (30.0%) 15 (42.8%) 0.422
ANX: anxiety disorders; ALC: alcohol use disorders; PG: pathological gamblers.
CSAD: childhood separation anxiety disorder; ASAD: adult separation anxiety disorder.

across the three diagnostic groups (𝑃 = 0.227). As a category, Table 3: Correlation of ASA-27 scores with TCI-R dimensions
ASAD is detected in about one-third of the anxiety patients across the three study groups (Spearman’s rho).
in comparison to some ten percent in the other study groups
ANX ALC PG
(𝑃 < 0.05). If separation anxiety is assessed dimensionally,
mean values do not differ in the three groups (𝑃 = 0.777). Novelty seeking −0.160 −0.097 −0.060
Finally, when the cut-off of ASA-27 is taken into account, Harm avoidance 0.670∗∗ 0.384∗ 0.383∗
the number of pathological gamblers scoring above the Reward dependence 0.240 −0.156 0.003
threshold is close to the amount found in the anxiety group Persistence 0.192 0.114 0.242
(Table 2). Cooperativeness 0.093 −0.395∗ −0.361∗
Self-directedness −0.482∗∗ −0.386∗ −0.566∗∗
Correlation of Separation Anxiety Scores and Personality Self-transcendence 0.144 0.088 0.436∗∗
Dimensions. Spearman’s rho correlation coefficients of the
ANX: anxiety disorders; ALC: alcohol use disorders; PG: pathological
seven TCI-R main dimensions with the ASA-27 rough scores gamblers.
∗
are shown in Table 3. A strong positive correlation is found 𝑃 < 0.05; ∗∗ 𝑃 < 0.01.
between the HA and the separation anxiety symptom scores:
this is statistically significant in all the three groups with a
maximum in the anxiety (𝑃 < 0.01). Another strong cor- 4. Discussion
relation, albeit inverse, is found in all three groups between
the SD and the ASA-27 scores, with maximum statistical With reference to study aims, the assessment of separation
significance for pathological gambling and anxiety patients anxiety in the three groups showed differences in the categor-
(𝑃 < 0.01). Further correlations are seen among addictive ical prevalence of ASAD, which was lower among alcoholics
patients only, that is, ST for gamblers (𝑃 < 0.01) and CO for and gamblers; moreover, the scores of separation anxiety
both alcoholics (𝑃 < 0.05) and gamblers (𝑃 < 0.05). showed specific correlations with some TCI-R dimensions.
4 BioMed Research International

4.1. Prevalence Rates. Our data almost confirm the previous in high HA and lower SD; the TCI-R profile of these subjects
literature results. Considering the prevalence of separation seems very similar to patients with anxiety disorders [10].
anxiety in general population, the National Comorbidity The results of our research partially confirm all these
Survey Replication (NCS-R) [6] showed a 12-month ASAD literature findings, even if there are some peculiar differences
prevalence of 1.9% and a lifetime prevalence of 6.6% [5]; more that deserve some clarification. The HA strongly correlates
than half of those diagnosed with ASAD had a history of with separation anxiety symptoms in all the three groups:
mood disorders (53%), and the majority (75%) had received the score of this dimension indicates fear of the unknown
or were in treatment for emotional problems. Scanning and shyness with strangers, which could lead to avoidance
the clinical studies, Pini et al. [21] reported that 42.4% of behaviour especially in new situations. High levels of HA
the anxiety and mood disorder outpatients screened also met are linked to overcaution, insecurity, and passivity [15, 33].
the ASAD criteria. The prevalence of ASAD in dependent On the contrary, NS does not correlate with separation
personality disorder patients was examined in a large patient anxiety in any of the groups, confirming that this kind of
sample with alcohol or drug addiction compared to nonpa- anxiety is different than that of the other anxiety disorders,
tient controls [14]: the rates in the control participants were as mentioned above.
from 2 to 5%, whilst in patients the results were significantly Focusing on the other results, SD shows a strong inverse
higher, ranging from 6 to 31%; in both cases, those with correlation with ASA-27 scores in all the three clinical
alcohol addictions had the lowest prevalence of ASAD. As samples. Since SD could be defined as the measure of
reported, we found that the ASAD lifetime frequency rate resourcefulness and self-acceptance [34], low levels of SD
is 11.4% in the gambling, 13.3% in the alcohol, and 34.2% are linked to irresponsibility, inefficiency, weakness, and bad
in the anxiety sample. To the best of our knowledge, this self-reliance. This is consistent with a fundamental role of
is the first study assessing the frequency of ASAD among separation anxiety in the integration of functions of the
gamblers, so confirming that the cooccurrence of separation self.
anxiety and addictive disorders is clearly less frequent than Cooperativeness seems to be inverse-correlated with
the cooccurrence of separation anxiety with mood or anxiety ASAD symptoms only within the addictive sample, both in
disorders. alcohol and gambling. Considering that CO is the capacity to
understand and accept other people [15], low levels of CO are
4.2. TCI-R Measures. Many studies showed a correlation linked to intolerance, incomprehension, nonsociability, and
between TCI-R dimensions and anxiety disorders, gambling indifference.
and alcohol addiction. The ST dimension appears to be characteristic of the
Regarding anxiety, all studies agreed on two core points: gamblers. ST refers to magical thinking, unselfishness, and
a high correlation between the temperamental dimension superstition, prototypical features of a behavioural addiction
of harm avoidance (HA) and anxiety symptoms and an [32].
important inverse correlation between the character dimen-
sions of self-directedness (SD) and anxiety symptoms, with 5. Conclusions
HA scores increasingly higher and SD increasingly lower
with the illness severity growing [22–25]. However Lu et al. This study is the first one assessing the frequency rates
[26] suggested that, although anxiety is linked to high of ASAD in both chemical and behavioural addiction, as
HA scores, only high novelty seeking (NS) appears as a compared to a sample of anxiety patients. In addition we
good predictor of anxiety; indeed in agreement with the pointed out the temperament and character correlations of
original viewpoint by Cloninger, people with high NS can separation anxiety in these patients, which were shared across
show anxiety characterized by generalized turmoil or alarm the disorders (HA, SD) or typical of the addictions (CO,
without specific premonitory cues, frequently bodily pains, ST). Limitations of this preliminary investigation include
and slow fatigability [27]. According to these results HA and a small sample size, some imbalance in the demographic
NS would then be connected and could be the litmus paper characteristics of the three populations, and a lack of clinical
of two different forms of anxiety. subtyping. So, our observations need to be replicated in
Regarding addictive disorders, alcohol-dependent larger groups, also widening the target on other chemical
patients in general scored higher on NS and lower on SD and behavioural addictions and taking into account further
than controls: according to the authors [28, 29] the lower comorbidities.
SD indicates a predisposing factor for alcohol dependence,
even if it could be seen as either preceding or consequent Disclosure
upon alcohol pathological use. Instead, pathological
gamblers showed higher NS values, lower SD, and lower No pharmaceutical and industry support was employed in
cooperativeness (CO) with higher NS associated with earlier this study.
age of onset of problem gambling [30–32].
The only study that measured the TCI-R dimension in Conflict of Interests
ASAD reported an elevation in HA, reward dependence
(RD), and self-transcendence (ST) levels and lower SD scores, The authors declare no conflict of interests regarding the
with ASAD patients showing quantitatively greater severity publication of this paper.
BioMed Research International 5

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