Your privacy, your choice

We use essential cookies to make sure the site can function. We also use optional cookies for advertising, personalisation of content, usage analysis, and social media.

By accepting optional cookies, you consent to the processing of your personal data - including transfers to third parties. Some third parties are outside of the European Economic Area, with varying standards of data protection.

See our privacy policy for more information on the use of your personal data.

for further information and to change your choices.

You are viewing the site in preview mode

Skip to main content

The mediating role of attachment in panic disorder and separation anxiety disorder

Abstract

Objective

This study aimed to investigate the mediating effect of attachment on the relationship between Panic Dısorder (PD) and Adult Separation Anxiety Disorder (ASAD).

Methods

76 patients with PD, who consecutively applied to the Psychiatry outpatient clinic of Rize Recep Tayyip Erdoğan University Training and Research Hospital between 1 April 2023 and 1 December 2023, and 79 healthy individuals were included in the study. The Panic Agoraphobia Scale (PAS), Adult Separation Anxiety Questionnaire (ASA), and Relationship Scales Questionnaire (RSQ) were administered to the participants who voluntarily agreed to participate in the study.

Results

In the study, it was found that the prevalence of ASAD was statistically significantly higher in patients with PD (66%) than in healthy individuals (34%) (p < 0.05). In the model created to examine the mediating effect of attachment on the relationship between PD and ASAD, it was observed that only ASAD had a direct effect on the development of PD (β = 0.063, 95% CI: 0.053, 0.306, p = 0.006). On the other hand, it was found that attachment styles did not play a mediating role in this relationship, either directly or indirectly (p > 0.05).

Conclusion

The study found that the prevalence of ASAD and insecure attachment problems was higher in patients with PD compared to healthy individuals. It was observed that there was no mediating effect of attachment in the relationship between PD and ASAD. On the other hand, it was determined that ASAD had a direct effect on the development of PD.

Peer Review reports

Introduction

Panic Disorder (PD) is a mental disorder that occurs unexpectedly suddenly, causes intense fear or anxiety, and is accompanied by recurrent panic attacks. It is a state characterized by a range of physical and cognitive symptoms, including fear of losing control, fear of dying, fear of going crazy, anticipatory anxiety, shortness of breath, sweating, trembling, heart palpitations, numbness, and tingling [1, 2]. Its prevalence rate is approximately 3–4%. It is more common in women, especially those between the ages of 20 and 25 [3]. The exact causes and contributing factors are not fully known. It has been suggested that early life traumatic experiences, such as childhood loss of a parent, separation, and divorce, may be effective on the occurrence of this disorder [4]. Studies have indicated that PD may be associated with all anxiety disorders, particularly Separation Anxiety Disorder (SAD) [3].

Separation anxiety is characterized by anxiety experienced in response to separation from or anticipation of separation from the mother or an attachment figure [5]. While it is seen as a normal developmental phase in early childhood (between 6 and 8 months and 3 years), the fact that it occurs in advancing ages, lasts for a long time, and impairs functionality is considered pathological [6]. Previously it was viewed as an issue observed in individuals below 18 years old, while the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has included it in the adult category and designated it as Adult Separation Anxiety Disorder (ASAD) [1].

Although separation anxiety has traditionally been considered a childhood disorder, recent studies have demonstrated that this disorder can persist into adulthood and even emerge primarily in adulthood [7, 8]. Silove et al. found that approximately 43.1% of SAD cases began after the age of 18 [9]. Similarly, Pini et al. reported that approximately 48.8% of SAD cases emerged in adulthood, while 51.2% originated in childhood [10]. These studies also highlighted the high comorbidity of SAD with other anxiety disorders and suggested that it may facilitate the development of these disorders. In particular, SAD has been proposed as a risk factor for PD in adulthood [9, 10]. These studies also highlighted the high comorbidity of SAD with other anxiety disorders and suggested that it may facilitate the development of these disorders. In particular, SAD has been proposed as a risk factor for PD in adulthood (9,10). This was also confirmed by a study in which Manicavasagar et al. investigated additional diagnoses in separation anxiety disorder. These scholars showed that approximately 67% of these cases were accompanied by agoraphobia and PD issues. They also associated this condition with early attachment styles [11].

Attachment is a natural process that begins with the infant-mother relationship, continues throughout life, and forms the basis of all relationships that the individual will establish in his/her life. It is characterized by behaviors such as seeking a caregiver, forming relationships, and seeking intimacy. It is crucial for an individual’s emotional development and psychological well-being, especially in controlling the stress response that may arise when separated from attachment figures [12]. The attachment concept is examined under two main headings: secure attachment and insecure attachment. While secure attachment represents healthier states, insecure attachment is associated with adult psychopathology (8). In a study examining psychopathology and attachment styles in adults, Santoro et al. found that insecure attachment styles such as preoccupied, fearful, and anxious attachment increased the frequency of adult psychopathology [13]. In a study examining the relationship between attachment styles, PD, and separation anxiety, Manicavasagar et al. reported that anxious attachment style was more common in the PD and separation anxiety groups compared to the control group (8). Similarly, Pini et al. found that PD was more common in the separation anxiety group compared to the control group, and this was associated with an anxious attachment style [14].

Despite numerous studies, the relationship between separation anxiety disorder, other anxiety disorders, and attachment styles could not be explained completely. Although many studies have been conducted on panic disorder, few studies have examined the relationship between ASAD and attachment styles.

In this study, it was aimed to investigate the relationship between ASAD and attachment styles in patients diagnosed with PD. Additionally, it was hypothesized that ASAD increases the risk of developing PD. Moreover, this study aimed to test whether attachment mediates the relationship between PD and ASAD.

Methods

76 patients who consecutively applied to the Psychiatry outpatient clinic of Rize Recep Tayyip Erdoğan University Training and Research Hospital, met the diagnostic criteria for PD as specified in the Diagnostic and Statistical Manual of Mental Disorders-5th edition (DSM-5), and were under follow-up at the clinic were included in the study. Additionally, 79 healthy individuals (control group) with similar sociodemographic characteristics were also included. In order to find the minimum number of participants required for the analysis of the research data, power analysis was performed using G-Power 3.1.9.7 software. Accordingly, the minimum number of participants was determined as 148 people with a 95% power and a 60% effect size at α = 0.05 level, with a 1:1 distribution of case and control groups. The sample of the study was created by selecting participants among PD patients who were aged 18–65, literate, able to comprehend what they read, willing to participate in the study, and did not have any additional psychiatric disorders. On the other hand, participants of the control group were selected among patients’ relatives and hospital staff with the same age, gender, and marital status as the case group. The inclusion criterion for the control group was determined as being willing to participate in the study, having no chronic physical or mental illnesses, no intellectual disability, or substance use disorder. For both groups, those who were illiterate, under 18, over 65, pregnant, breastfeeding, and had prominent psychotic symptoms, neurological disorders, additional psychiatric disorders, alcohol or substance use disorders, and intellectual disability were excluded from the study. The appropriateness of the participants to the inclusion and exclusion criteria was determined following interviews conducted by a psychiatrist, taking into account the DSM-5 diagnostic criteria. The sociodemographic data form, the Panic Agoraphobia Scale (PAS), the Adult Separation Anxiety Questionnaire (ASA), and the Relationship Scales Questionnaire (RSQ) were administered to the participants who volunteered to participate in the study.

Ethics

All participants were informed about the study, and written informed consent was obtained from each of them. Prior to the study, ethical approval was obtained from the Non-Interventional Clinical Research Ethics Committee of the Faculty of Medicine, Recep Tayyip Erdoğan University (Ethics Approval No: E-40465587-050.01.04-707; Date: May 26, 2023, and Decision No: 2023/127). The study was conducted in accordance with the principles of the 1964 Declaration of Helsinki. Throughout the study, the ethical principles of corporate and/or national research committees were followed.

Data collection tools

Sociodemographic data form

This is a form prepared by the researcher according to the characteristics of the study. It is used to investigate the individuals’ sociodemographic and clinical characteristics, such as gender, age, occupation, education level, socioeconomic status, clinical course of the disease, and alcohol-substance use.

Panic agoraphobia scale (PAS)

This scale was developed by Bandelow et al. in 1995 to measure the severity of panic disorder. This 5-point Likert-type scale consisting of 13 items assesses the severity of panic attacks, anticipatory anxiety, phobic avoidance, social inadequacy, and physical symptoms. It has both observer-rated and self-report forms. Tural et al. carried out the validation study of the Turkish version of the scale. The Cronbach’s alpha coefficient of the scale was reported as 0.88 for the observer-rated form and 0.86 for the self-report form [15, 16]. In our study, on the other hand, we calculated Cronbach’s alpha coefficient as 0.78 for the observer-rated form and 0.74 for the self-report form.

Adult separation anxiety questionnaire (ASA)

ASA, developed by Manicavasagar et al. in 2003, is a 27-item, 4-point Likert-type self-report scale designed to assess symptoms of separation anxiety in adults. It evaluates symptoms of separation anxiety that occur both in childhood and adulthood. The cut-off score was determined as 25. The validity and reliability study of its Turkish version was conducted by Diriöz et al. and the Cronbach’s alpha coefficient was calculated as 0.93 [17, 18]. In our study, on the other hand, we calculated the Cronbach’s alpha coefficient as 0.89. In addition, the scale we used in our study was also used in previous studies by Pini et al. and Selbes et al. [7, 10].

Relationship scales questionnaire (RSQ)

RSQ, developed by Griffin and Bartholomew in 1994, is a scale used to assess adult attachment styles. It evaluates adult attachment styles under four attachment patterns: fearful, preoccupied, dismissing, and secure. It is a 7-point Likert-type scale consisting of 30 items. Instead of obtaining a total score from the scale, the subscale scores are considered. The validity and reliability study of the Turkish version of the scale was conducted by Sümer and Güngör. The Cronbach’s alpha coefficient of the scale was reported as adequate and reliable for the Turkish population in this study. Sümer and Güngör adapted the scale to 17 items for the Turkish population [19, 20]. We also used the 17-item form of the questionnaire in this study. We calculated the Cronbach’s alpha coefficients as 0.82 for secure attachment, 0.74 for fearful attachment, 0.78 for dismissing attachment, and 0.76 for preoccupied attachment. In addition, the questionnaire we used in our study was also used in previous studies by Both et al. and Selbes et al. [7, 21].

Statistical analysis

SPSS 29 software was used for data analysis. The distribution characteristics of continuous variables were assessed using the Shapiro-Wilk test. The relationships between categorical variables were evaluated using the chi-square test. The Mann-Whitney U test and Independent Samples t-test were used to examine the relationships between continuous variables and case and control groups. Correlations between scores obtained from the scales were analyzed only in the patient group by using Pearson correlation analysis.

The mediating effect of attachment on the impact of separation on panic was evaluated using SPSS PROCESS Model 4 with four mediator variables. A detailed explanation of the model is provided in the Findings section. For all analyses, the significance level was accepted p < 0.05.

Results

A total of 155 participants, 76 of whom were in the patient group and 79 were in the control group, were included in the study. The mean age of the patient group was 32.09 ± 9.98, and the mean age of the control group was 35.34 ± 12.53. 45.6% (n = 47) of the patient group and 54.4% (n = 56) of the control group were female. 47.1% (n = 41) of the patient group were married, while 52.9% (n = 46) of the control group were married. 62.5% (n = 30) of the patient group and 37.5% (n = 18) of the control group had a history of psychiatric disorders. 66% (n = 62) of the patient group had ASAD, compared to 34% (n = 32) of the control group. When comparing the sociodemographic data between the patient and control groups, no statistically significant difference was found between the two groups, except for the presence of a history of psychiatric illness and ASAD. A family history of psychiatric illness and the presence of ASAD were significantly higher in the patient group compared to the control group (p-values: p = 0.025, p < 0.001, respectively). The distribution of sociodemographic and clinical characteristics of the patients and the control group is presented in Table 1.

Table 1 Distributions of sociodemographic and clinical characteristics of the patient and control groups

When the scale scores of the patient and control groups were compared, it was found that the ASA scores were significantly higher in the patient group compared to the control group (p < 0.001). In the comparison of attachment styles, it was determined that scores of the secure attachment style, one of the RSQ subscales, were significantly higher in the control group compared to the patients with PD (p < 0.001). On the other hand, scores of the dismissing and preoccupied attachment styles, known as the insecure attachment styles, were significantly higher in patients with PD compared to the control group (p = 0.027, p = 0.032, respectively). However, comparing the groups, no significant difference was found between the scores of fearful attachment style, which is another insecure attachment style (p = 0.067). The comparison of the scale scores of the patient and control groups is presented in Table 2.

Table 2 Comparison of the patient and control groups in terms of scale scores

As a result of the correlation analysis examining the relationships between scale scores in the patient group, a statistically significant positive correlation was found between PAS and ASA scores (r = 0.287; p = 0.012). Apart from this, no statistically significant correlations were found between the scale scores (p > 0.05). When we examined the relationship between attachment styles and PD and ASAD, it was observed that attachment styles were not related to either PD or ASA. The correlation analysis revealed that RSQ scores were not significantly related to PAS and ASA scores (p > 0.05). The relationships between scale scores within the patient group are presented in Table 3.

Table 3 Relationships between scale scores in the patient group

The mediation analysis model, created to examine the mediating effect of attachment on the relationship between ASAD and PD, is depicted in Fig. 1. The numerical representations in the figure indicate the direction of the relationships in the model and are explained in Table 4.

Fig. 1
figure 1

The model of the mediating effect of attachment styles on the relationship between Panic Disorder and Separation Anxiety Disorder

ASA: Adult Separation Anxiety Questionnaire

PAS: Panic-Agoraphobia Scale

RSQ: Relationship Scales Questionnaire

Table 4 Examination of the mediating effect of attachment styles on the relationship between panic disorder and separation anxiety disorder (Direct Effects)

In our analysis conducted to observe the direct effect of ASA on attachment styles, we found that ASAD affected fearful attachment (β = 0.009, 95% CI: -0.020, 0.019), dismissing attachment (β = 0.008, 95% CI: -0.017, 0.017), secure attachment (β = 0.007, 95% CI: -0.010, 0.018), and preoccupied attachment (β = 0.007, 95% CI: -0.014, 0.016). When the direct effects of attachment styles on PD were evaluated, it was observed that effects of fearful, dismissing, secure, and preoccupied attachment styles on PD were as follows, respectively: β = 0.898, 95% CI: -0.786, 2.796; β = 1.021, 95% CI: -2.064, 2.007; β = 1.115, 95% CI: -1.950, 2.498; β = 1.027, 95% CI: -1.848, 2.249. However, none of these relationships were significant (p > 0.05).

When indirect effects were examined, it was understood that fearful (β = -0.012, 95% CI: -0.067, 0.036), dismissing (β = 0.001, 95% CI: -0.031, 0.039), secure (β = 0.017, 95% CI: -0.037, 0.035), and preoccupied (β = 0.002, 95% CI: -0.019, 0.304) attachment styles did not play a statistically significant mediating role in this relationship. This means that the confidence interval of the prediction coefficient covers 0. The only statistically significant results obtained from the model were the direct effect of ASAD on PD (β = 0.063, 95% CI: 0.053, 0.306) and the total effect of the model (β = 0.062, 95% CI: 0.055, 0.304). The p-values were 0.006 and 0.005, respectively. This means that the confidence interval of the prediction coefficient did not cover 0.

In conclusion, the analysis revealed that ASAD has a direct effect on the development of PD, and attachment styles neither directly nor indirectly mediate this relationship. The results are presented in Fig. 1; Table 4, and Table 5.

Table 5 Examination of the mediating effect of attachment styles on the relationship between panic disorder and separation anxiety disorder (Indirect Effects)

Discussion

In this study, ASAD was found to be significantly higher in patients with PD compared to the control group. In the comparison of attachment styles, it was observed that secure attachment style scores were higher in the control group, while preoccupied and dismissing attachment style scores, known as insecure attachment styles, were higher in patients with PD compared to the control group. Additionally, when the patient group was examined in terms of scale scores, a statistically significant correlation was found between PD and ASAD in the correlation analysis. On the other hand, it was seen that the scale scores were not correlated with each other. In the mediation analysis model created to examine the effects of ASAD and attachment styles on the development of PD, it was observed that only ASAD had a direct effect on the development of PD. It was found that attachment styles had neither a direct nor an indirect effect on this relationship.

Separation anxiety has been shown to increase the prevalence of numerous anxiety disorders, particularly PD [9, 10]. Studies have reported higher levels of ASAD in individuals diagnosed with PD compared to healthy controls, both in childhood and adulthood [3, 7, 22]. In two studies conducted a year apart, Bandelow et al. found higher rates of both childhood and adulthood separation anxiety disorder in PD patients compared to healthy controls [23, 24]. Similar results were obtained in studies comparing scale scores to assess symptom severity [14, 25]. In their studies conducted to assess ASAD, Pini et al. and Gesi et al. found higher ASA scores in PD patients compared to healthy controls [14, 25].

In our study, consistent with the literature, we found that both the prevalence of ASAD and the scores obtained from the ASA were significantly higher in patients diagnosed with PD compared to healthy controls. A similar result was also reported in another recent study conducted in our country. Selbes et al. compared 65 healthy individuals (control group) with 65 PD patients in terms of ASAD and determined that the prevalence of ASAD was higher in PD patients compared to the control group [7].

Numerous factors contribute to the onset and development of panic attacks. Insecure attachment styles are also among these factors. Studies have shown that insecure attachment styles, such as anxious, dismissing, preoccupied, and fearful attachment, are closely linked to psychiatric disorders like social phobia, depression, and anxiety disorders [3, 26]. It has been stated that this relationship is particularly more evident in conditions such as panic disorder and agoraphobia [27]. In a 2009 study, Manicavasagar et al. drew attention to this relationship and demonstrated that insecure attachment problems were more prevalent in patients diagnosed with PD compared to the healthy control group [8]. In another study conducted in the following year, they compared the groups’ scale scores and found that patients with PD had higher scores on anxious attachment scales than the control group [28]. Similar results were obtained in the studies conducted by Selbes et al. and Marazziti et al. These studies also indicated that preoccupied, fearful, and dismissing attachment style scores were higher in patients diagnosed with PD compared to healthy controls [7, 29].

Consistent with the literature, this study found that scores on insecure attachment styles, specifically dismissing and preoccupied attachment styles, were higher in patients with PD compared to the control group. Conversely, it was observed that scores of the secure attachment style were higher in the control group compared to patients with PD. This finding may be associated with early childhood traumas.

In a correlation analysis conducted to examine the relationship between ASAD and attachment styles in patients diagnosed with PD, a statistically significant relationship was found between PD and ASAD. However, it was also observed that attachment styles were not associated with PD and ASAD. In many studies in the literature, it has been shown that there is a strong relationship between insecure attachment styles and anxiety disorders [29, 30]. On the other hand, our study revealed that attachment styles were not statistically significantly associated with ASAD and PD, contrary to both the general literature and our hypothesis. Although this result seems to contradict the existing literature, the results of a limited number of studies have been observed to support our findings [31, 32]. For example, similar to our study, Bifulco et al. and Aschenbrand et al. reported no statistically significant relationship between attachment styles and ASAD and PD [31, 32]. Another result obtained from the correlation analysis is the significant positive relationship between PD and ASAD. The review of the literature has shown that this result is consistent with previous studies [7, 8]. Furthermore, this result is supported by the studies of Bandelow et al. and Silove et al. [22,23,24]. In these studies, they also linked both childhood and adulthood separation anxiety to PD in a manner similar to our study [22,23,24]. This result may be related to the severity of the anxiety caused by separation anxiety. Additionally, this result can also be explained by the fact that insecure attachment styles may have changed over time due to the influence of environmental and social factors.

In the mediation analysis model created to examine the mediating effect of attachment in the relationship between PD and ASAD, it was concluded that ASAD may have a direct effect on the development of PD. This result is consistent with the findings of previous studies examining the effect of ASAD on the development of PD [10, 22, 23]. In studies on the subject, it has been stated that separation anxiety disorder facilitates the development of PD and that both mental disorders are often comorbid [10, 24]. Another result obtained from the model is that attachment styles have no direct or indirect effect on the relationship between PD and ASAD. This result is not compatible with the hypothesis of our study and the findings of other studies on the subject [14, 33]. However, there are also studies that support the results of our study [7, 31]. Selbes et al. reported that attachment styles, except for preoccupied attachment, have no effect on the development of PD [7]. Similarly, Bifulco et al. also reported that there was no statistically significant relationship between attachment styles and the development of PD and ASAD [31].

In this study, the result that separation anxiety may be directly related to the development of PD, independent of attachment styles, is noteworthy. This suggests that the negative impact of separation anxiety on individuals may be more important than insecure attachment. This situation is also noteworthy in that it shows that focusing directly on separation anxiety rather than attachment styles in clinical interventions may be a more effective approach.

This study has some limitations. The small sample size, the study being conducted in a single center, the cross-sectional design, the reliance on self-report measures, and the retrospective assessment of attachment styles can be considered as limitations of this study. This situation limits the generalizability of the results of the study. Another limitation is that environmental factors such as stress, living conditions, trauma history, social support, family dynamics, and confounding factors such as medication use were not excluded. Despite these limitations, our study also has several strengths. The inclusion of a control group, the careful selection of participants, the face-to-face interviews with each participant, and the consideration of mediating variables can be shown as strengths of this study.

Conclusion

In this study, it was found that ASAD was significantly higher in patients with PD compared to the control group. In addition, insecure attachment styles; especially preoccupied and dismissing attachment styles were found to be more prevalent in patients with PD compared to the control group. In the mediation model analysis, it was determined that attachment did not play a mediating role in the relationship between PD and ASAD. However, the result that ASAD may have a direct effect on the development of PD is noteworthy. More studies are needed in this area to better understand the complex relationship between PD and ASAD. Future studies that are better designed, exclude confounding factors, have larger samples and include longer follow-up periods may shed light on this issue.

Data availability

Derived data supporting the findings of this study are available from the corresponding author [B.M.] on request.

Abbreviations

ASAD:

Adult Separation Anxiety Disorder

PD:

Panic Dısorder

PAS:

Panic Agoraphobia Scale

ASA:

Adult Separation Anxiety Questionnaire

RSQ:

Relationship Scales Questionnaire

SAD:

Separation Anxiety Disorder

DSM-5:

Diagnostic and Statistical Manual of Mental Disorders-5th edition

F:

Fearful

D:

Dismissing

S:

Secure

P:

Preoccupied

References

  1. American Psychiatric Association, American Psychiatric D. A: Diagnostic and statistical manual of mental disorders: DSM-5. Volume 5. American psychiatric association Washington, DC; 2013.

  2. Klevebrant L, Frick A. Effects of caffeine on anxiety and panic attacks in patients with panic disorder: A systematic review and meta-analysis. Gen Hosp Psychiatry. 2022;74:22–31.

    Article  PubMed  Google Scholar 

  3. Dogan B, Kocabas O, Sevincok D, Baygin C, Memis CO, Sevincok L. Separation anxiety disorder in panic disorder patients with and without comorbid agoraphobia. Psychiatry. 2021;84(1):68–80.

    Article  PubMed  Google Scholar 

  4. Faravelli C, Abrardi L, Bartolozzi D, Cecchi C, Cosci F, D’Adamo D, Lo Iacono B, Ravaldi C, Scarpato MA, Truglia E, et al. The Sesto Fiorentino study: background, methods and preliminary results. Lifetime prevalence of psychiatric disorders in an Italian community sample using clinical interviewers. Psychother Psychosom. 2004;73(4):216–25.

    Article  PubMed  Google Scholar 

  5. Şen Tepe Ç, Cihan S, Durat G. The relationship of adult separation anxiety disorder with attachment and parental attitude. Social Sci Stud J (sssjournal). 2022;6(59):1390–8.

    Google Scholar 

  6. Deveci Şirin H. Parental Acceptance–Rejection and adult separation anxiety: the mediation of adult attachment insecurity. SAGE Open. 2019;9(4):2158244019885138.

    Article  Google Scholar 

  7. Selbes A, Berkol TD, Kunt S, Uğurpala C, Mehtar M, Gökçeimam P. Examination of adult separation anxiety and bonding styles in patients with panic disorder who applied to a psychiatric clinic. Turkish J Psychiatry. 2018;29(3):171–9.

    Google Scholar 

  8. Manicavasagar V, Silove D, Marnane C, Wagner R. Adult attachment styles in panic disorder with and without comorbid adult separation anxiety disorder. Aust N Z J Psychiatry. 2009;43(2):167–72.

    Article  PubMed  Google Scholar 

  9. Silove D, Alonso J, Bromet E, Gruber M, Sampson N, Scott K, Andrade L, Benjet C, Caldas de Almeida JM, De Girolamo G, et al. Pediatric-Onset and Adult-Onset separation anxiety disorder across countries in the world mental health survey. Am J Psychiatry. 2015;172(7):647–56.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Pini S, Abelli M, Shear KM, Cardini A, Lari L, Gesi C, Muti M, Calugi S, Galderisi S, Troisi A, et al. Frequency and clinical correlates of adult separation anxiety in a sample of 508 outpatients with mood and anxiety disorders. Acta Psychiatrica Scandinavica. 2010;122(1):40–6.

    Article  CAS  PubMed  Google Scholar 

  11. Manicavasagar V, Silove D, Curtis J. Separation anxiety in adulthood: a phenomenological investigation. Compr Psychiatr. 1997;38(5):274–82.

    Article  CAS  Google Scholar 

  12. Namli Z, Özbay A, Tamam L. Adult separation anxiety disorder: A review. Curr Approaches Psychiatry. 2022;14(1):46–56.

    Google Scholar 

  13. Santoro G, Midolo LR, Costanzo A, Schimmenti A. The vulnerability of insecure Minds: the mediating role of mentalization in the relationship between attachment styles and psychopathology. Bull Menninger Clin. 2021;85(4):358–84.

    Article  PubMed  Google Scholar 

  14. Pini S, Abelli M, Troisi A, Siracusano A, Cassano GB, Shear KM, Baldwin D. The relationships among separation anxiety disorder, adult attachment style and agoraphobia in patients with panic disorder. J Anxiety Disord. 2014;28(8):741–6.

    Article  PubMed  Google Scholar 

  15. Bandelow B. Assessing the efficacy of treatments for panic disorder and agoraphobia. II. The panic and agoraphobia scale. Int Clin Psychopharmacol. 1995;10(2):73–81.

    Article  CAS  PubMed  Google Scholar 

  16. Tural U, Fidane H, Alkin T, Bandelow B. Assessing the severity of panic disorder and agoraphobia: validity, reliability and objectivity of the Turkish translation of the panic and agoraphobia scale (P&A). J Anxiety Disord. 2002;16(3):331–40.

    Article  PubMed  Google Scholar 

  17. Manicavasagar V, Silove D, Wagner R, Drobny J. A self-report questionnaire for measuring separation anxiety in adulthood. Compr Psychiatr. 2003;44(2):146–53.

    Article  CAS  Google Scholar 

  18. Diriöz M, Alkın T, Yemez B, Onur E, Eminağaoğlu N. The validity and reliability of Turkish version of separation anxiety symptom inventory and adult separation anxiety questionnaire. Turkish J Psychiatry. 2012;23(2):108–16.

    Google Scholar 

  19. Griffin DW, Bartholomew K. Models of the self and other: fundamental dimensions underlying measures of adult attachment. J Personal Soc Psychol. 1994;67(3):430.

    Article  Google Scholar 

  20. Sümer N, Güngör D. Psychometric evaluation of adult attachment styles scales on a Turkish sample and a cross-cultural comparison. Turkish J Psychol. 1999;14(43):71–106.

    Google Scholar 

  21. Both LE, Best LA. A comparison of two attachment measures in relation to personality factors and facets. Pers Indiv Differ. 2017;112:1–5.

    Article  Google Scholar 

  22. Silove D, Slade T, Marnane C, Wagner R, Brooks R, Manicavasagar V. Separation anxiety in adulthood: dimensional or categorical? Compr Psychiatr. 2007;48(6):546–53.

    Article  Google Scholar 

  23. Bandelow B, Alvarez Tichauer G, Späth C, Broocks A, Hajak G, Bleich S, Rüther E. Separation anxiety and actual separation experiences during childhood in patients with panic disorder. Can J Psychiatry Revue Canadienne De Psychiatrie. 2001;46(10):948–52.

    Article  CAS  PubMed  Google Scholar 

  24. Bandelow B, Späth C, Tichauer GA, Broocks A, Hajak G, Rüther E. Early traumatic life events, parental attitudes, family history, and birth risk factors in patients with panic disorder. Compr Psychiatr. 2002;43(4):269–78.

    Article  Google Scholar 

  25. Gesi C, Abelli M, Cardini A, Lari L, Di Paolo L, Silove D, Pini S. Separation anxiety disorder from the perspective of DSM-5: clinical investigation among subjects with panic disorder and associations with mood disorders spectrum. CNS Spectr. 2016;21(1):70–5.

    Article  PubMed  Google Scholar 

  26. Kossowsky J, Pfaltz MC, Schneider S, Taeymans J, Locher C, Gaab J. The separation anxiety hypothesis of panic disorder revisited: a meta-analysis. Am J Psychiatry. 2013;170(7):768–81.

    Article  PubMed  Google Scholar 

  27. Silove D, Manicavasagar V, Pini S. Can separation anxiety disorder escape its attachment to childhood? World Psychiatry: Official J World Psychiatric Association (WPA). 2016;15(2):113–5.

    Article  Google Scholar 

  28. Manicavasagar V, Marnane C, Pini S, Abelli M, Rees S, Eapen V, Silove D. Adult separation anxiety disorder: a disorder comes of age. Curr Psychiatry Rep. 2010;12(4):290–7.

    Article  PubMed  Google Scholar 

  29. Marazziti D, Dell’osso B, Catena Dell’Osso M, Consoli G, Del Debbio A, Mungai F, Vivarelli L, Albanese F, Piccinni A, Rucci P, et al. Romantic attachment in patients with mood and anxiety disorders. CNS Spectr. 2007;12(10):751–6.

    Article  PubMed  Google Scholar 

  30. Bassi G, Mancinelli E, Spaggiari S, Lis A, Salcuni S, Di Riso D. Attachment style and its relationships with early memories of separation anxiety and adult separation anxiety symptoms among emerging adults. Int J Environ Res Public Health 2022, 19(14).

  31. Bifulco A, Kwon J, Jacobs C, Moran PM, Bunn A, Beer N. Adult attachment style as mediator between childhood neglect/abuse and adult depression and anxiety. Soc Psychiatry Psychiatr Epidemiol. 2006;41(10):796–805.

    Article  PubMed  Google Scholar 

  32. Aschenbrand SG, Kendall PC, Webb A, Safford SM, Flannery-Schroeder E. Is childhood separation anxiety disorder a predictor of adult panic disorder and agoraphobia? A seven-year longitudinal study. J Am Acad Child Adolesc Psychiatry. 2003;42(12):1478–85.

    Article  PubMed  Google Scholar 

  33. Jinyao Y, Xiongzhao Z, Auerbach RP, Gardiner CK, Lin C, Yuping W, Shuqiao Y. Insecure attachment as a predictor of depressive and anxious symptomology. Depress Anxiety. 2012;29(9):789–96.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

None.

Funding

No funding was received for this study.

Author information

Authors and Affiliations

Authors

Contributions

BM, PM and HÇF were responsible for conceptualisation, methodology, software, validation, formal analysis, investigation, resources, data curation, visualisation, project administration, funding acquisition. BM and PM were responsible for writing - original draft, writing - review & editing and supervision. All authors have read and approved the final version submitted and take public responsibility for all aspects of the work.

Corresponding authors

Correspondence to Mehmet Baltacioğlu or Meltem Puşuroğlu.

Ethics declarations

Ethics approval and consent to participate

All participants were informed about the study, and written informed consent was obtained from each of them. Prior to the study, ethical approval was obtained from the Non-Interventional Clinical Research Ethics Committee of the Faculty of Medicine, Recep Tayyip Erdoğan University (Ethics Approval No: E-40465587-050.01.04-707; Date: May 26, 2023, and Decision No: 2023/127). The study was conducted in accordance with the principles of the 1964 Declaration of Helsinki. Throughout the study, the ethical principles of corporate and/or national research committees were followed.

Competing interests

The authors declare no competing interests.

Presentations

This research has not been published anywhere before and has not been presented at any congress.

Clinical trial number

Not applicable.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Baltacioğlu, M., Çelik, F.H. & Puşuroğlu, M. The mediating role of attachment in panic disorder and separation anxiety disorder. BMC Psychiatry 25, 415 (2025). https://doi.org/10.1186/s12888-025-06852-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12888-025-06852-x

Keywords