• separation anxiety
• complicated grief

Background
Recent epidemiological studies indicate that separation anxiety disorder occurs more frequently in adults than children. Data from literature suggest that adult separation anxiety disorder (ASAD) may develop after a bereavement or threat of loss. Research has demonstrated that bereaved persons may present a clinically significant grief reaction, defined as complicated grief (CG) that causes a severe impairment in quality of life.
The aim of this study was to evaluate the relationship between ASAD and CG in a large cohort of outpatients with mood and anxiety disorders.

Methods
Study participants comprised 454 adult psychiatric outpatients with DSM-IV mood or anxiety disorders diagnoses. All subjects were assessed with the structured clinical interview for diagnostic and statistical manual (IV edition) axis I disorders to establish DSM-IV Axis I diagnosis and psychiatric comorbidity.
The Hamilton Depression Rating Scale and the Young Mania Rating Scale were used to assess severity of depression and mania, respectively. Anxiety and panic symptoms were assessed by the Hamilton Anxiety Rating Scale and the Panic Disorder Severity Scale.
Adult Separation anxietydisorder was assessed using an adapted version of the Structured Clinical Interview for Separation Anxiety Symptoms. Complicated grief symptoms were assessed by the Inventory of Complicated Grief. Social and work impairments were evaluated using the Sheehan Disability Scale.

Results
The overall frequency of ASAD in our sample was 43% and frequency of CG was 23%. CG resulted specifically associatedwith ASAD (p=.002) ) and not with childhood separation anxiety disorder neither with any other DSM-IV-TR disorder.
The presence of CG influenced various clinical features of subjects with ASAD; particularly CG determined more severe mania (p=.011) and depressive symptoms (p=.014). Furthermore subjects with ASAD and CG endorsed higher level offunctionalimpairment than those with only one of these conditions.
Finally in bipolar patients CG was associated with more severe mania (p=.026), depressive (p=.004) and anxiety (p=.005) symptoms and with a more severe lifetime bipolar symptomatology (MOOD total score: p=.000; MOOD depressive tot score: p=.000, MOOD mania tot score: p=000). Bipolar subjects with CG reported higher level of lifetime suicidal ideation (p=.027) and an higher number of suicide attempts (p=.027) than bipolar subjects without CG. In addition co-occurrence of CG and ASAD comprised a sub-population of bipolar patients at vey high risk of suicidality (60% CG with ASAD vs 40% CG without ASAD vs 40% CG with panic disorder vs 20% no CG).

Conclusions
We found that in our sample of psychiatric outpatients with mood and anxiety disorders, complicated grief is specifically associated with adult separation anxiety disorder. Co-occurrence of these two conditions was associated with high levels of functional impairment.
Furthermore in bipolar subjects, CG determinesaworsening in the symptomatology of both bipolar and comorbidity anxiety disorder; CG results associated with separation anxiety symptoms and with an high frequency of panic attacks but not with panic disorder suggesting that in bipolar subjects with CG,panic attacks could be secondary to ASAD and not correlated with a primary panic disorder.
Finally in bipolar subjects the presence of CG determines a more severe lifetime bipolar symptomatology and causes higher risk of suicidality, expecially if ASAD is in comorbidity with thoses diagnosis.
Further studies are warranted to investigate in more detail possible mediating factors in the putative relationship between ASAD, CG and other mood and anxiety disorders