Separation Anxiety Blended with Superstitious Belief in an Adult Female: A Case Report in Bangladesh

1. Introduction

Adult separation anxiety disorder (ASAD) has recently been reported in the psychiatric literature across the globe and diagnostic and statistical manual of mental disorders (DSM) omitted the age 18 years criterion for diagnosis of separation anxiety disorder (SAD) (1, 2). Adult onset ASAD refers to separation anxiety disorder in an adult without a prior documented history of childhood separation anxiety disorder (3, 4). Childhood onset ASAD is a separation anxiety disorder in an adult who also had the same diagnosis in childhood (3, 4). A large scale previous study revealed the lifetime prevalence of ASAD to be 6.6% (1, 3-5) and to be associated with different comorbidities; (2), such as mood disorders (4), emotional problems (4), anxiety disorders (4), and panic disorder (1). It can seriously affect functioning in different domains of life (3, 5). Adults with ASAD experience intense anxiety about separation from their attachment figures and engage themselves in wide ranges of activities to avoid separation and may show different emotional and behavioral disturbances that may lead to functional deterioration (1, 5). Previous research revealed different factors responsible for developing ASAD, such as childhood experiences (2), environmental factors (6), genetic factors (7), over protective parenting (1, 3), lack of healthy self (7), and collectivistic cultures (3). This recent recognized disorder affects multiple domains of life and is associated with different comorbidities that ultimately decrease quality of life. Here, we report an adult female presented with ASAD for her cats; she had superimposed superstitious beliefs, which were unusual, considering her religious and cultural background.

2. Case Presentation

A 27 year- old- female, married, currently unemployed, Muslim, nonsmoker, with good intelligent level, hailing from urban area with middle class economic background presented with excessive unusual preferences and preoccupation with her 2 cats since the last 4 years. She also presented with severe anxiety, fear, multiple physical symptoms of anxiety, and sleep disturbances associated with bad dreams, all of which were related to her cats for the same duration. She started to engage with the pets four years back and gradually became so strongly attached to them that her usual daily activities started to be hampered. She enjoyed to be busy with her pets and showed severe anxiety symptoms when she faced separation from her pets and became persistently distressed in such situations. She had a persistent fear of losing her cats and suspected that people including her family members might harm her pets. She was increasingly unwilling to keep herself away from the cats which subsequently limited her other activities. She used to avoid searching or getting a job or being involved with any other activities. She married 2 years ago, but suddenly she refused to stay in her in-laws’ residence without her pets. She avoided her husband’s company to be with her cats. She loved her 2 cats as if they were her children, she even did not want any children. Rather, she said that her cats fulfilled her motherly feelings. For the fear of possible pregnancy, she tried her best to avoid intercourse and even she did not feel any urge to have sex with her husband. When the act seldom happened, she forced her husband to take precautionary measures for birth control. She lost her previous 2 cats during her marriage conciliation period; 1 died just before the marriage and another was lost just after the marriage. She interpreted the situation that the marriage has brought misfortune for her and that her cats were lost as a proof of this misfortune. Then, she bought another 2 cats and stopped to stay with her husband in her in-laws’ residence.The related superstitious belief and her severe anxiety symptoms after separation from her cats gradually made her indifferent to her marital life, pushing her towards a pet-concerned life. All the family members were deeply concerned about her pet-centered emotional and behavioral problems. They tried to prevent her behaviors by discussing affectionately, censuring, and pressuring her in many ways. In the response, she became more irritable, impulsive, tempered, blaming, and suspicious that they will harm, injure, drive away, or kill the cats. She became increasingly anxious and fearful for her pets and anticipated to lose them and became more protective of the pets. The overall situation gradually aggravated day by day. Her husband was totally annoyed and disappointed with her and her parents and in-laws were worried about the fate of her marital life.

She was delivered by normal vaginal delivery and all her domains of milestone were age appropriate. She had one brother and she was brought up in an overprotective parenting milieu. She studied up to masters with excellent performance and then looked for a suitable job, but recently she stopped doing anything except being engaged with her cats. She had no documented history of substance abuse, forensic, or legal involvement. She had few friends with good understanding before illness. She had no comorbid medical illnesses. Her vital signs were within the normal limit and detailed systemic examination revealed nothing unusual.

On mental status examination, she was anxious and distressed. Rapport was established but it was difficult to sustain. She had anxious mood, but her speech was normal in rate, rhythm, volume, and tone. Her thoughts revealed inappropriate preoccupation with her pets related to separation, anticipatory forceful separation, and possible harm and fear of losing her cats. Hallucination or any abnormal perception was not elicited.She had no cognitive disturbance. Her insight was impaired as she had superstitious beliefs and her behavior towards her pets was somewhat inappropriate.

3. Discussion

We aimed at reporting an adult Bangladeshi female presented with ASAD for her 2 cats with additional superstitious belief with regards to her pets. She was brought up in an overprotective family, completed her formal education, and became engaged with her 2 cats for the last 4 years.After initiating pet culturing, she was gradually engaged more and more. At the time of consultation, she developed the symptoms of ASAD and she was ready to consider her married life, family life, occupational involvements; these symptoms have been explained in previous literature on ASAD (1-5). The lady was brought up in an overprotecting family, and a previous study revealed it as a risk factor for developing SAD (3, 6, 7). She started avoiding family members, refused to stay at her in-laws’ home, avoided her husband’s accompany, had an extreme precaution to avoid to have a child and she thought that the cats are enough to meet her expectation as children. She became furious in absences of her pets and ready to sacrifice any options to be with her cats (1, 3-5). The more complexity appeared with the superstitious belief of the lady regarding the loss of her previous 2 cats, as she believed she have lost them because of continuity of her marriage and she became indifferent to her married life. She started avoiding her in-laws to avoid separation from her cats. Behavioral addiction (pet addiction) was considered, as her concerns were related to her pets, but her beliefs regarding her cats could not be explained with the diagnosis. Histrionic personality disorder was also considered, but her longitudinal history and functional achievement refuted the diagnosis. Obsessive compulsion disorder could be explained as the next possibility, but she considered the thoughts were not senseless rather rational. Moreover, the thoughts lacked delusional intensity, thus excludes the delusional disorder, which may rare occur at age of 27 years. Overprotective parenting attitude, extreme concern with the separation of the cats, and extreme functional impairment in all domains with unexplained superstitious belief can mostly be explained by ASAD complicated with superstitious belief. Bangladesh is a country of religious practice and people are supposed to engage in family life after marriage, but the reported lady was so engaged with her cats that she started to avoid everything except the cats. Both cat nurturing and being fascinated with cats in such an intense way, which is uncommon, and presence of SAD symptoms in this case made the authors perplexed.

3.1. Conclusions

Extreme cat preference with avoidance of usual family life to avoid separation with the pets as well as complex superstitious belief and behaviors added difficulties to the situation to address and manage it properly. The very unusual presentation that contrasted the culture of the presented lady encouraged the authors to draw the attention of the scientific community.