FIRST IN A TWO-PART SERIES?Separation anxiety: Early drug intervention can be beneficial

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May 01, 2003

Introduction:

This column outlines the course of treatment for a dog who has been a patient for 2.5 years. It demonstrates the complexity of behavioral cases and as well as this client's understanding, tenacity and compassion. It also demonstrates the capacity of these distressed dogs to become more than we could ever have guessed.

Signalment:

At the initial consult Solo, a male, intact, red Border Collie, was approximately 12 months.

Presenting complaint:

Solo had been obtained two weeks before through an on-line rescue service who had very little information about him. The client, a graduate student, was frantic about his vocalization and destructive behaviors whenever she was out of his sight.

She could not even close the door to show without Solo shrieking and attempting to dig through the door. His vocalization was a problem because she lived in an apartment where, technically, dogs were not allowed. The destruction was a problem because of the expense and the risk to Solo when he had to be left. The client also had a cat to whom this dog seemed inordinately attentive.

History:

The client had lost her dog, a middle-aged Pomeranian, just weeks before after fighting autoimmune anemia, and ultimately neoplasia, for more than a year.

The Pom had been a terrific little dog and had enjoyed huge popularity at the university where she attended numerous classes. The client had not been permitted to have dogs when she grew up, and the Pom had been her first dog. The Pom was also an easy dog - not only had she been charming, complacent and easy to train, but she was perfectly happy to be stuck in an oversized bookbag to travel with her owner. The client had been counseled that grief affected all people differently, and that she should think seriously about whether another dog was the best choice at the stage of her life when she was expecting to travel to do her fieldwork.

She was also counseled about the most common mistakes made by people who have just lost dogs: impulse acquisitions and replacements with the same breed in an (unconscious) attempt to recreate the lost dog.

The client learned of Solo while browsing Internet dog rescue and adoption sites. Solo was intriguing because of his almost non-existent history and the apparent urgency to his case. She made arrangements to see Solo immediately.

When she met Solo and his caretaker, it became apparent that the caretaker was, at best, only loosely affiliated with the Border Collie rescue group and that he knew almost nothing about the dog.

He also wanted to unload this dog on anyone. In the classic struggle between brain and heart, the client immediately took Solo, while simultaneously justifying and regretting it.

Clingy, but not cuddly

Solo was clingy to her, but not cuddly. He didn't want to be held, he didn't play, he didn't seem to know what toys were, but she had to be constantly in sight. He

didn't really want a bed, and placement in a crate made him frantic.

He barely ate, his hair coat was poor, and he didn't seem to know what dog treats were. He just vocalized, stared, cowered and destroyed. When the client - who was still in deep mourning over the loss of the Pom would cry from loss and frustration, he withdrew more.

At the first appointment a few weeks after Solo had come to live with the client, the client sat on the floor and tried to groom, play with and massage the dog. Meanwhile, he shook and scanned the students in the room.

As we went through the history, it became apparent that the client's distress made Solo more uncertain of what was expected. When the client started to cry because of the loss of the other dog and her inability to make any kind of contact with this one, the students scurried for tissues while I sat on the floor and softly clicked to the dog who was looking for a corner in which to hide.

Solo came over to me, licked my mouth once and curled up in my lap. This triggered new waves of sobs including wails that Solo hated her, and although he

didn't even know me, look at how he responded to me. Wasn't this proof of the client's fundamental inadequacy?

Provide a safe haven

What the client had failed to realize was that all I had offered Solo was a clear rule structure and a safe haven. At some point, most herding dogs have been clicked at, and even if they haven't, clicking is a sound to which most dogs alert. I wasn't upset, and I looked directly at the dog and invited him to come to me. When he licked my lips, he was exhibiting a classic canine deferential behavior that also asks "What is expected next?"

When I patted my lap, he dove in, and I just pressed on him and petted him very slowly to calm him. When I explained all of this to the client, we reassured her that she could do this. But we all encouraged her to think of whether this was a dog she needed or wanted at this point in her life.

For many complex emotional reasons, the client felt that she had to keep this dog and make him whole. The guy who pawned him off on her had no papers, wasn't sure of his age, and only knew that two older women wanted to breed him, but never quite got around to it. So, the dog was kept locked up most of the time.

Before coming to rescue, he'd gone to a herding farm but was bounced almost immediately because he chased the sheep. We had no idea if he'd ever seen anyone early in his life except these two women, if he'd had any other social exposure; what he knew; where he'd been; he was one large dark hole.

Physical and laboratory evaluations:

Neither physical nor laboratory examination revealed any deficits or concerns. Solo's coat was terrible - sparse, dull, broken in spots - but suggested less than premium nutrition and lack of grooming rather than underlying disease.

Diagnosis:

The diagnoses were separation anxiety - both real and "virtual." This overly attached dog must have his person in sight at all times. Most likely, this dog had an incomplete exposure to other dogs, humans, other species and new experiences and environments during the sensitive periods.

Solo was also exhibiting extreme inappropriate herding behavior to the cat, but he wasn't predatory, and the cat, while not thrilled, did not seem overly concerned.

So, we instructed the client to get online and learn as much about him as possible (the Border Collie community on the East coast is pretty tight and shares a lot of info and gossip and could likely get to the roots of the story), and meanwhile, have realistic expectations.

I encouraged the client to realize that it was likely that this dog has missed beneficial exposure during most of the sensitive periods if the story was true. Sensitive periods - a term preferred but less often used than socialization periods - are developmental stages where, if a dog is prohibited from exposure to the relevant stimuli, they are more at risk for developing problems attendant with exposure they missed.

Generally, weeks six to 20 are the times when dogs are learning about the existence of a social and physical word other than that in which they were raised. During this time, they learn to make mistakes as a way of discovering new things, and as a way of learning to have more plastic responses.

Dogs that miss these periods may be less able to construct fluid responses to a variety of situations and they may either "shut down"(like Solo), or they may exhibit inappropriate behavior, given the context.

Most dogs that people think are poorly socialized are, in fact, not poorly socialized or exposed, but troubled. For a deficit to be caused by prohibition of experience during these periods, the deficit has to be pretty profound...very tiny amounts of exposure are sufficient to "vaccinate" the dog against such concerns. Solo actually may have met the criteria for deprivation during the sensitive periods.

If this was so, he could improve, but the trajectory would be shallow and the road long. We advised the client of these concerns.

Treatment and discussion

I explained that it was unlikely that Solo would improve without medication, and that in his case, medication might be lifelong because he may never have learned to be plastic in his response.

Fairly recent data support the mechanism of action of the tricylic antidepressants (TCAs) and the selective serotonin re-uptake inhibitors (SSRIs) to be one whereby serotonin is not actually the target, but is the neurochemical by which access is gained to the target.

Both SSRIs and TCAs inhibit the re-uptake into the pre-synaptic neuron of serotonin, thereby increasing the amount of serotonin in the synaptic cleft.

The increased serotonin ensures post-synaptic receptor saturation that, in turn, stimulates the post-synaptic 2nd messenger cAMP system. This then stimulates intracellular cytokines like brain derived neurotrophic factor (BDNF) which, in turn, stimulates protein production that creates new, more specific, more functional receptors, allowing the entire signaling system to work more efficiently.

What's remarkable about all of this is that this path - exploited so effectively by the TCAs and SSRIs - is the same pathway that is used in learning, and the cellular and molecular basis of learning, long-term potentiation (LTP).

This mechanism explains why double-blind placebo-controlled studies of behavior modification and drug use show that the drugs enhance the rate at which the behavior modification is acquired. It's unclear which patients will be able to maintain the receptor replacement and enhancement mechanism once the drugs are discontinued, and which will need life-long treatment to maintain this mechanism, but the rationale for combining behavior modification and medication is a sane one.

Furthermore, these recent findings suggest that we should be trying drugs sooner, rather than later, and using them especially to enhance the gains made with behavior modification.

Solo was treated with clomipramine (Clomicalm®) at 1 mg/kg po q. 12 h x 2 weeks, then 2 mg/kg po q. 12 h x 2 weeks, then 3 mg/kg po q. 12 h x 4 weeks (target dose), minimum. Maintenance was to be at the target dose.

Solo was also placed on the Protocol for Deference and the Protocol for Relaxation, and it was emphasized to the client that the goal here was not to have him "earn" attention. The goal was to use inherent, naturally deferential behaviors in dogs (e.g. sitting) to encourage them to seek guidance (this is what deference really is) from their owners in situations in which they might be uncertain.

Calm, relaxed behaviors should always be rewarded. The client was also instructed to take the dog with her as often as she could (the university permits dogs in offices), and she was to remove the dog from any situations in which he seemed frozen or spooked.

The client asked about taking Solo to agility or herding, since these were hot tickets on the Border Collie Web sites and chat rooms in which she participated. The dog was permitted to go to these only if they did not render him more distressed. If he froze or became agitated, then he had to be removed so that he did not get worse. Inherent in this instruction was the client's ability to recognize the earliest signs of distress or changes in behavior, and her ability to remove the dog before any of these behaviors worsened.

Finally, because we were not sure what would spook this dog we fitted him with a Gentle Leader canine head collar. He actually walked pretty nicely on a leash (because he was mostly terrified), but this gave us some control in an unexpected circumstance. At the time, we could not have known that this decision would be prescient.

Next month, we will continue this case work-up because it became increasingly complicated.