Treating anxiety is different than 'managing' the problem

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Jan 01, 2003

This column illustrates the importance of addressing anxiety disorders as soon as they appear. Many people choose to "manage", rather than truly treat these conditions in the early stages because it is easier for the clients to live with some aspect of the problem under the new management regime.

Unfortunately, this approach addresses the clients' complaints, but not the distress in the patient. Humane, modern care in veterinary behavioral medicine requires that the pets needs are assayed and addressed in a way that not only relieves the clients' complaints, but redresses the patient's distress and suffering.

Signalment

Jimmy is a 12-year-old, male, castrated, black and white, mixed breed dog weighing 22 kg. If people have to guess, they say that Jimmy is a Labrador/Setter/Spaniel mix.

Presenting complaint

Jimmy barks, howls, drools and occasionally eliminates when he is left alone. The problem has become an emergency because the client's next-door neighbor works nights and needs to sleep during the day. Jimmy's barking keeps her awake and she has complained to the landlord. Eviction is a likely option.

History

Jimmy was adopted from a humane shelter at approximately 24-30 months of age (shelter estimate). At the time he was brought to the shelter he was intact. There was very little previous history available for the dog, except for the comment on his relinquishment record that he was "partially housetrained".

The client chose him from the dogs at the shelter because he was right at the front of the runs/cages, leaning against the fencing, and he was quiet. He appeared to be much calmer and sweeter than the other dogs. When the client approached him and took him from the run he showed no signs of fear or withdrawal, and went willingly with her. At adoption he was neutered.

From the time the client brought Jimmy home she felt that he had separation anxiety. In this case, she doesn't base her assessment in the context of 'looking back' or 'given what I know now'. Instead, she frankly admits that he has never liked to be left alone, has been thrown out of two training classes because of his 'clinginess', and has always had a sacrificial rug at the front door that he would shred in her absence.

The client has moved about a dozen times since getting Jimmy and is now living in an apartment. Jimmy has lived in apartments before, but most of the moves have been to houses.

This time Jimmy is not clawing at the door, digging in or chewing the carpeting. However, he regularly urinates in the house when the client is gone, and occasionally defecates. In the past, he has also routinely eliminated when left, but more rarely, and the housing situation made it easier to clean up after Jimmy.

When questioned about his vocalization history, the client admits to an almost complete knowledge deficit. No one ever complained about his barking before, but they also lived in areas where his barking would not have been disruptive.

The client now estimates that Jimmy destroys and urinates 40 percent or less of the time when left alone, but vocalizes 100 percent of the time. After this move, he also exhibits signs of distress when just denied access to the client by door or gate. In these cases, he urinates or vocalizes 40 percent or less of the time, but the client finds him "clingy". He formerly followed her to different rooms, but now if she even moves, he is right by her side waiting for her next action.

During the appointment, he willingly came to me for treats, but even after three hours if I made any sudden moves, he jumped, increased his vigilance and scanning. He also clung to the client during the physical exam. When he had a choice of staying with me or following the client to the bathroom, he abandoned the treats and glued himself to the client.

Still skittish

When Jimmy was first adopted, he was "skittish" in certain situations: unfamiliar sounds, new people, dogs who did not approach slowly. To a lesser extent this continues today. If the human or dog is calm and gives Jimmy time and space to approach them, he will do so. He always seems to avoid children, although when faced with the client's nephews, he ignores them unless they have a ball. Jimmy will play ball with most children.

Because the client's former fiancé also had a dog, an intact male Border Collie named Zach, we have some idea of how Jimmy reacts in close canine quarters. The client always felt that Jimmy 'tolerated' Zach, although they would play. If Zach approached Jimmy while he was eating, Jimmy would bark or snarl. If Zach approached Jimmy when Jimmy had a favorite toy, Jimmy would bark, snarl or silently lift his lip. If Zach disturbed him, Jimmy would just move and ignore Zach. Although both dogs were relatively young when they lived together (Zach, 4, and Jimmy, 8) the client felt that Jimmy never really enjoyed being with Zach, although he was great with her fiancé. The client commented that you could always do anything you wanted with Zach and take him anywhere, but that this was not true for Jimmy. Jimmy always was alert for and barked at new people, dogs, circumstances and noises.

Oddly, Jimmy has always growled when startled while sleeping, so the client has learned to avoid petting him while he is asleep. The first time she kissed Jimmy when he was asleep, he growled and startled, catching her lip with his teeth. If Jimmy is called first and awakened he is fine. The client specifically commented that Jimmy has always been very sensitive to and 'reactive' in any new circumstance. Oddly enough, loud noises have never overly bothered Jimmy. He will alert to them, but exhibits none of the non-specific signs of anxiety associated with being left alone.

Physical and laboratory evaluations

Although he's an older dog Jimmy only had a small amount of lenticular clouding. Otherwise, his vision and hearing appeared good in a variety of ambient light and sound conditions. His joints had a full range of motion, and he resisted pressing on hips only slightly. His teeth and gums were in excellent condition. The client's veterinarian reported that he had noticed a heart murmur during the last exam, and indeed Jimmy had a grade I-II holosystolic murmur best auscultated over the mitral valve region. Jimmy had no pulse deficits and no exercise intolerance, so simple routine monitoring, including regular manual digital heart rate measures while on medication, was recommended.

Jimmy's lab work was fully within the laboratory's reference range. Additionally, I played some basic food games with Jimmy to see if I could trick him into nosing the hand that did not hold the food. I repeated this game both by slightly showing the food placement and completely hiding which hand contained the food. Jimmy chose the correct hand each time. Additionally, he was able to easily find his way out of a small maze created from furniture, and he was willing to play and fetch a variety of toys.

Diagnosis

Jimmy was diagnosed with some mild attention-seeking behavior associated with a need for reassurance, profound and long-term separation anxiety, generalized anxiety disorder, and panic associated with separation anxiety.

It was important to rule out old age changes including any non-specific cognitive dysfunction, since many of the signs routinely attributed to separation anxiety could also be attributed to cognitive dysfunction and attendant senility changes.

It was for this reason that I was so careful to evaluate Jimmy's senses and physical functioning, in addition to quizzing the client intensely about any relevant changes. Jimmy's basic cognitive and problem solving (executive function) abilities appeared unimpaired. It is unlikely that cognitive dysfunction plays any major role in Jimmy's condition, although I did discuss aging changes and how they could worsen the condition with the client.

The client had been told by a variety of people that she should "dominate" the dog and forbid him from sleeping on her bed because he growled while he was asleep. It is important to note that while this non-specific sign can be a correlate of impulse control (formerly poorly labeled as "dominance") aggression, Jimmy did not meet the definitional criteria that he became aggressive in situations involving control or access to control in situations involving humans. The dog is very reactive, and has likely always had some small level of generalized anxiety disorder accompanied by a heightened sense of vigilance.

When one considers that all social animals are more vulnerable when they are sleeping, a response like the one exhibited by Jimmy makes a lot of sense, especially given his behavioral pathology. Fortunately, although commonly recommended, the client had avoided any aversive treatment of Jimmy. She correctly perceived that this would make him more anxious and less trusting.

Treatment and discussion

Many people recommended using a citronella or an electric shock collar to stop the barking. It's a good thing that the client listened to that queasy feeling in her stomach.

Citronella collars only work for reactive barking in dogs that are not startle, noise or scent sensitive. In these cases, the dog learns to avoid the undesirable stimulus by either not barking or barking below the sensitivity level of the collar. Anxious dogs will bark, regardless, because their behavior is not about volitional barking, which they can control; it's about anxiety that they cannot control.

Furthermore, if the dog is afraid of the scent, the noise, or is generally anxious and terrified by the startle, the result will make the dog worse.

Shocking a dog like Jimmy would turn him into a basket case. Punishing an anxious and an abnormal behavior with such an aversive stimulus will only make the anxiety worse, albeit different. In these dogs, such cruel interventions make the dog more reactive, not less, because you have added - from the dog's viewpoint - another unpredictable stimulus to his world. Even worse, this stimulus causes pain. I don't believe any dog should be treated for a behavioral problem using shock.

Rx intervention

The referring veterinarian had already placed Jimmy on Clomicalm® (clomipramine) at a dosage of ~2 mg / kg q. 12 h. The client had noted some mild changes: Jimmy salivated less, and his frequency of defecating when she left him dropped to almost zero. Jimmy's barking, though, remained almost unchanged, and the client was now to the point where she had to have Jimmy watched daily.

It's important to note that Jimmy's problematic behaviors had been ongoing for almost a decade. Second, he has become worse in intensity and frequency of his problem behaviors over time. Third, the pattern of his separation anxiety has changed over time: he went from mild destruction (fairly easy to get under control) to almost continuous vocalization (very hard to get under control).

Defecation and destruction resolve more easily than urination, which still resolves more easily than vocalization and salivation. It is important to realize that these non-specific signs may be governed by different underlying pathologies in neurochemical tracts or interactions.

Translation: if clomipramine - a tricyclic anti-depressant (TCA) that is fairly specific for inhibiting re-uptake of serotonin via 5-HT 1A subtype receptor - doesn't have an equal effect on all signs, not all signs are routed in that specific neurochemical pathway.

The biggest part of Jimmy's problem is that he now panics at the first sign "his person" might leave. Upon deeper questioning, it became clear that Jimmy assayed the probability that his person would leave the second they both opened their eyes, and then he behaved accordingly.

If the client was going to leave, he stuck to her like glue; if she was to stay home, he was more relaxed and could eat his biscuits and breakfast.

One of the keys to treating this problem is going to be to treat the panic. So, in addition to increasing the dose of clomipramine to 3 mg/kg po q. 12 h, we started Jimmy on 1-2 mg (the high end + of 0.02-0.04 mg/kg po q. 4-6 h prn) of alprazolam, a true anti-panic medication, as soon as he opened his eyes on days he was alone. As a benzodiazepine, alprazolam, at very low levels, has a mild calming effect; at intermediate levels it has an anti-anxiety effect, and at high levels it acts as a sedative.

Jimmy was initially given a range that exceeded the normal high dose because in the few cases where he had been given sedatives, he had a "high tolerance". As with any panicolytic drug, a trial run should be done when the client is home and can monitor the dog.

Behavior modification essential

Behavior modification is an essential part of any behavioral intervention; however, with a dog as panicky as Jimmy, complex behavior modification involving desensitization and counter-conditioning, including desensitizing the dog to cues that signal departure, is not going to be immediately possible. First, Jimmy is going to have to learn to relax and be calm. This dog is so wired for sound that any change in any social or environmental circumstance renders him clingy and unable to eat or play. Until he can be calm and sit quietly for any attention (Protocol for Deference) and begin to learn to sit or lie down and enjoy getting treats while the client moves around the room (Protocol for Relaxation), any complex behavior modification will plunge this dog into the depths of panic.

This case perfectly illustrates the patient that cannot do without medication. The medications - if they work - will break through the panic and allow the dog to replace a rule structure that is not working (e.g. panic) with one where he could learn a new set of behaviors (e.g. relaxation). The newer TCAs and selective serotonin re-uptake inhibitors (SSRIs) speed the rate at which behavior modification is acquired by working through the same neurochemical pathways involved in learning.

With the newer, more specific drugs, the long-term anti-anxiety effects and the learning effects are dependent on new protein synthesis involved in remodeling receptors. This process takes at least three to five weeks to kick in, so minimum treatment time to evaluate any effect, or any change of dose, is six to eight weeks. Unfortunately, this client is desperate, so her best plan is to continue to have the dog cared for during the day, while she teaches him as much basic behavior modification as possible. Only when she can leave him alone in another room and have him sleep through her departure, should she consider beginning to teach him that he can be left alone.

Within 10 days the client called and reported that at 2 mg of alprazolam Jimmy became much quieter but still attendant to the client; within three or so hours he was a bit ataxic. These behavioral signs are good correlates of levels of both parent compound and intermediate metabolite levels and indicate that Jimmy might do better on a lower dosage (1-1.5 mg).

The idea is to find a level at which the dog is calm, but not ataxic. If the dog sleeps calmly without ataxia when the client is home, he will likely be able to be alert but not panicked when in provocative circumstances. It's likely that the client will be able to find this dose.

Although we had practiced teaching the dog to sit or lie down and relax for a treat by rewarding slowing of respiratory and heart rates (which could easily be seen and monitored in this dog) and the gentle cocking his head, the client had questions.

Was it okay for Jimmy to lie down all the time? He seemed more comfortable this way. Yes, in fact, he has to go through more behaviors to get up from lying down than he does for sitting, so many dogs who lie down are less reactive than those who sit.

It turns out that Jimmy began to show the whites of his eyes when the client was completely behind him. This is a sign of uncertainty, so I recommended that she not circle all the way around Jimmy until he could stay calm (baby steps, baby steps).

The client was trying to scramble departure cues by picking up her keys, and sitting down, but Jimmy freaked out. Unless she can have the departure cue present and successfully do some of the Protocol for Relaxation, he cannot learn anything when he is panicked except to be more panicked.

When can we expect to know if we have to change drugs? She has barely left him alone since his appointment. If the increased dosage of clomipramine combined with alprazolam is not helpful, we may decide to switch to alprazolam and either sertraline (Zoloft), a drug excellent for the treatment of generalized anxiety disorder in humans, or fluoxetine (Prozac), a drug beneficial for explosive events.

The question here is whether his panic is explosive. Sadly, we just do not know enough yet to predict which combination is ideal. If we are able to control his generalized anxiety disorder and separation anxiety, but not the panicky component, we may decide to add one of the anti-psychotic drugs that have been useful in profound human panic.

Unless this client can teach Jimmy to truly relax in daily conditions, he will not get better.

I also recommended a local certified pet dog trainer (CPDT) who could both help the client get Jimmy more exercise, which may also decrease his anxiety, and work with her so that she is certain that she is not inadvertently rewarding subtle but anxious behaviors.

CPDTs are now certified by the Association of Pet Dog Trainers (www.apdt.com). Having these people on your team is a practice builder.