Treating anxiety is different than 'managing' the problem

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 notthe distress in the patient. Humane, modern care in veterinary behavioralmedicine requires that the pets needs are assayed and addressed in a waythat not only relieves the clients' complaints, but redresses the patient'sdistress and suffering.

Signalment

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

Presenting complaint

Jimmy barks, howls, drools and occasionally eliminates when he is leftalone. The problem has become an emergency because the client's next-doorneighbor works nights and needs to sleep during the day. Jimmy's barkingkeeps her awake and she has complained to the landlord. Eviction is a likelyoption.

History

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

The client chose him from the dogs at the shelter because he was rightat the front of the runs/cages, leaning against the fencing, and he wasquiet. He appeared to be much calmer and sweeter than the other dogs. Whenthe client approached him and took him from the run he showed no signs offear 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 separationanxiety. 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 thathe has never liked to be left alone, has been thrown out of two trainingclasses because of his 'clinginess', and has always had a sacrificial rugat the front door that he would shred in her absence.

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

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

When questioned about his vocalization history, the client admits toan almost complete knowledge deficit. No one ever complained about his barkingbefore, but they also lived in areas where his barking would not have beendisruptive.

The client now estimates that Jimmy destroys and urinates 40 percentor 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 accessto the client by door or gate. In these cases, he urinates or vocalizes40 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 evenafter three hours if I made any sudden moves, he jumped, increased his vigilanceand scanning. He also clung to the client during the physical exam. Whenhe 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 certainsituations: unfamiliar sounds, new people, dogs who did not approach slowly.To a lesser extent this continues today. If the human or dog is calm andgives Jimmy time and space to approach them, he will do so. He always seemsto avoid children, although when faced with the client's nephews, he ignoresthem unless they have a ball. Jimmy will play ball with most children.

Because the client's former fiancé also had a dog, an intact maleBorder Collie named Zach, we have some idea of how Jimmy reacts in closecanine quarters. The client always felt that Jimmy 'tolerated' Zach, althoughthey would play. If Zach approached Jimmy while he was eating, Jimmy wouldbark or snarl. If Zach approached Jimmy when Jimmy had a favorite toy, Jimmywould bark, snarl or silently lift his lip. If Zach disturbed him, Jimmywould just move and ignore Zach. Although both dogs were relatively youngwhen they lived together (Zach, 4, and Jimmy, 8) the client felt that Jimmynever really enjoyed being with Zach, although he was great with her fiancé.The client commented that you could always do anything you wanted with Zachand take him anywhere, but that this was not true for Jimmy. Jimmy alwayswas alert for and barked at new people, dogs, circumstances and noises.

Oddly, Jimmy has always growled when startled while sleeping, so theclient has learned to avoid petting him while he is asleep. The first timeshe kissed Jimmy when he was asleep, he growled and startled, catching herlip with his teeth. If Jimmy is called first and awakened he is fine. Theclient specifically commented that Jimmy has always been very sensitiveto and 'reactive' in any new circumstance. Oddly enough, loud noises havenever overly bothered Jimmy. He will alert to them, but exhibits none ofthe 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 lenticularclouding. Otherwise, his vision and hearing appeared good in a variety ofambient light and sound conditions. His joints had a full range of motion,and he resisted pressing on hips only slightly. His teeth and gums werein excellent condition. The client's veterinarian reported that he had noticeda heart murmur during the last exam, and indeed Jimmy had a grade I-II holosystolicmurmur best auscultated over the mitral valve region. Jimmy had no pulsedeficits and no exercise intolerance, so simple routine monitoring, includingregular 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 intonosing the hand that did not hold the food. I repeated this game both byslightly showing the food placement and completely hiding which hand containedthe food. Jimmy chose the correct hand each time. Additionally, he was ableto easily find his way out of a small maze created from furniture, and hewas willing to play and fetch a variety of toys.

Diagnosis

Jimmy was diagnosed with some mild attention-seeking behavior associatedwith 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-specificcognitive dysfunction, since many of the signs routinely attributed to separationanxiety could also be attributed to cognitive dysfunction and attendantsenility changes.

It was for this reason that I was so careful to evaluate Jimmy's sensesand physical functioning, in addition to quizzing the client intensely aboutany relevant changes. Jimmy's basic cognitive and problem solving (executivefunction) abilities appeared unimpaired. It is unlikely that cognitive dysfunctionplays any major role in Jimmy's condition, although I did discuss agingchanges 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 whilehe was asleep. It is important to note that while this non-specific signcan be a correlate of impulse control (formerly poorly labeled as "dominance")aggression, Jimmy did not meet the definitional criteria that he becameaggressive in situations involving control or access to control in situationsinvolving humans. The dog is very reactive, and has likely always had somesmall level of generalized anxiety disorder accompanied by a heightenedsense of vigilance.

When one considers that all social animals are more vulnerable when theyare sleeping, a response like the one exhibited by Jimmy makes a lot ofsense, especially given his behavioral pathology. Fortunately, althoughcommonly 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 collarto stop the barking. It's a good thing that the client listened to thatqueasy feeling in her stomach.

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

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

Shocking a dog like Jimmy would turn him into a basket case. Punishingan anxious and an abnormal behavior with such an aversive stimulus willonly make the anxiety worse, albeit different. In these dogs, such cruelinterventions 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 betreated 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 somemild changes: Jimmy salivated less, and his frequency of defecating whenshe left him dropped to almost zero. Jimmy's barking, though, remained almostunchanged, and the client was now to the point where she had to have Jimmywatched daily.

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

Defecation and destruction resolve more easily than urination, whichstill resolves more easily than vocalization and salivation. It is importantto realize that these non-specific signs may be governed by different underlyingpathologies in neurochemical tracts or interactions.

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

The biggest part of Jimmy's problem is that he now panics at the firstsign "his person" might leave. Upon deeper questioning, it becameclear that Jimmy assayed the probability that his person would leave thesecond 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 wasto 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 thepanic. So, in addition to increasing the dose of clomipramine to 3 mg/kgpo q. 12 h, we started Jimmy on 1-2 mg (the high end + of 0.02-0.04 mg/kgpo q. 4-6 h prn) of alprazolam, a true anti-panic medication, as soon ashe opened his eyes on days he was alone. As a benzodiazepine, alprazolam,at very low levels, has a mild calming effect; at intermediate levels ithas an anti-anxiety effect, and at high levels it acts as a sedative.

Jimmy was initially given a range that exceeded the normal high dosebecause in the few cases where he had been given sedatives, he had a "hightolerance". As with any panicolytic drug, a trial run should be donewhen 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 involvingdesensitization and counter-conditioning, including desensitizing the dogto 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 isso wired for sound that any change in any social or environmental circumstancerenders him clingy and unable to eat or play. Until he can be calm and sitquietly for any attention (Protocol for Deference) and begin to learn tosit or lie down and enjoy getting treats while the client moves around theroom (Protocol for Relaxation), any complex behavior modification will plungethis 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 allowthe dog to replace a rule structure that is not working (e.g. panic) withone where he could learn a new set of behaviors (e.g. relaxation). The newerTCAs and selective serotonin re-uptake inhibitors (SSRIs) speed the rateat which behavior modification is acquired by working through the same neurochemicalpathways involved in learning.

With the newer, more specific drugs, the long-term anti-anxiety effectsand the learning effects are dependent on new protein synthesis involvedin remodeling receptors. This process takes at least three to five weeksto kick in, so minimum treatment time to evaluate any effect, or any changeof 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. Onlywhen she can leave him alone in another room and have him sleep throughher departure, should she consider beginning to teach him that he can beleft alone.

Within 10 days the client called and reported that at 2 mg of alprazolamJimmy became much quieter but still attendant to the client; within threeor so hours he was a bit ataxic. These behavioral signs are good correlatesof levels of both parent compound and intermediate metabolite levels andindicate 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 willlikely 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 relaxfor a treat by rewarding slowing of respiratory and heart rates (which couldeasily 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 comfortablethis way. Yes, in fact, he has to go through more behaviors to get up fromlying down than he does for sitting, so many dogs who lie down are lessreactive than those who sit.

It turns out that Jimmy began to show the whites of his eyes when theclient was completely behind him. This is a sign of uncertainty, so I recommendedthat she not circle all the way around Jimmy until he could stay calm (babysteps, 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 departurecue present and successfully do some of the Protocol for Relaxation, hecannot 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 barelyleft him alone since his appointment. If the increased dosage of clomipraminecombined with alprazolam is not helpful, we may decide to switch to alprazolamand either sertraline (Zoloft), a drug excellent for the treatment of generalizedanxiety disorder in humans, or fluoxetine (Prozac), a drug beneficial forexplosive events.

The question here is whether his panic is explosive. Sadly, we just donot know enough yet to predict which combination is ideal. If we are ableto control his generalized anxiety disorder and separation anxiety, butnot the panicky component, we may decide to add one of the anti-psychoticdrugs 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 couldboth help the client get Jimmy more exercise, which may also decrease hisanxiety, and work with her so that she is certain that she is not inadvertentlyrewarding 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.