Real fear always involves avoidance, while apparently trying to decrease the probability of social interaction.
ANXIETY
Unlike fear, avoidance is not anxiety’s first choice. Dogs that are driven primarily by anxiety may put themselves into a social system, although it can make them uncomfortable and worried. Both fear and anxiety have signs that overlap. Some non-specific signs like lowering of the back, shaking and trembling can be characteristic of both fear and anxiety.
Generally anxiety is defined as the apprehensive anticipation of future danger or misfortune accompanied by feeling of dysphoria (in humans) and, or somatic symptoms of tension (vigilance and scanning, autonomic hyperactivity, increased motor activity and tension). Focusing on the anxiety can be both internal or external. For an anxiety or fear to be pathological in nature, it must be exhibited out-of-context, or in a degree or form that would be sufficient to accomplish an ostensible goal. The focus on context for the response, degree, and form of behavior informs all of our definitions of canine and feline behavior problems.
SOME OF THE PHYSIOLOGICAL AND BEHAVIORAL SIGNS OF ANXIETY IN DOGS
NON-SPECIFIC SIGNS OF ANXIETY THAT INCLUDE:
Defecation
Anal sac expression
Urination
Panting
Trembling/shaking
Increased respiration and heart rates
Muscle rigidity (usually with tremors)
Lip licking
Nose licking
Grimace (retraction of lips)
Head shaking
Smacking or popping lips/jaws together
Salivation/hypersalivation
Vocalization (excessive and/or out of context) which includes: frequent repetitive sounds, including high pitched whines, like those associated with associated with isolation
Yawning
Immobility/freezing or profoundly decreased activity
Pacing and profoundly increased activity
Hiding or hiding attempts
Escaping or escape attempts
Body language of social disengagement (turning the head or body away from the signaler)
Lowering of head and neck
Inability to meet a direct gaze
Lowered body posture (in fear, the body is extremely lowered and tail tucked)
Staring at some middle distance
Ears lowered and possibly droopy because of changes in facial muscle tone
Mydriasis
Scanning
Hyper-vigilance/hyper-alertness (may only be noticed when touh or interrupt the dog or cat – may hyper-react to stimuli that otherwise would not elicit this reaction)
Shifting legs
Lifting paw in an intention movement
Increased closeness to preferred associates
Decrease closeness to preferred associates
Profound alterations in eating and drinking (acute stress is usually associated with decreases in appetite and thirst, chronic stress is often associated with increases)
Possible appearance of ritualized or repetitive activities
Changes in other behaviors including increased reactivity and increased aggressiveness (may be non-specific)
PHOBIAS
Phobias involve profound, non-graded, extreme response and manifest as intense avoidance, escape, or anxiety associated with the sympathetic branch of the autonomic nervous system or ANS.
AT THE CORE OF MOST BEHAVIORAL CONDITIONS
Most all behavioral conditions, especially those related to anxiety, is the arousal level of the dog. Heightened arousal, beyond a certain adaptive level:
Prohibits accurate observation and assimilation of the information presented
Interferes with processing of that information, and
Can adversely affect actions taken based on these earlier steps
SO JUST WHAT IS SEPARATION ANXIETY?
Basically it’s the physical, physiological and/or behavioral signs of distress exhibited by the dog only in the absence of, or lack of access to the client (you).
The diagnosis is confirmed if there is consistent, intensive destruction, elimination, vocalization, or salivation exhibited only in the virtual and/or actual absence of the client. In virtual absences the client is present but the dog or cat does not have access to the client (e.g., a door is closed).
When we signs of distress they should be evaluated in currency and terminology that is meaningful to the dog (which is not usually the case; instead we evaluate client complaints).
The most commonly reported behaviors (elimination, destruction, excessive vocalization) are only the most readily apparent signs of anxiety.
Drooling, panting, freezing, withdrawal and cognitive signs of anxiety will be less commonly diagnosed because they are less apparent to people, but they occur and dogs displaying them may be even more profoundly affected than are dogs who show more obvious signs.
Certain dogs may show areas of correlated behaviors. For example, salivation appears to occur more commonly in dogs that freeze and become immobile. Clients will want to note which areas of behavior that their dogs exhibit so that they can monitor these non-specific signs for changes (hopefully, improvement) during treatment.
Separation anxiety is a condition that is often a problem for the client. so it gets a lot of attention, and lucky dogs have people who seek help.
It would be a good idea for veterinarians to use the increasing awareness of separation anxiety to educate clients about the extent to which separation anxiety and other behavioral conditions are problems for the dog and his quality of life. When clients understand which behaviors indicate problems, there is an increased chance that they will be better participants in the dog’s behavioral and overall veterinary care.
Asking about elimination patterns is extremely important for assessing the presence of anxity disorders, but even when this is routinely done, sporadic/periodic diarrhea or loose stool is often uncritically considered a sign of IBS. We need to be more critical in our thought process. If the dog always has diarrhea or soft/loose stool when the client returns home, but not on weekends when the client is home, the dog may have subclinical separation anxiety or separation that is undiagnosed.
Dog owners who have rescue dogs or have adopted dogs from shelters may be ‘pre-adapted’ to watch for signs of separation anxiety. By ensuring that they know the history of the dog in their care veterinarians can provide anticipatory guidance.
Affiliations between veterinarians – and pure breed groups – and shelter/rescue groups can only help decrease the severity of separation anxiety experienced by the affected dogs.
All dogs should be screened for all behavioral conditions at all visits to your veterinarian. Dogs with separation anxiety worsen the longer they are untreated.
IS SEPARATION ANXIETY COMMON?
It is fairly common – estimates are that 10-20% of dogs could experience it at some point, and some people estimate that affected dogs could go as high as 30%. As with most canine conditions we do not really know, and as noted, what is bothering the client is noted first, and not all signs are easily noted.
WHEN DOES SEPARATION ANXIETY COMMONLY OCCUR?
Depending on the form – some dogs have internal clocks (they can wait until 5PM but not 8PM), older dogs may have nighttime anxiety (which may be the first phase of cognitive dysfunction and/or debility associated with changes in auditory/visual cues), but most dogs who have the most common morph are distressed with the first 30 minutes of being left alone.
HAS RESEARCH BEEN ABLE TO COME UP WITH AN ACTUAL DEFINITION OF SEPARATION ANXIETY?
There is likely a genetic predisposition to all of this. Separation anxiety is so many things that without a good survey of what dogs actually do, we are unlikely to identify associations worthy of further study. We do not know what ‘normal’ is. Given that the different forms of separation anxiety respond differently to meds and involve different regions of the amygdala…there is a lot to think about here. People think this is completely understood, it is not.
We tend to see most behavioral conditions appear as full blown conditions as the dog is undergoing social maturity but puppies 4-6 months of age can also show separation anxiety.
CAN SEPARATION ANXIETY BE TREATED?
Strangely enough, we may not completely understand them but virtually all behavior problems in dogs respond to treatment. Questions about the presence and pattern of behaviors associated with separation anxiety should be included in all histories for all visits because the problem is among the most common canine problems, and yet is so often missed in its early stages. Early intervention is important.
CONSULTATION FOR DOG SEPARATION ANXIETY
Your veterinarian is the best person to consult and should be screening all dogs and cats at all non-emergency appointments for behavioral problems. It can’t be over emphasized at how important these visits are, but most vets still receive little or no formal training in veterinary behavioral medicine.
EDUCATION OF THE DOG OWNER IN THE UNDERSTANDING OF SEPARATION ANXIETY
While there may be attachment concerns for some types of separation anxiety, breaking the dog and owner ‘bond’ and ignoring the dog is a disaster. Owners should instead learn the signs of calm behavior versus anxious behavior and only reward calm behavior throughout. Dogs that are anxious may look normal part of the time, but they actually may not be and the best time to teach a dog that they do not have to distressed, is when they are not frantic.
Owners should be encouraged to keep a log of your dog’s behavior using the non-specific signs exhibited by the dog. Monitoring the non-specific signs allows the owner and the veterinarian to recognize the dog’s progress, or lack thereof. The pattern of the signs can also be essential in helping the vet to decide if the dog meets the criteria for diagnosis, in cases where multiple behavioral conditions may be ongoing.
For example if the owner learns that the dog can be left for 4 hours without elimination, but not 6 hours, then the owner knows that – for now – he needs to avoid longer absences. Avoidance is key in the treatment of all behavioral problems since every time the behavior – no matter how undesirable or abnormal – is repeated, the dog will be reinforced for that behavior. Practice reinforces learning at the molecular level is reinforced. Logs are best used in combination with video surveillance because some signs are much easier for owners to note than others.
HOW CAN YOU USE THE DOGS ENVIRONMENT TO HELP WITH HIS SEPARATION ANXIETY?
Never should the dog be left alone unless there is no other choice. The dog may be able to go many places with the owner
A lot of dogs with separation anxiety are less distressed if left in cars because cars signal that the owner is going to come back. Just like with children Never Leave A Dog In A Car In Hot Or Even Warm weather, Ever!. Even when weather isn’t a problem leaving a dog in a car is an emergency, short-term situation and may not be appropriate in certain locations. There have been report of the dog damaging the inside of the car.
Dog sitters, dog walkers, day care, boarding, pet sitting by an older child who is not otherwise allowed to have a dog may all be options that could mitigate the dog’s distress.
If the dog likes crates, will go into a crate willingly, can sleep and eat in a crate, and is calm when in a closed and locked crate, crating or gating the dog may be part of the solution.
But not all dogs can be crated/gated. Many dogs have broken their nails or teeth attempting to get out of the crate, and dogs have killed themselves by becoming entangled in or impaled on the crate when they’ve panicked. Owners should not even consider using a crate as a management strategy for dogs with separation anxiety unless they can video the dog responding as stated when they are home and not with the dog for hours at a time. The risk of gating or crating a dog who views this as entrapment rather than security is huge, and in such cases, it will always make the dog worse.
Never should a dog with separation anxiety be tied-up. Tied dogs are at increased risk of injury or death from strangulation if they become distressed.
Food toys can be good indicators of when dogs start to improve enough to eat, but they are not a treatment for separation anxiety. Dogs who are profoundly distressed cannot eat. If a fresh food toy is left for the dog daily, the day he starts to use it indicates that he was sufficiently less distressed to be able to take food and so to be rewarded for less distress.
Sadly, dogs vary from less to more distressed during the time they are left, so thinking of the food toy as a true reward for not reacting to an absence may not be accurate.
BEHAVIOR MODIFICATION STRATEGIES THAT CAN HELP YOUR DOG
All emphasis must be placed on ensuring that the dog does not panic and that she learns to be as calm as possible when left or as people signal that they might leave.
A cue that may trigger worry or panic for the dog may be one that occurred the night before. When owners only set an alarm, lay out clothes or pack a briefcase on the night before they will leave the dog could start to show signs or distress or panic the night before. Routines to teach the dog that she should remain calm and not worry need to address these triggers also.
2 COMMON REASONS OWNERS INADVERTENTLY REWARD ANXIOUS BEHAVIOR.
They think the dog is just seeking their attention and they don’t distinguish between dogs that want attention and those who need it, so the latter group of dogs is inadvertently rewarded for anxious, pesky behaviors.
They recognize that the dog is distressed and they are seeking ot reassure the dog. Unless the dog is rewarded only when calm, anxious behaviors are also being reinforced resulting in a miscommunication.
Dogs who are globally anxious will benefit greatly from deep breathing. Deep breathing allows owners to use the physical signs of an underlying physiological state to help decide how much and what kind of attention to provide these dogs. Attention of the right sort will help these dogs improve at the most rapid rate possible. If she can learn that she is rewarded for physiological changes that indicate a lower reactive state, the dog will not only learn to calm down to get attention but will also learn that she feels better when she does and will repeat these behaviors (this is cognitive therapy for dogs).
Owners should ignore all instructions to ignore these dogs until they lie down and stop interacting with the owner. This is probably both counter-productive and cruel.
Co-morbidity is the rule with anxiety conditions, and lack of human input, especially when the human is available, may contribute to true clinical depression in these dogs.
While we do not wish to reward the anxious behaviors, we also must avoid behaviors that provide the dogs with no useful information. Punishment – which is how the dog could interpret this tactic – does not provide information about which behaviors are rewarded.
It is far more preferable to talk calmly to the dog, but not hug, kiss, fawn over, or otherwise interact in any way that provisions social attention until the dog is calm enough to ensure that anxious behaviors are not being inadvertently reinforced.
BEHAVIORAL PROTOCOLS CAN BE USED TO TEACH DOGS TO BE LESS ANXIOUS
Leaving the dog alone is no way to teach him that he will be rewarded for calm behavior, unless he can learn that he will be rewarded when in the presence of the owner. Until the dog can sit calmly and wait for the owners rewards and cues while separated in the house and under different types of stimulating circumstances, it is useless to try to implement this plan when the owner leaves the home.
It is recommended that treatment of separation anxiety include instructions to teach the dog to ignore ‘departure cues’. This test also has a handout about how to implement this recommendation. The intent of these ‘departure cues’ is to desensitize dogs – who are already sensitized to cues that signal the owners departure – to such cues. Common cues that cause dogs distress can include packing or picking up a briefcase, putting on sunglasses, picking up the car keys, for example. When the owner can identify cues that cause the dog to begin to worry – including setting an alarm the night before a departure – and if they are successful in their initial behavior modification efforts they may be able to use desensitization and counter – conditioning techniques to help the dogs not react to these triggers.
Be cautious, in attempting rapid progression by trying to fix everything at once. All behavior modification should be monitored for behaviors indicating progress and those indicating trouble. It is easy to video any desensitization plan that uses departure cues. Any owner seeking to desensitize dogs to events, triggers, et cetera associated with actually leaving the dog alone need to be aware that there is a huge risk that they will actually sensitize the dog and make him worse. Video will allow the owners to see if their interventions are having the desired effect.
Owner are often encouraged to teach the dog that he can be left alone for increasing amounts of time or that he need not be so concerned about activities that occur by the door. Again, these behavior modification programs may be helpful if the client be helpful if the owner is good at basic behavior modification techniques and they can monitor the dog’s response using video. Otherwise, these techniques can cause the dog to worsen and to become more sensitized and reactive to departures and activity at doors.
When there is any doubt, watch a video of the owners work with the dog and the results.
If there is still a concern that the client may not be executing the behavior modification well and correctly they are encouraged to enlist the help of an educated and certified trainer who is excellent at operant conditioning and techniques used in behavior modification and who has the certification and ethical credentials that provide some comfort level that only positive techniques will be used.
CAN DRUGS HELP TREAT THE ANXIETY
There are diets such as the brand CALM Diet formulated by Royal Canin, which contains alpha-casozepine and an anti-oxidant complex of vitamin E, vitamin C, taurine and lutein is intended to be fed before and during stressful events. There isn’t any specific, controlled data for the treatment of dogs with separation anxiety, and in the published literature the effects were mild.
Nutraceuticals like alpha-casozepine (brands: Zylkene, L-theanine (Anxitane); Calmex (which includes other compounds), and Harmonese have been reported to help distressed and anxious animals, but there are no specific, controlled data for separation anxiety.
Because the act of being distressed, anxious, and panicky can itself contribute to the production of reactive oxygen species and other neurochemical stressors, non-specific treatment with anti-oxidants and omega-3 fatty acids (Nordic Naturals) may provide an ancillary benefit for patients with many behavioral conditions, including separation anxiety.
It has been shown that dogs with separation anxiety and/or other co-morbid anxieties may have period diarrhea. There have been suggestions that probiotic supplements or additions of food containing probiotics (such as natural yogurts) to the diet may support a ‘healthier’ and less reactive gastro-intestinal system and provide ‘immune support’. Data for such interventions in behavioral conditions are lacking – and clients should know this – but there are few to no risks to such approaches.
Medication is almost always an essential part of treatment of clinical separation anxiety. In the USA two medications have had veterinary labels and are licensed for use in dogs with separation anxiety (brands: Reconcile [fluoxetine: Lilly] and Clomicalm [clomipramine: Novartis]; only Clomicalm is now marketed for dogs. For the most part we use human generic medications.
And as a result of the placebo-controlled, double blind studies require to license these medications we know that they substantially decrease distressed behaviors in dogs over a treatment period of 2 months.
Clomipramine has been studied for long-term treatment of separation anxiety with favorable outcomes.
In both the clomipramine and fluoxetine studies, treatment with medication sped the rate at which dogs acquired calmer behaviors through behavior modification, in addition to having direct effects on anxiety.
Medications to which these dogs best responded to include/may include:
TCAs (clomipramine, amitriptyline if in combination with an SSRI). If the separation anxiety is primarily characterized by ritualistic components, clomipramine may be the drug of choice.
SSRIs (fluoxetine, sertraline, luvoxamine). When the separation anxiety is primarily characterized by explosive components, fluoxetine may be the drug of choice.
SARIs (trazadone). Trazadone affects regions of the brain associated with motor activity and so may be a suitable ancillary medication for some affected dogs.
Benzodiazepines (alprazolam, clonazepam) may be helpful if there is concomitant noise reactivity/phobia or the dog’s reaction to a specific stimulus or set of stimuli is extreme because they affect the reticular activating system. BZD can be used as discussed in the protocols for noise/storm phobia and panic.
Gabapentin, alone or in combination with TCAs and/or SSRIs, may be useful if reactivity is the primary concern. The side effect profile of this medication is favorable so owners may feel more confident when using it in combination with other medications. Because it affects BZD receptors it may also augment BZDs without some of the more systemic potential side effects of BZD (e.g., concerns about any of the hepatic metabolic pathways.
Central alpha agonists like clonidine depending on the level of the arousal response. For dogs who panic this medication is an option should the dog be unresponsive to or suffer from side effects of BZD, and be unresponsive to gabapentin. Because clonidine affects central NE/NA receptors, the peripheral sympathetic response is lessoned which helps some dogs who become quickly and profoundly distressed.
Because the diarrhea may be a non-specific sign of arousal, as needed treatment with Imodium may be beneficial since it will decrease a physiological component of arousal.
IS USING DRUGS CONCURRENTLY WITH BEHAVIOR MODIFICATION BENEFICIAL?
Medication is best used with behavior modification. All the placebo controlled double blind studies have shown that dogs treated with medication acquire the behavior modification more quickly. When the owner has anti-anxiety medication in their home for human use can it be used on their dogs? The answer is ‘no’, and it shouldn’t be used for other people either. Dosages and formulations may vary so seek the advice of your vet. In fact, your dog can end up with the same fluoxetine you’re getting, but you need the informed environment that makes such coincidence occur safely and responsibly.
THE USE OF GABAPENTIN TO HELP MANAGE ANXIETY IN DOGS
For some veterinary patients, the anti-anxiety effects of a single medication might not be enough. When monotherapy is insufficient, consider adding this drug to your treatment plan.
The use of psychoactive pharmaceuticals in veterinary behavior medicine has proved invaluable in managing anxiety-based disorders. Without the appropriate and judicious use of these medications, many dogs would be much less likely to respond to treatment with environmental management and behavior modification therapy.
Medications such as fluoxetine and sertraline (selective serotonin reuptake inhibitors [SSRIs]) and clomipramine (a tricyclic antidepressant [TCA]) can successfully treat patients affected by conditions such as separation anxiety, noise phobia and fear-based aggression. In some cases, however, use of a single pharmaceutical agent doesn’t provide sufficient anti-anxiety effects to achieve a suitable outcome. When a patient fails to respond to monotherapy with an SSRI or a TCA, veterinarians have three options:1-3
1. Increase the dose of the medication if the typical maximum dose has not been reached and the patient has not shown undesirable side effects.
2. Switch to a different drug.
3. Augment the first drug with a second drug.
If the first two steps prove ineffective in reducing the intensity or frequency of the patient’s fear or anxiety, combination drug therapy is a viable option. Numerous possible combinations of agents can be used to manage particular cases. In this article, we review the use of gabapentin in dogs for treating anxiety-related conditions.
Indication and dosage
Traditionally, gabapentin has been utilized in veterinary medicine for management of neuropathic pain and as an anticonvulsant.4 However, in human medicine it has also been used to treat patients with social anxiety and panic disorder.5 In the last several years veterinary behaviorists have used gabapentin as an adjunctive therapy for anxiety in dogs and cats. In dogs, it is frequently used in the treatment of generalized anxiety, impulsivity, phobias and panic disorders, and compulsive disorders.3
Generally, gabapentin is used as an adjunctive medication when an SSRI or TCA has already been prescribed but has failed to significantly reduce the intensity of the patient’s fear or anxiety. Gabapentin has frequently been given alongside fluoxetine, sertraline, paroxetine and clomipramine in treating these conditions.
Gabapentin is a structural analog of gamma-aminobutyric acid (GABA), but it does not interact with GABA receptors nor does it affect GABA uptake or degradation.4 Gabapentin binds selectively to the alpha-2-delta subunit on voltage-sensitive calcium channels, thereby reducing the release of excitatory neurotransmitters, including glutamate, from presynaptic neurons.5 These calcium channels are upregulated when nerves are stimulated in conditions such as epilepsy, neuropathic pain and anxiety.4,5 Blocking these channels has minimal effect on normal neurons but suppresses stimulated neurons.4
In dogs, gabapentin is metabolized into N-methyl-gabapentin.6 It has greater than 80% systemic oral availability,7 and absorption is not affected by food. Maximum blood levels are achieved in one to three hours and it has an elimination half-life of three to four hours.6 Gabapentin is excreted almost completely by the kidneys and it does not rely on hepatic biotransformation,7 making it a good choice for patients with hepatic disease.
Dosages can vary, but commonly gabapentin is dosed in dogs at 5-30 mg/kg up to three times daily,3 though in our own patients we have used 10-40 mg/kg up to three times daily as well. Gabapentin has also been used on an as-needed basis to achieve anxiolysis at 30-60 mg/kg one to two hours before an anticipated stressful event, such as a veterinary visit.
Experts suggest beginning at the low end of the dose range and gradually titrating up to effect with dose adjustments occurring about seven days apart, allowing time to evaluate the effect. Wean patients off gabapentin gradually to reduce the potential for seizures.8 Also, when using this drug in conjunction with antacids, separate dosing by two hours.8 Keep in mind that gabapentin can cause a false positive result for urinary protein, and concomitant use of morphine or hydromorphone can result in increased activity of gabapentin as well as causing a reduced activity of the opioid.8
While we’re discussing dogs here, it’s worth noting that in cats, gabapentin is increasingly being used prior to veterinary visits at a dose of 10 mg/kg up to 100 mg/cat given 1.5 to 3 hours before an appointment.9
The drug is available in 100-, 300- and 400-mg capsules as well as 600- and 800-mg tablets. Use caution when prescribing or administering prepared liquid gabapentin since some formulations contain xylitol as a flavoring agent.
Potential side effects
While sedation and ataxia can occur with the use of gabapentin, there have been no reported serious safety issues in animals.4 In our experience, other possible side effects include gastrointestinal distress—such as loss of appetite, vomiting and diarrhea—and increased anxiety or agitation.
These side effects are typically transient and mild. In some cases, however, effects can be more prolonged and serious. Be sure to educate clients about possible side effects and tell them to contact you or another veterinarian immediately with any concerns.
If you encounter adverse effects, you can decrease the dose (50% reduction is common) or, in more severe cases, discontinue the medication completely. While compounds with longer half-lives (such as SSRIs) can be discontinued abruptly, shorter-acting compounds, such as gabapentin, should be gradually tapered to minimize withdrawal signs. Gradual withdrawal is also helpful in cases when there is a need to determine the lowest effective dose.
Dose adjustments for gabapentin can be made every one or two weeks. There is no need to withdraw these medications before anesthesia, but consider reducing premedication sedation to minimize interactions.
In order to monitor hepatic and renal function, perform baseline premedication database testing, including a complete blood count, serum chemistry profile and urinalysis. Repeat this testing one or two months after starting the medication and then again every six to 12 months.
Summary
Gabapentin is an excellent option in managing anxiety when previous therapies alone have proven to be insufficient. It may be used situationally, prior to predictable stressful events, or administered daily in combination with an SSRI or TCA. With judicious management of dosing and close communication with owners, gabapentin can be an effective and safe adjunctive agent for the treatment of behavioral disorders.
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