Separation Related Disorders in Dogs: A Practical Approach to Treatment in Primary Care
Introduction
Separation related disorders are common in dogs in the United States. Diagnoses and treatment in primary care is most effective when broken up into multiple, shorter appointments. Just as with medical appointments in which the technician takes the animal to another location to draw blood or administer treatments, the technician is an integral part of the efficient and effective management of behavior cases. This paper addresses the format through which separation anxiety cases can be diagnosed and treated effectively and efficiently in primary care practice.
Separation related disorders involve a physiologic response to the stress of isolation or separation from one or both of the owners. Some patients may only respond to the owner’s departure with a stress response when left completely alone, remaining calm if any person is home, even an unfamiliar one. Other patients will react to the movement of one particular owner throughout the house with no clear signs that the owner is actually departing.
The signs include: hypersalivation, urination, defecation, vomiting, panting, self-mutilation, destruction, attempts to escape, aggression, pacing, vocalization, immobilization, injury, and vocalization. Dogs with separation related disorders are often hyper-attached to one or both owners, showing increased greeting and following behavior. As mentioned above, dogs can exhibit signs of separation anxiety when there is a virtual absence (i.e., owner in another room), most commonly the signs will be exhibited when the owner has departed. The signs of separation related disorders can look very similar to other behavioral disorders such as storm phobia, noise phobia, canine cognitive dysfunction, inappropriate elimination, attention seeking behavior, normal territorial behavior, frustration related destruction and confinement anxiety. In addition, medical diseases which cause diarrhea, polyuria and/or polydipsia can cause elimination when the owner is not home leading to an incorrect diagnosis of separation anxiety. Because there is a physiologic component to this disorder, medical diagnoses can contribute and other behavior disorders can present similarly, it is imperative that the veterinarian interview the client and examine the patient to make the diagnosis. The best way to make an accurate diagnosis is through a detailed history obtained through a history form and interview and a video of the pet’s behavior when the owner departs. Once the diagnosis is made, the treatment plan can be laid out and the technician can be utilized to teach the owner how to implement the plan.
Just as in any discipline, there are basic tools necessary to treat behavior problems. A questionnaire and handouts are necessary to efficiently collect history and explain the treatment plan. Just as with dermatology and internal medicine cases, the veterinarian can rely heavily on the technicians in the practice to help gather an accurate history and communicate the treatment plan to the clients.
First Appointment
The focus of the first appointment is medical work up, diagnosis, and emergency treatment. Collecting history is more efficient with a one-page history form filled out while the client waits in the lobby. This way, the history taken in the examination room can be more targeted. A one-page questionnaire intended for use by primary care veterinarians is available on the Veterinarians page at the following website: www.flvetbehavior.com/. A complete physical examination is warranted with any ancillary tests indicated as necessary from the physical examination results. Most separation related disorders will need some sort of medical treatment in the form of either supplements or medications so screening labwork (CBC, serum chemistry, T4, fT4, U/A) is often indicated at the first appointment. When the history has been taken and the diagnosis made, emergency treatment intended to stabilize the patient should be instituted.
Emergency treatments take the form of environmental changes, avoidance and pharmaceutical therapy.
When deciding to institute pharmacologic therapy, the veterinary should consider 7 basic questions:
1. Is the environment conducive for a positive outcome?
2. What is the animal’s latency to arousal?
3. Is the animal’s quality of life affected?
4. Is the animal at risk?
5. Is the behavior predictable?
6. Is the behavior mild, moderate or severe?
7. Are there concurrent diagnoses which would cause medication choices to be limited?
While it is impossible to predict how diligently a particular client will implement the behavior modification and management changes, certain factors can be considered when assessing the adequacy of a particular environment. Veterinarians should consider the presence of young children, the number of caretakers in the house, the number of hours that the dog has to be left alone during the day and the owner’s willingness to participate. If the household is clearly deficit in the qualities needed for a positive outcome, medication should be strongly considered as a part of the treatment plan.
The latency to arousal is the amount of time that it takes for the animal to mount a stress response once the owner has started her morning routine. For example, if the dog begins to show signs of stress when the owner picks up her keys, the dog has a long latency to arousal. If the dog shows signs of stress when the owner’s alarm goes off or when she takes a shower (early in the departure sequence) she has a short latency to arousal. Dogs with a short latency to arousal should be considered candidates for treatment with at least one pharmaceutical.
Behavior problems can significantly affect an animal’s quality of life. Daily panic attacks contribute to chronic stress which can cause various sequelae including suppression of the immune system and muscle wasting. If the animal’s stress reaction is intense on a daily basis, a pharmaceutical should be considered as a part of the treatment plan.
The assessment of risk to the patient is dependent on owner attitude toward the patient and the problem as well as the strength of the human animal bond. Because the signs of separation anxiety frequently include damage to the owner’s property and the injury to the pet, it is not uncommon for owners to approach their veterinarian about euthanasia. If the owner is considering euthanasia or if the pet is causing injury to herself, a pharmaceutical should be considered for the patient.
Predictable behaviors can often be treated with PRN pharmaceutical whereas unpredictable behaviors or behaviors where the stimulus cannot be controlled are more likely to need a daily administered maintenance medication and/or an as needed medication.
The veterinarian should attempt to characterize behaviors as mild moderate or severe. There is no validated scale which can be used to classify the severity of behaviors, however, generally the veterinarian should consider whether or not the patient has injured itself, the strength of the physiologic reaction which accompanies the behavior and the owner’s stress level.
Patient’s whose owners can’t premedicate for departures or who have concurrent behavioral diagnoses will most likely need long term and PRN pharmaceutical treatment. Patients who are mildly affected or who have concurrent medical diseases may be better served through the use of supplements instead of medications. The choice of an individual supplement or medication should be made based on the clinical signs of the patient. For example, if the patient is withdrawn and will not eat while the owner is gone, a benzodiazepine which will increase appetite, decrease anxiety and elevate mood while offering mild sedation or Zylkene® may be the best choice. On the other hand if the patient is frantic, panting and pacing, raiding the garbage, trazodone or Solliquin® may be the most successful pharmaceutical treatment.
Once the decision of whether or not to institute medical treatment has been made, the veterinarian should prescribe behavior modification and management changes. The standard of care for veterinary behavioral medicine is to prescribe behavior modification for behavioral diseases.
First appointment management changes include: leaving the dog with food toys, hiding departure cues from the dog, discontinuing all punishment and making the owner’s departure and return nonevents. Many dogs with separation related disorders are best treated without confinement due to the likelihood of confinement anxiety. Finally, offer day boarding or daycare until the dog is stable.
An appointment should be made within 7 days for behavioral treatments. These treatments are generally conducted by the technician and include: adding structure to the owner/dog relationship, rewarding the dog when he is relaxed and stopping all physical punishment. Make sure to address any safety issues and ask the owner if the dog is showing any aggression toward the family.
The second appointment should be scheduled about one month after the initial appointment. At this appointment, additional history should be gathered, progress and the effect of medications can be assessed and second level behavior modification should be recommended. At this time, medication changes can be made as well. During this appointment, the technician will become indispensable, as she will be teaching the client how to complete the behavior modification. Second line behavior modification includes techniques that are best completed when the dog’s anxiety has started to subside. These include uncoupling departure cues and relaxation techniques.
A third appointment should be scheduled 8–12 weeks from the first appointment. At this appointment, gradual departures can be added if needed and the effect of the daily-administered medication (if prescribed) can be assessed completely. At this time, any changes to medication doses can be made and a more accurate prognosis can be given to the owner.