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

Introduction:

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

Signalment:

At the initial consult Solo, a male, intact, red Border Collie, was approximately12 months.

Presenting complaint:

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

She could not even close the door to show without Solo shrieking andattempting to dig through the door. His vocalization was a problem becauseshe lived in an apartment where, technically, dogs were not allowed. Thedestruction was a problem because of the expense and the risk to Solo whenhe had to be left. The client also had a cat to whom this dog seemed inordinatelyattentive.

History:

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

The Pom had been a terrific little dog and had enjoyed huge popularityat the university where she attended numerous classes. The client had notbeen permitted to have dogs when she grew up, and the Pom had been her firstdog. The Pom was also an easy dog - not only had she been charming, complacentand easy to train, but she was perfectly happy to be stuck in an oversizedbookbag to travel with her owner. The client had been counseled that griefaffected all people differently, and that she should think seriously aboutwhether another dog was the best choice at the stage of her life when shewas expecting to travel to do her fieldwork.

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

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

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

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

Clingy, but not cuddly

Solo was clingy to her, but not cuddly. He didn't want to be held, hedidn't play, he didn't seem to know what toys were, but she had to be constantlyin 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 whatdog treats were. He just vocalized, stared, cowered and destroyed. Whenthe client - who was still in deep mourning over the loss of the Pom wouldcry from loss and frustration, he withdrew more.

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

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

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

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

Provide a safe haven

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

When I patted my lap, he dove in, and I just pressed on him and pettedhim 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 thinkof 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 keepthis 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 breedhim, but never quite got around to it. So, the dog was kept locked up mostof the time.

Before coming to rescue, he'd gone to a herding farm but was bouncedalmost immediately because he chased the sheep. We had no idea if he'd everseen anyone early in his life except these two women, if he'd had any othersocial exposure; what he knew; where he'd been; he was one large darkhole.

Physical and laboratory evaluations:

Neither physical nor laboratory examination revealed any deficits orconcerns. Solo's coat was terrible - sparse, dull, broken in spots - butsuggested less than premium nutrition and lack of grooming rather than underlyingdisease.

Diagnosis:

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

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

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

I encouraged the client to realize that it was likely that this dog hasmissed beneficial exposure during most of the sensitive periods if the storywas true. Sensitive periods - a term preferred but less often used thansocialization periods - are developmental stages where, if a dog is prohibitedfrom exposure to the relevant stimuli, they are more at risk for developingproblems attendant with exposure they missed.

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

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

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

If this was so, he could improve, but the trajectory would be shallowand 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 neverhave 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 onewhereby serotonin is not actually the target, but is the neurochemical bywhich access is gained to the target.

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

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

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

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

Furthermore, these recent findings suggest that we should be trying drugssooner, rather than later, and using them especially to enhance the gainsmade 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. 12h x 4 weeks (target dose), minimum. Maintenance was to be at the targetdose.

Solo was also placed on the Protocol for Deference and the Protocol forRelaxation, and it was emphasized to the client that the goal here was notto have him "earn" attention. The goal was to use inherent, naturallydeferential behaviors in dogs (e.g. sitting) to encourage them to seek guidance(this is what deference really is) from their owners in situations in whichthey might be uncertain.

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

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

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

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