Separation anxiety – New approaches to therapy (Proceedings)

Causes of separation anxiety

Domestication and selective breeding (genetics) may lead to increasingly affectionate, socially dependent and infantilized dogs with excessive owner attachment and intolerance to being left alone. Puppies that come to expect excessive social interactions following adoption, may be unable to handle subsequent decrease in social interaction. Therefore, gradually introducing puppies to separation and enforcing time away from puppies may help them better cope with spending time alone When separation distress reactions persist beyond the puppy stage they are maladaptive and may be indicative of a either dysfunctional attachment or perhaps even a pathological state.

Separation anxiety may also be acquired. For example, separation anxiety may arise when a dog is suddenly separated from its owners following a period of constant contact or after a sudden change in routine. In addition, separation anxiety may develop in individuals that have other anxiety disorders, such as noise and storm phobias. These dogs may become dependent on the owners to alleviate their anxiety and the owners' response may further intensify the behavior.

Clinical signs

The most common signs of separation anxiety are vocalization, destructiveness, and housesoiling during the owner's absence. Since the anxiety is due to the dog inability to gain access to the owners, the behavior is not likely to be seen when the owners are at home or the dog has access to the owners. Destructive activity may focus on doors, confinement area exits, or owner possessions, such as clothes and furniture. When owners are at home, dogs with separation anxiety commonly exhibit extreme following, continuous seeking of contact, departure cue anxiety, excessive greeting and rarely spend time outdoors alone. Other signs related to the pets anxiety might include depression, anorexia during departure (which resumes when the owner is home), hypersalivation, vomiting and diarrhea, increased motor activity, excess licking or grooming, acral lick dermatitis, restlessness, shivering and shaking, stereotypic behaviors such as ritualized circling and pacing, and occasional cases of aggression as the owners prepare to depart.. Most signs arise prior to or within the first 30 minutes of departure. Signs may decrease over time or have a cyclical nature ranging from 25 to 60 minutes.. External stimuli can also lead to rearousal.

Diagnosing separation anxiety

Although the presence of destruction, vocalization and to a lesser extent elimination when the owner departs may be due to separation anxiety, other possible causes for these signs must be ruled out. While video monitoring is the most accurate means of assessing whether the signs are due to anxiety, and for assessing response to therapy, this is sometimes impractical. The primary reason for ruling out separation anxiety would be if the signs arise when the owner is present or has access to the owners. If the signs arise primarily in the owner's absence but with increasing duration of departure, rather than arising prior to or immediately following departure, separation anxiety is less likely to be the cause. Pets that are crated, confined, or caged may be distressed about the confinement itself and may react with anxiety, destructive behavior, escape attempts, and vocalization. Therefore dogs that are crated or confined should be evaluated when the owners are at home; conversely the owners should determine the pet's response during departure when the dog is not confined. The tonality and quality of vocalization can also be an indication of whether, it is related to distress or other causes.

Prognosis

When behavior modification is combined with drug or pheromone therapy a faster and greater improvement can be achieved, with 73% overall improvement after 8 weeks with fluoxetine plus behavior modification compared to 51% improvement with behavior modification alone, while 63% of dogs treated with clomipramine plus behavior modification showed improvement after 4 weeks compared to 29% of placebo cases. Some dogs required ongoing treatment to maintain or improve control.11 Although an extensive program specifically tailored to the pet and the owner may be most successful if the owner is willing and compliant, the prognosis appears to be poorest when more instructions are given (>5).

Treating separation anxiety

The consultation should begin with an explanation of why the pet is displaying the undesirable behaviors, to insure that the owners are aware that their dog is anxious (rather than spiteful) because it cannot cope with separation from the owner. A combination of behavior modification and drugs are most effective for reducing the pet's anxiety and its over dependent state. Training should focus on reinforcing settled, calm and independent behaviors and not anxious or attention seeking behavior. Since any program will take time to implement some more immediate, temporary steps may be necessary. Unless the owner can schedule time at home to work on the problem, other alternatives include day care, house sitters, a dog walker (for pets that tolerate short departures), confinement training, or anxiolytics.

A combination of behavior modification and medication will need to be combined to reduce the pet's anxiety and overdependent state. The owners should be advised that training must focus on reinforcing settled, calm and independent behaviors and never anxious nor attention seeking behaviors. Therefore during the consultation, all potential rewards should be identified and the owner instructed as to how these can be used to gradually train and shape longer times spent without owner interaction. Prior to any specific therapy for separation anxiety, the owners should also receive some basic counseling on the need for a predictable daily routine which provides sufficient opportunities for social interactions, physical exercise and elimination, followed by scheduled periods of inattention where the dog can engage in object play or spend time in a resting or bedding area. The specific program can then be reviewed.

Behavior modification

Enrichment and predictability

Develop a predictable daily routine that provides social interactions, exercise, training, enrichment and an opportunity to eliminate on a schedule that matches when the owner will be at home, and to play with toys and relax (periods of inattention) when the owner is usually away from home.

Reinforcement based training

a) The goal of training is to teach the dog to feel comfortable and secure when the owner is not present. The owners should therefore identify all rewards and remove them entirely except for when the pet is calm and settled. This should be practiced whenever the owner has food, treats, or toys that can be used to train or motivate the dog, as well as whenever the dog wants something of value including affection and attention. Conversely, the dog should never be rewarded for solicitous behavior. While ignoring the dog until it settles is an effective means of teaching the dog what behaviors earn rewards, ignoring can be difficult at the outset since the behavior is likely to intensify before it becomes extinct. It may help to add a visual cue for inattention (such as working on the computer or reading a book, so that the owner could consider placing a towel or blanket on their laps for the duration of inattention training. Training with lure and target techniques, clicker training, or using a head halter can be effective ways to faster achieve desirable outcomes.

b) Gradually shape longer stays and more relaxed behaviors so that the dog learns to spend longer sessions without owner interaction. After each social play, exercise, and training session, this would be the ideal time to practice extended down stays, preferably in a location where the pet can find alternative outlets to help it settle. Try establishing a comfortable mat or bed for training purposes, and gradually spend increasing time and increasing distance away from the pet. During these times, the pet can be given its favored chew objects and stuffed toys to help encourage use of the area (exploratory play). The owner might also use cues that the pet associates with their presence (non-departure) that might help to reduce departure anxiety such as leaving on a TV or radio. Sometimes a piece of the owners clothing, DAP or aromatherapy may also help to relax some pets.

c) Do not punish or reprimand undesirable behavior. Punishment can act as an inadvertent reinforcer (negative attention) or can cause further anxiety and conflict.

Departure cues

Most dogs quickly learn to associate certain cues with departure, such as picking up keys or a purse, opening an exit door, opening the garage, or starting the car. While many of these cues might merely be avoided (see below), another alternative is to decouple these cues from actual departures. For example, the owners might handle their keys or purse, put on a coat, or open and shut the door without actually departing. Associating rewards with these activities (counterconditioning) may help achieve faster results.

Graduated departures

When the pet is relaxed or distracted with a toy in its mat area, graduated departures can begin. The owner should leave while the pet is calm and return before the pet becomes excessively anxious. Gradually increase the length and duration of departure. Some owners will find that if they can leave without the dog noticing their departure (i.e. while it is sleeping, or distracted by its toys, a CD or TV), the dog may not become anxious.

Actual arrivals and departures

Exercise, play, attention, and elimination should be completed at least 15 to 20 minutes before departure. The owners should then utilize the same settle exercises and schedule that have been practiced during training sessions and distract the pet with a number of highly motivating chews and treats. Toys that can be stuffed, frozen, delivered over time or have the longest possible duration may provide the best and longest distraction. Depart when the pet is settled or resting and provide cues that are associated with non-departure. Initially the departure lengths should approximate the maximum length that the dog will remain relaxed during training sessions. At homecoming, no attention should be offered until the pet settles.

Immediate management

Most dogs with separation anxiety will take weeks to months to adapt to the new training and routine and for drug therapy to be effective. Therefore temporary management measures will be required for both the owner and the pet in the short term. Some dogs can be crated or left in a confined area in the home where they will minimal damage and anxiolytics such as benzodiazepines or DAP might be added for a more immediate anxiolytic effect. Some owners can leave for a short time if they sneak out when the dog is sleeping or occupied while some owners will find that the dog has less problems when certain family members leave, so that this can leave last. As training progresses, dogs that begin to feel comfortable with inattention when they are resting in their bed might be left alone for a few hours as long as the owner or perhaps even a dog walker returns before the anxiety recurs. Alternately day care, pet sitters or short term anxiolytics may be needed.

Drugs and pheromones

Drugs are used in conjunction with behavior modification to reduce the pet's anxiety, improve learning and help it to better cope with owner departures especially during the initial retraining. In placebo controlled studies with fluoxetine and clomipramine plus behavior modification, significant improvement was demonstrated over behavior modification alone. In another study fluoxetine was compared to placebo without concurrent behavior modification and while a significant drug effect was demonstrated, greater and more significant improvement was achieved using a combination of behavior modification and fluoxetine.12 Amitriptyline is another tricyclic antidepressant that has been suggested as a treatment option for separation anxiety. However, it is not licensed for use in dogs, and in one retrospective study only 56% of cases improved.8 Generally treatment should last about 8 weeks at which case some pets can be successfully controlled if weaned off medication. However, in one follow-up study of 76 cases treated with clomipramine plus behavior modification, 12 dogs had been on ongoing treatment for over 13 months and 10 of the dogs showed further improvement. Of 22 dogs with complete resolution when the drug was ceased, 13,6% relapsed.

While some improvement may be seen within the first week or two, generally 4 to 8 weeks are required to fully assess therapeutic effects.

a) Fluoxetine is a selective serotonin reuptake inhibitor that has recently been licensed in the United States for the treatment of separation anxiety in dogs at a dose of 1-2 mg/kg per day when combined a program of behavior modification. Anorexia and lethargy are the most common side effects. Clomipramine, also licensed for treatment of separation anxiety is a tricyclic antidepressant that inhibits serotonin reuptake and, to a lesser extent, noradrenaline reuptake. It also has anticholinergic and antihistaminic effects, which might account for some its side effects, such as lethargy, dry mouth or gastrointestinal upset. The dose is 1-2 mg/kg twice daily. Tricyclic antidepressants are contraindicated with cardiac disease, glaucoma, and where urine retention is a concern. While fluoxetine may theoretically lead to less side effects because it is selective for serotonin reuptake blockade, clomipramine has not been shown to have any adverse effects on the heart or intra-ocular pressure in healthy pets. Antidepressants should not be used concurrently with MAO inhibitors or other antidepressants and should be used cautiously in pets with seizures. DAP is a synthetic version of the intermammary appeasing pheromone from the lactating bitch. When a DAP diffuser was compared to clomipramine in a placebo controlled trial (both groups received behavior modification advice) behaviors improved in both groups over a 28 day trial with no significant difference between the two groups.10

b) Benzodiazepines such as alprazolam at .02-0.1 mg/kg, clorazepate, diazepam or clonazepam may be used on an as needed basis prior to departure. DAP, buspirone, or natural products that are purported to reduce anxiety might also be considered are no contraindications to concurrent use with antidepressants.

Summary

• A videotape and owner history are generally required to confirm a diagnosis of separation anxiety and rule out other potential causes. The videotape also provides for more accurate followup.

• Treatment will generally require the use of a reinforcement based behavior modification program where desirable (settled) behaviors are reinforced and attention seeking behaviors are ignored.

• Drugs are generally needed in conjunction with behavior modification to achieve faster and in some times a greater or more lasting improvement.

References

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