Karen L. Overall, MA, VMD, PhD, DACVB, CAAB
Dr. Overall, faculty member at the University of Pennsylvania, has given hundreds of national and international presentations on behavioral medicine. She is diplomate of the American College of Veterinary Behavior (ACVB) and is board-certified by the Animal Behavior Society (ABS) as an Applied Animal Behaviorist.
So, for all the pets who suffer, here's the take home message: Storm and noise phobias are emergencies.
Storm phobias: No other problem is as widespread, as devastating for the animal, and as frustrating for the veterinarian in practice as is the issue of managing animals experience seasonal terror.
Karen L. Overall
The issue of noise and storm phobias and their tendency to be associated with other anxiety disorders was an issue much discussed by me and others at the recent AVMA meetings and the associated behavior meetings. Ironically, as these meetings were wrapping up, a dog I loved very much was dying - because of her terror of storms.
About nine years ago, I obtained a retired show champion Tibetan Spaniel, Susie, for my mother, with the understanding that should my mother predecease the dog, the dog would come to me. During the time that my mother had Susie, the dog became more fearful of storms of all kinds, as are many dogs in the southeast United States.
Whenever my mother would tell me how much Susie had suffered during the most recent storm, I would launch into my speech about how much medication can help, and how important it is to treat these dogs early and often.
My mother's response was invariably that drugs were overused. Susie just needed love. My mother would hold her to get through the storm, and Susie was fine, but tired, the next day. It's entirely possible that my mother could or would have taken advice about medication from anyone but me, but this logic is also something that veterinarians in practice tell me they often hear from clients. Surely, I failed to convince the client to avail herself of expertise.
When my mother died, the people who had been fostering Susie for the months when my mother was unable to care for her asked if they could keep her. I had no choice but to acquiesce: they loved her and were in tears at the thought of me taking her away. Again, I mentioned treatment for storms, but their response was that their other little dog was also distressed during storms and they would just sit with her.
The day after the AVMA meetings wrapped up, I answered the phone to hear the voices of Susie's adopted parents. They wanted me to know that there had been a terrible series of storms the night before.
Susie had trouble breathing during the first one. During the second storm — in the middle of the night and in these people's arms - Susie went into cardiac and respiratory arrest and died.
Susie's adopted parents asked me if she had always been so terrified of storms. My response was no; her terror worsened with time and exposure. How could I revisit the drug argument with someone who held a dead dog?
So, for all the pets who suffer, here's the take home message:
Storm and noise phobias are emergencies.
They will only worsen with exposure, and the rate at which they worsen depends on the neurochemistry of the dog and the severity and unpredictability of the storms.
Data suggest that ~70 percent of all dogs who react profoundly to miscellaneous noises also have storm phobias, and 90 percent of dogs with storm phobias react badly to other noises.
Co-morbidity is the rule: ~70 percent of dogs seen in a clinical setting with noise or storm phobias also have often undiagnosed separation anxiety. Screen for all of these at every visit.
Dogs experiencing fearful noises (e.g. shipping on a plane) as youngsters may be at increased risk for later development of more profound noise or storm phobias.
Dogs who react to storms may not be reacting to the noise: trigger stimuli could include other sounds (wind, rain), darkness, changes in light intensity, barometric pressure changes, ozone changes and changes in human behavior. Any of these can lead to panic and must be treated. The medications that treat phobias also treat panic.
Strategies to treat
Treatment not only saves lives, but it means the difference between a life of quality or a life of pain and suffering. Treatment can involve the dreaded behavior modification, but this is one case where drugs are essential and
optional. The rationale for behavioral medication follows.
Alprazolam (Xanax) is my preferred drug of choice for storm and noise phobias, and for all dogs who panic, whether the panic is a solitary diagnosis or a co-morbid one with separation anxiety or other anxiety-related condition. This benzodiazepine (BZ) is considered the classic "panicolytic" drug in human medicine, and has the advantage of a broad dosage range for anxiolytic effects, and a more narrow range for sedation. With diazepam, the pattern is reversed; however, dogs, like people, are incredibly individual in their response to benzodiazepines. Some dogs do better with one of these while other dogs show the reverse patterns. The only drawback to these medications is that they can be addictive and abused by humans, so there is the occasional household in which such medications should not be placed.
The key to treatment for noise phobias and panic is to give the BZ early and often. The half-life of diazepam in dogs is about 5h, and that of its intermediate metabolite, nordiazepam—which is active and highly sedative—is ~3h. The half-life of alprazolam is somewhere in the 3 or 4-6h range but its intermediate metabolite is not sedating, less active, and more directly excreted so you get a more moderate and continuous patterns of anti-anxiety effects. If clients are expecting storms, and if they can get the dose of alprazolam into the dog two hours before hand and the other half ~30 minutes before hand, they can easily achieve a great anti-anxiety effect.
The medication can then be repeated as needed, but clients should allow at least 2h between doses to assess effects. Generally, alprazolam is repeated q.4-6h. This dosage can be used continuously over a period of days or weeks during a profound thunderstorm season. If this scenario ensues, it is best to slowly withdraw the dog from the meds.
Dosages for alprazolam range from 0.01-0.001 mg/kg for dogs and 0.025-0.05 mg/kg for cats who panic (e.g. coming to the clinic). Most people don't think of storm phobias in cats, but they may well occur because cats hide when distressed. We need to treat all of these cats and dogs.
For most average size dogs, dosages in excess of 4 mg/DOG can result in ataxia, and there is one publication stating that this is the maximum daily dosage. Such logic is unrealistic for big dogs, but as with all BZ, clients will need to experiment with the dose to learn the best dosage level for their dogs. Clients need to learn about the potential side effects of different dosages when the dog or cat is not distressed, and about the best dosage level to treat the panic during the experience. For this reason, I recommend a trial run at the estimated dosage when the clients are home and the animal is calm.
If the animal is seriously sedated, the clients need to adjust the dose to a lesser one. If the animal is fine, but sleeps more quickly or more deeply, the dose is a good one as long as the pet awakens without grogginess.
Tips from the pros
Here are some tips to consider. Many people prefer diazepam (0.5-2.0 mg/kg po q. 4-6h - dogs; 0.2-0.4 mg/kg po q. 12-24 h - cats) because they swear that no matter how high the dose they cannot get an effect with alprazolam. There are some individuals who have genetic variants of enzymes that metabolize these drugs that can cause extreme effects. However, mostly I think people confuse an anxiolytic effect with a sedative one. And, they only give one or two doses. Instead, if you use alprazolam as discussed and keep giving it to one full dose as needed, the dogs—and cats—begin to learn that they don't have to be so frightened. This formula also works like a charm for dogs who get upset during veterinary visits. So for a 25 kg dog, I'd give 0.125 or 0.25 mg to start (the smallest tablet available is a scored 0.25 mg one) and evaluate the effect. If in 15-30 minutes the dog isn't noticeably calmer, give him more.
Alprazolam is a true panicolytic drug, meaning that it can also stop a panic attack. So if clients find the dog or cat in distress, giving a whole dose and then evaluate what to do 15-30 minutes later can really work because the panic will be lysed within a relatively short period of time.
Cats do better with alprazolam than diazepam because they have a very slow metabolic rate for nordiazepam, the sedating intermediate metabolite of diazepam. Because the intermediate metabolites of alprazolam are hydroxylated, this may be a safer BZ with cats who may be compromised or who are slow metabolizers than is diazepam.
I know that the common "treatment" for storm and noise phobias and veterinary office visits is acepromazine. In truth, I wish this medication would be placed at the far back of a top shelf and used only exceptionally. Acepromazine is a dissociative anesthetic meaning that it scrambles perceptions. Ask yourself if a scrambling of perceptions will make an anxious or uncertain dog worse or better. It's always worse, and we make many if not most dogs more sensitive to storms by using this drug. In part this is also because sensitivity to noise is heightened.
This is a recipe for disaster for these dogs, and, in fact, they learn to be more fearful and more reactive because of these associations. If what you need is sedation - acepromazine can be an acceptable adjuvant, but it makes most of my really fearful and really reactive patients worse, so all sorts of other drug combos can work better and do less harm than is done by the routine use of acepromazine.
Finally, if the dog or cat calms using alprazolam or another BZ, the clients should be encouraged to do four things:
- They should ensure that they are treating any co-morbid anxieties (e.g., separation anxiety, generalized anxiety disorder, most aggressions) with an appropriate tricyclic antidepressant or selective serotonin re-uptake inhibitor, plus the chosen BZ.
- The clients should not pet the dog or cat and tell him or her that it is okay. The animal knows it's not okay and such contradictory signals, especially in profoundly obedient pets, increase anxiety. Instead, just talk normally to them, and press firmly, or lie next to them without petting. Such behavior provides closeness and allows the pet's muscles to relax without inadvertently rewarding any of the signs of anxiety.
Clients should work with behavior modification designed to teach the dog or cat to relax when there is no problematic stimulus so that they can start to transfer the learned lessons of physical and physiological relaxation to situations that are provocative.
Clients should have a benign, but clear, rule for how animals will be handled if they become upset or panicked. This will help the client, and it will really help the pet. For example, if a sudden storm surprises us in the night, one of us will take our storm phobic dogs from the room in which they sleep, get the alprazolam, give it immediately, and lead them to the spare bedroom where whomever gets up first will sleep with them. This room is better insulated from noise and storm pyrotechnics and is super-well air-conditioned to remove humidity. The process of removing the dogs from their room and giving the medication takes less than 5 minutes. Within minutes of that we are in bed with them, and last week, both were asleep five minutes later. That's not the medication, alone: that's the learning of the pattern that everything will be okay because it has become okay. That's the benefit of the BZ, alprazolam: the dogs can still learn, and if they are physiologically distressed, such distress is chemically blunted so no or little learning occurs about how to become better distressed during the storm. In this case, medication facilitates complex associative learning about how to relax.
I failed Susie by not making treatment with medication a requirement for her adoption to a foster family. So, in memory of Susie, a wonderful, wonderful dog, I offer this column in the hope that other animals cease to suffer because their people stopped fearing drugs.