Animal Behavior Case of the Month

Liz Stelow William R. Pritchard Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California-Davis, Davis, CA 95616.

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Statement of the Problem

A dog was evaluated because of refusal to leave the owners’ property or car for walks and for barking and snapping at strangers in the house.

Signalment

The patient was an 8-year-old 38-kg (84-lb) spayed female mixed-breed (shepherd-type and Foxhound) dog.

History

The patient lived with the owners and another dog (a 5-year-old spayed female Collie) in a rural home. The patient had been obtained from a shelter at 5 years of age and had previously been part of an animal hoarding case.

The owners reported that the dog always hid during thunderstorms, fireworks, or active avalanche control interventions (blasting) at nearby ski resorts. Approximately 4 months before the consultation, following a very loud storm, the patient began refusing to step off of the owners’ property for walks. Attempts to walk beyond the driveway resulted in the dog rolling on its back, and it would often duck its head into a corner to avoid having the head collar and leash put on. Although it eagerly entered the car and seemed to enjoy car rides, the owners reported a sudden refusal to exit the car at any destination. The owners noted that, in the weeks prior to these new behaviors, the patient began to startle at the sound of a neighbor's horse kicking a metal wall in its stall and at the sound of target practice (gunshots) on neighboring properties; hearing these sounds elicited widening of the eyes, looking quickly around with the ears back, and running to the house.

The owners had tried a few approaches to get the dog to walk beyond the driveway, including use of flat and martingale collars and leashes of different lengths, waiting calmly at the end of the driveway for the dog to comply (but giving in and walking back to the house in the event of steady refusal), pulling the dog along despite its resistance, and walking it with and without the other dog. None of these approaches improved the behavior.

The dog had a recent history (approx 16 months) of barking and snapping at strangers in the home. If people did not approach, it would simply bark; if people approached or reached for the dog, it would sometimes attempt to bite. The dog's tail would be tucked and its ears would be back during these encounters, suggesting fear.1 Off the owners’ property, the dog appeared fearful of strangers (standing or walking with its head and tail lowered and ears back), but never attempted to bite.

Physical Examination Findings and Laboratory Results

At the initial appointment, the dog would not leave the side of the owners’ car, so the evaluation was conducted in the clinic parking lot. During the first hour of the appointment, the dog tried repeatedly to climb into an owner's lap, paced back and forth over the owner's outstretched legs, and panted. It made little eye contact with anyone other than the owner, rarely sat, and kept its tail tucked and ears held back during the entire visit. For the physical examination, the patient was very tense and sometimes trembled; when let into the back seat of the car after the examination, it sat panting, occasionally rising and repositioning.

Physical examination findings were unremarkable except for a body condition score of 6 of 9. Examination in the parking lot precluded weight determination, but a recent weight was reported as 38 kg (84 lb). A blood sample was collected for a CBC and serum biochemical analysis in anticipation of prescribing medications2; results were within the respective reference ranges. A recent serum thyroxine concentration (determined by the primary care veterinarian approx 3 months prior to this examination) had been within the reference range.

Diagnosis

Sudden refusal to leave the owners’ property or to leave the car at another destination can be attributable to medical or behavioral causes. Medical causes include arthritis, exercise intolerance (secondary to cardiac conditions, portosystemic shunt, or other abnormalities), vision problems, and hepatic encephalopathy.1,3 Behavioral causes include noise phobia, attention-seeking behavior, generalized anxiety, and other nonspecific anxieties.1,4 Generalized anxiety was ruled out because triggers were identified and the patient was reportedly very relaxed at home in the absence of aversive noises.4 No medical issues were evident in the history or on physical examination. Because noise triggers (thunder, fireworks, gunshots, and hooves striking metal) were known to cause escape behaviors and had appeared temporally close to the onset of the behavioral problems for which the patient was referred, noise phobia was considered the most fitting diagnosis.4 A phobia is considered to be a marked, persistent, and excessive fear of specific stimuli.5 The signs of noise phobia in dogs often include hiding and attempts to escape, but can also include panting, hyperactivity, destructiveness, and self-trauma.5,6 The patient of this report would pant and attempt to escape or hide on exposure to certain noise triggers indoors and on walks. It has been reported7 that the noises to which dogs most commonly develop phobias are fireworks, thunderstorms, and gunshots; this dog reacted fearfully to all 3, as well as to avalanche control detonations and the sound of a horse kicking its stall. These are all high-decibel, unpredictable sounds that occur in short bursts, giving them a profile that often induces signs of fear in dogs.8 Because noise phobia is frequently comorbid with separation anxiety,6 the owners were questioned about the patient's behavior when they were not at home; evidence (including a video recording during the owners’ absence) revealed that the dog showed no signs of anxiety or discomfort when left at home alone.

Differential diagnoses for barking and snapping at unfamiliar people in the home included medical causes such as brain disease (infectious, neoplastic, endocrine, nutritional, or epileptic), other conditions causing pain, and metabolic dysfunction.2,3 Behavioral causes include fear-based, territorial, food-guarding, learned, redirected, or predatory aggression.9,10 Considering the patient's overall health and lack of hematologic or serum biochemical abnormalities, medical causes were considered unlikely. Owing to a lack of apparent food triggers or reinforcement of aggressive behavior by the owners, lack of obvious history of redirected aggression, and lack of reported attempts to approach, follow, or stalk unfamiliar visitors, all behavioral causes other than territoriality and fear were ruled out. On the basis of the owners’ description of the dog's body postures when barking or snapping at strangers, fear aggression was considered the most likely diagnosis.2 Although the patient was reported to behave more aggressively at home than when away, many dogs that have aggressive behaviors within their own territories are primarily showing signs of fear.10 Thus, although territoriality remained a possible component of the aggression, the primary diagnosis for this component of the dog's behavior was stranger-directed fear aggression.

Treatment

A comprehensive plan was developed to address the noise phobia and aggression issues. The owners were asked to minimize the patient's exposure to trigger sounds as much as possible, except as directed in the treatment plan.1,9 All the identified triggers emanated from outdoors, and the owners were willing to keep the windows and doors of the house closed. Also, thunderstorms were unlikely during the season when the behavioral consultation was conducted.

The owners were advised to teach the dog hand-targeting and eye contact cues. These would be used to encourage the dog to focus on the owners during systematic desensitization and counterconditioning treatment.11 Additionally, the owners were to teach the dog to relax on cue by encouraging a prolonged down-stay (through use of a cue with soothing tones) and rewarding the dog for relaxed posture and calm appearance, with a relaxed expression around the eyes (commonly described as soft eyes).1,6,11

To help change the dog's response to identified noise triggers, the owners were instructed in the use of desensitization and counterconditioning techniques, which can be effective for treatment of noise phobias in dogs.9,12 These methods are used to achieve and reinforce a positive response to an apparently fear-inducing stimulus; behavior modification is gained through very gradual exposure to the stimulus paired with a reinforcement (such as food or praise) for calm behavior in the presence of the stimulus.4,9 To address the dog's adverse responses to noises, the owners were advised to obtain digital recordings of the trigger sounds. They were to play these sounds at a very low volume and to use a hand-targeting or eye contact cue to focus the dog's attention on an owner. If the patient remained calm and focused on the owner as the noises were played, this behavior was to be reinforced with small pieces of highly palatable food.4,13 If signs of fear were observed at any time, the owners were instructed to end that session and start the next one with the sound recording played at a lower volume.1,13 Brief but frequent sessions (5 minutes’ duration, several times daily) were recommended. The owners were given a journal with spaces to track sound volume, session length, and the dog's responses.

Because of the severity of the dog's reactions to some sounds, an antianxiety medication was also prescribed. These medications can enhance a patient's response to behavior modification techniques for treatment of noise phobia.14 A short-acting, as-needed medication such as a benzodiazepine was considered, as these are very potent anxiolytics9; however, because the noise triggers could occur frequently but not predictably, this drug class was not considered ideal.9 Instead, generic fluoxetine hydrochloride was prescribed. Fluoxetine selectively reduces serotonin reuptake into presynaptic neurons, thereby increasing the availability of serotonin.15 This drug has been shown to be effective in treatment of noise phobias in dogs.9 Owing to its serotonin selectivity, fluoxetine has fewer reported adverse effects, compared with tricyclic antidepressants (another class of medication often prescribed for noise phobias).9 Adverse effects of fluoxetine in dogs can include lethargy, inappetence, signs of agitation or irritability, panting, and possibly seizures.16 The dosage range for dogs is 1.0 to 2.0 mg/kg (0.45 to 0.91 mg/lb), once daily.16 The owners were instructed to give fluoxetine at a starting dosage of 15 mg (0.4 mg/kg [0.18 mg/lb]), PO, every 24 hours for 14 days. The goal of starting at a low dosage was to minimize any adverse effects such as inappetence17; if no unwanted effects were observed, the owners were to increase the dose to 30 mg (0.8 mg/kg [0.36 mg/lb]) on the 14th day of treatment. After 6 weeks of treatment with the 30-mg dose, the patient was to be reevaluated and the response to treatment reviewed before determination of whether another dose adjustment would be desirable. The owners were told that up to 8 weeks could pass before the full effect of fluoxetine would be evident4 and that a decision regarding its effectiveness would be made at that time. They were also informed that this was an extralabel use of the medication.13

Initial treatment for the aggressive behavior consisted of placing the dog in another room when strangers arrived. The owners were told that the plan would include desensitization and counterconditioning to strangers, but should start with people encountered off the owners’ property, which would be a less intense trigger for the undesired behavior than an encounter in the home, thus giving the dog the best opportunity to remain calm when exposed to the trigger.18 To facilitate this treatment, the owners would first need to be able to have the dog willingly exit the car at destinations other than their own property. Given the complexity of the treatment plan, detailed instructions were provided in writing.1

Follow-up

Twelve days after the initial consultation, an owner reported that the dog did not respond to digitized trigger sounds played on a computer at any volume. Options were discussed for making the sounds more powerful to elicit a response, and the owner subsequently used a 5-speaker surround-sound system to play the recorded sounds in 1 room of the house. The next day, it was reported that the dog had responded by trying to escape from the sounds, and that the desensitization and counterconditioning treatments would be initiated in the hallway outside the room with the speakers because the dog refused to enter the room if the sounds were playing. Beginning 17 days after the initial behavioral consultation, the fluoxetine dosage was increased to 0.8 mg/kg every 24 hours. The only apparent adverse effect at the lower dosage had been very mild inappetence.

Three weeks into treatment, the owners reported that the dog was responding very well to the desensitization and counterconditioning treatment with the sound recording. Further, the dog had shown some willingness to go on walks again, but only when the owner was riding a bicycle. Three months into treatment, the dog willingly walked with the owner only if the bicycle was present, whether or not the owner was riding it. It was also noted that, as the weather warmed, the patient was exposed more frequently to the sound of the neighboring horse kicking its metal stall and would often attempt to run home in response. At this time, the fluoxetine dosage was increased to 40 mg (1.05 mg/kg [0.48 mg/lb]) every 24 hours, and the owners were instructed to add a metal percussion sound (such as a hammer on a metal pail) to the recording used in the desensitization and counterconditioning program. Alternatives to the owner walking a bicycle (which was cumbersome) while walking the dog were discussed. These included use of a folding bicycle or scooter, as long as the dog seemed amenable to the change.

When the fourth month of treatment began, the patient still refused to exit the car away from home, and the owners began desensitization and counterconditioning training for exiting the car at another destination.1 The treatment started with driving a short distance (down the driveway) and inviting the dog to exit the car. If the dog complied, the behavior was reinforced with treats; if not, the car was driven back to the house. With success, the plan was to increase the distance slightly on the next drive, traveling to the street in front of the house, in front of the neighboring house, down the street, and eventually to more distant locations. Within 3 weeks, the owner reported that the dog was willingly exiting the car at a park 3 miles away from home.

A phone call from the owner in the sixth month of the treatment plan confirmed that the patient was no longer showing any reaction to the previously aversive sounds played at a comfortable (for the owner) volume with the speaker system. The patient also no longer reacted to the sounds of gunfire during target practice in the neighborhood, was mostly calm during thunderstorms, and would walk with the owner when the bicycle or scooter was not present. The owners believed that the dog had improved enough to be brought to the veterinary teaching hospital for an inoffice recheck. However, the visit was delayed for personal reasons (the hospital was 2 hours’ drive from the clients’ home), and follow-up by telephone was continued. A blood sample was submitted by the primary care veterinarian for CBC and serum biochemical analysis to monitor the dog's liver function and overall health13,19; results of both were within reference ranges. At this time, the owners were asked to begin desensitization and counterconditioning to strangers. They were to use distance from people as a gradient, starting with a distance at which the patient appeared very relaxed and reducing the distance slowly as signs of improvement were observed. The training was to start in public areas, then gradually transition to working with people on the owners’ property. Once the desired calm behaviors were seen routinely, they could work with people inside their home.18

Eight months after the initial consultation, the owners reported that desensitization and counterconditioning to strangers in public places and on their own property had been successful, but that the dog sometimes barked at people inside the home. The owners planned to continue with the treatment plan, but were very happy with the patient's progress.

Nearly 1 year after the initial appointment, the patient was brought to the veterinary teaching hospital for a recheck examination. On entering the examination room, the dog's tail was tucked and its head was held low, but it willingly entered the room. During the first few minutes of the appointment, the dog yawned repeatedly and attempted to climb into the owner's lap. Later, it sniffed offered treats but did not eat them. After approximately 30 minutes, it began to explore more of the room and showed signs of mild interest in sounds from the hallway. The dog approached clinical staff members a few times but did not wait to be petted; after an hour, it ate offered treats and lay on the floor with a relaxed body posture. The owner indicated a desire to wean the patient off fluoxetine. It was agreed that this should be done slowly and that any apparently fearful behaviors should be reported to the clinican.2,6 The owner reduced the dosage to 30 mg (0.8 mg/kg) every 24 hours, beginning on the next day. One month later, after no apparent increase in fearful behavior, the dosage was reduced to 20 mg (0.53 mg/kg [0.24 mg/lb]) every 24 hours; after an additional month, it was again reduced to 10 mg (0.26 mg/kg [0.12 mg/lb]), every 24 hours. At that dosage, the patient remained unreactive to the sounds of gunshots and the neighboring horse kicking its stall, and after 1 month of treatment with the 10-mg dose, the owner stopped giving the medication. At last follow-up, the dog had not been receiving fluoxetine for > 1 year and was showing no signs of fear in response to noises.

References

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