Statement of the Problem

A cat was evaluated for defecating on the owner's bed, vocalization, excessive self-grooming, unwillingness to eat in the owner's absence, and constantly following the owner around the house (ie, shadowing).

Signalment

The patient was an approximately 10-year-old 4.4-kg (9.7-lb) neutered male domestic shorthair cat of red tabby coat color.

History

The cat had been adopted at approximately 1 year of age from a shelter. The owner and the cat had moved a total of 10 times during the 9 years since the adoption. Owing to these frequent moves, they had lived in a variety of home settings (eg, houses and apartments) with a variety of other people and animals. Six months prior to the behavior consultation, the cat's owner had returned home after 2 years of living overseas. While the owner was away, the cat had lived with the owner's parents, a dog, and another cat.

While living at and visiting the owner's parents' house, the cat would often show aggression toward the owner's mother and father. The cat would growl, hiss, and swat at the parents when they tried to pet it or pick it up; growling at, swatting at, and chasing the other cat in the home were also reported. Aggression toward the dog was not observed unless the owner was in the parents' house, but the cat would growl, jump to the floor, and chase the dog away if it came into close proximity to the owner while the cat was on her lap or next to her on the sofa. This behavior did not occur in the current home environment; however, the cat and its owner were living alone in a 2-bedroom house.

Over the years and with each move, the cat had started to withdraw, and its appetite was observed to decrease when boxes were brought out and packing of household items began. The withdrawn behavior and decreased appetite continued during the move and the subsequent unpacking of boxes in the new environment. Since the most recent move, 3 months prior to the consultation, the cat had started to constantly solicit attention from the owner. It shadowed her around the house, vocalizing and making physical contact such as immediately jumping into her lap when she sat or lay on the bed or sofa.

The owner worked away from home, and the cat was alone in the house for approximately 9 hours for 5 d/wk. Every day, when the owner left the house, the cat would sit at the front door and watch her walk to and get into her car; it was usually waiting for her in the same location when she returned home. The few times that she returned home at a different time than normally scheduled, the cat would be sleeping but immediately come running when the owner opened the door and entered the house. The owner noted that upon her exit from the car, she could usually hear the cat vocalizing. This vocalization would continue through her entering the house and conclude when she placed food in its bowl. When provided with the food, the cat was reported to appear anxious (vocalizing and running between the owner and the bowl), eat quickly, and often vomit undigested food shortly afterward. In the owner's absence, the cat would not eat but would settle quickly to eat if the owner was home and petted it after placing the food. Frequent self-grooming (described as constant) and vomiting of hair balls were also described.

One month prior to the consultation, the client had traveled to her parents' house with the cat for a short visit. Upon returning home from this trip, the cat had defecated on the owner's bed while she was at work. There had been no recent changes in the location of the litter box, litter type, or cleaning routine. For 2 weeks after this incident, the owner closed the bedroom door to keep the cat out but slept on the couch with the cat at night. After 2 weeks, she had left the bedroom door open, and the cat had defecated on her bed while she was at work. That evening, she went to bed and closed the door to keep the cat out of the bedroom. A few hours later, the cat began to vocalize, scratch, and throw itself at the closed door until the door flew open, and it ran into the room vocalizing, with piloerection, low tail carriage, arched back, and dilated pupils. It then jumped into the bed and onto the owner, where it maintained a relaxed state as long as it was petted and comforted by the owner.

Physical Examination Findings and Laboratory Results

Physical examination revealed a corneal scar on the cat's right eye, a moderate amount of dental tartar, and a body condition score of 5 (scale, 1 to 9). No other abnormalities were found. During the rest of the consultation, the cat remained in sternal recumbency, with its eyes half-closed and front feet tucked under its chest, next to the owner on the couch. It showed minimal interest in the environment or in toys brought from home and no interest in food treats. Results of a CBC and serum biochemical analysis including total thyroxine concentration were within the respective reference limits. A urinalysis and fecal analysis could not be obtained at the initial visit because of a small urinary bladder size and increasing signs of stress during venipuncture. A urinalysis obtained at a subsequent visit revealed no clinically relevant abnormalities, and the client was instructed to collect a fecal sample from the cat at home and deliver it to the hospital for evaluation.

Diagnosis

On the basis of the cat's history and the clinical signs observed, separation anxiety, generalized anxiety, and marking by inappropriate defecation (termed middening) were diagnosed. Separation anxiety is an emotional, behavioral, and physiologic response that is triggered by separation from or lack of access to an attachment figure.^1,2 Cats are selectively social but can form strong social bonds with specific cats and people.^3,4 These selected relationships are evidenced by sleeping in close proximity, sharing food, playing or sitting together, allogrooming, and allorubbing.^4–8 Few studies have identified separation anxiety in cats; however, the most common clinical signs reported are house soiling, urinating or defecating exclusively on the owner's bed, excessive grooming, destructiveness, and excessive vocalization.^1,2 The cat of the present report had formed a strong social attachment to the owner as indicated by vocalizations, shadowing her around the house, and making frequent physical contact when resting or in stressful situations.³ These signs along with the refusal to eat alone, excessive grooming, and elimination on the bed all supported a diagnosis of separation anxiety.^1,2,7 House soiling in cats can have a variety of medical and behavioral causes.^8,9 There was no previous history of house soiling or recent change to the litter box location, litter type, or cleaning routine; on the basis of this information and the location of inappropriate elimination (on the bed), middening was diagnosed.^4–7,10 Middening, a clear communication signal used by cats, often indicates anxiety and marking of territory.¹¹ Although evaluation of a fecal sample would have been ideal to rule out intestinal parasites as a potential cause for defecation outside the litter box, in the case of this patient, anxiety was the suspected motivation for this behavior because the hematologic data (including serum total thyroxine concentration), urinalysis results, and physical examination findings were unremarkable.¹² Separation anxiety is commonly associated with other anxiety disorders such as noise phobias, cognitive dysfunction syndrome, and generalized anxiety.^5,7,10 Noise phobias and cognitive dysfunction syndrome were ruled out from the history provided, considering that the cat's anxious behaviors (vocalization, shadowing, and constant need for physical contact) continued in a quiet environment with the owner at home.^13,14 Generalized anxiety was suspected as a comorbidity.^6,13 Genetic influences, lack of adequate socialization, learning, and owner attention can all contribute to anxiety and anxious behavior.^5,7,10,13 In the cat of the present report, it was likely that all these factors were associated with the behavior.

Treatment

The owner was instructed to increase environmental enrichment by providing hiding places and vertical spaces to encourage exploration and create alternative resting areas throughout the house.^15–19 To help reduce stress and condition a more positive emotional response to being alone, food-dispensing and puzzle toys were recommended.²⁰ It was anticipated that such toys could also slow the cat's rapid food intake and thus help reduce the frequency of vomiting. These devices could also be used to monitor the cat's response to treatment over time on the basis of increased use. The owner was also advised to increase social enrichment.^16–19 This type of enrichment involves structured play time with the owner and reward-based training methods.^5–7,9,10 Both approaches can help to teach a cat more appropriate ways to interact with people while reducing inadvertent reinforcement of anxious behaviors by an owner.^5–7,9,10 Training also provides a set of behaviors to use for clear communication and redirection between the owner and cat.^5–7,9,10 A minimum of 15 minutes of structured play time with the cat each day was recommended.^5–7,9,10 Structured play time recommendations included games such as fetch, playing with fishing pole–type toys, and laser light games with a food find at the end of the chase.^5–7,9,10 The owner was educated on the benefits of positive reinforcement training techniques for teaching and reinforcing behaviors in response to cues such as come, sit, touch (hand targeting), and go (to a mat).^7,10 These behaviors could be used to redirect and move the cat (eg, off of furniture and to a specific location) without picking it up.^7,10 Pharmacological treatment was also recommended but initially declined by the owner. Other environmental measures, such as classical music, recorded audiobooks, and aromatherapy and lavender essential oils, which have been advocated as aiding relaxation in other species,^21–26 were discussed for the cat when it was to be left alone.

Follow-up

Three weeks after the initial consultation, the owner was contacted via email and reported that the cat did not like the food-dispensing toys. When the toys were introduced, the cat stopped eating for a few days and then would take only 1 or 2 pieces of food before walking away, so the owner had resumed feeding from bowls. In addition to having a decreased appetite, the cat had reportedly become more anxious around the food and food bowl since the use of food-dispensing toys. The new behavior was to rush to the bowl and then vocalize when the owner walked anywhere near it. The night before this follow-up communication, the cat had awakened the client by jumping on the bed and vocalizing when ignored. The cat appeared agitated and jumped off the bed, scratching the owner's forehead in the process. Until that episode, the owner believed that the cat's anxious behavior had initially improved; it had done well with learning the touch command and would perform this behavior when cued from across the room. The owner had been using a fishing pole– type toy and played fetch with the cat several times a day. Classical music was played when the cat was home alone, and a lavender diffuser was plugged in.

The owner was instructed to continue feeding the cat from its customary bowl as scheduled, in addition to providing food-dispensing toys to reduce frustration and encourage exploration. A small amount of canned food was recommended to use as positive reinforcement when training new behaviors. Because of the cat's continued anxious behaviors, fluoxetine administration was started at an initial dosage of 0.6 mg/kg (0.27 mg/lb), PO, every 24 hours, to be increased to 1.1 mg/kg (0.5 mg/lb) every 24 hours after 7 days.^27,28 Fluoxetine, a selective serotonin reuptake inhibitor, was chosen because blockage of the serotonin reuptake and downregulation of serotonin receptors have been shown to decrease signs of anxiety in cats.^10,27 Fluoxetine was chosen over a tricyclic antidepressant because it is more selective for serotonin and it has a lower potential for adverse effects, especially in cats.^27,28 The owner was informed that use of the drug is extralabel in cats and was advised of the potential for adverse effects such as sedation, decreased appetite, vomiting, diarrhea, tremors, urinary retention, constipation, and increasing signs of anxiety.^27,28 Positive reinforcement training and structured play were continued.

Four weeks later, the cat was doing well. The owner noted that the cat was lethargic during the first week of fluoxetine treatment, but this had resolved. No other adverse effects attributable to the medication were noted at this time. The cat would still vocalize and rush to the food bowl but had started to sleep in a chair away from the owner at night; although it still solicited petting when the owner sat on the couch, the self-grooming had become less frequent as evidenced by less frequent hair ball production. The owner indicated that the cat enjoyed structured play and watching the birds outside when the front door was open. The owner was instructed to continue fluoxetine administration at the same dosage and to implement a cue-response-reward system of interacting with the cat to increase the predictability and consistency of her interaction with the cat while avoiding the inadvertent reinforcement of anxious behaviors.^7,10

Five months after the initial consultation, the cat was returned to the hospital for a follow-up visit. A few weeks prior to this visit, the owner had slept in the guest bedroom instead of her own room, and since that time the cat had started to sleep in the guest bed instead of the living room chair. During this period, the owner's parents had come with their dog and cat for a visit, and during that time, the cat had consistently slept in the doorway outside of the guest room instead of on the bed. The day the guests left, the cat had defecated on the owner's bed, started to shadow the owner throughout the house again, and had a decreased appetite. All these behaviors were similar to those described at the initial consultation. In addition, the owner was concerned because she had plans to move again, and her parents were coming to help with that move in a few weeks. At this consultation, the results of physical examination were unremarkable, and the patient's weight was unchanged from the previous examination. Because of the recent regression of behavior and the upcoming stressors, lorazepam, a benzodiazepine, was recommended^9,10,28 but declined by the owner. Although a benzodiazepine was recommended for this cat on the basis of its true anxiolytic effects,^10,28 the owner chose to purchase a dietary supplement-type product, 75-mg α-casozepine capsules, to sprinkle onto the cat's food instead. α-Casozepine has an affinity for benzodiazepine receptors and is similar in structure to γ-aminobutyric acid²⁹; some reports^29,30 suggest that the dietary product may help some cats cope better in situations of environmental stress.

Six months after the second consultation, the cat continued to do well. The owner had moved, and her parents visited. The cat had adjusted very well to the move and to the presence of visitors in the home. The owner reported that the cat's appetite had returned to normal since she had started adding α-casozepine and that it appeared much less anxious overall. The plan at this time was to continue fluoxetine treatment at 1.1 mg/kg every 24 hours; the owner would add the α-casozepine product when she felt household conditions were stressful. A 1-year follow-up examination with hematologic analysis was scheduled for 6 months later.