July/August 2014 Todays Veterinary Practice 63

ON YOUR BEST BEHAVIOR

PEER REVIEWED
tvpjournal.com
Ilana Reisner, DVM, PhD, Diplomate ACVB
Reisner Veterinary Behavior & Consulting Services, Media, Pennsylvania
Q & A
:
The presentation of behavior problems during routine
appointments is one of the inevitabilities of todays vet-
erinary practice. Behavioral drugs can help manage
these problemsbut not all drugs are equally useful,
and their use is not always indicated. The plot thickens
when some clients demand medication, while others re-
fuse to use it despite veterinary recommendations (see
Addressing Client Reluctance).

WHY USE BEHAVIORAL
MEDICATION?
Augmentation of Behavior Modification
The treatment goal of any behavior problem is modi-
fication of that behavior. However, the term behavior
modification is vague and depends upon the individu-
al patient and behavior being addressed.
1. Management of any problem behavior requires
recognizing and avoiding the stimuli that trigger the
behavior in question.
2. The dog needs to learn to behave differently in
response to the stimulus. The term differently is
intentionally nonspecific because it is tailored to the
individual animal and context in which the problem
behavior occurs.
Behavior modification might include anything from
counter-conditioning a fearful dog; actively training an
appropriate, alternative behavior to a cue; or desensitiz-
ing a separationdistress dog to its owners leaving the
room. Thus, behavior modification can play an impor-
tant role in management of a problem behavior.
The Use of Medications in
Canine Behavior Therapy
Y
our longtime client, Mrs. Jones, presents
Buttercup, the Papillon, with a behavior
problem: For several months, Buttercup has
been biting houseguests. Through questioning and
observation, you determine that Buttercup is anxious.
She was shy as a puppy, exhibits fearful postures
when unfamiliar people try to pet her, andas a
home video of her behavior revealsruns away from
guests trying to interact with her.
Addressing Client
Reluctance
If behavioral medication
is indicated, but the client is reluctant, discuss-
ing specific concerns educates the client about the
benefits of medication. Common concerns include:
1. My pets much-loved personality will change.
This is not the goal. The only personality charac-
teristics targeted for change with drug therapy are
those associated with anxiety and reactivity, or
such problems as repetitive (compulsive) behavior.
Because psychopharmacology can have unexpect-
ed effectsfor example, one client reported that
her dog seemed less inclined to play with toys after
administration of a drugit is also important to
reassure the client that his or her pets response will
be monitored, and the medication effects can be
reversed or limited by reducing the dose or switch-
ing to a different drug.
2. Drugs are unhealthy or unsafe.
There are many behavioral drugs, and most are
quite safe to useeven with chronic administra-
tionin healthy patients. Medication is prescribed
only after a physical examination and, if the medica-
tion will be administered for a long period of time,
screening blood analysis should be performed.
This testing, including CBC, serum biochemistry
profile, and urinalysis, is recommended:
t Annually for patients receiving behavior drugs for
over 1 year
t Semiannually for patients over 8 years of age that
are receiving behavior drugs, or more frequently if
there are concurrent medical issues of concern.
3. My pet will be sleepy all the time.
Unless sedation is the goal, such as during thun-
derstorms for phobic dogs, nonsedating drugs
are used, so sleepiness should not be an issue. If
unexpected sedation is a side effect of behavioral
medication, the drug dose can be reduced or a dif-
ferent medication can be prescribed. While it is not
uncommon for behavioral drugs to cause transient
sedation initially, it can often be avoided by starting
with a lower dosage, then increasing it over several
weeks to the desired dose.
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Todays Veterinary Practice July/August 2014 64 tvpjournal.com
Reduction of Stress
In some cases, there are limits to how far behavior mod-
ification alone can go. Extreme situational stress or fear
can interfere with learning and decision making.
When dogs are overtly reactiveor, in the language
of dog training, over thresholdthey are physiologi-
cally aroused, which involves both the autonomic (fight
or flight instinct) and endocrine (hypothalamicpitu-
itaryadrenal axis up-regulation) systems. In these cases,
there is rarely any middle groundthe dog will move
rapidly from a lack of reaction to extreme avoidance, ag-
gression, or panic.
Temperamental or inherited generalized anxiety can
also interfere with learning. Generalized anxiety, similar
to situational anxiety, is more pervasive and challenging
to overcome through training alone.
In these patients, the addition of behavioral drug
therapy can significantly improve response to treatment.
When underlying anxiety is reduced, the dog is more
receptive to learning and its behavior can change more
reliably in the long-term. As one owner of a fearfully
aggressive dog reported after 2 months of fluoxetine ad-
ministration, I feel like its opened a door to her brain.
Sedation, If Needed
Although, on a day-to-day basis, sedation is not a desir-
able drug effect, it may be necessary to eliminate distress
spikes in specific situations, most frequently:
U Separation anxiety (administered at point of the
owners departure)
U Thunderstorm or fireworks fear (administered just
before the event)
U Car or airplane travel (administered 30 minutes
before travel; then repeated as needed during travel).
Rather than administration on a daily or standing
basis, sedative medication can be given on an as-needed
basis, often in combination with a daily medication.
WHEN SHOULD BEHAVIORAL
MEDICATION BE PRESCRIBED?
There is some flexibility with regard to prescribing medi-
cation relative to the behavior modification plan.
U If drug therapy is unequivocally indicated (eg,
severe separation anxiety or severe fear, including
fear-aggressive behavior), ideally prescribe it during
the same appointment as the behavior assessment,
which incorporates it into the entire behavior man-
agement plan.
U If the plan includes significant management
changes that do not require medication and/or
the pet is not impaired by stress (ie, pet has rea-
sonably good quality of life at time of presentation),
consider delaying medication implementation until a
follow-up visit. In some cases, behavioral drugs may
be unnecessary.
U If a pet undergoing behavior modification has
reached a plateau with little advancement in
learned tasks, successful desensitization, and/or
counter-conditioning, drug therapy may allow the
owner to move further toward treatment goals.
HOW SHOULD MEDICATION BE
PRESCRIBED?
Anxiety is an underlying component of many canine be-
havior problems (Table 1). Reducing this anxiety often
improves the problem behavior directly or decreases
stress, raising the threshold for reactivity, fear respons-
es, and other behaviors.
Before starting drug therapy in any animal, regardless of
age, physical health, or category of drug, a medical history
(including current medications) and physical examination
are indicated, along with analysis of blood and urine.
Duration of Therapy
Duration of treatment with behavior medication
ranges from:
U Relatively short-term (eg, 6 months for patients in
which anxiety must be reduced to allow learning to
occur) to
U Longer-term therapy (eg, years for animals whose
behavior is not adequately responsive to behavior
modification alone).
Other considerations include:
U Length of time for medication to take effect:
Some medications (eg, antidepressants) require 1 to 2
Case Application: Buttercup
In Buttercups case, the first stepavoid-
ing the stimuli that trigger the behaviormight
simply mean keeping her in a separate area or
gated part of the house while Mrs. Jones en-
tertains guests.
The second steplearning to behave differ-
ently in response to these stimulican include:
t Feeding Buttercup a high-value food while a
guest is seated and in view (counter-conditioning)
t Asking her to lie down on a previously speci-
fied mat while the owner is entertaining (alter-
native behavior).
TABLE 1. Canine Behavior Problems
Associated with Underlying Anxiety
t Agression between household dogs
t Compulsive disorder
t Fear-related aggression
t Fears/phobias
t Inappropriate attention-seeking behavior
t Leash reactivity
t Resource guarding
t Separation anxiety
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July/August 2014 Todays Veterinary Practice 65
ON YOUR BEST BEHAVIOR |
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months for full effect, while others, such as benzodi-
azepines and other sedatives, act more immediately.
U Loading period: The initial loading period of
some drugs should be considered when planning
therapy and duration of treatment.
Once its been determined that the patients response
to medication is adequate, a reasonable duration of ini-
tial therapy would be at least 6 months, which allows
a generous period of time for behavior modification
(learning).
Discontinuation
Abrupt discontinuation of medication may cause re-
bound anxiety or exacerbate behavior problems. Any
medication should be tapered gradually (weeks to months,
depending on duration of therapy); a good guideline is a
25% reduction every 1 to 2 weeks. Slow discontinuation
also allows the owner to report any reappearance of the
behavior problem, in which case a lower, but effective,
dose can be continued or the original dose resumed.
WHAT MEDICATION SHOULD
BE USED?
Antidepressants
The most commonly used anxiolytic agents are:
U Selective serotonin-reuptake inhibitors (SSRIs),
such as fluoxetine (Prozac, lilly.com), sertraline
(Zoloft; pfizer.com), or paroxetine (Paxil, gsk.com)
U Tricyclic antidepressants (TCAs), such as clomip-
ramine (Clomicalm, novartis.us) and amitriptyline.
U Selegiline (Anipryl, zoetisus.com), a monoamine
oxidase inhibitor (MAOI) approved for treatment
of canine cognitive dysfunction syndrome or senile
dementia.
Fluoxetine (no longer available as a veterinary
The Importance of Informed Consent
Many drugs used in veterinary behavioral
medicine fall into the following 2 categories:
1. Human psychiatric agents not licensed by
the Food and Drug Administration (FDA) for
use in companion animals
2. FDA-approved drugs for use in dogs with
specific behavior problems, such as fluoxetine
(veterinary product no longer available) and
clomipramine for separation anxiety and sele-
giline for cognitive dysfunction syndrome; how-
ever, administration for other behaviors, such
as anxiety-based aggression, is extra-label.
When recommending these drugs, inform
clients that the use is off- or extra-label. It
may be advisable to have the owner sign a
release form that lists the risks, limitations,
and potential adverse effects of the drug
being prescribed.
TABLE 2. Common Medications Used for Ca-
nine Behavioral Problems
(Alpha Order by Class)
DRUG DOSE
POTENTIAL
ADVERSE
EFFECTS
Azapirone
Buspirone 12 mg/kg PO Q
824 H
t Aggression
disinhibition
(anecdotal)
t Increased
anxiety
Benzodiazepine
Alprazolam 0.020.1 mg/kg
PO Q 8 H or PRN
t Agitation
t Ataxia
t Polyphagia
t Sedation
Clorazepate 0.52.2 mg/kg
PO Q 8 H or PRN
Diazepam 0.52.2 mg/kg
PO Q 8 H or PRN
Monoamine Oxidase Inhibitor
Selegiline 0.51 mg/kg PO
Q 24 H
t Agitation
t Disorientation
t Vomiting/
diarrhea
Serotonin Antagonist-Reuptake Inhibitor
Trazodone 35 mg/kg PO Q
824 H or PRN
t Increased
anxiety
t Sedation
Selective Serotonin-Reuptake Inhibitor
Fluoxetine 0.52 mg/kg PO
Q 24 H
t Agitation/
increased
anxiety
t Inappetence*
t Lowered sei-
zure threshold
t Sedation
t Tremors
Paroxetine 1 mg/kg PO Q
24 H
Sertraline 13 mg/kg PO Q
24 H
Tricyclic Antidepressant
Amitriptyline 14 mg/kg PO Q
12 H
t Constipation
t Decreased
appetite
t Dry mouth/dry
eyes
t Increased
anxiety
t Lowered sei-
zure threshold
t Sedation
t Tachycardia/
tachyarrhyth-
mia
t Urine retention
Clomipramine 13 mg/kg PO Q
12 H
* Less likely with paroxetine and sertraline
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Todays Veterinary Practice July/August 2014 66 tvpjournal.com
product) and clomipramine were approved by the FDA for
use in canine separation anxiety; either agent can be ben-
eficial for other anxiety-related problems.
Anxiolytic antidepressants should be given daily on a regular
basis. Adverse effects may include agitation, increased anxiety,
undesirable sedation, inappetence (fluoxetine), and lowered
seizure threshold. Side effects may be dose-dependent; initiat-
ing treatment with a lower dose may help.
Table 2 (page 65) lists the behavioral medications for
use in dogs discussed in this section, along with doses
and side effects.
Benzodiazepines & Trazodone
In cases when sedation or an extra boost of anxiolysis
would be helpful, shorter-acting drugs can be given on
an as-needed (PRN) basis; examples are benzodiazepines
(eg, alprazolam) or trazodone. Benzodiazepines are anx-
iolytic drugs and, used longer-term, can elicit anxiolysis
without sedation.
Trazodone can be dosed either regularly or PRN; an
example of the latter would be its use in fearful dogs
during thunderstorms. However, if used in combination
with SSRIs, TCAs, or MAOIs, it should be used with caution
due to the potential for serotonin syndrome (see Beware
of Serotonin Syndrome).
Benzodiazepines are often useful for PRN sedation in
cases, such as separation anxiety or thunderstorm fear, when
a focused need for anxiolysis is needed. Side effects include
polyphagia, aggression disinhibition, and paradoxical agi-
tation and ataxia without adequate anxiolysis, and may be
dose dependent.
The dose range tends to be wide; owners can use a start-
ing dose while they are home to observe, and increase the
dose on subsequent days with veterinary guidance. The
goal should be relaxation and mild sedation.
Drugs in this class may vary significantly in their clinical
effect for individual patients.
U Alprazolam is relatively short-acting and, therefore,
may be useful for separation anxiety (because af-
fected dogs are typically distressed just after owner
departure).
U Clorazepate is longer-acting and perhaps more useful
overnight or when a thunderstorm is predicted several
hours after administration.
Buspirone
Buspirone, a nonsedating anxiolytic, can be useful for gen-
eralized anxiety. Because it has been anecdotally associated
with aggression disinhibition, it may be best limited to treat-
ment of anxiety with no history of aggression to humans
or to other dogs. However, it is important to keep in mind
that any psychotropic drug may cause increased agitation
or aggression.
Combination Therapy
Combination therapy can be helpful for some individual
patients, and may include a:
U Standing antidepressant + benzodiazepine
U Standing antidepressant + trazodone (with caution)
U Standing antidepressant + benzodiazepine + trazodone.
However, monotherapy with an antidepressant (or the
PRN benzodiazepine) is recommended initially so that side
effects can be identified and linked to the drug being ad-
ministered.
Other Agents
To further effect anxiolysis or other behavior change, nonphar-
maceutical agents can also be added to therapy (Table 3).
Case Application: Buttercup
Buttercup tends to be distressed during Mrs. Jones
book club meetings and dinner parties, and is now
often restricted to the back bedroom during these
times. Administration of a sedative and a special,
long-lasting, food-filled toy could help Buttercup
relax and be less worried in these situations.
Beware of Serotonin
Syndrome
Because trazodone, SSRIs,
TCAs, and MAOIs boost
serotonin levels, their use in combination (any 2
of these drugs together) may potentially trigger
serotonin toxicity, or serotonin syndrome, a
potentially fatal reaction. Tell owners to watch for
early signs of serotonin syndrome, which can be
ambiguous, but include agitation, tremors, and
seizures. At the doses typically used in veterinary
behavioral medicine such reactions are rare, but
the potential for them indicates monitoring the
dogs response.
TABLE 3. Complementary Nonpharmaceu-
tical Agents for Behavioral Therapy
NONPHARMACEUTICAL
AGENT
EXAMPLES
l-theanine t Anxitane,
virbacvet.com
t Composure,
vetriscience.com
Pheromone diffusers,
collars, or sprays
t Adaptil, ceva.us
t Feliway, ceva.us
Prescription diets t Veterinary Diet Calm,
royalcanin.us
t Hills b/d, hillspet.com
S-adenosylmethionine
(SAMe)
t NOVIFIT (NoviSAMe),
virbacvet.com
Vitamins & natural
compounds
t Senilife, ceva.us
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WHAT OTHER FACTORS SHOULD
BE CONSIDERED?
Management Changes
It is sometimes too easy to think that a medication or
combination of medications will do most of the work,
when in fact management changes, safety practices, and
re-learning are needed for a successful outcome. Unfor-
tunately, administration of a behavior drug often pushes
these efforts to the back of the line.
Follow-Up
Follow-up is critical in management of behavior cases,
not only for dose adjustment and changes in choice of
drug, but also for feedback on modification, implemen-
tation, and progress.
Client Expectations
Behavioral drug use in pets is common enough that clients
may ask specifically for medication (puppy Prozac) for a
variety of problems. Before accommodating that request,
however, consider these recommendations:
U Remember that behavioral medication use is deter-
mined by the veterinarian per the Animal Medicinal
Drug Use Clarification Act (avma.org/KB/Resources/
Reference/Pages/AMDUCA.aspx)
U Review the indications and mechanisms of action
U Be familiar with potential contraindications and
adverse effects
U Address any confounding or comorbid medical prob-
lems associated with the behavior problem, includ-
ing pain, sensory decline, or hypersensitivity.
The client should also be forewarned that patience
will be needed, especially while waiting for the drug to
load over the course of 1 to 2 months.
If the medication is being administered at the correct
therapeutic doses, and there still is no measurable
changedecreased frequency or intensity of the problem
behaviorit may be necessary to taper and discontinue
that medication; then
begin a new one and
start the wait again.
This lag period can
be helped by use of a
more immediately ef-
fective anxiolytic, such
as trazodone, but con-
sider educating clients
that the beginning
of drug administra-
tion can mimic a long
ride on a slow-motion
roller coaster.
IN SUMMARY
Behavioral medi-
cations can make a
significant difference
in the management of a variety of problems. The ac-
cessibility of information about their use, and growing
choices of the medications themselves, increase their
convenience. Most important, they can facilitate a posi-
tive outcome in otherwise complicated behavior cases.
Medications are now a conventional option for manage-
ment of behavioral problems rather than a last resort.
FDA = Food and Drug Administration; PRN = as need-
ed; SSRI = selective serotonin-reuptake inhibitor; TCA
= tricyclic antidepressant; MAOI = monoamine oxi-
dase inhibitor
Case Application:
Buttercup
Buttercups lunging
and snapping behavior
significantly decreased
after 2 months of:
1. Treatment with fluox-
etine
2. Consistent effort by
the owner to counter-
condition her to visi-
tors (seated a safe
distance away)
3. Creation of a separate
safe haven, where
she could indulge in
feeder toys.
Ilana Reisner, DVM, PhD, Diplomate
ACVB, is a veterinary behaviorist and
consultant in Media, Pennsylvania. She
has served as the director of the Vet-
erinary Behavior Clinic at University of
Pennsylvania Veterinary Hospital and as-
sistant professor of behavioral medicine
at Penns School of Veterinary Medicine.
She is past president of the American Veterinary Society
of Animal Behavior. She received her DVM from Oregon
State University and her PhD from Cornell University.
The Special Case of Aggression
Human-directed aggression is the most common
canine behavior complaint; fear or self-defense is
the most frequent reason for aggression. Although
clients may naturally assume that anti-anxiety
medication can resolve this problem, remind
themideally in a written documentthat there is
no reliable cure for aggressive behavior, and no
drug will prevent biting.
More important than any medication is the need
for clients to understand safety recommendations,
avoidance of triggers of aggression, and the
application of behavior modification, including
both classical and operant conditioning. It should
be emphasized that punishment or other harsh
training methods, including shock collars and
outdated dominance exercises, can backfire
by increasing defensiveness and the likelihood of
further biting.
In any animal with a history of biting, the risk
for future bites can never be entirely elimi-
nated. Owners may not want to
face the prospect of permanent
caution, but nevertheless it is
important to emphasize safety
and preventive measures.
Read Dog Bites: Protecting
Your Staff & Clients (November/
December 2011) for further informa-
tion, available at tvpjournal.com.
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