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Storm Phobias

Storm Phobias

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Published by Nicholay Atanassov

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Published by: Nicholay Atanassov on May 03, 2012
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01/26/2013

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Storm Phobias
DVM NEWSMAGAZINE
Storm phobias: No other problem is as widespread, as devastating for the animal, and asfrustrating for the veterinarian in practice as is the issue of managing animals experience seasonal terror.The issue of noise and storm phobias and their tendency to be associated with other anxietydisorders was an issue much discussed by me and others at the recent AVMA meetings and the associatedbehavior 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. Duringthe time that my mother had Susie, the dog became more fearful of storms of all kinds, as are many dogsin the southeast United States.Whenever my mother would tell me how much Susie had suffered during the most recent storm, Iwould launch into my speech about how much medication can help, and how important it is to treat thesedogs early and often.
Client resistance
My mother's response was invariably that drugs were overused. Susie justneeded love. My mother would hold her to get through the storm, and Susie was fine, but tired, the nextday. It's entirely possible that my mother could or would have taken advice about medication fromanyone but me, but this logic is also something that veterinarians in practice tell me they often hear fromclients. 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 motherwas unable to care for her asked if they could keep her. I had no choice but to acquiesce: they loved herand were in tears at the thought of me taking her away. Again, I mentioned treatment for storms, buttheir response was that their other little dog was also distressed during storms and they would just sitwith her.The day after the AVMA meetings wrapped up, I answered the phone to hear the voices of Susie'sadopted parents. They wanted me to know that there had been a terrible series of storms the nightbefore.Susie had trouble breathing during the first one. During the second storm — in the middle of thenight 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 wasno; her terror worsened with time and exposure. How could I revisit the drug argument with someonewho 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 theneurochemistry of the dog and the severity and unpredictability of the storms.
Data talks
Data suggest that ~70 percent of all dogs who react profoundly to miscellaneous noisesalso 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 phobiasalso 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 riskfor 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 othersounds (wind, rain), darkness, changes in light intensity, barometric pressure changes, ozone changesand changes in human behavior. Any of these can lead to panic and must be treated. The medicationsthat 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 painand suffering. Treatment can involve the dreaded behavior modification, but this is one case where drugsare essential and
not 
optional. The rationale for behavioral medication follows.Alprazolam (Xanax) is my preferred drug of choice for storm and noise phobias, and for all dogswho panic, whether the panic is a solitary diagnosis or a co-morbid one with separation anxiety or otheranxiety-related condition. This benzodiazepine (BZ) is considered the classic "panicolytic" drug in humanmedicine, and has the advantage of a broad dosage range for anxiolytic effects, and a more narrow rangefor sedation. With diazepam, the pattern is reversed; however, dogs, like people, are incredibly individualin their response to benzodiazepines. Some dogs do better with one of these while other dogs show thereverse patterns. The only drawback to these medications is that they can be addictive and abused byhumans, so there is the occasional household in which such medications should not be placed.
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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 andhighly sedative—is ~3h. The half-life of alprazolam is somewhere in the 3 or 4-6h range but itsintermediate metabolite is not sedating, less active, and more directly excreted so you get a moremoderate and continuous patterns of anti-anxiety effects. If clients are expecting storms, and if they canget the dose of alprazolam into the dog two hours before hand and the other half ~30 minutes beforehand, 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 dosesto assess effects. Generally, alprazolam is repeated q.4-6h. This dosage can be used continuously over aperiod of days or weeks during a profound thunderstorm season. If this scenario ensues, it is best toslowly 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 whopanic (e.g. coming to the clinic). Most people don't think of storm phobias in cats, but they may well occurbecause 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 onepublication stating that this is the maximum daily dosage. Such logic is unrealistic for big dogs, but aswith 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 notdistressed, and about the best dosage level to treat the panic during the experience. For this reason, Irecommend 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 animalis fine, but sleeps more quickly or more deeply, the dose is a good one as long as the pet awakenswithout 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 cannotget an effect with alprazolam. There are some individuals who have genetic variants of enzymes thatmetabolize these drugs that can cause extreme effects. However, mostly I think people confuse ananxiolytic effect with a sedative one. And, they only give one or two doses. Instead, if you use alprazolamas discussed and keep giving it to one full dose as needed, the dogs—and cats—begin to learn that theydon't have to be so frightened. This formula also works like a charm for dogs who get upset duringveterinary visits. So for a 25 kg dog, I'd give 0.125 or 0.25 mg to start (the smallest tablet available is ascored 0.25 mg one) and evaluate the effect. If in 15-30 minutes the dog isn't noticeably calmer, give himmore.Alprazolam is a true panicolytic drug, meaning that it can also
stop
a panic attack. So if clients findthe dog or cat in distress, giving a whole dose and then evaluate what to do 15-30 minutes later canreally 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 fornordiazepam, 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 slowmetabolizers than is diazepam.I know that the common "treatment" for storm and noise phobias and veterinary office visits isacepromazine. In truth, I wish this medication would be placed at the far back of a top shelf and usedonly exceptionally. Acepromazine is a dissociative anesthetic meaning that it scrambles perceptions. Askyourself if a scrambling of perceptions will make an anxious or uncertain dog worse or better. It's alwaysworse, and we make many if not most dogs more sensitive to storms by using this drug. In part this isalso 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 morereactive because of these associations. If what you need is sedation - acepromazine can be an acceptableadjuvant, but it makes most of my really fearful and really reactive patients worse, so all sorts of otherdrug 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 dofour 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 orselective 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'snot 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. Suchbehavior provides closeness and allows the pet's muscles to relax without inadvertently rewardingany of the signs of anxiety.
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