764246

research-article2018
JFM0010.1177/1098612X18764246Journal of Feline Medicine and SurgeryAmengual Batle et al

Case Series

Journal of Feline Medicine and Surgery

Feline hyperaesthesia syndrome with 1­–8

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DOI: 10.1177/1098612X18764246
https://doi.org/10.1177/1098612X18764246

study of seven cases and proposal journals.sagepub.com/home/jfms

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diagnostic approach

Pablo Amengual Batle1, Clare Rusbridge2,3, Tim Nuttall1,

Sarah Heath4 and Katia Marioni-Henry1

Abstract
Case series summary This was a retrospective study on the clinical features and response to treatment in seven cats
with feline hyperaesthesia syndrome (FHS) and tail mutilation. FHS is a poorly understood disorder characterised by
skin rippling over the dorsal lumbar area, episodes of jumping and running, excessive vocalisation, and tail chasing
and self-trauma. The majority of the cats were young, with a median age of 1 year at the onset of clinical signs,
male (n = 6) and with access to the outdoors (n = 5). Multiple daily episodes of tail chasing and self-trauma were
reported in five cats, with tail mutilation in four cats. Vocalisation during the episodes (n = 5) and rippling of lumbar
skin (n = 5) were also reported. Haematology, serum biochemistry, Toxoplasma gondii and feline immunodeficiency
virus/feline leukaemia virus serology, MRI scans of brain, spinal cord and cauda equina, cerebrospinal fluid analysis
and electrodiagnostic tests did not reveal any clinically significant abnormalities. A definitive final diagnosis was not
reached in any of the cats, but hypersensitivity dermatitis was suspected in two cases. A variety of medications was
used alone or in combination, including gabapentin (n = 6), meloxicam (n = 4) antibiotics (n = 4), phenobarbital
(n = 2), prednisolone (n = 2) and topiramate (n = 2); ciclosporin, clomipramine, fluoxetine, amitriptyline and
tramadol were used in one cat each. Clinical improvement was achieved in six cases; in five cats complete remission
of clinical signs was achieved with gabapentin alone (n = 2), a combination of gabapentin/ciclosporin/amitriptyline
(n = 1), gabapentin/prednisolone/phenobarbital (n = 1) or gabapentin/topiramate/meloxicam (n = 1).
Relevance and novel information This is the first retrospective study on a series of cats with FHS. The diagnostic
work-up did not reveal any significant abnormalities of the central or peripheral nervous system; dermatological and
behavioural problems could not be ruled out. We propose an integrated multidisciplinary diagnostic pathway to be
used for the management of clinical cases and for future prospective studies.

Accepted: 12 February 2018

Introduction 1Hospital for Small Animals, Royal (Dick) School of Veterinary

Feline hyperaesthesia syndrome (FHS) is a poorly under-
stood disorder of cats characterised by a wide variety of
clinical signs. This condition was first reported in 1980
and several names have been used since, including
‘apparent neuritis’, ‘atypical neurodermatitis’, ‘rolling
Studies and the Roslin Institute, University of Edinburgh,
Edinburgh, UK
2Fitzpatrick Referrals, Godalming, UK
3School of Veterinary Medicine, Faculty of Health and Medical
Sciences, University of Surrey, Guildford, UK
4Behavioural Referrals Veterinary Practice, Chester, UK

skin syndrome’ or ‘twitchy cat disease’.1 Despite the dis-

parity of names used to describe this disorder, the
reported clinical signs are reasonably consistent and
include tail chasing, biting or licking the lumbar area,
flank, anal area, or tail; and skin rippling and muscle
spasms of the dorsal lumbar area, which may be
Corresponding author:
Katia Marioni-Henry DVM, PhD, DipACVIM (Neurology), DipECVN,
MRCVS, Hospital for Small Animals, Royal (Dick) School of
Veterinary Studies and the Roslin Institute, University of Edinburgh,
Easter Bush Campus, Roslin, Midlothian EH25 9RG, UK
Email: katia.marioni-henry@ed.ac.uk
2 Journal of Feline Medicine and Surgery
spontaneous or elicited by a light touch. Other clinical
signs such as excessive and unusual vocalisations, epi-
sodes of apparently wild and uncontrolled jumping and
running, hallucination and behaviours that mimic signs
of oestrus were described in the first report on this con-
dition by Tuttle in 1980.1
Although FHS has been described for almost 40
years its aetiology is still unknown; indeed, many clini-
cians consider FHS an umbrella term, covering a vari-
ety of conditions ranging from excessive skin twitching
to mutilation associated with a variety of pathologies.2
In fact, clinical signs consistent with FHS have been
anecdotally reported in association with dermatologi-
cal (eg, flea allergic or hypersensitivity dermatitis),
behavioural (eg, compulsive disorder and displace-
ment behaviour), orthopaedic (eg, trauma to tail) and
neurological conditions (primary epilepsy or second-
ary to encephalitis or brain tumours, spinal disease
such as intervertebral disc disease, neoplasia or infec-
tious myelitis).2,3
In the most severe form, cats with clinical signs of
FHS can severely damage or even mutilate their tails,
requiring immediate medical assistance.2,4 Treatment
with several medications with different indications, such
as antiepileptic drugs (eg, phenobarbital, diazepam),
anti-inflammatory drugs (eg, prednisolone), adjuvant
analgesics (eg, gabapentin), behaviour-modifying medi-
cations (eg, lorazepam, oxazepam, buspirone, amitripty-
line, fluoxetine, paroxetine or clomipramine), a synthetic
progestin (megestrol acetate), and vitamins and other
supplements (acetyl-L-carnitine, coenzymes, riboflavin,
vitamin E) has been proposed; however, to date, we are
not aware of any scientific study reporting results of
these treatments in cats with clinical signs of FHS.1–5
The aims of this retrospective study were to report the
results of diagnostic investigation and treatment in cats
presenting with clinical signs associated with FHS (ie,
skin twitching, vocalisation and/or over-grooming/
mutilating of the tail without apparent inciting cause)
and formulate an integrated multidisciplinary diagnos-
tic approach to be used for the management of clinical
cases and for future prospective studies.
Case series description
The electronic databases of two referral veterinary cen-
tres were retrospectively searched for information on
signalment, history, clinical presentation, diagnostic
work-up and treatment of cats with clinical signs com-
patible with FHS.1 Inclusion criteria were a history of
attacking or over-grooming the tail causing soft tissue
damage associated with either vocalisation and/or lum-
bar hyperaesthesia, manifested as rippling of the lumbar
skin occurring spontaneously or induced by gentle
touch. Videos (see video in supplementary material)
were also evaluated when available.
Seven cats met the criteria and were included in the
study; information on signalment and clinical presenta-
tion are summarised in Table 1. All seven cats were
domestic shorthair, six were male and one female; two
male cats were entire and the other five were neutered.
The median age of presentation was 1 year (range 1–7
years). Two cats were indoor only. Episodes of tail chas-
ing causing superficial soft tissue trauma were reported
in all cats as per inclusion criteria, and in some cats the
damage was deeper (ie, mutilation) leading to removal
of a conspicuous part of the tail in 4/7 cats (Figure 1 and
Video 1 [supplementary material]). These episodes
occurred multiple times per day in five cats, multiple
times per week in one cat and the frequency was not
reported for one cat. Vocalisation during the episodes
was reported in five cats and rippling of the dorsal lum-
bar skin occurring spontaneously or induced by gentle
touch was reported in 5/7 cats.
In addition to the clinical signs described above, three
cats presented with dermatological signs, including dan-
druff, alopecia and erythema; two of these cats also had
a history of intermittent gastrointestinal signs (vomiting
and diarrhoea). One cat had a prior history of unaccepta-
ble urination of suspected behavioural aetiology. All cats
received a complete physical and neurological examina-
tion, which did not reveal any other abnormalities.
Results of haematology and biochemistry were avail-
able for all cats and were unremarkable. Serology for
Toxoplasma gondii and feline immunodeficiency virus
(FIV)/feline leukaemia virus (FeLV) was performed in
five and six cats, respectively. Mildly positive IgG titres
for T gondii (1:100, normal ⩽1:50) with negative IgM titres
were found in two cats, suggesting previous exposure to
the agent. FIV and FeLV serology was negative. Five cats
had MRI scans of the skull and vertebral column, includ-
ing caudal vertebrae, and cerebrospinal fluid (CSF)
­analysis (total cell count, cytology and protein concentra-
tion) was performed in three cats. No significant abnor-
malities were detected in any of the cats with either
diagnostic procedure. Four cats underwent electrodiag-
nostic tests, including electromyography, of the muscles
of the pelvic limbs and tail (in all four cats) and motor
nerve conduction studies of the sciatic-tibial nerves (two
cats). The electrodiagnostic studies were normal with the
exception of prolonged insertional activity and mild
spontaneous activity detected in the muscles of the tip of
the tail in two cats; both cats had mutilated the tip of their
tail and therefore these mild abnormalities could have
been associated with recent muscle trauma and were con-
sidered of unknown clinical significance.
Dermatological tests were performed in two cats with
clinical signs suggestive of a dermatological condition.
The tests included cytology of skin lesions and coat
brushing and intradermal testing for environmental
allergens (negative) in one cat and a serological test for
Table 1 Signalment, clinical signs, treatment and follow-up in seven cats with feline hyperaesthesia syndrome with tail mutilation

Case Age Sex Breed Outdoor Flea Clinical Frequency* Other clinical Diagnostic work-up Treatment Final Outcome Follow-up
(years) treatment signs signs diagnosis (days)

1 5 MN DSH Yes Yes AT, ST +++ Intermittent CBC, biochemistry, Exclusion diet, Open Unsuccessful, poor owner 17
and M vomiting and lead level, MRI, gabapentin, compliance
(tail), V diarrhoea, Toxoplasma and
alopecia ventrum FeLV/FIV serology
Amengual Batle et al

2 1 ME DSH Yes Yes AT, ST +++ Ventral erythema CBC, biochemistry, Meloxicam, Suspected Remission with ciclosporin 989
and M and hair loss, radiographs, antibiotics, hypersen­ gabapentin amitriptyline;
(tail), V, intermittent MRI, CSF, EMG, prednisolone, sitivity one recurrence after the
LH, diarrhoea Toxoplasma and phenobarbital, dermatitis cat was lost for 48 h and
FeLV/FIV serology, gabapentin, treatment was briefly
dermatological amitriptyline. interrupted
work-up by primary Exclusion diet, poor
veterinarian owner compliance
3 1 MN DSH No No AT, ST ++ Inappropriate CBC, biochemistry, Gabapentin Open Remission with gabapentin 101
(tail), LH urination, MRI
suspected
behavioural
4 7 ME DSH Yes NA AT, ST +++ None reported CBC, biochemistry, Meloxicam, Open Remission with 77
(tail), V, radiographs, antibiotics, phenobarbital, gabapentin
LH MRI, CSF, EMG, tramadol, fluoxetine, and prednisolone. Lost
Toxoplasma and phenobarbital, to follow-up during
FeLV/FIV serology gabapentin, prednisolone tapering
5 7 FN DSH Yes Yes AT, ST +++ Dry scales CBC, biochemistry, Clomipramine Open Reduction in frequency 4
(tail), V T4, Toxoplasma and and review of flea of episodes (from
FeLV/FIV serology treatment 10–12/day to 2/day)
with clomipramine,
recommended flea
treatment and dermatology
consult; lost to follow-up
6 1 MN DSH No Yes AT, ST +++ None reported CBC, biochemistry, Meloxicam, Open Remission with a 971
and M (tail radiographs, MRI, antibiotics, combination of meloxicam,
and area CSF, EMG, nerve gabapentin, gabapentin and
between conduction study and topiramate topiramate. Recurrence
shoulder FeLV/FIV serology after an attempt to reduce
blades), the topiramate dose
V, LH
7 1 MN DSH Yes NA AT, ST NA None reported CBC, biochemistry, Meloxicam, Open Complete remission with 0
and M spinal radiographs, antibiotics, gabapentin, recurrence
(tail), LH EMG, gabapentin, of clinical signs after
nerve conduction topiramate discontinuation, lost to
study, Toxoplasma follow-up after starting
and FeLV/FIV serology topiramate

*Frequency of episodes of self-trauma and vocalisation: +++ daily, ++ weekly, + monthly or occasional
MN = male neutered; DSH = domestic shorthair; AT = attacking or over-grooming the tail, flank, lumbar or perineal area; ST = soft tissue damage; M = mutilation; V = vocalisation; CBC = complete blood count;
FeLV = feline leukaemia virus; FIV = feline immunodeficiency virus; ME = male entire; LH = lumbar hyperaesthesia (skin rippling and/or muscle spasms); CSF = cerebrospinal fluid; EMG = electromyogram; NA =
3

not available; FN = female neutered

4 Journal of Feline Medicine and Surgery
Figure 1 Self-mutilation of the tail in one of the affected cats
(cat 6 in Table 1)
detection of IgE antibodies to flea antigens (negative) in
another cat. Four cats received regular flea treatment,
one indoor-only cat did not receive any flea preventative
and the information was not available for two cats.
A definitive final diagnosis was not reached in any of
the cats. Hypersensitivity dermatitis was suspected in
two cases, but it could not be proven as the diagnostic
work-up for this condition was performed elsewhere
and detailed information was not available.
A variety of medications were used alone or in combi-
nation to treat the clinical signs prior or after referral,
including gabapentin (six cats), meloxicam (four cats),
antibiotics (four cats), phenobarbital (two cats), predni-
solone (two cats) and topiramate (two cats). Ciclosporin,
clomipramine, fluoxetine, amitriptyline and tramadol
were used in one cat each. In two cats with gastrointesti-
nal and dermatological problems an exclusion diet was
also attempted, but the dietary trial failed owing to poor
owner compliance. Four cats received a combination of
two or more medications, whereas three cats showed
improvement with monotherapy.
Clinical improvement was achieved in six cases;
in five cats remission of the clinical signs was
achieved with gabapentin alone (two cats) or a combina-
tion of gabapentin/ciclosporin/amitriptyline (one cat),
gabapentin/prednisolone/phenobarbital (one cat) or
­ active medications such as selective serotonin reuptake
gabapentin/topiramate/meloxicam (one cat). Two of
these cats with severe clinical signs (cases 2 and 6) had a
recurrence of clinical signs approximately 2 years from
remission after all medications had been briefly inter-
rupted (case 2) or the topiramate dose tapered (case 6);
another case was lost to follow-up during the slow taper-
ing of prednisolone (see Table 1). One cat had a reduc-
tion in frequency of the episodes following treatment
with clomipramine alone (see Table 1).
A diagnostic pathway for FHS (shown as a flow diagram
in Figure 2) was created based on the information collected
with this study and the combined experience of specialists
in neurology, dermatology and behavioural medicine.
Discussion
This retrospective study is, to our knowledge, the first to
report the results of the diagnostic work-up and treat-
ment of cats with clinical signs of FHS. The main limita-
tions of this study are its retrospective nature and the
limited number of cases included. The definition of FHS
is still controversial as some authors consider mutilation
of the tail part of the clinical presentation of FHS,5
whereas others consider tail mutilation a different entity
associated with neuropathic pain, possibly secondary to
prior trauma to the tail and/or caudectomy.6 To address
this controversy, we decided to include in this retrospec-
tive case series only cats with clinical signs associated
with the classical form of FHS, such lumbar hyperaes-
thesia, rippling skin, vocalisation, and episodes of
attacking or over-grooming the tail causing soft tissue
damage or mutilation. Self-trauma to the tail was chosen
as an inclusion criterion as in our experience this repre-
sents the most debilitating clinical sign that may lead to
referral and/or recurrence of clinical signs after partial
caudectomy.7
FHS is a debilitating condition, especially in the most
severe cases with mutilation of the tail. However, there is
a tendency to treat FHS with a series of therapeutic trials
prior to referral, including surgical removal of the injured
part and/or a variety of medications. This reluctance to
refer cases of FHS is not unexpected, considering the fact
that the aetiopathology and organ systems involved in
the development of this constellation of clinical signs
remain unclear 38 years after the first report.1 Ciribassi
suggested that FHS is a behavioural displacement disor-
der, in which the cat develops high motivation for two or
more conflicting behaviours (eg, eating or escaping
another cat) that might lead to a species-­appropriate but
unrelated behaviour such as grooming. If this conflicting
situation persists for a prolonged period of time the cat
may manifest displacement behaviour, even when the
competing motivations are not present, leading to a com-
pulsive behaviour.3 Based on this premise, signs of FHS
should diminish and/or disappear after initiation of
behaviour modification and/or treatment with psycho-
inhibitors (SSRIs; eg, fluoxetine) or tricyclic antidepres-
sants (eg, clomipramine or amitriptyline), and glutamate-
modulating medications (eg, topiramate and gabapentin)
(see Figure 2).3,8 Although in some cases this therapeutic
approach might be satisfactory, in our study 2/4 cats
achieved remission of clinical signs only after anti-
inflammatory or immunosuppressive medications were
added to psychotropic drugs.
Some authors have suggested that the episodes of
wild and uncontrolled jumping and running, tail chasing
and vocalisation seen in FHS cats are a manifestation of
epileptic activity.9,10 The partial response to treatment
with antiepileptic drugs (AEDs) such as phenobarbital,
 Amengual Batle et al

Figure 2 Flow diagram of proposed diagnostic pathways for feline hyperaesthesia syndrome (FHS). CBC = complete blood count; UA = urinalysis; EMG = electromyogram; CK
= creatine kinase; FIV = feline immunodeficiency virus; FeLV = feline leukaemia virus; CSF = cerebrospinal fluid
5
6 Journal of Feline Medicine and Surgery
gabapentin or topiramate, and the fact that some owners
reported that cats with FHS appeared to be dazed and
their pupils dilated during or immediately before the
­episodes, seem to support the theory of focal e­ pileptic
seizures. An extensive neurological work-up, including
neurological examination, haematology, biochemistry,
MRI of the central nervous system, evaluation of periph-
eral nerves and muscles with electrodiagnostic tests, CSF
analysis and serology for T gondii, FeLV and FIV, was per-
formed in three cats in our study and a more limited
work-up, including blood work and MRI, was performed
in two additional cats without evidence of intra- or
extracranial causes of seizures. These findings do not rule
out the possibility that FHS could be an idiopathic form
of epilepsy characterised by focal seizures, but the results
of the diagnostic work-up and the incomplete response
to treatment with AEDs cast doubt on this hypothesis.
Furthermore, the rippling or rolling of the skin over the
lumbar spine occurring spontaneously or in response to
gentle touch conforms to the definition of allodynia and/
or alloknesis, which are abnormal sensory states wherein
normally innocuous stimuli elicit unpleasant sensations
or aversive responses (eg, pain or itch).6,11 The response
of some cases of FHS to treatment with gabapentin and
topiramate may support the presence of neuropathic itch
or pain, as these AEDs have been successfully used for
the treatment of neuropathic itch and pain in humans
and veterinary patients, including cats.6,12,13
Gabapentin is a structural analogue of gamma-­
aminobutyric acid (GABA) neurotransmitter that was
originally designed as an anticonvulsant, but has been
found to be more effective in the treatment of neuropathic
pain and anxiety in humans and companion animals.14,15
Gabapentin is reported to be a safe medication, the sug-
gested initial dosage for analgesia is 3 mg/kg PO q24h
titrated upwards to 5–10 mg/kg PO q8–12h as needed;
mild side effects are reported, including sedation and
ataxia.16 Topiramate is a glutamate-modulating anticon-
vulsant medication with a reportedly complex mecha-
nism of action, including blockage of voltage-dependent
Na+ channels and potentiation of GABAA neurotrans-
mission, and inhibition of alpha-amino-3-hydroxy-5-­
methyl-4-isoxazolepropionic acid and kainate receptor
facilitation of Ca2+ influx.17 In addition to anticonvulsant
properties, there are reports of a potential beneficial effect
of topiramate in the treatment of obsessive-­compulsive
disorders and self-mutilation in humans and idiopathic
ulcerative dermatitis in a cat.12,17,18 Grant and Rusbridge
reported that a 2-year-old domestic shorthair cat diag-
nosed with idiopathic ulcerative dermatitis and self-
trauma to the skin of the neck showed a significant
improvement within 2 weeks of initiating treatment with
topiramate (Topamax; Janssen-Cilag), 5 mg/kg PO q12h;
this after treatment with gabapentin 10 mg/kg PO q12h,
pregabalin (Lyrica; Pfizer) 5 mg/kg PO q12h and
phenobarbital 12.5 mg PO q12h for 4 weeks each failed to
improve the clinical signs.12 During a 30-month follow-up
the clinical signs were controlled by topiramate, with the
exception of two recurrences following two attempts to
stop this medication; no significant side effects were
reported in the cat in this case report; however, sedation
and inappetence have been noted in cats treated with
topiramate for refractory epilepsy.12,16
A definitive final diagnosis was not reached in any of
the cats in our study, although hypersensitivity dermatitis
was suspected in two cats. This is consistent with earlier
anecdotal reports suggesting that dermatological diseases
may be involved in the pathogenesis of FHS.1,2 Owing to
the retrospective nature of this study and the fact that the
cats were referred after dermatological conditions were
ruled out by the primary veterinarian, specific history and
detailed information on the dermatological work-up were
missing. A full dermatological history and investigation is
important as, unlike dogs, clinical signs are not specific
for any particular hypersensitivity dermatoses or other
causes of itch.19 Thorough parasite control should be used
to eliminate fleas, even in indoor cats.20 Drugs with known
efficacy in feline hypersensitivity disorders include pred-
nisolone or methylprednisolone (1–2 mg/kg PO q24h to
remission and taper), ciclosporin (Atopica Cat; Elanco
Animal Health [7 mg/kg PO q24h to remission and
taper]) and oclacitinib (Apoquel; Zoetis [0.6–1.0 mg/kg
PO q12h to remission and then q24h]).13,21 In dogs, oclaci-
tinib acts on Janus kinase (JAK)-1 and JAK-2 receptors
involved in cell signalling pathways activated by various
cytokines and could potentially cause bone marrow sup-
pression when used at high dosages over a long period of
time.13 There is little information available on the poten-
tial immunosuppressive effects of oclacitinib in cats,
Ortalda et al treated 12 cats with hypersensitivity derma-
titis (>12 months of age and >3 kg body weight) for
28 days and did not observe any adverse effects; however,
they selected cats with negative FIV and FeLV status and
without exposure to raw meat to reduce the risk of toxo-
plasmosis.13 The authors of this small pilot study on the
use of oclacitinib in cats advised monitoring blood cells
count on a regular basis when using oclacitinib at dosages
>1.0 mg/kg PO q12h.13
Therapeutic trials with corticosteroids, ciclosporin or
oclacitinib may help eliminate cats with hypersensitivity
dermatitis and/or control itch and inflammation where
this is a component of FHS (see Figure 2).
Similarly, we do not have access to information that
will allow us to rule out the possibility of a behavioural
problem, even in cases in which a prior behavioural prob-
lem was suspected (see case 3 in Table 1). Ideally, cases of
FHS should be referred to a specialist in behaviour, when
this is not possible, a detailed behavioural history should
be collected to identify factors predisposing to anxiety,
fear, over-attachment to owner (eg, adoption from
Amengual Batle et al
humane shelter, arrival of new pets in the house and
multi-cat household tension; see Figure 2). Then, if a
behavioural disorder is suspected, attempts to reduce det-
rimental physiological stress and optimise the emotional
state, and physical and social environment should be
made prior to or in conjunction with therapeutic trials
with tricyclic antidepressants (TCAs), such as clomi-
pramine or amitriptyline (the recommended dosage for
both medications is 0.5–1.0 mg/kg PO q24h and should
be gradually increased and gradually discontinued), or
SSRIs, such as fluoxetine (0.5– 2.0 mg/kg PO q24h dos-
ages should be gradually increased and gradually discon-
tinued).3,16 The main side effects of TCAs in cats are
sedation, diarrhoea, anticholinergic effects (eg, dry mouth,
mydriasis, urine retention, constipation).3,16 Potentiation
of arrhythmias (due to the anticholinergic effects) in pre-
disposed patients, lowering of seizure threshold and ele-
vation of liver enzymes may also occur; some clinicians
recommend measuring liver enzymes prior to therapy, 1
month after initial therapy and yearly thereafter.3,16 TCAs
should be used with caution in association with other cen-
tral nervous system depressants such as SSRIs and
AEDs.16 Clomipramine is licensed for the treatment of
compulsive and anxiety disorders of dogs and cats in var-
ious countries (including the USA and the UK), it is the
most selective inhibitor of serotonin uptake of all of the
TCAs, with similar indications and application of SSRIs,
and is preferred to other TCAs such as amitriptyline for its
better anti-compulsive action and palatability.22 SSRIs,
such as fluoxetine, have been advocated for the treatment
of urine spraying and compulsive disorders of cats. The
onset of action for SSRIs is similar to that of TCAs, with
the onset of effect 3–4 weeks from the start of treatment;
however, for the treatment of compulsive disorders the
effect may not be seen for as long as 8 weeks.23 The exact
time for improvement could not be evaluated in our study
and it is possible that the short duration of treatment may
have affected the outcome of treatment with fluoxetine in
case 4 (see Table 1). SSRIs inhibit the function of the liver
cytochrome P450 enzymes; therefore, caution should be
used when administered concurrently with other medica-
tions that rely on these enzymes for their metabolism, in
particular phenobarbital, benzodiazepines and TCAs.3,16
SSRIs should not be used in combination with each other
or with other drugs that increase serotonin levels, such as
TCAs.3,16 The main side effects of SSRIs in cats are behav-
iour changes (anxiety, irritability and sleep distur-
bances), anorexia, diarrhoea and changes in elimination
patterns.3,16
Another limitation of this study, in addition to its ret-
rospective nature and limited number of cases, is that
none of the cats had a complete assessment and diag-
nostic work-up performed by specialists in behaviour,
dermatology and neurology. Referral to a clinical behav-
iourist was strongly recommended for four cats and
7
referral to a dermatologist was recommended for the
other three cats; in four cases the owners declined a ter-
tiary referral owing to financial limitations and three
cats were lost to follow-up. This highlights the need for
a systematic and comprehensive approach to the diag-
nosis of FHS.
Conclusions
In this study we retrospectively collected and analysed
information on seven cats with clinical signs of FHS,
including self-trauma to the tail. A definitive diagnosis
for this complex constellation of clinical signs is still elu-
sive and it is difficult to draw conclusions regarding the
ideal therapy. Based on the information derived from
this study and review of the available literature we for-
mulated a diagnostic pathway for FHS and created a
flow diagram for easy interpretation (Figure 2). This
diagnostic pathway needs to be validated by its applica-
tion on a larger number of cases, but it is the first step
toward a standardised approach to this condition and
forms the basis for prospective studies.
Supplementary material Video to show an episode of tail
chasing and vocalisation in one of the affected cats (cat 2, Table 1).
Conflict of interest The authors declared no potential con-
flicts of interest with respect to the research, authorship, and/
or publication of this article.
Funding The authors received no financial support for the
research, authorship, and/or publication of this article.
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