Policy Statement
"It is recognised that dogs may show signs of fear or phobia of the loud noises associated with fireworks. It is the duty of veterinary surgeons to recommend and support evidence-based therapies for this noise fear or phobia in order that they may improve the welfare of animals under their care"
Summary of recommendations
Management of phobias should involve evidence-based treatments:
• Behavioural management.
• Anxiolytic/amnesic drugs.
• Support with pheromones.
Management of phobias is not enough; as with any other chronic, degenerative condition it is essential that phobias be treated. Treatment should also involve evidence-based treatments:
• Behavioural therapy using desensitisation and counter-conditioning
(possibly with pheromones as an adjunct).
• Long-term drug therapy, where required.
Guidance notes
Introduction
In a review of firework fears and phobias in the domestic dog, Blackwell et al (2005) found that 49% of dogs (n=383) had a fear of loud noises, with firework, thunder and gunshot noises being the most commonly represented. Many were fearful of several noises. Only 4% of those dogs affected had shown a spontaneous reduction in the fear/phobia symptoms. This indicates that there is a large population of dogs in the UK whose welfare is adversely affected by noise phobia, and which would benefit from consistent and effective management and treatment.
One element of the definition of a phobia is that it is a form of fear that does not diminish with repeated exposure to the stimulus, so this data apparently indicates that most of the dogs involved in the study had a genuine phobia of loud noises. However, the maximum permissible sound pressure level for fireworks in the UK (Fireworks Act, 2004) is 120dB at 15 metres, which is much higher than the maximum 97dB level recommended by charities such as the RSPCA. It is therefore probable that a proportion of dogs are not genuinely phobic, and in fact these dogs display a normal fear response to what is an intolerably intense sound stimulus.
No breed or sex difference was found, but older dogs and cross breeds had a higher incidence. Interestingly, Autumn-Winter born puppies had a lower incidence, presumably due to the benefit of early habituation to seasonal fireworks during puppyhood. This indicates that the use of recorded sounds may be beneficial for problem prevention in puppies.
There is accumulating evidence that treatment of phobias is possible, and as with any other medical problem it is the duty of veterinary surgeons to recommend and support evidence-based therapies for this noise fear/phobia in order that they improve the welfare of animals under their care.
Dealing with phobias is divided into short-term management and treatment. In many cases clients will not seek help until it is so close to a firework event that long-term drug and behaviour therapy will not be effective in time. So, the initial decision for many clinicians is what kind of short-term management to use.
However, clinicians should always aim to treat fears and phobias, rather than merely manage them, as these conditions have an impact on welfare and can become very severe. Health problems that cause pain, debilitation, sensory or cognitive impairment, or that have a direct or indirect effect on emotionality can influence the severity or pattern of expression of emotional disorders. It is therefore vital that the health status of animals showing fearful or phobic behaviour be investigated.
Short-term management
1.Behavioural
When afraid, dogs will attempt to escape from the source of their fear. They may become destructive or aggressive if their attempts to escape are thwarted; for example if they are locked into a room or restrained by the owner. Dogs with a fear or phobia of loud noises should be provided with unrestricted access to a place where they can hide. Fearful and phobic responses may also be reinforced or intensified by the behaviour of the dog’s owner. Attempts to soothe or comfort and animal when it is afraid can increase future expression of fearful behaviour. Attempts to coerce animals into confronting their fears, or to punish fearful behaviour will intensify fear. Owners should aim to remain relaxed and therefore provide a good role model to the animal when it is afraid.
2.Drugs
The aim of using short-term medication is to reduce the emotional impact of a fearful/phobic event without producing sedation, ataxia or hyper-excitability that might make the animal more difficult to manage. The emotional impact of a fearful/phobic event may be reduced either by reducing the dog’s emotional response to that event, or by altering its memory of it. In either case, the dog’s experience of the event is less likely to have a deleterious influence on future behaviour. Given that all short term medications used for phobia management are liable to produce adverse effects, some of which might be highly undesirable or even dangerous during a phobic event, it is essential that any drug used must be tested with an individual patient and the dose titrated to effect. It is generally inadvisable to leave animals unsupervised when they have been given short-term tranquillisers or anxiolytic drugs, especially during phobic events. Animals must not be left alone together if one of them has been given such a drug. For current drug doses please consult relevant formularies and texts.
Acepromazine (ACP)
ACP has, in the past, been used as a short-term tranquilliser during phobic events. However, it does not have anxiolytic properties and will therefore not alter the impact of an event unless the animal is rendered unconscious thoughout it. It is believed that immobilising an animal whilst leaving it aware of, and emotionally responsive, to a phobic event may intensify the experience and lead to worsening of phobia in the future. Oral dosing produces unreliable effects, and onset of action may vary between 15 and 60 minutes (BSAVA Formulary). High doses may be required in order to sedate a dog during a phobic event. High doses may lead to hypovolaemia, hyperexcitability and extrapyramidal side effects in some animals (BSAVA Formulary). For these reasons ACP is not considered suitable for the management of canine noise phobias.
Benzodiazepines
Diazepam produces short-term anxiolytic effects (GABA receptor agonism), and impairs the consolidation of short-term memory (NMDA receptor antagonism) so that events experienced immediately after a dose of the drug will be remembered less clearly (anterograde amnesia). The duration of amnesic effects is unknown but may be considered to last throughout the half-life of the drug. At low doses diazepam retains its amnesic effects, whilst at higher doses anxiolysis and sedation are achieved. Responses to diazepam are highly individual, so that dose response must be titrated. Action of onset is also variable (20-40 minutes), and diazepam should be given prior to an anticipated fearful or phobic event. Apart from medical cautions and adverse effects, diazepam may produce behavioural adverse effects of ataxia, hyperexcitability and disinhibition. Before giving this drug in advance of a phobic event at least one trial dose should be given to the animal, at a quiet and non-stressful time, in order to identify a dose effect, speed of onset, and any adverse effects. Diazepam is a schedule 4 controlled drug and there is no licensed oral veterinary preparation.
Triazolobenzodiazepines
Alprazolam (Xanax) produces broadly similar anxiolytic and anterograde amnesic effects to the benzodiazepine drug diazepam, through its effects on GABA and NMDA receptors. It is also a platelet activating factor antagonist, leading to retrograde amnesic effects (Saraf et al, 2003). It may be used in advance of an expected fearful or phobic event in the same way as diazepam. However, alprazolam may also be given after a phobic event in order to impair the dog’s memory of it (Crowell-Davies, 2003). It may therefore be used to block the effects of unanticipated phobic events in order to prevent them from having an emotional impact on the animal in the future. When used in this capacity the drug should be given as soon after the event as is safe and practical. The same cautions apply with this drug as with diazepam. At least one trial dose must be administered to the animal at a quiet, non-stressful time, in order to determine the correct dose, speed of onset and any adverse effects. Alprazolam is a schedule 4 controlled drug. There is no licensed veterinary preparation.
3.Pheromones
DAP (dog appeasing pheromone) is a synthetic analogue of a semiochemical produced by the bitch while she is lactating. It has anxiolytic properties in a number of situations (Gandia Estellés et al, 2006. Gaultier et al, 2005), and has been shown to reduce the signs of fearfulness during firework events (Sheppard et al, 2003). In this study DAP did not alleviate the more severe signs of anxiety, such as urination, and so it cannot be used as the sole treatment for phobia management. DAP has no known adverse effects and is not a licensed preparation. It may be safely combined with other treatments, such as benzodiazepines and triazolobenzodiazepines. DAP is available in the form of a diffuser and a collar. The diffuser is most useful for reducing fearfulness of dogs that are inside during a noise event, and, if positioned correctly, provides the dog with a location to go to in order to feel more secure. The diffuser must be installed at floor level in a location where the animal can get access to it at all times.
Long-term therapy
Fears and phobias may be managed on a short-term basis, but once the firework season, or other period of phobic exposure, comes to an end it is important to treat the problem so that it is less severe in the future. Behavioural therapy, sometimes combined with medication or pheromones, can achieve this.
1.Behavioural
Desensitisation and counterconditioning have been shown to be safe and effective methods for the treatment of fears and phobias of fireworks. In a study to evaluate the effectiveness of owner-administered behavioural therapy using recorded sounds Levine et al (2007) showed that such programmes could significantly reduce signs of fear in sound sensitive dogs, without the need for specialist support. One of the products in this study achieved consistently positive results across all tests and 93% of owners indicated that they had seen an improvement in their dog’s behaviour at the end of the trial. There were differences in the performance of the two products tested in this study, and it is likely that poorly designed recordings and treatment programmes will be less effective. Poorly managed therapy has the potential to make a problem worse, rather than better, and well designed products will provide owners with guidance on severity of a problem and the need for veterinary involvement should it be more severe or likely to have a medical basis. It is therefore recommended that owners be supplied with a commercially produced product that is properly designed, supported by evidence of efficacy and that provides responsible guidance regarding the need for additional specialist support and treatment. Desensitisation must be followed by counter-conditioning in order to consolidate any behavioural improvement. In order for behavioural therapy to work, the animal must be healthy, cognitively normal and in a relaxed state during the training.
2.Drugs
Benzodiazepines
Benzodiazepine drugs may be used to reduce the emotional impact of events experienced during therapy, in order to prevent a relapse and to ensure that the animal only learns for events that are non-phobic and properly controlled. Diazepam can reduce anxiety and reduce the impact of memories of events that occur in the period immediately after dosing, so this drug is useful for events that can be anticipated.
Alprazolam also has retrograde amnesic events and can therefore be used to limit the impact of events that are unexpected. In such situations the dog is given a dose of the drug as soon as possible after an event that elicits fear or anxiety that does not subside within a few minutes. If the dog returns to normal exploratory behaviour, playing, investigating its environment in a normal manner, then the drug is not required. This provides owners with a safety net so that they can prevent a relapse during therapy. It is also advisable for owners to use alprazolam in the same manner after therapy is completed.
Selegiline (Selgian, CEVA Animal Health) is licensed for the treatment of behavioural disorders with an emotional origin, which includes fears and phobias. It is the only licensed preparation for the treatment of sound phobia problems. This drug reduces fearfulness, increases exploratory behaviour and has positive effects on cognition even in healthy animals. It takes 4-8 weeks to begin to become effective, and is a useful adjunct to behavioural therapy, especially in individuals that are frequently exposed to noise events, show signs of a generalisation or are inhibited in situations when they are fearful or anxious. For example, the drug might be used to increase the confidence of a dog that has become afraid of going outside after dark due to a number of fearful experiences. Clinicians should consult the current data sheet for full information, including warnings and dosing.
Selective serotonin reuptake inhibitors
Other, non-licensed, preparations are also sometimes used for the long-term treatment of phobia. These include the selective serotonin reuptake inhibitor drugs sertraline and fluvoxamine. These drugs should only be used when there is a specific behavioural or medical reason not to use the licensed preparation and there is published or expert support for their use. In general, serotonergic drugs are used when anticipation of an adverse event (anxiety) has a greater effect on the animal’s behaviour than actual fear; i.e. the dog is often anxious in situations where there is very little likelihood of a phobic event. They can also be indicated when the animal’s response to the stimulus is characterised by elements of panic.
3.Pheromones
DAP has been shown to be effective in assisting the response to behavioural therapy. By reducing the dog’s general level of anxiety the pheromone provides a reassuring environment within which the animal is more likely to respond to behavioural therapy.
4.Herbal and homeopathic drugs, and food supplements
Noise phobias are serious conditions that have a great impact on the welfare of animals. If managed incorrectly, they tend to be progressive and can become so severe as to warrant the euthanasia of some animals. Given that an evidence base exists for conventional drugs and behavioural therapies, a clinician should not prescribe an unproven alternative that directly or indirectly results in the worsening of a behavioural problem. There is no peer-reviewed evidence for the efficacy of herbal or homeopathic drugs, or food supplements in the management or treatment of noise phobias. They should not be considered to be suitable for the treatment of noise fears and phobias.
References
Blackwell, E., Casey, R., Bradshaw, J., (2005) Firework Fears and Phobias in the Domestic Dog. RSPCA website.
Crowell-Davis, S.L., Seibert, L.M., W, Parthasarathy, V, T.M. (2003) Use of clomipramine, alprazolam, and behavior modification for treatment of storm phobia in dogs. J Am Vet Med Assoc. 222(6): 744-8.
Gandia Estellés, M., Mills D.S. (2006) Signs of travel-related problems in dogs and their response to treatment with dog-appeasing pheromone. Vet Rec. 159(5): 143-8.
Gaultier, E., Bonnafous, L., Bougrat, L., Lafont, C., Pageat, P. (2005) Comparison of the efficacy of a synthetic dog-appeasing pheromone with clomipramine for the treatment of separation-related disorders in dogs. Vet Rec. 156(17): 533-8. Levine, E.D., Ramos, D., Mills, D.S. (2007) A prospective study of two self-help CD based desensitisation and counter-conditioning programmes with the use of Dog Appeasing Pheromone for the treatment of fireworks fears in dogs (Canis familiaris). Applied Animal Behaviour Science. 105(4): 311-329
Saraf, M.K., Kishore, K., Thomas, K.M., Sharma, A., Singh, M. (2003) Role of platelet activating factor in triazolobenzodiazepines-induced retrograde amnesia. Behav Brain Res. 142(1-2): 31-40.
Sheppard, G., Mills, D.S. (2003) Evaluation of dog-appeasing pheromone as a potential treatment for dogs fearful of fireworks. Vet Rec. 152(14): 432-6.