Hello everybody, I hope you can hear me OK. Thank you very much for joining our webinar this afternoon with Miriam Pryor speaking on No Dogs Left Behind Rethinking separation Related behaviour Problems. And thank you very much to Domes Pharma for kindly sponsoring our webinar.
So some housekeeping for you all, if anyone has questions for our speaker, please put them into the Q&A box for comments or other queries, please use the chat box. And we are going to leave some time at the end to address some of those Q&A's. And if there's not time to answer them all, because I'm sure there'll be a lot, then we'll forward the rest of them on to Miriam and she'll get back to you herself.
So, a little bit of an introduction about Miriam before we let her loose on you. Mary is a practising GP vet at a very busy hospital practise, a veterinary behaviourist and co-owner of Pet behaviour Company with her colleague Lynn. She is a CCAB veterinary behaviourist registered with the ABTC and also a member of the BVBA and the FABC.
Lots of letters there. Glad I know my alphabet, Miriam. Pet behaviour Company was established in 2022 to bring together the strengths of both owners and our colleagues.
They provide veterinary behaviour referrals locally to Lincoln and as a remote referral service. So Miriam, over to you. Thank you so much for the introduction, Helen, and hi everyone, thanks so much for being here.
Just before I get started, I just wanted to give a quick disclaimer as well, so this session is being sponsored by Domas Farmer, but the views are my own. So in terms of what we're going to cover today, we're gonna start with how separation behaviours are classified and the evidence around generic and tailored advice. Then we're going to go on to cover the steps to take when you are first presented with a separation case in consults.
Then we're gonna cover all of the medications that you might use for separation related behaviours, and finally, we're going to finish with some case studies. So But the thing to clarify is. When clients say separation anxiety, they typically mean any unwanted behaviour that is occurring when they're out, but behaviourists will typically say separation-related behaviours instead because not all of these cases are motivated by anxiety.
So historically separation behaviours were thought to be predominantly dog attachment problems, so either an excessive bond with the owner or an unpredictable relationship between the dog and the owner. And this can occur in some cases, but more recently it's been recognised that there can be many other causes of separation behaviours, including pain, fear, or frustration, and that can be in response to specific triggers or just in general. In terms of prevalence, figures from the literature do vary quite a lot, but if anything, the survey style reports are more likely to under diagnose because if you have a dog that is not destructive and the neighbours haven't complained, then many owners may not even be aware that their dogs are distressed.
It seems safe to. Kind of the range of figures that we have that something close to 25% of pet dogs probably exhibit some separation behaviours, that is a huge welfare implication, even more so because only 7% of owners of dogs with separation behaviours actually seek assistance. So I just wanted to highlight this lovely study by Blackwell and Colleague which is preventative advice is genuinely.
So dogs being rehomed from a rescue centre were allocated into either a control group whose owners were given health advice or a treatment group whose owners were given behavioural advice on preventing separation behaviours. There were 88 dogs in each group. And when the owners were then surveyed 12 weeks after reuming, 38% of the control group were separation behaviours relative to only 22% of the treatment group who'd been given that preventative advice.
So assuming that the difference was entirely due to the advice given, which of course it might not have been, but if it was, then 14 dogs were prevented from developing separation behaviours by that study. The advice given is as shown on the slide, and it's pretty similar to the generic first aid advice that we would give to dogs already presenting with separation behaviours, and we'll go through that in a few slides' time. Additional preventative advice has come out of the Generation Pup Study, which is a longitudinal study of puppy owners across the country.
And they found that puppy owners who used more punishment or reversive techniques, the puppies had increased odds of separation behaviours. Puppies whose owners reported fussing over their dogs in response to unwanted behaviour on their return versus those who responded in other ways were 6 times likely to display separation behaviours. And puppies were also less likely to display separation behaviours if 16 weeks old, they were restricted to crates or rooms overnight and had over 9 hours of sleep per night.
Now, of course, it's possible that this relationship is the other way round, so that owners of pups more preparation issues might be more likely to give up on sleeping the pups in their own space, and more research is needed, but this is certainly useful information to give to new puppy owners who are asking the questions. Another study published this year by Batista and colleagues has also found er that aversive training sort of owners who. Using aversive training and also owners who co-slipped with their dogs, were more likely to then have puppies with separation behaviours.
So we can make a massive difference by providing this preventative advice, particularly in first vaccine consults or with the first consultation with new rescue dogs. There is also an app, so the Zigzag puppy and dog training app, which. Has been developed by the group at Lincoln, so they've provided a lot of the, the advice to the makers of that.
Up, and that is a good pair of donors to help them get started on their way. Similar generic has been out in this 2006 study of dogs who were already struggling with separation behaviours, so this is now treatment and prevention. Sweep and behavioural advice, 14 were controls.
Both of the treatment groups, so the blue group and the orange group, showed significant improvements and differed significantly from the control group, which is the green bars on the graph in which material change. Overall, 56% of owners of treated dogs reported significant improvements, with a further 25% reporting slight improvement. So that's pretty good.
But the same study also looked at 30 individual case studies of dogs seen for behaviour consultations and given tailored advice. And of these, 59% reported significant improvement, and the remaining 41% all reported some improvement. So that suggests that tailored advice will actually have a greater chance of success.
In practise, he use a combination of applied behaviour analysis and a first principles approach to look at the possible underlying emotion. Tailored advice will be specific to the emotional origin of the behaviour, but also the individual dog and the household. So even within a given emotional origin, there's no one size fits all plan, and many dogs will also be experiencing a combination of emotions and motivations for their behaviour.
It's also important to introduce just a small amount for owners to do at a time to avoid overwhelm. So if we just give them every possible technique, then they're not likely to do any of them well. It's important to consider the owner's lifestyle to fit training around, to consider the dog's temperament and arousal levels.
So as an example, nothing in life is free is a regime that can really help to add consistency, increase calm, and strengthen the dog owner bond in some cases. But it could actually create a bite risk in some dogs, so we need to choose these cases carefully. Equally, most cases will benefit from a change in leaving location to remove any conditioned negative response.
It will also potentially reduce exposure to fear or frustration inducing triggers, . And resources that are available. But what this looks like in terms of which room of the house is going to be most suitable will differ on a case by case basis.
So all separation behaviour consults include a tour of the owner's house, either via Zoom or through a home visit. If an owner is working on training departures that they hope the dog can cope with, then these also need to be clearly differentiated from essential departures that we know the dog will find distressing. So usually it's easiest to keep the essential departures in the original location and select a new location for training departures to avoid any conditioned negative responses.
So I promised this talk would be directly relevant for all of you who are GP vets in practise, and here are the spark notes. In the next few slides, we're going to go through the process of seeing a brand new separation behaviour case for the first time. This starts with a thorough assessment of physical health, including history taking and clinical exam.
Then a very brief behavioural history, and you do have to really work to keep that part short. Followed by a provision of the basic first aid advice, a discussion about medication, and an offer to start the referral process. I haven't made a separate slide on how to refer, but the important thing is of course to select an accredited behaviourist and for medical advice, a veterinary behaviourist.
Hopefully you may have one in your area, but many of us will also see cases remotely, so myself and Lynn at Pet behaviour Company do see cases from all around the country. It's still a lot to get through in 15 minutes, but this is actually quite manageable, and as a GP vet as well as a veterinary behaviourist myself, these are the same steps that I take when I'm in general practise. So in terms of clinical history and a physical exam, we're looking for potential pain contributions to the dog's behaviour.
At a big international conference, the various referral centres compared their case logs to assess what percentage of the cases they saw had a pain component. In 2019, 68% of the cases referred to Bristol, 92% of the cases referred to Lincoln behaviour, suspected to be painful. Orthopaedic pain is the most common offender with hips and stifles high on the list, but GI discomfort featured too.
Specific questions are really important with this part of the history taking. So if you ask, have you seen any lameness, you'll probably be told, no, he still loves chasing his ball. But if you ask, have you seen any hesitation before he gets on and off the sofa, we're quite often told yes, or even, oh, he can't jump up there anymore.
In terms of GI function, I always ask whether the dog is ever sick, whether the owners hear frequent tummy gurgling. And I often ask about specific frequency or what exactly do the poos look like and so on. So especially with the brachycephalic breeds, a huge proportion of owners actually think that daily reflux and vomiting is normal.
I know I'm preaching to the choir here, but I've had several cases where addressing these signs have actually made a massive behavioural difference. So I had one really memorable case where boa surgery pretty much cured high intensity owner-directed aggressive behaviour. In terms of the gate, watching the dog walk at the practise isn't all that helpful for subtle lamenesses because the dog is gonna be full of adrenaline, the floors are gonna be slippy, and there's a million distractions, plus there really isn't time.
But you can ask the owners to record some gate footage and bring it to their next appointment. And there's a handy how-to video for owners on our website. But if you're in any doubt about whether Encourage you to a pain.
On cases on referral where the dog has had a week of Metaca, it hasn't fixed the issue. And so it's been concluded that pain can be ruled out. But we quite often go on to find pain in those cases.
And that really makes sense if you think about the mechanisms through which pain is behaviour. So if you have a dog that is painful, as well as the direct feeling of being more vulnerable because they are sore, they will also have a lower overall mood or affective state because of the fact that they will have a reduced sleep quality and reduced sleep duration. And it's gonna take a few weeks for the dog to feel more comfortable, start sleeping better, and then start to be in a better mood as a result of that.
So we always recommend for our pain relief trials to make it at least 4 to 6 weeks in length. Some behaviourists would even say 12 weeks. I typically recommend using at least 2 medications for most cases to make sure that we are providing adequate pain relief to really see a difference behaviourally, and I always ask that the client keeps a diary from 2 weeks before starting the pain relief until at least 2 weeks after finishing the pain relief.
So for some cases, it's really dramatic. They start the pain relief and whoa, it's like a different log. But for some cases with more subtle pain, it might be that the biggest change they actually notice if there's been a subtle improvement throughout no pain relief, is the sudden deterioration when they stop it.
The other thing to bear in mind with these behaviour cases is we're quite often identifying chronic painful conditions in younger dogs, particularly with our separation cases, which we often find are younger individuals. So it can be really useful at this point, obviously a few appointments in, to start discussing the complementary treatment options, so things like our physiotherapy, hydro, laser, or acupuncture, so that the owners feel comfortable maintaining. The dog in good comfort in the long term, as few medications as possible.
Physiotherapy can also be really helpful as an extra form of mental and physical stimulation for some dogs. Some dogs may need a short acting anti-anxiety medication to be given before their first physio session just to help them cope with it. As per all cases, we recommend baseline bloods should be taken before starting on any long-term medication, that is the gold standard, but it is always a cost benefit analysis to be discussed with the owner.
And then just a note on keeping the behavioural history short, so we do want to behaviour history, but at this point all we really need to do is make sure that the dog's basic needs are being met and that the owner doesn't have any massively unrealistic expectations about how long a dog can go without a toilet break. So As much as possible, we want to avoid leaving the dog alone during the initial retraining period to prevent escalation of the behaviour and to avoid distress as well. I've just said that may not be possible for a lot of owners, and that's where you might want to be using the short acting medications to help the dog cope.
But if it is possible, then encouraging owners to recruit dog walkers, neighbours, or friends can really help for minimising times when the dog otherwise wouldn't cope. It can also help for the dog to have a safe space. So for some dogs, this will be a covered crate.
But for others, it could be a dog bed in the corner of their favourite room or a blanket under the stairs. The main thing is for it to be a location in the house where the dog won't be disturbed if they're resting. So probably away from the front windows and not in a thoroughfare where the family is going to need constant access.
A pheromone diffuser plugged in nearby can also help to create an association with safety. As can regular provision of treats in this area. So in a one dog house, you might just periodically leave treats there for the dog to find, or in a multi-dog household, the dog might actually be encouraged to their bed a few times a day and rewarded there by the owner.
Food toys can be really useful for owners with busy lifestyles as an easy way of adding additional mental stimulation. They can be used instead of food bowls to serve dinner. For some dogs, food toys could also be used when the dog is left, but that is case dependent because it's obviously not safe if the dog is either an enthusiastic chewer or in multi-dog households where it could create a risk of conflict.
It's really important for the owners to routinely initiate physical and mental stimulation, and that means that the owner has to choose times that they're going to play with the dog, not when the dog is bringing them a toy. And that ties into rewarding relaxed behaviour, so it's so, so easy to ignore a dog that's being good. But what we actually want to do is either praise or play with the dog at those times to encourage that relaxed behaviour to happen more often.
And then I've carefully phrased, withdraw attention in response to unwanted behaviour, because a lot of people will say ignore unwanted behaviour, but if you've got a Labrador or, you know, a Rottweiler jumping on top of you and humping your leg, that's not really something that you can ignore. So if it's possible to ignore unwanted behaviour, absolutely do so. But if not, the normal advice is just to leave the room as soon as you notice that something is afoot.
But ideally, we actually want to prevent unwanted behaviour as often as possible by preempting it. So if there's a specific time that we know the dog always struggles, then we actually want to give the dog a food toy in another room about 10 minutes before we expect that's likely to happen. If the dog is particularly attached to one person, it does help to involve someone else in the walks or the treats or the training.
Just to reduce that dependence level, and the most important thing is to never punish unwanted behaviour, no matter how much mess has been made when the dog is left. Now, in terms of punishment. We may think it's not that common, but actually looking at the studies that we have, a huge number of owners are actually punishing their dogs.
So in that Blackwell study of 176 dogs. 77 owners said that they were verbally punishing their dogs when they got in, and 49 owners said they were showing their dogs the scene of the crime. We don't want to criticise owners for punishing their dogs, but we do want to ask the question and educate.
So it could be helpful to actually discuss the basics of learning theory with some of these owners, especially if they're from a generation or a school of thought where they're not automatically into positive reinforcement training. In terms of the way learning theory works, there's a behaviour and that behaviour will have a consequence. And if the consequence is positive, the behaviour is more likely to happen again.
And if the consequence is negative, the behaviour is less likely to happen again. But in terms of our separation behaviours, there's inevitably going to be a long time delay between when the dog does the destruction and when the owner gets home. So for the dog, the destructive behaviour is not actually the cause of the punishment.
For the dog, the destructive behaviour is just a release for their emotional overwhelm. But for the dog, it's the owner's return that is the cause of the punishment. So not only is that punishment going to be ineffective, but it is also going to really deteriorate the quality of that dog owner bond.
So, onto the next slide. I just said ideally we're going to avoid leaving the dog if they won't be able to cope. But often that's impossible.
So owners might have to do the school run or the shopping, or go to an appointment tomorrow, and they don't have family nearby, and there isn't time to arrange a dog sitter, and so on. So this is one place for our short acting medication, and how amazing is it to say we can make your dog feel less stressed when you have to leave him tomorrow. In the long term, we'll look at referral and a behaviour modification plan, but until we get that sorted, let's help him to cope right now.
The other place for short acting medication is the occasionally left dog. So excuse the caricature, but this is the little old lady who takes her dog everywhere and doesn't need to work or go out much. But now she has some hospital appointments coming up and doesn't know what to do.
This dog doesn't actually need referral, so the likelihood is this dog isn't ever going to have to learn to cope to be comfortable being left. He just has to manage to cope with one short appointment or so per month without getting distressed. And in that sort of situation, the combination of first aid behaviour advice and a prescription of taspimidine or another medication that works for that dog is going to be enough.
The other medical consideration is whether to start long-term daily medication, so fluoxetine or Pexion, straight away or await referral. That's a case by case decision, but it can be influenced by things like the owner's attitude towards medication, the waiting time for a referral appointment. And the frequency with which the dog has to be left.
So is it once a week or is it every day? If you've got a good relationship with them, you can also ask the advice of the behaviourist that you're referring to. So we will quite often provide that sort of advice to vets via email before seeing a case.
Long acting behaviour medication must always be accompanied by a behaviour modification plan, so ideally these cases will be referred, but if not, it is important to arrange regular follow up appointments with the clients and check in and see how they're doing. We also always need to warn owners that there is a risk of disinhibition with any behaviour medication. So what does disinhibition actually mean?
Well, if you have a dog who maybe was thinking about biting but is feeling anxious and inhibited, then they're more likely to back away. But if you remove that inhibition, then there is theoretically a risk that that dog could actually go ahead and lunge or bite. Now that doesn't happen often at all, but we always warn owners that it is a potential with any behaviour medication.
So we always want to make sure that we have sensible safety management in place before we start a dog on a new behaviour medication. Onto the next slide, so. Thinking about tazapiidine, this is a new licenced medication, so it was only licenced in November 2024.
It's fast acting, short-term medication. Based on the licencing, this is the first line for those dogs with separation behaviours that either need immediate rescue or for owners who are only leaving their dogs on rare occasions. It's an alpha 2 ago agonist, so the same drug class as Saleo or Domitor.
But this is a liquid formulation, so it can be given straight into the mouth by syringe. It is though recommended to give Tessie on an empty stomach, so the advice is to syringe it straight in. It can be followed by a tiny treat or put on the tiniest, tiniest bit of something if needed to get it in.
But if you give Tessie with a full bowl of food, then the maximum plasma concentration would actually be halved, and the time to reach the maximum plasma concentration is increased from a predictable 30 to 90 minutes up to a much less predictable 0.7 to 6 hours, which potentially makes it not useful for those situational times that we're, we're wanting to actually use it for. It is always recommended that owners do a test dose of Tessie at home before using it when they're going out, just so that they can see how their dog responds, because some adverse effects, such as lethargy and vomiting can be seen relatively often, and obviously we don't want that to happen when the owner is out.
Typically, we want to give Tessie an hour before the owner is due to leave, and it should last for about 3 hours. It can be repeated after 3 hours if needed, so potentially a middle of the day dog walker could give an additional dose. The graph on this slide is from a study of 12 dogs in a randomised blinded crossover design with 4 day periods of either Tessie at the licenced dose, Tessie at a 1/3 dose, or a placebo, and no behaviour modification plan was given.
There were significant owner rated improvements in acute anxiety at the point of departure. And significant decreases in destructiveness and vocalisation, as rated by owners when watching back video footage of their dog. And that was for obviously the group taking the Tessie at the full dose.
So looking at the graph, dark green is excellent, light green is good, and yellow is some effect. Now, if you consider a fig seed to be good or excellent, then in this study, the success rate is only about 60/40. But bear in mind that this is in the absence of any behaviour modification plan.
There have been some more studies that haven't yet been published, carried out by Domas Farmer who produced Tessie. So there's been a study of randomised double-blind placebo control with 66 dogs who had separation behaviours given Tessie an hour before departure as needed over a 5-week period. And they found a similar success rate in that study.
Tessi has also been studied alongside fluoxetine, and the recommendation is to reduce the dose of Tessie to a 2/3 dose if using it in combination with fluoxetine, just to avoid any excessive sedation. So trazodone was always my go to first line situational medication for separation behaviours before the development of Tessie, and it would still be my go to for dogs who don't tolerate Tessie, or if for a one-off, they need support for say 5 or 6 hours. I haven't yet had the opportunity to use trazodone alongside Tessie, but this is also something that I would potentially do if Tessie alone was insufficient.
Again, starting with a decreased dose, so maybe a 1/2 or a 2/3 dose of Tessi, assessing the effect and then titrating up as needed. So trazodone is a serotonin antagonist and reuptake inhibitor, and in humans, it's used to help with sleep disturbance. As vets, we're probably most familiar with trazodone for pre-vet visits, and there are some papers to support this, as well as anecdotally years of successful use in practise.
Although we don't have any published studies to date looking specifically at trazodone for separation behaviours. There is evidence to support its use in dogs with generalised and noise related fear. And anecdotally, I also recommend trazodone for dogs struggling with frustration tolerance as well.
So The very first paper looking at the use of trazodone in dogs from back in 2008 was a retrospective case series of 56 dogs treated with trazodone following behaviour referral. Specifically, cases with anxieties or phobias. These dogs were already receiving a variety of other behavioural medications, including fluoxetine.
And in general, the dog's tolerated the trazodone really well. So we can use low doses of trazodone alongside low doses of fluoxetine if we need to. But we always recommend not to use trazodone if a dog is on a higher dose of fluoxetine.
So I would quite happily use sort of 3 or 4 mg per kg of trazodone with 1 mg per kg of fluoxetine. But if I've got a dog on 2 mg per kg of fluoxetine, then I'm going to. Not give them any trazodone or or wean them off it.
OK, and that is because of the risk of serotonin syndrome, which can cause seizures and hypothermia. So trazodone was very well tolerated in that study. 3 out of 56 dogs discontinued because of side effects, but the remaining dogs all tolerated it very well, and the owners reported it to be very effective.
In terms of some other studies looking at trazodone in relation to fear. There was a small German study comparing trazodone versus Saleo for fireworks, which actually found trazodone to be more effective. And then the graph on this slide is from a small study comparing trazodone versus CBD for fireworks.
And it's only a very small study, so 4 dogs in each group, but I, I like this one because it shows that trazodone actually lowers the plasma cortisol. In addition, the dogs who were given trazodone spent more time with their tail relaxed. So onto the next slide, the other short acting medications that we commonly use in behaviour practise are clonidine, gabapentin, and less often, alprazolam.
So clonidine is a tablet version of an alpha 2 agonist, so the same drug class as Tessi, Saleo, and medaomidine. It's off licence, but because it can be hidden in food, it is indicated for those dogs who won't take Tessie willingly and whose owners could not safely syringe it in. So I'm thinking about some of the bitier patients that we see, or some of the very head shy dogs.
It's a human medication and it's used in humans as an anti-hypertensive and to treat ADHD and the tics in Tourette's syndrome. As with Tessie, test dosing first when the owners are at home to gauge effect is a good idea. So we normally ask the owners to give the dose and just see how the dog is, and we might do that a couple of times to get to the ideal dose.
Unlike with Tessie, we recommend giving clonidine 2 hours before the owner leaves rather than 1 hour before. There's only actually been one published paper on the use of clonidine in dogs. There was no control group, and the authors were looking at the responses of dogs seen at Tuft's behaviour clinic, where all of the dogs had previously trialled long acting medication, and some had tried other short acting medications, including Xanax and propranolol.
In that little trial, 70% of the owners of fearful dogs reported clonidine to be more effective than the medications that they'd tried previously. Next up is gabapentin. So you'll all be familiar with gabapentin and obviously we often use it alongside trazodone for situational use.
It can also be used on its own, both for ankylysis or as part of a pain relief trial. I really just wanted to point out the difference in dosing when using gabapentin for anxiety versus pain relief. So we typically use higher doses for anxiety with a recommended dose of 20 mg per kilos given 2 hours before a stressful situation.
And if anything, we would round up on that 20 mg per kilos rather than down. And then finally, Xanax. So I don't use Xanax anywhere near as often because it does have quite a variable dose variable response and I have seen a couple of cases of paradoxical hyperactivity with it as well.
But I will sometimes add it in alongside the other medications if additional support is needed. Going on to the next slide to look at fluoxetine. So since it was licenced, and of course the licenced products are both Fluoxabet made by Jonas Parma and Reconcile, made by Forte, the use of fluoxetine has massively increased in general practise.
Relative to the generic human fluoxetine that we were using before, there is actually increased bioavailability of both of the licenced products. And that means that we're now erring on the side of lower doses to avoid side effects and then titrating up as needed. So I will typically start dogs on closer to 1 milligramme per kilo, or just under, and then.
Increase that dose if all's going well after a few weeks. It does mean starting potentially on a lower dose than what it says on the side of the bottle, but anecdotally we found that as we switched from the human generic onto the licenced form, we were seeing more side effects, and that has resolved since we've started on a lower dose and then titrated up. Although initial improvements are often reported after 1 to 2 weeks, it takes 4 to 6 weeks to see the full effect.
So we do need to assess things over this period before considering a change in dose. And as I mentioned before, we can combine low-end doses of trazodone and fluoxetine, but not high-end doses. And you do actually need a washout period if you're switching from a different long acting serotonin mediating drug such as selegiline.
So you actually then need 4 weeks off medication altogether before starting the fluoxetine. If you see a good response to fluoxetine, you want to continue this for twice as long as it took to see a good effect, and then you want to wean it off slowly, so decreasing the dose by around 25% or 5 every 1 to 2 months. Onto the next slide, looking at some of the evidence around fluoxetine.
So Sherman Simpson and colleagues demonstrated that fluoxetine alongside a behaviour modification plan gave a greater improvement than a behaviour modification plan alone. Interestingly with that one, bigger improvements were seen when Phlox's team was given alongside the behaviour plan after just 1 week, even though it takes 4 to 6 weeks for the full effect of Flo's teen to be seen. The subsequent paper by Landsberg and colleagues looked at floxetine use alone without any behaviour modification plan.
In that study, over 58% of owners did report improved severity scores compared with before treatment, but that still means that over 40% did not see any improvement, and those seeing improvement did not see resolution. And so the paper concludes that a behaviour modification plan is essential alongside fluoxetine for optimum results. And then I finally wanted to mention the 2015 paper by Karaiannis and colleagues, which looked at dogs' responses to a cognitive bias test.
So in this test, a food bowl in the R+ location always has a reward in, and a food bowl in the R minus location never has a reward. After dogs have realised this and learned this over a few trials, they'll start to run faster to the R+ location than the location. In cognitive bias tests, researchers then measure the time taken to travel to an ambiguous location in between the positive and negative bowls.
Untreated dogs with separation behaviours have been shown to run relatively slower towards ambiguous locations, which can be interpreted as pessimism. In the 2015 study, five dogs with separation behaviours were treated with fluoxetine. By week 6 of treatment with fluoxetine, those dogs were then showing more optimistic responses in the cognitive bias test, so moving relatively faster to the near negative location than they had been before they started on medication.
It's a shame that this hasn't been repeated with a bigger sample size and a placebo group, but it's a really interesting area for further research and explaining to us how the fluoxetine is actually affecting the dog's behaviour and their overall effective state. So onto the next slide, I'm thinking about Pexin or Emepatoin, which is the other longer acting drug that we might use in our separation cases. As you'll know, it's licenced for firework fears, but it is used off label for other fear related conditions.
It was of course initially licenced to treat seizures before the behavioural studies were carried out. So Pexion is useful for fearful dogs, and I might select Pexion over fluoxetine for a dog that is just terrified by life and doesn't appear to be struggling with frustration or arousal issues, but is just scared. We do need to be careful with mepatoin if there is a history of aggressive behaviour because there is a theoretical increased risk of disinhibition with drugs from the benzodiazepine class.
We sometimes also use Pexion alongside fluoxetine if needed, so they can both be used together to provide additional support. A Pexion can be used long-term or medium term. So for example, if a couple of weeks of additional support is needed whilst the owner goes on holiday, then we could add that in for say 3 or 4 weeks.
But it does have to be started at least 3 days ahead of the time that it's needed. So it isn't useful for separation dogs who just need occasional support here and there. Now, the dose range in the formulary for Pexin is between 10 to 30 mgs per kg twice a day, and it's licenced at 30 mg per kg twice a day for phobias.
But I would always recommend to start at lower doses, around 10 mg per kg to avoid side effects and then increase if needed or if well tolerated. In terms of the literature, there are no published studies relating specifically to separation behaviours, but we have extensive peer reviewed evidence for use in noise phobia, storm anxiety, generalised anxiety and fear related problems. So the graph on this slide is from the licencing study on firework fears with 114 in the Pexian group and 124 placebo controls.
Any dogs with a history of aggressive behaviour were excluded. Dogs were given Pexin at the 30 mg per kg dose twice a day, starting two years before the two days before the New Year's Eve fireworks. So transient ataxia was the most commonly reported side effect, and 35% of those dogs actually showed ataxia, usually within 4 hours of being given the first dose of Pexin.
Now that ataxia does actually resolve with continuous dosing, so if you have a dog that goes ataxicaia and you don't have to stop it, you can continue it. But in a few cases, the researchers did drop the dose to help that ataxia to to resolve. There's been a 2nd study looking at the effectiveness of Pexin for storm phobia, and in that study, 10 out of the 30 dogs given Pexin actually withdrew due to side effects.
And those side effects included ataxia, appetite changes, aggression, and impulsivity. So when you look between those two studies at the frequency with which side effects are seen at that 30 mg per kg dose, we generally find we've not had any issues at all, starting with 10 mg per kg and then gradually titrating up over a few weeks if needed. As you can see from the graph, the dogs who were given the Pexin did better than the placebo dogs, and we know it is really effective, but always just start at that lower dose and then titrate up gradually.
So moving on to talk about neutering. Just a quick note, because there is quite conflicting evidence on this. So some studies find an increased risk in neutered dogs, for example, Flanagan and Dobman, and some studies find the opposite.
So McGreevy and colleagues in one of the biggest studies that we have on the effect of castration found that dogs with a longer percentage lifetime exposure to goady hormones were more likely to howl when they were left alone. So effectively, that means that dogs who were castrated at a younger age were less likely to howl. Although it's not actually clear whether that's a genuine increase in relaxation in castrated dogs, or whether it's just a reduction in vocalisation about it.
Either way, I suspect that the reason that we have so many conflicting results is that the effect of castration on separation behaviours is almost certainly case dependent based on the diagnosis. So for example, if you have a separation case that is fear motivated, then the behaviour is probably likely to be exacerbated by castration. Whereas if separation behaviours are related to over arousal, a frustrated dog that's maybe attending to other dogs outside of the window.
Then that behaviour is probably more likely to be improved following castration. Onto the next slide and we're going to start our case studies. So our first case study is Luna, a young Frenchie who was breaking out of her crate and whose owners were considering rehoming.
Luna's owners were absolutely lovely and really well-meaning family, but they'd been given some poor advice on crate training and they'd persisted with the crate despite Luna clearly not tolerating the confinement. Her temperament is such that she has poor frustration tolerance and high baseline arousal and impulsivity. She's quite a bouncy Frenchie.
And Luna was also bringing up bile most mornings. So if we flick to the next slide, we can see the behaviour plan that we gave her. Luna did not need any behaviour medication and she didn't need onus to do any departures.
There was a massive improvement as soon as we removed the crate. There was still some jumping up and some low level scratching at the door, but she was much better. Within 2 months of implementing the full behaviour modification plan, which included consistency in the house rules, increased walks, toy rotations, settle training, and some trick training with the male family members, Luna achieved a full resolution of her separation behaviours.
So when I first saw this case, the women in the family had a much stronger bond with Luna than the men. And actually, the dad and son really enjoyed doing that trick training, and I think that made a good difference. But one thing that made an enormous difference for Luna's owners was fitting a really basic baby gate about 2 metres away from their front door in the entrance hall.
And that meant that when they got in from school or the shops, they could calmly take off their shoes and their coats and put down their shopping without Luna jumping up all over them. And that actually just made everyone so much more relaxed. So Luna did fantastically, and made a full resolution and is now a lovely, more grown-up dog.
Onto the next slide, we have Luca. So Luca is a 2 year old male neutered foreign rescue dog who had been glued to his owner's side 24/7 since coming home. And the owner and the dog were both getting very little rest.
Luca was also ending up often right next to the noisy baby. His owner felt trapped because Luca was intensely destructive when he was left, even for very short periods. And so his poor owner couldn't get out to any baby classes or even to the shops.
From looking at gate footage, it became clear pretty quickly that Luca was painful, and on a video call with Luca's owner, he showed a marked and consistent pain reaction to gentle spinal palpation. He was also fearful, particularly of outside noises, including fireworks and car doors banging. So if we go on to the next slide to have a look at the training plan.
The first thing we did was start Luca on pain relief and. His vets used Pravacox and gabapentin. We saw an immediate reduction in following the owner and clingy behaviour, and Lucas started to remain settled when the owner left the room and even chose to take himself off to his bed upstairs.
We then started fluoxetine and we worked on training departures. Luke was able to relax in his bed with a stuffed cog while his owner spent increasing time outside the front door. He would acknowledge the departure and then relax again.
Luca had quite a few interruptions to his training, so the family accidentally went out for a lot longer than planned on one occasion, and then there was also quite a bit of family illness. Subsequently, they then got another dog, which is not something we typically recommend for separation cases, but Luca did well, and last time I spoke to his owners, he was generally happy, and he's still not. A dog who likes to be left for long periods, but he's doing all right.
So our final case study is Billy. Billy is a gorgeous 1-year-old cockapoo, owned by a family with two school-age children. At the time of our consultation, the in-laws had been coming over twice every day to sit with Billy while his owner did the school run.
Billy was particularly attached to his female owner and struggled to settle with her husband or in-laws, but he was quiet when they were present, whereas if he was completely on his own, he made the most remarkable screaming noise. It was really quite dramatic. He would also get frustrated quite easily and had started to show increased humping behaviour towards his owners and visitors.
He did a lot of leg cocking on walks and he'd begun growling specifically towards the other entire male dog at day boarding. So onto the next slide to have a look at our training plan. Billy's behaviour modification plan was adjusted week on week over the two month follow-up period.
So starting with provision of more dog beds because he previously only had the human sofa, reduced exposure to triggers, settle training, and scent work alongside fluoxetine. Later we started baby gate training and then a few weeks after baby gate training with the owners in, we progressed to training departures, using the living room because this was at the back of the house. We also assessed response to a suprearin implant, and having seen a positive response, Billy went on to have a surgical castration.
And onto the next slide, this is just a little quote from Billy's owners. So they worked really, really hard to implement all of the elements of his behaviour modification plan. And they became able to do the school run without needing a dog sitter, which is a lovely note to finish on.
I've just got the references on the next couple of slides, and then I just wanted to know if anyone has any questions. Thank you very much, Miriam, that was absolutely fascinating. So we do have some questions and we'll run through as many of these as we can before we run out of time.
One of our attendees has asked if we could share the details again of the Lincoln puppy app. Yes, so it is called Zigzag, puppy and dog training. ZIG ZAG puppy and dog training.
So it doesn't sail Lincoluni very obviously on it, but the group Luciana Assis and colleagues who did the relatively recent principal components analysis study on the different groups of separation behaviours, they provided a lot of the advice to the people who wrote the app, and it's completely free for owners to download, so it's, yeah, a good place to start. Thank you. Somebody has asked, the question isn't fully related, but what would you recommend for a long flight for large breed dog which cannot stay with their owner?
So, it depends, is the short answer. Potentially things you could consider, you could consider trazodone and gabapentin, that's. Possibly my first line, how long is the flight?
So I'm presuming it's longer than 3 hours, which means that Tessie is probably not gonna last long enough. You, You really want to find out is this dog just fearful or is it getting frustrated? There's a lot of questions to ask, and we also want to make sure that the dog is completely comfortable because if there is any pain, then again, that's going to limit the dog being able to settle.
And we want to see if the owners can do some training maybe to get the the dog comfortable with the crate that it's going to be in for the flight, but. Most likely trazodone and gabapentin would be my first line, but it, it really depends on so many factors. Yes, yeah, thank you.
Sophia would like to know when using gabapentin as part of a pain trial, if the pain trial is positive, how are you going to then decide that it is indeed pain and not the behavioural effect of the gabapentin that has made this improvement? I know you said the dose used is usually higher for behavioural cases, but isn't it still possible that in a pain trial it wasn't a reduction in pain, why it improved? Yes, really good question, and we do sometimes have this coming up.
Obviously with our referral cases, we are working with them over a couple of months period, so we will quite often then. Look into things further and it obviously depends on on the case and the dog. So for example, all of our behaviour cases we will generally look at the dog moving, and we actually work with a couple of physiotherapists.
So if we think there might be something going on, we'll quite often get a physio assessment of the dog in their own home where they're more relaxed and comfortable, and we find that that provides then. More information about those possible kind of subtle pain elements. Yes, there is some potential for for overlap and sometimes if we want to avoid that, we might choose, for example, a non-steroidal and Pardale, .
But sometimes in terms of the dog's welfare, we're also looking at going, do you know what, if gabapentin has the double benefit of anxiolytic and pain relief when we suspect there might be pain involved, then that's a really good thing to do to get that dog comfortable and then we can maybe look into the, the diagnostics further down the line. So I also find it it depends, for example, if you've got a really elderly dog, we might be more likely to go, OK, we'll just keep them on gabapentin, but with a younger dog. We might kind of encourage the owner more to try and get a diagnosis to say well actually, you know, we need to treat the underlying cause rather than just medicating, but it's often a really good first step and it can also often I think get the owner.
So we quite often will find that owners maybe don't. Naturally understand the link between pain and behaviour, and you can explain it to them and say, you know, have you ever had a bad back, yep, were you grumpy, yep. But often if they actually see the response of their dog to pain relief, they will then be more open to the idea of having physiotherapy or having some imaging done, for example, than on that first day where you go, oh, maybe your dog's painful, and they're like, whoa, no one's ever said this to me before.
So it's kind of working up to it gradually as well. But yeah, great question. There is, there is definitely a possibility that can happen.
Yeah. OK. Someone has asked what your favourite medication is for short-term noise phobias, i.e.g., fireworks.
Well, based on the licencing, obviously you've got, your, your Saleo or your, your Tessi, and then off label, you've got trazodone which you might add in alongside, and if you've got the time to start it, you've got Pexium, so I have, if you're interested, I've done a separate webinar, on. Behaviour medications, all of the medications, and firework fears which you can access through our, Sort of company website it's Pet BCpro.co.uk and we've got some recorded webinars on, on there, but, We always follow the, the licencing unless there's a specific reason not to follow the licencing, but the, the ones that I will typically use will include your, your Saleo or your Tessi, .
Then your Pexin if you have time, so if you've got a couple of days beforehand to get it started, and or your trazodone, gabapentin, and sometimes in an especially fearful dog, you might actually use a combination of all of them if needed, but there has been. Evidence that if you can get the dog to a place where they're not anxious by using, for example, Saleo during fireworks, then actually over time you're less likely to need medication or as much medication going forward, because if you can enable them to experience it without being scared, they can then learn that it's not scary. So you're actually better, if anything, to overmedicate than to to undermedicate with firework fears, but it's, it's a whole another ball game.
Very happy to do another webinar on it for, for here if, if you want as well. And there is also a free client video which doesn't talk about medication cos obviously it's aimed at clients, but on our website there is a free client webinar about the things they can do at home for fireworks as well, so feel free to give that out to clients too. Excellent, thank you.
Next question, so ataxia, if it's a side effect with Pexia and how long until that improves. So typically, it will improve over 24 hours, even if you can continue dosing. But obviously it can be quite frightening for owners, especially if they haven't seen their dog be like that before.
So yeah, it does typically improve pretty quickly, typically within 24 to 48 hours, certainly within 3 days, but. I prefer to avoid it by starting on the low doses, and I think I've only ever seen one dog go slightly ataxic on the 10 mg per kick dose of, of Pepin. Whereas it's, it's really common if you start at the high-end dose.
Thank you. So we have a bit of a scenario here. So the dogs were jumping up here, this attendee has said at visitors upon arrival, but not owners.
And do you have any suggestions about how to handle that? Yeah, absolutely. Again, it's case dependent.
It's always case dependent. But I had a, a similar case that we went round to the other day, and a baby, I cannot emphasise enough how are really, really helpful with behaviour cases because shutting doors is much more difficult and also much more, kind of likely to be frustrating for dogs. But if they can have a baby gate and make sure that that is always shut when owners first come in to prevent any injuries in particular, but then it is getting those dogs less aroused, calmer noses down to the floor, so it might be a case of maybe depending on the dog and how many dogs and whether there's a risk of conflict and so on and so on.
So there's always loads and loads of things to think about, but maybe tossing some treats onto the floor to get their noses down. Can be helpful, you want to avoid the dogs. Practising the jumping up because they will find that inherently rewarding, but also, You're unlikely to be able to get those dogs like 100% calm, so you're working on rewarding what is calmer than what you would have had otherwise and then working up from, from there.
So there are other kind of formal trainings that you can do where you. Encourage the dog to a specific location and and get them to lie down and then practise with fake visitors and doorbells. Certainly can be done successfully, but most owners don't have the, the patience for it.
Settle training at other times at home though would definitely be helpful. So settle map training, we've got a, a video that I'm sure we would be helpful to, to pass on, or the Victoria Stillwell website also has some good kind of training tips on it. But general settlement training at other times to encourage calm behaviour and then baby gates and noses down as calm as you can.
But yeah, everything, I'm afraid the answer to everything is going to be, it's case dependent because there's so many things that you would tweak and change depending on, on the individual. Yes, and as clinicians, I'm sure everybody understands that. So we have reached the end of our webinar.
Thank you so much everybody for attending. Thank you, Miriam. That was absolutely fascinating.
Everybody, this will be available for you to watch back on the website after 24 hours and of course get your CE certificates. They'll be available in 24 hours' time as well. And, we'll do our best to, answer the Q&A.
We've got all the, the questions here, so we'll get those off to Miriam. And yes, thank you very much, thank you to our host, our host, our sponsor, Dom's Pharma, and yes, we'll see you on the next one. Thank you everybody.
Guys, thank you very much everyone.
