THE use of an evidence base to make informed decisions for our patients is key to modern veterinary medicine. Behavioural medicine is no different.
Unfortunately, for many of the diagnoses we make and the treatments we use in behavioural medicine, the evidence base is limited, complicated or inaccessible to general practitioners.
Learning-based therapies that involve training, desensitisation and counter-conditioning are all well supported by evidence from basic sciences. They have been applied in laboratory animal models and often shown to be effective in human patients, but the direct evidence for their efficacy in specific veterinary behavioural indications is more limited.
There are licensed medications, with specific behavioural indications, such as clomipramine (Clomicalm, Novartis) and selegiline (Selgian, Ceva). However, the evidence base for the specific treatment of many of the more serious problems, such as inter-dog aggression, is still limited.
The notable exception to this is the treatment of noise fears or phobias. These are not only the commonest of the behavioural problems seen in general practice, potentially affecting 49% of dogs (Blackwell et al, 2005), but are also some of the most studied.
The treatment of phobias should include short-term management to reduce stress for the animal during phobic events, followed by treatment to reduce the problem in the future.
The pheromone product DAP has been shown to reduce behavioural signs of noise fear during noise events (Sheppard and Mills, 2003), and behavioural therapy using desensitisation and counterconditioning with the Sounds Scary product in conjunction with DAP has been shown to produce a beneficial effect in more than 90% of cases (Levine et al, 2007).
For more serious cases, selegiline is licensed for the treatment of behavioural problems with an emotional origin, including fears and phobias.
Despite this, noise phobias continue to be managed and treated in a variety of ways that are not supported by independent evidence. In particular, there is an ever growing market in food supplements and homoeopathic treatments, often available from internet sources, that are unproven but may be portrayed in a manner that makes them appear similar to licensed preparations.
The use of unproven methods matters because noise phobias can become highly debilitating for the animal and distressing for the owner. During phobic events, animals can cause a great deal of damage to themselves and to their owner’s property. They may even become aggressive.
Each firework season provides an opportunity for the problem to get worse, if the situation is not managed correctly. Progression can be avoided through good management and by using a triazolobenzodiazepine anxiolytic and memory-blocking drug like alprazolam.
Some unlicensed products and food supplements may allude to “benzodiazepine-like” effects, but they do not produce the highly valuable amnesic effects of alprazolam. As clinicians we are partly to blame for this. By not taking phobias seriously we encourage clients to seek help elsewhere, and if we don’t discriminate between effective proven products and unproven ones in this instance, how can we expect clients to follow our advice in other situations?
One piece of evidence for the inconsistency of phobia therapy arises from a small, unpublished study carried out by an RVC student in 2005-06. This reviewed veterinary prescribing for firework fear; within the study population a total of 13 different drug combinations were used. Many were unlicensed, unsuitable, or had no indications or publications to support their use.
Despite an encouraging trend in favour of the use of benzodiazepines in 44% of cases, the same study showed that these drugs were also the most likely to be given incorrectly: 41% of prescribed diazepam doses were subtherapeutic, and clients were not provided with essential dosing or dose-response testing instructions (Gehring, 2006).
Before using any treatment for noise phobia, we should ask ourselves whether it is supported by peerreviewed evidence. If not, then we should choose something else that is.
For more detailed information on the treatment of phobias, go to the BSAVA website to read the policy statement. For drug doses, consult current texts and monographs.
Recommended approach to firework phobia
Evidence base?
■ Is the product supported by peerreviewed evidence of efficacy in noise phobia?
■ If not then choose another product that is.
Short-term management
■ DAP: diffuser should be installed approximately two weeks prior to firework night, but DAP is still reasonably effective if installed much closer to the event.
■ Alprazolam (Crowell-Davis, 2003): may be used to block memory of specific events (Crowell-Davis, 2003; Saraf, 2003) or to produce greater anxiolysis when used in combination with DAP. The individual effects of alprazolam must be tested in the patient before it is used in a real phobic situation.
■ Provide the dog with a refuge and allow full-time access to it.
■ Do not give the dog attention or reassurance when it is anxious or fearful.
■ Use music to block the sounds of noises from outside (as long as this does not worry the dog).
■ Keep windows and curtains closed to prevent the dog from hearing quieter noises and seeing light flashes.
Long-term treatment
■ Desensitisation and counterconditioning with a product that has known efficacy. This must be done outside the firework season. Sounds Scary is the only noise phobia therapy product endorsed by the RSPCA.
■ Use DAP to improve response to behavioural therapy.
■ If the problem is severe or complicated, then consider referral or drug therapy (after an appropriate medical work-up).
References
Blackwell, E., Casey, R. and Bradshaw, J. (2005) Firework Fears and Phobias in the Domestic Dog. RSPCA website.
Crowell-Davis, S. L., Seibert, L. M. W. and 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): 744-748.
Levine, E. D., Ramos, D. and Mills, D. S. (2007) A prospective study of two self-help CD based desensitisation and counterconditioning 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. and Singh, M. (2003) Role of platelet activating factor in triazolobenzodiazepinesinduced retrograde amnesia. Behav Brain Res. 142 (1-2): 31-40.
Sheppard, G. and Mills, D. S. (2003) Evaluation of dog-appeasing pheromone as a potential treatment for dogs fearful of fireworks. Vet Rec. 152 (14): 432-436.
