S16C

Anxiety Disorders in Cats Kersti Seksel, BVSc (Hons), MRCVS, MA (Hons), FACVSc (Animal Behaviour), DACVB Sydney Animal Behaviour Service Sydney, NSW, Australia
OBJECTIVES OF THE PRESENTATION

To review some of the manifestations of anxiety in cats. To summarise current options for managing anxiety related disorders in cats.
GENERAL KEY POINTS

Anxiety disorders represent up to 80% of cases seen in a referral veterinary behaviour practice. Cats that are stressed or anxious may present with a number of non specific signs. These may include a change in appetite (e.g., a decrease in appetite or pica); grooming (an increase or decrease); elimination (e.g., spraying or non-spraying marking); changes in social interactions (e.g., vocalisation); and physical activity (e.g., increased or decreased).
KEY CLINICAL DIAGNOSTIC POINTS Pica (Eating Non-food Material)

Pica may include the ingestion of substances such as soil, rubber, paper, wood, string, house plants, wool or fabric. Individual cats tend to ingest one type of substance only. Fabric eating cats appear to start by eating woolen fabrics. They may then proceed to other fabrics such as cotton, silk and synthetics, but this is not always the case. While the cat is chewing it appears to be totally engrossed and quite large quantities can be ingested.
Overgrooming

Hair can be removed by plucking, barbering or just by licking and excoriation. Self licking, biting, and alopecia are seen wherever the cat can reach, especially around the sides and rump, back legs and groin. The head and back of neck may still have normal hair coat. Usually the alopecia is non- symmetrical and the skin may look normal. The hair in the area is a ginger or rusty brown colour due to the action of the saliva. Microscopic examination of plucked hair shows evidence of shear.
Inappropriate Elimination

Inappropriate urination or defecation involves the cat passing normal amounts of urine or faeces outside the litter box. Cats that are urinating out of the litter box usually squat, produce a large quantity of urine, use a horizontal surface and often scratch afterwards. Spraying or urine marking involves the cat passing small amounts of urine usually on vertical objects, often in response to an anxiety provoking stimulus. Cats that spray usually stand, but may squat, usually produce only a small quantity of urine, frequently use vertical surfaces but may use horizontal surfaces and rarely scratch afterwards. Cats exhibiting separation anxiety may eliminate on the objects associated with the owner e.g., clothes, bedding, brief cases, shoes. It is usually seen after separation greater than 12 hours, or immediately the owner returns. It is important to differentiate urine marking from non- use of the litter box, but both can be associated with anxiety
Inappropriate Vocalisation

With excessive vocalisation associated with anxiety, the vocalisation is of changed duration, frequency or intensity. It may be nocturnal, or just more noticeable at night.

KEY ETIOLOGIC AND PATHOPHYSIOLOGIC POINTS Diagnosis

Diagnosis is based on a complete behavioural history and thorough physical examination. It may involve complete blood work, urinalysis, dermatological and neurological work, up as well as radiography to rule out contributing or concurrent medical factors. The predisposing factors are discussed are discussed under each of the non-specific signs of anxiety in cats.

Pica (Eating Non-food Material) Plant eating may be due to lack of access to grass or vegetation, or be a normal investigatory behaviour. Young cats especially, may chew, but not necessarily ingest, non-food substances as part of their normal exploratory behaviour. It may also be due to an underlying obsessive compulsive disorder (OCD) with stereotypic chewing or mouth movements. The chewing is carried out differently from eating food items. This is a problem if blankets, socks and sweaters are eaten, as there is the potential for intestinal obstruction. Genetics may be a predisposing factor. Oriental breeds such as Siamese and Burmese have a greater tendency to engage in wool chewing as a ritualistic or stereotypic behaviour, although it has been reported in all breeds including crossbreeds. No sex predisposition for wool eating has been reported. This behaviour is reported to start at around 2 to 8 months of age up to 12 years of age and it is reportedly more common in cats that are entirely indoors and be triggered by stress. It has been postulated that early weaning (at 24 weeks), insufficient handling of kittens before homing, insufficient fibre in the diet, separation anxiety, having no opportunity to develop exploratory and hunting behaviours or a malfunction in the neural control of appetitive behaviour may contribute to the behaviour. Some cats appear to grow out of it and the problem resolves during early adulthood without treatment. Ingestion of houseplants may occur in cats confined indoors with no access to grass or vegetation and ingestion of small amounts of grass or other vegetation is a normal behaviour in cats. Overgrooming Normal adult cats spend about 30 to 50% of their time awake grooming. Grooming serves many purposes including cleaning, removal of parasites, thermoregulation, and alleviation of stress. It may be a behavioural response to environmental conditions which stress the cat. These environmental conditions could be obvious such as moving house, a new baby or spouse, or too many cats in the household or area to the less obvious ones such as punishment from the owner, presence of attacking birds (e.g., magpies) and lack of stimulation. Medical conditions such as flea allergy, dietary allergy, sensitivity to dust mites can trigger the initial grooming episodes. Inappropriate Elimination Elimination problems are the most common behavioural problem reported in cats, accounting for between 4075% of behavioural problems. Both males and females, neutered and entire, present with elimination problems. They have been reported in all breeds and across all age groups. Inappropriate elimination is a non-specific sign. It may be associated with a medical condition, fear or anxiety, or factors associated with the litter box. Medical conditions such as cystitis, diarrhoea, constipation, feline lower urinary tract disease and diseases causing polyuria have been implicated as contributing factors. It is reported that up to 30% of cats that present for spraying may have a concurrent medical condition. Cats that experience pain while urinating (e.g., with cystitis, arthritic pain) may develop an aversion to using the litter tray in a particular location or to a particular substrate. Additionally some cats can develop an aversion to the litter box due to a new type of litter being introduced or a dirty box. Aversion can also be induced by catching the cat in the litter tray prior to performing potentially unpleasant procedures such as medicating or grooming.

Preference to eliminating in a specific location is also developed by some cats. Many cats prefer to eliminate in quiet or safe places where they will not be disturbed e.g., under beds, behind furniture. They may have learnt to urinate in the location where the litter tray was originally placed, even though the litter tray has now been relocated. Some cats develop preferences or aversions to eliminating in specific substrates. Some cats prefer to scratch in soft textures or surfaces, others on hard, some cats do not like getting their feet wet or dirty so they will not use soiled litter trays. Every cat litter also has a different odour, so many cats develop a preference or aversion to a particular smell. Spraying is a marking behaviour, often associated with anxiety. It may be territorial, sexual or agonistic. In multi-cat households it is associated with overt or covert aggression. It is estimated that 10% of castrated males and 5% of spayed females spray. Spraying appears to be more common in multi-cat households with a 100% chance of at least one cat spraying in a household with more than 10 cats. Male cats that live with a female cat are more likely to spray than those living with another male cat. Territorial, agonistic encounters or any highly arousing circumstances as well as environmental stimuli such as the sight, sound or smell of another cat, within the household, as well as outside can precipitate spraying. Anxiety-related problems including separation anxiety, changes in routine (for example, moving house), the introduction of a new spouse, new baby or new cat in the area have also been reported to be predisposing factors.

Inappropriate Vocalisation Excessive vocalisation may be a normal innate behaviour in some breeds such as the Siamese. Vocalisation may indicate a need for social contact, attention, or food. This has been reported in cats that are on restricted calorie diets. Anxiety resulting from social stressors such as the presence of other cats, a change in routine, or after a move has been implicated as a trigger. Excessive vocalisation may be a function of ageing, cerebral degeneration and alteration of neurotransmitter activity. It may be seen in aged cats exhibiting other signs of senile behaviour.
KEY THERAPEUTIC POINTS Treatment / Management Options for Anxiety Disorders

Treatment of any concurrent or underlying medical problem is essential. Additionally if the underlying cause(s) of stress to the cat are known they should be removed or minimized if possible. Cats do not like change so that a regular predictable routine should be provided. This should include feeding and playing at a set time each day. Environmental enrichment is important in many cases, especially indoor cats. This can be done by providing toys and mental stimulation, as well as training tricks. An indoor garden with grass, catnip, and or cat mint as a safe source of vegetation, is also beneficial. Medication is often necessary while the behaviour modification programme is instigated. Complete blood work should be done prior to starting any medication to determine baseline concentrations especially for liver and kidney parameters. In most cases medication is needed for a prolonged period (up to 612 months). Medication should always be gradually withdrawn. If cats require longer term or lifetime medication, biochemistry parameters should be monitored every 612 months.

Pica (Eating Non-food Material) Allowing cats that present with pica access to dried food all day, increasing the fibre content of the diet by adding bran or vegetables, providing gristly meat and raw bones to chew on to increase time spent chewing and eating have been recommended. Some authors have also suggested giving cats that eat fabric small strips of woolen fabric or sheepskin to ingest with their meal. This must be done under veterinary supervision, and the owner warned that it could lead to constipation or intestinal obstruction.

Overgrooming In cases of overgrooming elimination of fleas, or resolution of food allergy by changing the diet is important. Then establishing a routine as well as psychotropic medication may be needed. Inappropriate Elimination Careful questioning of the owner is important to differentiate urine marking from inappropriate urination.
Treatment of inappropriate urination and/or defecation involves 1. Increasing the attractiveness of the area the owner wants the cat to use, and 2. Decreasing the attractiveness of the area that the cat wants to use. Increasing the frequency with which the litter tray is cleaned and changed is an important first step. Initially daily is recommended. Increasing the number of litter trays may also be necessary. A good rule of thumb is one litter tray per cat and one extra. To help make the litter tray more attractive to the cat changing the type of litter may help. Alternatives include sawdust, soil, rabbit pellets, shredded newspaper, clumping litters, sand or other type of commercial litter. Sometimes a combination of substrates is effective. To decrease the attractiveness of the area the cat prefers to use can be done by changing its significance. Feeding the cat in these places as leaving the cats toys or bedding in the area may help. Making the area less accessible and less pleasant to the cat by covering the area with thick plastic, aluminium foil, double sided sticky tape, sandpaper or place trays of marbles in the area so the cat cannot get a solid surface on which to stand has also been advocated. For cats that spray environmental manipulation has often been recommended. This can often be difficult to achieve in practice, although theoretically it should work well. It is rarely possible or practical to remove the neighbours cat, the new baby, or new spouse, or entirely prevent other anxiety provoking circumstances such as moving house. Decreasing the number of cats in the household as well as decreasing access to windows and doors to decrease the sight sound and smell stimuli can help. Cleaning the soiled areas with non-ammonia based products such as enzymatic washing powders is important in elimination cases.

Inappropriate Vocalisation Establishment of a routine and providing sufficient stimulation is important. Cognitive dysfunction may need to be managed with medication.
KEY PROGNOSTIC POINTS

Education of the owners about normal cat behaviour is important so that they understand that most behaviours cannot be eliminated entirely but can be successfully managed. The treatment or management of any behaviour problem takes time and patience so owner commitment is essential. The prognosis is variable and depends on the owner commitment, success in determining an underlying cause, and management of the underlying problem. The prognosis deteriorates with increased length of time the problem is left untreated. The prognosis is guarded if an inherited predisposition is suspected.
OVERVIEW OF THE ISSUE

Anxiety disorders represent up to 80% of cases seen in a referral veterinary behaviour practice. Anxiety has been defined as the anticipation of future danger or misfortune and there is not always an obvious cause. The threat may be real or imagined and may be normal or abnormal depending on the context. Anxiety can occur after sensitization to a specific stimulus and then become generalized to other situations. It may also be non-specific in origin. It is considered to be a problem when it is out of context, occurs at a constant and elevated level and interferes with the cats ability able to function normally.

Cats that are stressed or anxious may present with a number of non specific signs. These may be a change in appetite (e.g., a decrease in appetite or pica); grooming (an increase or decrease); elimination (e.g., spraying or non-spraying marking); changes in social interactions (e.g., vocalisation); and physical activity (e.g., increased or decreased). These signs may co-occur Medical conditions such as hyperthyroidism have been associated with feline anxiety, as have some medications.
ADDITIONAL DETAIL

Rewarding the desired behaviour is important. Punishment should be avoided as it is not effective in changing behaviour and should be avoided. It serves to further increase the anxiety, as well as impede learning of non-anxious behaviour.
KEY DRUGS, DOSAGES AND INDICATIONS Key Drug Amitriptyline Clomipramine Drug Class TCA TCA Dose Range 0.51mg / kg 0.5 mg / kg Frequency q 24h q 24h Route PO PO Indications Anxiety. Spraying, overgrooming, Spraying, overgrooming, OCD increased vocalization Spraying, overgrooming Spraying, overgrooming increased vocalization Spraying Spraying Spraying, overgrooming Spraying, overgrooming CDS (and increased vocalization) spraying spraying Spraying, overgrooming, intercat aggression

Nortriptyline Fluoxetine Paroxetine Fluvoxamine * Diazepam** Oxazepam**** Selegiline buspirone cyproheptadine Feliway

TCA SSRI SSRI SSRI BZD*** BZD MAOI Azaperone Antihistamine synthetic analogue of the cheek gland pheromone

0.52.0 mg /kg 0.5 mg / kg 0.5 mg / kg 0.25 mg / kg 0.20.4 mg / kg 0.20.5 mg/kg 0.5mg/kg 0.51mg / kg 0.40.5 mg / kg In room frequented most by cat(s) Spray

q 1224h q 24h q 24h q 12 h q 12h q 1224h q 24h q 812 h q 12h Daily for min 1 month

PO PO PO PO PO PO PO PO PO Diffuser

2 x daily

Spray

* concurrent use with benzodiazepines should be avoided. ** average of 12 mg / cat PO q 12h) *** Care needs to be taken to monitor responses especially in overweight cats. Also use with caution in aggressive animals as diazepam may lead to disinhibition and potentiate aggression ****is useful where diazepam leads to excessive sedation SUMMARY

Anxiety disorders are common in cats and may manifest in several ways including increased vocalization, overgrooming, pica and spraying. Several types of anxiety disorder can co-occur. Anxiety disorders can be managed successfully by using behaviour modification techniques and psychotropic medication as required.

Punishment should be avoided as that may increase anxiety. Early intervention is recommended.
REFERENCES 1. Houpt, K.A. Domestic animal behavior for veterinarians and animal scientists. Ames. Iowa State University Press. 1998. 2. Landsberg, G., Hunthausen, W. Ackerman, L. Handbook of behaviour problems of the dog and cat. Oxford: Butterworth-Heinemann: 2003. 3. Overall, K.L. Clinical behavioral medicine for small animals. St Louis, Missouri: Mosby 1997. 4. Seksel K, Lindeman MJ. Use of clomipramine in the treatment of anxiety-related and obsessive-compulsive disorders in cats. Aust Vet J 1998; 76: 317-321. KEYWORDS

stress anxiety