FEAR, ANXIETY, STRESS

Feline Anxiety – 

When Enrichment Isn’t Enough  Meghan Herron, DVM, DACVB   Senior Director Behavioral Medicine, Research, Education, and Outreach  Gigi’s  Columbus, Ohio  

Introduction  

Cats are notorious for a number of normal, yet nuisance behaviors, including destructive scratching,  early morning wake-up calls, sudden playful ankle-biting ambushes, toileting in potted plants, and  kitchen counter lounging. Fortunately, most of these behaviors can be redirected to more human preferred outlets with the provision of resource rich environments and litter box dynamics that cater to  natural feline proclivities and each individual cat’s unique needs. What happens when the wake-up calls  present as day long calls and/or excessive vocalization? When sudden biting isn’t so playful? Or when  urine starts to decorate most floor basins throughout the home? If these behaviors are not normal, how  can we explain them?  As practitioners it is important to consider whether anxiety may be playing a role. Anxiety is defined as a  state of worry or anticipation that something unpleasant, painful, frightening, even life-threatening may  happen soon. As one of the smaller mammals to grace human households as pets and a species that  does not adapt well to abrupt or major change, cats have plenty of reason to worry. Some level of  anxiety in response to change, new people or pets, and/or car travel can be normal. Pathological anxiety  is diagnosed when persistent signs extend beyond or in the absence of changes in lifestyle or household.  Anxiety in cats is often underrecognized as it can manifest in a number of ways. In many cases the  anxiety itself is not as noticeable as the other behavioral pathologies it exacerbates, such as fear  aggression, phobias, and excessive urine marking.   

Clinical signs  

Behavioral signs of anxiety can be frenetic in nature for some cats, and more somnolent for others.  Frenetic manifestations of anxiety might include excessive vocalization, destructive chewing or  scratching that extends beyond what adequate enrichment can satisfy, play-biting that is hard,  excessive, and difficult to interrupt in a cat older than 1-2 years, difficulty being separated from human  attachment figures, or difficulty settling/resting even when the environment is quiet and uneventful.   More somnolent forms of anxiety might look more like frequent hiding, avoidance of social interactions,  spending little time on the floor and/or more central areas of the home, poor appetite, toileting on beds  or other soft areas close to places of comfort, or a lack of display of any normal feline vocalizations  (meowing, purring, chirping, etc.). In some cases anxiety can lead to physical ailments – a group of  behaviors referred to as “sickness” behaviors, although no underlying physical etiology is detectable1.   Many feline patients with anxiety have other behavioral comorbidities, such as fear aggression. In these  patients, anxiety can fuel an aggression problem by lowering the threshold for what might prompt an  aggressive response, causing the aggressive episodes to be more severe, intense or prolonged, and  preventing full or prompt sympathetic nervous system and hypothalmo-pituitary-adrenal axis recovery.  Fear aggressive cats can be easily trigger stacked due to this lack of adequate recovery between stimuli  that prompt an aggressive response. Urine marking is another common problem either caused or  exacerbated by anxiety and stress. As a form of communication, the act of marking with urine can be  relieving to an anxious cat and is likely to worsen the more often it is rehearsed and/or the underlying  stressors remain in the environment.   

Rule-out underlying physical disease  

For patients presenting with signs suggestive of anxiety, a rule-out of physical pathologies, such as  hormonal abnormalities, sources of pain, inflammation or infection, and neoplasia is the first place to  start. A minimum database that includes a thorough physical exam (including oral exam), complete  blood count, serum chemistry profile, total T4 and urinalysis is recommended before making a definitive  diagnosis and before starting treatment, particularly if psychopharmacology may be part of the  treatment plan. Abnormalities in the database should be addressed through treatment and/or  additional diagnostics. Once you assess the cat’s response to treatment for their physical ailments, you  can consider a treatment for their anxiety. In some cases anxiety is a comorbidity and both conditions  will need to be addressed.   Addressing anxious behaviors  Ensuring the home environment provides for both the physical and behavioral resource needs of the cat  is of utmost importance. Cats living in multi-cat households need multiple options for resource access so  that social tension between the cats does not develop around them. Furthermore, giving cats choices in  their environment provides a sense of control which in itself can be anxiety-relieving. Basic physical  needs to be met include appealing latrine, wet and dry food options, access to fresh, cold water, and  warm, indoor shelter. Basic behavioral needs to be met include, but are not limited to appealing  scratching and chewing options, access to elevated, peripheral resting/viewing options, and  opportunities to engage in preferred play activities.  Provision of core areas where multiple resources can be met make useful “stations” and having more  than in a home may be helpful for the anxious cat and is essential for an anxious cat living with other  cats. For cats experiencing anxiety related to social tension with other animals (even children) in the  home, access to a safe haven where only they have access may be needed. Safe havens might include a  bedroom, walk-in closet, or large bathroom where a single cat has sole access through a microchip activated cat door, blocking other cats/pets/young children from entering. The anxious cat then has sole  access to physical and behavioral needs without having to face competition or ambush. If social  dynamics between other pets or humans in the home are contributing to anxiety in the remainder of the  home, counsel clients on how to identify and minimize it.  

Behavioral support through synthetic pheromone products has been shown to be anxiety-relieving in  feline households (REF). Specific products include:  FELIWAY Classic – Contains F3 facial pheromone analog – mimicking what cats deposit in their  environment when they bunt (rub their cheeks on objects/people). Available in a spray and 30-day  electric plug-in diffuser catridges, it helps to relieve stress by helping the cat feel comfortable in  unfamiliar or stressful environments, much like if they came upon previously self-marked locations in  their home.   FELIWAY Multicat - Mimics the maternal appeasing pheromone that queens produce when nursing their  kittens. It works to comfort and relax cats in stressful situations, particularly stress related to inter-cat  tension. Available in a diffuser only.  FELIWAY Optimum (Ceva): Feline Pheromone Complex with 3% F3 facial pheromone analog is a  combination product that provides benefits similar to both of the above listed products and is marketed  to reduce common signs of stress in cats such as scratching, fears, reactions to changes, urine spraying,  tension and conflict.   ZENIFEL (Virbac) – Contains concentrated F3 facial pheromone analog (6%) – mimicking what cats  deposit in their environment when they bunt (rub their cheeks on objects/people). Available in a spray  and a 60-day gel diffuser (no plug-in required). Shown to reduce hypervigilance, excessive attention seeking, hiding, excessive vocalization, inactivity, and excessive scratching2.  1. Field Efficacy study: Ceva Sante Animale Internal report 19-DPH-941(2020)  2. Field Substitution study: Ceva Sante Animale Internal report CLT-D921-1804 (2018)  

Nutrition/Nutraceutical options  

Consider nutritional options for anxiety relief through diet and supplements. Depending on the specific  nutritional needs of the cat, several prescription diets contain ingredients shown to decrease overall  anxiety and to help cats cope with daily stressors. Several nutraceutical products have been shown to  alleviate stress and anxiety and to promote relaxation in cats. Common nutritional ingredients/natural  supplements with anti-anxiety benefits include:  Milk or whey proteins (alpha-cazosepine, dried hydrolyzed casein) – Promote relaxation, have an affinity  for GABA receptors; anxiolysis without sedation.  L-tryptophan – Precursor to serotonin and melatonin – monoamines essential in anxiety and sleep  regulation.  L-theanine – An amino acid found naturally in green tea. It directly stimulates the production of alpha  brain waves to create a state of deep relaxation, wakefulness, and mental awareness.  Thiamine (Vitamin B1) – Enhances neurotransmission signals in the brain  Omega-3 fatty acids/antioxidants - Help support healthy neurons and the body’s response to stress.  Magnolia/Phellodendron – Plant extracts suggested to increase relaxation and reduce anxiety and stress  when combined.   Specific products/diets:  Royal Canin® - CALM diets – Diets with the CALM additive contain alpha-casozepine and l-tryptophan.  Available as URINARY SO + CALM, URINARY SO + SATIETY + CALM, and URINARY AGING 7+ + CALM.  Hill’s Prescription Diets - Stress diets – Diets with the Stress additive contain L-tryptophan, dried  hydrolyzed casein, thiamine, and omega-3 fatty acids and antioxidants.   

Nutritional support products:  

Note the following information has not been evaluated by the Food and Drug Administration. These  products are not intended to diagnose, treat, cure, or prevent any disease. All are available at various  retailers without a prescription.  Purina® Pro Plan Veterinary Supplements: Calming Care – A proprietary use of probiotic strain BL999  powder sprinkled on food once daily to promotes positive behaviors, and help cats cope with stress of  change; May need 6 weeks to see full therapeutic effects.  Zylkene® - by Vetoquinol – Capsule that contains concentrated alpha-casezepine; Double dose for acute  stressors, regular dose for daily anxiety relief.  Solliquin® - by Nutramax – Flavored chew that contains L-theanine, Magnolia/Phellodendron blend, and  whey protein concentrate NMXSLQ05®a high-quality protein source containing the precursors of  glutathione and serotonin.  Composure® Pro – by VetriSCIENCE – Flavored chew that contains Colostrum Calming Complex®, L theanine, Thiamine, and L-tryptophan. Effects within 30 minutes, double dose recommended for acute  stress, regular dose for daily anxiety relief.  Anxitane® – by Virbac – Flavored tablet that contains patented Suntheanine brand of 99.95% L-theanine;  highly palatable for cats3. 

 Psychopharmacology  

Note that with the exception Bonqat® the following medications are not approved for use in cats and  prescribing as such is considered off-label use and should be done with extreme caution and at the  discretion of a licensed veterinarian.   Two major categories of medications:  “Daily” (standing) medications – These are administered every day, regardless of situation and most will  take 4-6 weeks before therapeutic effects are seen. Common classes include:  Selective serotonin reuptake inhibitors (SSRIs) - fluoxetine (Prozac ® /Reconcile®), paroxetine (Paxil ),  sertraline (Zoloft ®); Tricyclic antidepressants (TCAs) – clomipramine (Clomicalm ®), amitriptyline (Elavil ®);  Azapirones - Buspirone (Buspar ®); Monoamine oxidase inhibitor (MAOI) - Selegiline (Anipryl ®)  “Event” medications – These have a quick onset (30-90 min) and last for a predictable number of hours  with no residual effects. Timing of administration should be prior to anticipated stressful events with  enough time for onset of action to reach full therapeutic effects. For some patients event medications  are used daily as part of a poly-therapy plan. Common classes include GABA analogues – Bonqat  (pregabalin) – FDA approved to reduce anxiety and stress associated with transportation and veterinary  visits; gabapentin (Neurontin®); Serotonin antagonist and reuptake inhibitors (SARIs) – trazodone; Alpha 2 agonists – clonidine; Benzodiazepines - lorazepam (Ativan®) AVOID oral diazepam in cats due to acute  fulminating hepatic necrosis!; Phenothiazine neuroleptic tranquilizer – acepromazine NOT to be used as  a sole agent due to lack of anxiolytic effect.   

Polypharmacy  

Polypsychopharmacology may be needed for full management of anxiety in cats. Three scenarios when  polypharmacy may be indicated include:   a) When immediate relief of symptoms is needed: Some patients’ behavior is concerning enough that  immediate alleviation of clinical signs is needed- whether for their welfare, safety, or for their ability to  stay in their current home and/or to avoid euthanasia. If that is the case, then starting one of the event  medications on a daily basis, every 8-12 hours BEFORE starting your daily, longer-lasting medications can  give your patient (and client) some immediate benefit. The event medication can then be maintained  daily while onboarding a daily medication. When we do this, we refer to the initial rapid acting event  medication as a bridge medication. In some cases you can wean the patient off of the bridge medication  once your daily medication reaches therapeutic levels.   b) The daily medication is not sufficient for certain anticipated stressful events: Some patients have  known and anticipated events that trigger panic and stress that are likely to override the effects of their  daily medication. Consider storms, vet visits, visitors, or neighboring construction for example. In those  situations, you have time to start a daily medication and give it time to reach therapeutic effects. Once  you have confirmed there are no major side effects from the daily medication (give it at least 5-10 days),  you can have the client administer a test dose of an event medication on a day when no stressful events  are anticipated. That way they have a plan for the stressful event, whether it occurs during daily  medication onboarding, or after.  c) The daily medication is helpful, but not quite enough even at maximum dose: Often when patients  struggle with severe behavioral disorders even the maximum dose of a daily medication may not be  enough to adequately control their symptoms. Many clients may not want to risk regression by weaning  off a medication that has been at least moderately helpful in just to try a new daily medication. In these  cases, it is reasonable to add an event medication every 8-24 hours on a daily basis.   

Weaning  

There is a common misconception that once you start a psychotropic medication the treatment must be  life-long. While indeed there are cats whose behavioral pathologies warrant long-term psychotropic  medication therapy, many pets can and should eventually be weaned off their medications. Much  depends on the severity of the illness, the ability of the client to manage triggers, and/or the progress  that can be made through behavior modification and training. The choice to wean involves a balancing  act between the benefits and the costs repeatedly assessed along the way. A typical approach for  patients responding well to behavior modification is to maintain the support of medication until clinical  signs resolve and all behavioral goals are met. At that point medications should be maintained for a  minimum of 90 additional days, at which point weaning, rather than abrupt discontinuation, can be  attempted (Crowell-Davis, Murray and Dantas, 2019). Weaning is typically accomplished by decreasing  the dose by 25% every 2-4 weeks. If there is a return of undesirable behaviors, therapy is resumed at the  lowest effective dose and the plan is re-evaluated.   When weaning for the purpose of changing a medication that isn’t providing adequate relief for the  patient, the process can be much faster. This is especially true for patients who have been on therapy  for only a few weeks or months’ time. In these cases, you could consider cutting the dose in thirds or  halves every few days, then providing a washout period without medication to make sure the initial drug  is eliminated prior to starting the new medication. Washout periods depend on the half-life of the  individual drug being discontinued. Most SSRIs, SNRIs and TCAs have a half-life of 24 hours or less,  except for fluoxetine and its active metabolites, which have half-lives of several days.  When changing  from fluoxetine to another drug with SRI properties, a washout period of 6 days is recommended. For  cats on polypharmacy plans, event medications are weaned gradually if given daily typically before daily  medications are weaned.  

Administering tablets, capsules, chews, and liquids  

Flavored supplements and medications may be more palatable to cats and minimize stress associated  with daily administration. Cats who are highly food motivated may readily take pills covered in anything  that smells and tastes delicious, but many others are far pickier. In general, “pilling” a cat is not  recommended, as it can cause fear, stress, and anxiety which defeats the purpose of  psychopharmacological treatment. There is also the risk of triggering aggression towards the person  administering it. Alternatives to pilling include teaching the cat to take pills as a pattern hidden in the  second treat in a 3-treat series (“treat-pill-treat” method), compounding medication into a flavored  liquid or treat that can be given alone or added to food (liquid medications should not be directly  squirted into a cat’s mouth as syringe avoidance will likely result), or transdermal application of a  compounded medication. Be aware that some cats may find transdermal application aversive and that  altering the pH and binding agents of medications for compounded options may alter their  bioavailability and lower effectiveness4.  Additional reading  Lilly, ML. Approach to psychopharmacology in Companion Animals. In: Herron, M.E. ed.,  2024. Introduction to Animal Behavior and Veterinary Behavioral Medicine. John Wiley & Sons, pp 420 434.  References  1. Stella, J.L., Lord, L.K. and Buffington, C.T., 2011. Sickness behaviors in response to unusual external  events in healthy cats and cats with feline interstitial cystitis. Journal of the American Veterinary Medical  Association, 238(1), pp.67-73.  2. Espuña, G., Nicolas, C.S., Girardin, A., Fatjó, J., Bowen, J., Monginoux, P. and Rème, C.A., 2024. A long lasting gel-based diffuser of feline pheromone can help reduce undesirable behaviors in cats at home:  comparison with an electric diffuser. Frontiers in Veterinary Science, 11, p.1445108.  3. Dramard, V., Kern, L., Hofmans, J., Rème, C.A., Nicolas, C.S., Chala, V. and Navarro, C., 2018. Effect of l theanine tablets in reducing stress-related emotional signs in cats: an open-label field study. Irish  veterinary journal, 71(1), pp.1-7.  4. Ciribassi, J., Luescher, A., Pasloske, K.S., Robertson-Plouch, C., Zimmerman, A. and Kaloostian Whittymore, L., 2003. Comparative bioavailability of fluoxetine after transdermal and oral  administration to healthy cats. American journal of veterinary research, 64(8), pp.994-998.