This continuing education - PowerPoint Presentation

Slide1

This continuing education web conference is brought to you by

The web conference will start at 8:02 p.m. (EST).

1

Slide2

How Stress Affects Health and Behaviour; Strategies for Prevention and Treatment

G. M. Landsberg DVM, DACVB, Dip. ECVBM-CANorth Toronto Animal Clinic, northtorontovets.comCanCog Technologies, Director Veterinary Affairs

2

Slide3

Presentation OutlineDiagnostic dilemma: «behaviour» or «medical»? Normal vs. abnormal behaviour Fear prevention & enrichment Integrated approach to common stress-related behaviour problems Behaviour modification program Natural products and drugs

Case study Question period 3

Slide4

Veterinarian’s RoleAssess behaviour at each visit

Maintain health, welfare, bondBehavior – may be first or only

sign of

medical issue

Central

nervous

system (CNS),

metabolic

, cognitive

dysfunction

syndrome (CDS),

sensory

, Pain

Welfare

(5 freedoms)expression of normal behaviourfreedom from fear, discomfort, pain, hungerVeterinarian’s role to prevent, diagnose, treatDo the pet a favour ► ask about behaviour

4

Slide5

Diagnostic Dilemma:Is it «Behaviour» or is it «Medical»?Medical: Behaviour

SignsStress: Effects on health / behaviour Behaviour: Normal vs. Abnormal / Pathological Combined5

Slide6

Medical Causing Behavioural Neurologic / Central / Peripheral / CDSInternal medicineEndocrine – increase / decrease (e.g. thyroid)

Metabolic (e.g. encephalopathy)Pain / welfare: Behavioural change, mobilitySensory: Response to stimuliDermatology (e.g. self – trauma)Drug effects (e.g. steroids / irritability)

6

Slide7

StressAltered homeostasis: Affects health and behaviourEndocrine, immune, psychologicalHypothalamic-pituitary-adrenal axis (cortisol)acute / chronic effects on behaviour health

Noradrenergic systemAcute / chronicsympathetic arousal – lack conscious controlProlactin: Lower in acute stress, higher in chronicHyperglycemia with stress in catsOpioid / beta-endorphin

7

Slide8

Stress Effects on Medical Health Acute vs. chronic effectsChronicImmune: Increased sensitivity to pathogensOxidative damage: stress

, disease, age, drugsStress related diseases in human / dogs / catsGI, urinary, dermatologic, respiratory, agingFeline example: stressful events and skin, GI / appetite, urinary, respiratory, avoidance (Stella et al, JAVMA)8

Slide9

Stress: Ingestive and GI SignsHumansAlter bacterial flora, gastric emptying, heartburn, colonic activity, intestinal permeability, irritable bowel, ulcerative colitis PetsAnorexia (particularly problematic in some cats)gastrointestinal

signs / colitispsychogenic polydypsiapica (lick, suck, gulp, gorge, coprophagia)obesity9

Slide10

Is it «Medical» or is it «Behavioural»?Environmental licking n = 20 (Frank et al, ACVIM 2009)

Full workup including GI, scope, biopsyGI disorders 14/20 dogs / resolved 10 of 18

10

Slide11

11

Video

: LICK3

Slide12

12

Video: CAT01

Slide13

Stress and the Urinary Health Feline Interstitial Cystitis (FIC) and stressAltered bladder permeability, noradrenaline ↑MEMO (multi-modal environmental modification)reduce FIC, respiratory, fear, nervous, IBD, aggression (www.indoorpet.osu.edu)Feliway

diffuser – less bouts13

Slide14

Stress and the Urinary Health FIC – Seawright et al., Cameron et al.Higher risk with recent move, recent injury, dogs in home, movement restricted by other catImprovement over placebo by reducing anxiety, increasing space, separating resources

14

Slide15

Stress and Dermatology Brain-skin connectionStress may be a trigger for skin diseasePsycho-

neuro-immuno-endocrinological responseHumanStress and atopic dermatitis, psoriasis, urticariaStress increase cytokines, IgE, eosinophils, vasoactive peptides in atopic vs. non-atopicStress and increased epidermal permeability

15

Slide16

Stress and Dermatology PetsIncreased severity and frequency of skin disorders in separation anxiety, non-social fearPsychogenic and recurrent pyoderma in dogsPsychogenic and pruritus in dogs

Allergen penetration if increased permeability?16

Slide17

Stress and Mental Health Enrichment, behavioural needs / time budgetUndesirable may fill void

17

Slide18

Stress and Mental Health Conflict: Competing motivationFrustration: Unable to achieve goalDisplacement: Lick, circle, yawn, suck,

drink18

Slide19

19

Video: GREETCIRCLE

Slide20

20

Video: CIMG6542

Slide21

Contributing Factors Medical complicationsOwner response

21

Slide22

Stress and Mental Health Recurrent / Chronic stressCope vs. unable to achieve homeostasis

22

Slide23

Stress and Mental Health Correlates to humansphobia, generalized anxiety disorder, compulsive

behaviourpost traumatic stress, impulsivity, panic23

Slide24

Behaviour Pathology Deprivation: Prenatal / neonatal / maternalInsufficient early socialization / habituationGeneticsAbnormal serotonin and aggressionEnglish Cocker Spaniel, Springer Spaniel

Compulsive – outside situations of conflictRepetitive, exaggerated, sustainedAttention to particular goalSelf-trauma, neurologic, ingestive24

Slide25

Compulsive Behaviour

Doberman

exhibiting

obsessive

flank-sucking

.

Photo:

Tufts

University

.

25

Slide26

26

Video: P1000025

Slide27

Is it «Behavioural» or «Medical»?

27

Slide28

Evaluation of 21 Cats with a Presumptive Diagnosis of Psychogenic AlopeciaNon-seasonal, no primary lesions, no scratch

Exam, blood / urine, derm assessmentRevolution (3 tx), food (Feline z/d - 8 weeks) Response assessed – food challenge if improved Methylprednisolone acetate at 8 / 11 weeks Response to therapy assessed S. E. Waisglass, G. M. Landsberg , J.A. Yager, J. A. Hall, JAVMA 2006

28

Slide29

Polling question29

• 0• 4• 8• 16• 21Of the 21 cats referred with psychogenic alopecia, how many had an entirely medical cause?

Slide30

ResultsMedical: 16/21 (76.2%) Food 57% / Multifactorial 52% Psychogenic + Medical: 3/21 (14.3%) Psychogenic alopecia (PA): 2/21 (9.5%) Histology not confirmatory

30

Slide31

Diagnosis - Behaviour Problems Normal? Inappropriate / undesirable: Time / place / targetNo drugs indicated but natural products may helpAbnormal? Fear / anxiety,

attention deficit, hyperactivity disorder (ADHD), panic, phobia, compulsiveRule out medicalDrugs and/or natural products are indicated31

Slide32

Normal behaviour Eliminate /markClimb / exploreScratching

Play / nocturnalVocalizePredationMating

Common

problems

Eliminate /mark

Climb / explore

Scratching

Play / nocturnal

Vocalize

Predation

Mating (neuter)

Feline Behaviour

32

Slide33

Common

problems

Eliminate /mark

Climb / exploreScratchingPlay / nocturnal

Vocalize

Predation

Mating (neuter)

Canine

Behaviour

Normal behaviour

Age, breed, Individual

Hunt / scavenge

Eliminate /

markSocial / object playTerritorial – vocalSexual33

Slide34

Fear, Anxiety, Stress Fear: Response to perceived threatAnxiety: Anticipation of threat / dangerGenetics / development / socialization / experienceInsufficient outlets / enrichment

Unpredictable consequencesLack of environment controlPunishment – owner emotional state34

Slide35

Signs of Fear, AnxietyBehavioral – anxiety, stress, fear Fight / threat, flight (avoid), freezeEars, eyes, lips, tail, postureAutonomic: Heart and respiratory rates, salivation, trembling

35

Slide36

36Video: Snapping dog on table - no GL

Slide37

Fear Prevention

Socialize/Habituate: 7-9 wks. cats, 12-14 wks. DogsReward desirable, not punish undesirableProvide outlets – enrichmentEnvironmental controlNatural products to adapt

37

Slide38

Understand normal behaviourAge/breed/health appropriateSocial intraspecificSocial interspecific – pets, peopleObject play – work for food

Canine Enrichment

38

Slide39

Canine

Enrichment - Humain Social time, play, exercise, train for rewardsConsider canine, breed, individual needs

39

Slide40

Canine Object PlayExplore, scavenge, chewProvide outletsWork / train for food

Stuff, freeze, manipulateSearch and find

40

Slide41

41Dog playing with Konk toy

Video: CIMG9745

Slide42

Understand normal behaviourMultiple small meals / play sessions – mouse sizePredation 8-10 mice per day – 2 of 3 missedObject play / exploreSocial: intraspecific / interspecific

Feline Enrichment – Indoor Housing

42

Slide43

Play: Novelty wears off but interest heightensIndividual: Movement, texture, food, sizePlay: Increase with hunger, end with foodReward train

Enrichment – Social (human)

43

Slide44

44

Video: cattrain

Slide45

45

Video: play2CIMG5043

Slide46

Food toys: Hunt / work for food Hunt independent of

killExplore: Climb, perch, scratch Rest / comfort / securityObject Play / Explore

46

Slide47

Provide outlets - reward use Prevent – positive confine Control, securitySupervise – inhibit - deterrentsSet

Up to Succeed

47

Slide48

48Cat on counter

- deterrrentVideo: Case39part3

Slide49

Adoption – new home – moving – changeBoarding, confinement, travelUnfamilar people / petsVeterinary clinic,

groomerUrine markingSeparation related problemsNoise / Storm / FireworksFear, Anxiety, Stress

49

Slide50

Physiologic, emotional, behavioral outcomes Identify fear stimuli: Avoid Expose below threshold: Desensitize (DS) Response substitution (RS)

Train / reward behaviorCountercondition (CC)Positive associationNatural products / drugs: Start early!Fear, Anxiety

, Stress -

Treatment

50

Slide51

May decrease behaviour: Avoid / retreat Does not decrease fear or train desirable Herron et al, AABS, 2009 Confront – alpha roll, yelling «NO» can increase aggression expecially if aggressive to family

Blackwell et al, JVB – 2008 Punish: Increase fear / avoidancePunish + reinforce: higher risk of aggressionConfrontation and Punishment

51

Slide52

Start early!Build confidence, reduce stress Reduce arousal – anxiety Low: Conscious control – allows for learningHigh: Immediate response vs. learning

Alter neurotransmitters / receptors Natural productsSafer? Adverse effects? Standardization?Show me the evidence!Natural Products / Drugs

52

Slide53

Randomized Control Trial – Placebo Effect up to 50% Clinical trials – owner measures – subjective? Time / expense – inclusions / exclusions Placebo effect - No one wants placebo Laboratory trials – lab measures – objective? Standardized population - Less time / expense Need to validate model – does it predict clinical

Behaviour Therapeutic Trials53

Slide54

Polling question – Check all that apply54

Which of these natural supplements have you already used for anxious pets?Bach’s flower remediesL-theanine (Anxitane)L-tryptophan

Pheromones (DAP, Feliway

)

Alpha-

casozepine

(

Zylkène

)

None

Slide55

Natural products Veterinary labelled: Zylkène, Anxitane, DAP/Feliway, Harmonease (USA)Tryptophan/low protein, aromatherapy, melatonin

Drugs Veterinary labelled: Reconcile, Clomicalm, AniprylBuspirone, benzodiazepines, propranolol, trazodone, clonidine, carbamazepine, memantine Evidence-Based Products

55

Slide56

Tryptic hydrolysis of milk as in newborn Bovine milk hydrolysate - alpha S-1 caseinCalming - Safe – Crosses blood-brain barrier Affinity for GABA receptors – inhibitory, anxiolytic Dose > 15 mg/kg

Cat: Open into food sid / Dog: Sid or divided Up to 30 mg/kg for situational (e.g. travel, noise) Trial: 2 weeks to 2 months. May be used long term if successfulAlone or combine with other

natural

/ drug

Zylkène

®

56

Slide57

Social stress, development, age related stress Environmental stress change, moving, adoption Fear: Animate, inanimate, situationsUrine marking (cats)

Indications – Dogs / Cats57

Slide58

JVB 2007– Beata et al. 38 dogs, 56 days trial – alpha-casozephine vs. S

elegilineEvaluation of Dog's Emotional Disorder (EDED) Feed, drink (pu/pd), groom, sleep, explore Aggression, social, learning, stereotypic / acral lick dermatitis Physical: HR, RR, gastrointestinal, obesity Comparable in improving EDED score

Effects

of Alpha-Casozepine on Anxiety Disorders in Dogs

58

Slide59

JVB 2007 – Beata, Beaumont-Graff, Coll et al. 34 cats, 56 day trial – placebo trial Anxious disorders – emotional scale for cats Tolerance of contact familiar people Contact with strangers Aggression, fear Physical signs / autonomic signs Significant improvement in global score

Effects of Alpha-Casozepine on Anxiety Disorders in Cats

59

Slide60

Feliway: Feline facial pheromones (F3) Marking, scratching, transport, moving Idiopathic cystitisDAP (Adaptil) – Lactating bitch sebaceous pheromones Separation anxiety, storm / fireworks New home, socialization Travel, veterinary clinic

Evidence - Pheromones

60

Slide61

L-theanine (Anxitane) – JVB - Laboratory trial (CanCog) – fear of unfamiliar human Magnolia / Phellodendron (Harmonease, USA) JVB - Laboratory trial (CanCog) – induced thunder L-tryptophan / low protein diet – JAVMA – canine

territorial and aggression Aromatherapy – lavender – JAVMA – travelEvidence –

Other Natural

Products

61

Slide62

Fluoxetine – RCT – separation anxiety – ongoing Compulsive, marking (feline), generalized anxiety Clomipramine – RCT - separation anxiety – ongoing Compulsive, marking (feline), storms Buspirone / benzodiazepines / propranolol Trazodone, Clonidine, Carbamazepine

, Memantine Adjunctive or as needed Could combine with natural

Drugs

62

Slide63

Control, reward train, predictable, enrich, routine Set up to succeed / safe area Puppy – second dog, other dogs Age of adoption, puppy class, socialize Avoid fear evoking stimuli Anxiety: DS / CC / RS Natural products / drugs

Positive Adoption63

Slide64

Positive from outset: Car – reception – exam Owner – staff – DVM Treats, toys - avoid negative Fear / anxiety: DS / CC – safety – natural / drugs www.abrionline.org

Positive

Veterinary

Visits

64

Slide65

Positive association with restraint / carrier / car Secure restraint – head halter Other pet – owner - treats / toys Fear / anxiety: Avoid till DS / CC / RS Natural products early Drugs – as needed

Positive Car Travel

65

Slide66

Reactive – Anxious – Territorial – Hormonal Identify stimuli Prevent / block / deter stimulus access to cat Prevent / block / deter cat access to stimulus Determine cause – resolve (e.g. conflicts) Evidence - pheromones, fluoxetine, clomipramine Other natural products

Feline Urine Marking

66

Slide67

Anxiety / distress panic during departure, not spite Destructive, soil, vocal, ANS signs (pant, salivate)

Separation Distress

67

Slide68

Behaviour Modification Program (BMP) Reward relaxed / settled behaviour - safe location Structure interactions: No attention on demand Avoid punishment Habituate to cues - departure exercises Schedule – enrich – toys / settle pre-departure Natural product if mild / early / adjunctive or labelled drug (e.g. fluoxetine, clomipramine)

Separation Distress

68

Slide69

40-50% of dogs - increases with age Fireworks 32 %, Thunder 31%, Gunshots 18%

Noise Sensitivity / Aversion

69

Slide70

Safe havenVisual (home, pet)Reduce soundStatic

Environmental Modification

70

Slide71

Reward train settle / relax – comfort location DS / CC and RS with recordings Products: Head halter, anxiety wrap, thundershirt Natural products / Drugs – ongoing +/- as needed

Behavior Modification

71

Slide72

13.5 yr F(S) soft coated Wheaten Terrier – 15 kgRecent stressors: Divorce – shared custody – in two homes - loss of dog housemate of 12.5 yearsNo health issues – ruled out cognitive dysfunction Increasingly nervous – shakes, trembles, pants Sensitive to noises - wind, coffee maker, ice maker Worst in car – shake, drool, climb on owner Jumps on owner or anyone for comfort

Maggie the Anxious Wheaten

72

Slide73

Can’t continue to see Maggie this way Numerous previous products with no effect Rx Zylkène – 225 mg tablet daily (15 mg/kg) Effect within few days

Maggie

73

Slide74

2 months - More relaxed / calm (not perfect) Car rides – biggest relief – lies down, no shaking / panting but does not yet enjoyMedication discontinued Immediate recurrence of nervous, noise fear6 month follow-up – well controlled Happier dog – happier owner

Follow-up

74

Slide75

The Happy

Ending75

Slide76

Question Period76

Slide77

This continuing education web conference was brought to you by

77