Fearless columnist Natalie L. Marks is an educator, consultant and practicing Chicago veterinarian. Dr. Marks is a leader within the Fear Free movement, was a member of the original Fear Free advisory board and is Fear Free Certified Elite. She passionately believes that all veterinarians should be committed to the physical and emotional health of their patients.Read Articles Written by Natalie Marks
Although this column focuses on the emotional health of our patients and how that can translate into more compliant clients and better business, like many of you I’m a clinician at heart. The better we can use all our diagnostic skills, including recognizing and interpreting canine body language, the more thorough we can be in treating our patients’ emotional and physical health.
Behavioral diseases are more and more common in today’s small animal practices and are one of the most common reasons for relinquishment of pets to shelters and humane societies. Sadly, we also see from time to time the dreaded appointment on the scheduler: “Quality of life discussion/contemplating euthanasia for reactivity.” Not only is this situation incredibly challenging and draining for the pet’s family, it causes tremendous compassion fatigue for the veterinarian and the oftentimes lesser-acknowledged paraprofessional staff.
Behavioral discussions can be time-consuming and frustrating for small animal veterinarians, not only because many clients do not completely follow our recommendations, but because complete resolution sometimes isn’t always possible. Behavioral discussions, history questions and body language assessments, when paired with physical exams and diagnostic tests, can be invaluable in diagnosing an underlying medical disease. They also can also be a huge opportunity for practice building and client retention.
Normal Versus Abnormal
First, let’s stay true to one of the basic tenets of veterinary medicine: Body language clues should not be assumed strictly behavioral until we’ve ruled out medical disease.
Anxious and fearful behavior manifests in many ways in dogs, from tail tucking, yawning, hiding, dilated pupils and trembling to defecating in the house, excessive barking, pacing, panting and biting. While these signs might seem fairly obvious to veterinarians, they can be difficult for clients to recognize and communicate, due to ignorance, denial or embarrassment.
We educate clients about heartworm disease and vaccination protocols from rote memory, but helping them understand which behaviors are normal or abnormal is just as important. This doesn’t mean that every patient we see who demonstrates fear and anxiety has an underlying medical disease, but some do. The diagnosis of an underlying disease and the hope for patient improvement instantly wins a client’s trust, creating a stronger veterinarian-client bond and usually better compliance with immediate and future recommendations.
The Clinical Checklist
Let’s consider what we could be missing. Many neurologic diseases can be underlying culprits for demonstration of the behaviors above. The issues can range from seizure disorders to inflammatory diseases (meningitis or encephalitis) to brain tumors. We must consider infectious diseases in this differential list, such as distemper and toxoplasmosis, and other peripheral neurologic disease such as neuropathies. These behaviors can even be seen with congenital lesions, such as hydrocephaly in brachycephalic or toy breeds.
I do not scare my clients by making an immediate jump from a dog who is pacing at night and yawning to the suggestion of a brain tumor. However, if the patient is exhibiting other neurologic changes either at home or upon physical exam, neurologic disease should stay on your differential list.
Endocrine diseases can cause secondary behavioral manifestations. Specifically, hypothyroidism is a disorder associated with less than normal production of thyroid hormone from the thyroid gland. Along with the clinical features such as weight gain, hair loss, lethargy and the classic “sardonic grin,” we can see signs of restlessness, panting, pacing or even new compulsive behaviors. What is important to consider is signalment, objective vital signs including weight trends, and complete blood work (with a full thyroid panel) to accurately screen or rule out this hormonal disease. While rare in dogs, hyperthyroidism can cause similar behavioral changes, but physical exam and diagnostic lab values will be very different in comparison.
Check the Ears and Skin
Hearing loss can be a significant reason for anxious behavior because dogs at home or in the clinic will startle easily to what should be familiar cues and stimuli. These patients might fail to respond to commands, growl, snap or start to become reactive to the owner. While we do not have great audiology testing in private practice, we must do diligence to perform a thorough otoscopic and neurology exam of the cranial nerves. This is also a time when we can support pet owners who have a hard time adjusting to the condition at home, giving them suggestions such as placing bells on the dog’s collar, using aromatherapy as cues for common logistics in the house, and using visual and tactile cues when approaching the patient.
Dermatologic conditions, including many cases of atopic dermatitis, can create situations in which the patient might resemble an anxious dog. Remember, these dogs are chronically itching, deal with painful skin in many areas and might not sleep well. Some of these severely affected patients can develop compulsive disorders and secondary neuropathies associated with tail chewing and chronic interdigital licking.
Drugs, Pain and Tests
Acute or chronic use of certain medications can cause anxious or even reactive behavior in canine patients. The most common classes of drug to keep in mind would be corticosteroids and phenylpropanolamine.
Finally, pain of any kind is commonly associated with anxiety and anxious behaviors. Some experts suggest that one causes the other. The causes can range from chronic (and often undiagnosed or misdiagnosed) cruciate or patella disease and degenerative disc pain to periodontal disease and chronic ear infections. As mentioned, the starting point for all these possible underlying medical diseases is a thorough physical exam.
For patients where the history, physical exam findings and other clinical signs lend suspicion toward underlying medical disease, what is helpful is to start with a complete database, including a complete blood count, chemistry panel with electrolytes, urinalysis and blood pressure. If a definitive cause is not revealed, we then need to start tailoring the workup to a more specific focus, such as referral to neurology if indicated, dermatologic diagnostics, assessment of current medications, specific endocrine testing or other advanced diagnostics. Not only is this testing best medicine, it generates appropriate revenue for the practice.
Learn the Language
All in all, we have so much more to learn, share and teach regarding the emotional health of our patients. The one thing I know to be true is that, just like in people, the emotional and physical health of our patients is intertwined and difficult to separate, and this certainly explains why some medical diseases and conditions can have behavioral manifestations.
I encourage all my colleagues to start with familiarization and interpretation of canine body language and to educate clients so that the owners can help answer questions about at-home behavior. This, paired with a detailed physical exam and other diagnostics, can help us, as the clinicians we are, to not miss any medical disease.
If the patient is physically healthy, we then can properly address and treat anxious and fearful behaviors and give the dog and the owner a better quality of life.