Facing fear head on: Tips for veterinarians to create a more behavior-centered practice

If you're not conducting routine evaluations for common behavior problems, you're not alone. Taking a proactive approach to behavior is almost nonexistent in most of our practices, yet research suggests that implementing a fear and anxiety assessment at each veterinary visit could go a long way toward preventing relinquishment and suffering in pet dogs and cats.

In part one of this series ("Fear factor: Is routine veterinary care contributing to lifelong patient anxiety?" September 2013 dvm360), we discussed dramatic research suggesting that a simple veterinary visit can greatly contribute to a lifetime of fearful behavior, starting with the first puppy or kitten wellness exam. The good news: Changing a fearful practice environment into a fun, rewarding and behavior-centered experience is easier than you think.

A trip to the veterinarian doesn’t have to be a painful experience for pets-or pet owners. By incorporating a fear and anxiety assessment into each patient visit, you’ll create a better experience for everyone.

The fearful 10 percent

A study of 102 puppies between 8 and 16 weeks of age involved videotaping a standardized veterinary examination for each dog.1 The exam included watching the puppy unrestrained on the floor, performing a physical exam on the table and doing a series of manipulations on the floor. The authors used the videos to define and classify the signals and behaviors.

The findings were striking: Most puppies exhibited what we think of as typical puppy exploratory and social behaviors, but about 10 percent of the pups did not exhibit exploratory behavior, did not warm to interactions or did not want to be touched and handled by the staff. A follow-up study, not yet fully published, reexamined these same dogs under the same conditions at 18 months of age, and virtually all the pups that had been fearful when younger were fearful as adults—and fearful in the same contexts.2 Some of the dogs that were considered normal pups had developed behavioral concerns—fears among them.

So what can we do to alleviate these emerging behaviors? First, we can assess puppies for behavioral propensities in a repeatable manner (here's a hint: the exam takes the same amount of time whether or not there's video camera mounted on the wall or on a tripod). We can think of the pup's behaviors in terms of risk assessment and explain any concerns to clients. We can disabuse the clients—and our staff members—of the common notion that these dogs will "grow out of it," as they often don't. In fact, to assume they will is to potentially condemn them to a lifetime of mental suffering. Finally, we can treat these fearful pets early and often and explain that treatment is always best when brains are developing.

Fast, effective assessment

We cannot accomplish a behavior-centered practice that's fun for the patient until we recognize and measure behaviors that are occurring and remeasure them after we have attempted interventions. A study provided some simple assessment scales,3 which I've expanded and adapted to routine veterinary practice (see the table below; a downloadable packet of these and other scales can be found in the Manual of Clinical Behavioral Medicine for Dogs and Cats [Elsevier, 2013] and on the accompanying DVD).

Assigning a ’stress value’ to dogs

Implementing treatment

Any dog who consistently has a score of 3 or higher needs help, especially if the scores across all three situations agree. Many dogs are fearful of moving scales, but if the dog shows consistent fear in this and the other two contexts, help is warranted. Treatment here is aimed at preventing the suffering that accompanies worsening fear and requires a four-pronged approach:

1. Protection. Protect these pups from situations in which they are overtly fearful. Explain to owners that these are not the pups that should go to soccer games, busy shopping malls or even for a ride in the car if it has to be parked in a lot. Encourage clients to identify sentinel behaviors that are good and sentinel behaviors that are not so good. For example, ask, "Does your dog pull forward confidently with his head and tail up and face relaxed, or does he pull back, ducking his head and tucking his tail?"

2. Encouragement. Encourage behavioral, mental and emotional change for the better. Help owners teach the dogs to sit, relax, take a deep breath and be calm in response to a series of cues. Start in the place they are most secure and practice a series of behaviors so that more than nine times out of 10, they can do them well and happily. Then move to another room.

The rule for expanding the dog's horizons is that you must go at the dog's pace, which may be snail-like. But if you simply force a dog to comply with you despite its distress, you will have rendered the dog worse and caused suffering. An expert (preferably a diplomate of the American College of Veterinary Behaviorists; see dacvb.org) may be helpful in designing this program. Many licensed and certified dog trainers may also be helpful, but beware that operant conditioning does not require calm mental states that are desired for truly distressed pets —it just requires rewarding targeted, repeated behaviors. Help your clients find trainers who understand and act on this distinction.

3. Supplementation. Consider supplementing these dogs with polyunsaturated fatty acids to increase DHA (docahexanoic acid) and EPA (eicosapentanoic acid). Not only are these polyunsaturated fatty acids essential for normal brain development, but if the laboratory research is correct, they might protect against the oxidative damage4 that occurs in times of distress.5 Aim for somewhere in the zone of 1,200 to 1,500 mg/day/dog.

4. Medical intervention. Consider early treatment with antianxiety medication. I have treated pups as young as 5 to 6 weeks of age with such medication, and the change can be dramatic. Laboratory data show that treatment with selective serotonin reuptake inhibitors and tricyclic antidepressants can normalize neuronal migration and pruning in baby mice that either have knockout genes for certain neurotransmitters or that have been selected for more reactive or aggressive behaviors.6 This result may be due to the neurotrophic effect of continued use of such medications.

All placebo-controlled, double-blind studies of behavioral medication in dogs have shown that dogs taking medication acquire the behavior modification more quickly, which supports the concept of neurotrophic benefits. Given this finding, early combined pharmacological and behavioral treatment may be the key to engendering normal brain development and normal social behavior. And the earlier we intervene, the less suffering and damage we can expect.

We should remember that clients recognize that their animals are ill based on their behavioral changes. We are how we behave. If we use any aspect of behavioral change to inform us about somatic illness, we should also be using such changes to inform us about behavioral illness.

Yet, as so eloquently reported by Roshier and McBride,7 most veterinarians are not sufficiently comfortable with their knowledge of veterinary behavioral medicine to deliver appropriate care. Of the six veterinarians participating in the study, only two had acquired some training in veterinary behavior or behavioral medicine while in veterinary school, and only one conducted behavioral consultations. Of the 17 areas of behavioral concern about which the veterinarians were specifically asked, none of the veterinarians reported always discussing any of these issues with clients. Included in the areas of concern were aggression to people; aggression to animals; training, including housetraining; destruction of property; and issues attendant with geriatric pets.

These issues must be viewed as the lymph nodes of the canine mental health field; we must address them if the dog is not to die or to suffer and be relinquished. Interestingly, clients consider animals exhibiting these concerns to be manageable, treatable and adoptable, until the concerns are deemed severe.8 "Severe" is what happens when we fail to do our due diligence early.

Assessing and changing our behavior

We must change the way that we behave during consultations to help our fearful patients. We can do this by:

> Not interrupting clients. Clients cannot evaluate our medical skills, but they can evaluate our ability to convey information, to understand their concerns and to show empathy. And our value is assessed by how well we listen. Yet the median and mean lengths of time clients talk before being interrupted by the veterinarian are 11 and 15.3 seconds, respectively.9 The main reason clients provide incomplete information to closed-ended questions is that we are interrupting them. As a result, the primary concern or key piece of information is often delivered at the end of the appointment when it's least likely to be competently addressed.

The Manual of Clinical Behavioral Medicine for Dogs and Cats contains a one-page questionnaire that can be completed by all clients at all appointments and can help owners provide behavioral information in objective terms while also helping veterinarians accurately assess and treat complaints in a data-driven manner.

> Not scaring our patients. We must cease to be part of the problem. In the studies discussed above,3,10 dogs that had had only positive experiences were less fearful than others. And dogs less than 2 years of age that saw veterinarians frequently were often more fearful than older dogs that saw veterinarians infrequently, suggesting that repeated exposure may enhance fear to a certain age. Another study noted that muzzles interfere with our behavioral and physical assessments.11 All early fear must become a treatment priority.1,2

> Teaching patients to participate. Discuss with owners the importance of encouraging and practicing compliance at home, so at exam time the pet is comfortable with a tip-to-tail examination. And we need to include in every patient record the objective assessment of patient behaviors, as outlined above. We cannot fix what we cannot see, understand or quantify.

> Calling on our understanding of neuroscience. We must incorporate what we know about the neurochemistry and molecular genetics that affect fear, arousal, learning and development into any neuroscience taught in the veterinary curriculum, and here's why:

• Learning of adaptive fear at the neurochemical level in the amygdala and the hippocampus is modulated by cortisol concentrations.

• As cortisol concentrations increase, brain-derived neurotrophic factor (BDNF) increases, which allows molecular memory to be made through the creation of new proteins.

• Fear can be almost instantly encoded because the amygdala is "preadapted" to respond to perceived threats. However, behaviors associated with learning to cope with arousal cannot be encoded at the molecular level if the cortisol concentration is too high.

• An optimal range of cortisol produces an optimal range of BDNF and cytosolic response element binding (CREB) protein.

• Only when CREB and BDNF are within this range is true complex, associative and adaptive learning occurring at the molecular level.12

We now know that neurodevelopmental periods interact with absent or excessive stimuli to alter brain function and development. What we do not know is why this area of neuroscience is essentially missing from veterinary education and veterinary medicine when the stakes are so clear and so high. It is incumbent on us to address the single most important aspect of our patients' well-being—their behavioral and mental health needs—using the same rigor and scientific approach that we use to vaccinate patients or treat them for diabetes. It's time to fight fear.

Dr. Karen L. Overall is a researcher, the editor of The Journal of Veterinary Behavior: Clinical Applications and Research, and the author of more than 100 publications, dozens of chapters and a new book, The Manual of Clinical Behavior Medicine for Dogs and Cats.

References

1. Godbout M, Palestrini C, Beauchamp G, et al. Puppy behavior at the veterinary clinic: a pilot study. J Vet Behav 2007;2(4):126-135.

2. Godbout M, Frank D. Persistence of puppy behaviors and signs of anxiety during adulthood. J Vet Behav 2011;6(1):92.

3. Hernander L. Factors influencing dogs' stress levels in the waiting room at a veterinary clinic. Student report. Swedish University of Agricultural Sciences, Department of Animal Environment and Health. Ethology and Animal Welfare programme. 2008. Available at http://ex-epsilon.slu.se:8080/archive/00003006/.

4. Taha AY, Henderson ST, Burnham WM. Dietary enrichment with medium chain triglycerides (AC-1203) elevated polyunsaturated fatty acids in the parietal cortex of aged dogs: implication for treating age-related cognitive decline. Neurochem Res 2009;34:1619-1625.

5. Pandya CD, Howll KR, Pillai A. Antioxidants as potential therapeutics for neuropsychiatric disorders. Prog Neuro-Psychopharm Biol Psychiat 2012; doi.org/10.1016/j.pnpbp.2012.10.017

6. Gross C, Zhuang X, Stark K, et al. Serotonin1A receptor acts during development to establish normal anxiety-like behavior in the adult. Nature 2002;416:396-400.

7. Roshier AL, McBride EA. Canine behaviour problems: dicussions between veterinarians and dog owners during annual booster consultations. Vet Rec 2013;172(9):235.

8. Murphy MD, Larson J, Tyler A, et al. Assessment of owner willingness to treat or manage diseases of dogs and cats as a guide to shelter animal adoptability. J Am Vet Med Assoc 2013;242(1):46-53.

9. Dysart LMA, Coe JB, Adam CL. Analysis of solicitation of client concerns in companion animal practice. J Am Vet Med Assoc 2011;238(12):1609-1615.

10. Döring D, Roscher A, Scheipl F, et al. Fear-related behavior of dogs in veterinary practice. Vet J 2009;182(1):38-43.

11. Roshier AL, McBride EA. Veterinarians' perception of behaviour support in small-animal practice. Vet Rec 2013;172(10):267.

12. Peters A, Schweiger U, Pellerin L, et al. The selfish brain: competing for energy resources. Neurosci Biobehav Rev 2004;28(2):143-180.