How to identify, treat self-injurious patients - DVM
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How to identify, treat self-injurious patients
Keys to differentiating behavior patients from allergic and endocrine patients—and how to treat them


DVM360 MAGAZINE


Tail chasing in dogs: Tail chasing often happens in play and as an occasional displacement behavior (i.e., in response to conflict or stress). When it becomes more chronic and debilitating by interfering with normal activities or causing damage to the tail tip, it is considered pathologic. Underlying differentials include compulsive disorder, epileptic episodic behavior, a neuropathological disorder or even hallucination.5 In some cases, a familial predisposition (e.g., whirling or spinning in bull terriers) is suspected.

Feline psychogenic alopecia: This condition is characterized by excessive self-grooming that occurs without an underlying dermatologic or physiologic condition.5 Often the owner doesn't see the grooming bouts but notices the alopecia. The affected areas appear primarily on the medial forelimbs, caudal abdomen, inguinal region, tail or dorsal lumbar areas. Physical examination shows short, broken hairs in these areas. In our experience, lichenification, hyperpigmentation or secondary bacterial infection is rarely present in overgroomed areas. It's suspected this disorder may be a displacement activity, as a means of self-appeasement during times of stress, anxiety or conflict.

Although many practitioners diagnose this disorder, it's likely much less prominent than once thought. When pursued correctly, most cases are found to have a medical cause. In one published study, 21 cats were referred to a behaviorist for psychogenic alopecia. Medical causes of pruritus were identified in 16 of the 21 cats, and treatment of the medical condition alone resulted in complete cessation of the excessive licking. Psychogenic alopecia was diagnosed in only two of the cats.14


Photo 3: A cat exhibiting hyperesthesia.
Feline hyperesthesia: This refers to a complex group of behaviors that may include signs such as rippling or rolling of the skin and twitches along the thoracolumbar region (Photo 3). The cat may vocalize, arch its back, exhibit spastic tail twitching and often run, jump or engage in self-directed or redirected aggression. Affected cats appear difficult to redirect from the activity, or if they can be, only for a short time. The occurrence of signs, however, may be sporadic and episodic.11 An underlying anxiety or compulsive disorder may be the cause, but a number of dermatologic conditions (e.g., food allergy, neurologic conditions, painful conditions, systemic diseases, and possibly hallucinations) also have been suggested.5,11

Treatment

Clinical management of self-injurious behaviors should take into account the multifactorial origins of the disorders. Treatment should incorporate environmental and social management in addition to treating secondary medical complications. Some stereotypies may serve as coping mechanisms for animals, and the behavior in itself may not be deleterious. Treatment in these cases may not be warranted and may actually be harmful for the patient.

Treatment should be implemented in cases in which the behavior is causing secondary medical sequelae, is affecting the animal's ability to function or is becoming stressful for the owners. In the case of compulsive disorders, treatment is most successful when behavioral management, behavior modification and pharmacologic intervention are combined. Since many of these disorders ultimately are based in anxiety, punishment of the behavior is generally contraindicated. And in the case of attention-seeking behaviors, consistently and reliably removing the reinforcement will eventually cause this behavior to diminish.

If possible, identify the source of the instigating conflict, arousal, stress or frustration, and attempt to eliminate it. Often the underlying stressor may be another pet or family member, so removal is not an option. In these cases, the owner should give the pet its own area of the house or, for cats, various vertical areas to escape confrontations. If a particular situation is identified as a stressor, behavior therapy may involve teaching and reinforcing calm alternative responses or behaviors (response substitution). In these situations, systematic desensitization and counterconditioning to that stimulus may prove helpful.

Inconsistency in the environment or with interactions with the owners is likely a large component in the development of these behaviors. So it's extremely important to stress to owners that they create a consistent, reliable environment and provide predictable daily interactions to address the conflict and anxiety that sustain their pets' behaviors. All interactions between owner and pet should be structured and in a command-response-reward format. The client's response to the pet, especially when it's performing the problem behavior, should be carefully evaluated and counseled. Punishment can lead to exacerbation of the frustration or anxiety. Consoling or inappropriate redirection, distraction or punishment can reinforce the behavior.

Environmental enrichment is also a critical element in eliminating many of these behaviors. Aerobic exercise (e.g., walking, running, agility exercises, flyball) help many patients. Interactive obedience work or play can help mentally stimulate a patient as well as enhance the relationship between pet and owner. Social play with conspecifics can be an important factor for many pets. And owners should rotate interactive food toys or devices.

Suggest that cat owners provide access to elevated sites or window perches and encourage marking, rubbing, rolling and scratching. Also suggest they provide meals in interactive food toys and offer cardboard boxes, paper bags and catnip or cat grasses. A birdfeeder can be placed outside a window where the cat lays, or cat videos can be played to provide visual stimulation.


Table 2: Key TCA and SSRI drugs and dosages
Therapy with psychotropic medication may be warranted, and SSRIs or tricyclic antidepressants (TCAs) have been used successfully in many cases of compulsive behaviors (Table 2). Select pharmacologic agents based on the individual patient and the underlying emotion or motivation of the behavior. At this time, all use of medications for treating compulsive disorders in animals is considered extra label. Without concurrent behavioral and environmental management, however, the prognosis is guarded. Note, other anxiolytic medications (e.g., benzodiazepines) have been used, depending on the behavior's underlying stimulus.


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Source: DVM360 MAGAZINE,
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