Pet Forum / Miscellaneous / Animal Health / December 2005

HOWEDY alphalpha,

Your dog's "ALLERGIES" are CAUSED BY STRESS from ABUSING him..

BWEEEEEEEEEEAAHAHAHAHHHAHAAAA!!!

                      Behavioral Dermatology:
          Acral Lick Dermatitis, Psychogenic Alopecia,
               Hyperesthesia, & Related Conditions
                        Vint Virga, DVM,
             Dipl. ACVB Behavioral Medicine for Animals
                  SM Veterinary Healing Arts, Inc.
                       New York / Newport

HOWEDY People,

Here's The Puppy Wizard's Syndrome. CAVEAT: The Amazing Puppy
Wizard DOES NOT CONDONE or ENDORSE the good Doctor's METHODS
for treating STRESS INDUCED AUTO-IMMUNE DIS-EASE aka The Puppy
Wizard's Syndrome.  He's ONLY a veterinarian and there's ONLY THREE
CURES for it and HE AIN'T GOT 'em.

Here's WON of 'em:

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           <{#}: ~ } >               < { ~ :{@}>
   <{#}: ~ } >                               < { ~ :{@}>
   <{#}: ~ } >                               < { ~ :{@}>
   <{#}: ~ } >  http://www.tinyurl.com/7bl5u < { ~ :{@}>
   <{#}: ~ } >                               < { ~ :{@}>
   <{#}: ~ } >                               < { ~ :{@}>
           <{#}: ~ } >               < { ~ :{@}>
                  <{#}: ~ } >8< { ~ :{@}>

                     Behavioral Dermatology:
          Acral Lick Dermatitis, Psychogenic Alopecia,
               Hyperesthesia, & Related Conditions
                        Vint Virga, DVM,
             Dipl. ACVB Behavioral Medicine for Animals
                  SM Veterinary Healing Arts, Inc.
                       New York / Newport

Introduction

The practice of behavioral dermatology encompasses the diagnosis
and management of a etiologically diverse set of disorders which
phenotypically manifest with dermatologic presentations. Not only
are primary behavioral etiologies included, but also primary
dermatologic conditions with secondary or contributory behavioral
components. It is not uncommon, for example, for veterinary or human
patients to experience anxiety, tension, or stress secondary to chronic
or acute dermatologic conditions. Ultimately, it is the interplay
between
neurosensory, dermatologic, and behavioral components which contribute
to
the manifestation of clinical signs associated with psychocutaneous
syndromes, including:

Self injurious behaviors

Compulsive disorders

Stereotypic behaviors

Displacement activities

Other anxiety related behaviors

Attention seeking behavior

Sensory Neuropathies

Psychotic Illnesses

A diagnosis of self-injurious behavior in small animals must meet the
criteria of barbering or removal of hair and/or abrasion, petechiation,
or ulceration of any body part using the teeth, tongue, claws, or an
external substrate (e.g. rubbing against a wall). A condition for a
diagnosis of SIB is that these behaviors must be demonstrated
repeatedly
and consistently in the absence of any primary dermatologic or
physiologic
condition.

In veterinary behavioral medicine, compulsive behaviors may be defined
as
sequences of movements which serve no obvious purpose or function and
which
occur repetitively, out-of-context or at an excessive frequency or
duration,
and in a relatively unvaried fashion. In most cases they are derived
from
behaviors which are part of the animal's normal behavioral
repertoire.

While such behaviors in animals have been traditionally referred to as
stereotypies, to establish a diagnosis of a compulsive disorder, the
behavior must occur outside of its normal context or at a frequency or
duration which exceeds that necessary to achieve a real or potential
goal and must interfere with the patient's ability to function
normally
in its social environment.

Considering these criteria, it is evident that some patients presenting

to the small animal practitioner may meet the conditions for both self-
injurious behavior and compulsive disorder. Compulsive behaviors
associated
with dermatologic signs are most commonly classified as grooming
compulsive
disorders, although some may be neurotic in origin. In canine patients
these
may include acral lick dermatitis/granuloma (ALD/ALG), flank sucking,
tail
chewing (which may or may not be associated with tail chasing),
excessive
chewing of the feet and/or nails, and excessive scratching. Other
compulsive
behaviors observed in canine patients may be classified as
hallucinatory (e.g.
fly/light chasing, prey searching, staring); locomotor (e.g. circling,
tail
chasing, fence running); eating/drinking (e.g. fabric sucking,
psychogenic
polydypsia, some picas); vocal (e.g. rhythmic barking, barking at food
or
inanimate objects); or neurotic (e.g. vicious self-biting, spontaneous
aggression to humans).

In feline patients compulsive behaviors associated with grooming
include
psychogenic dermatitis, feline hyperesthesia syndrome, and excessive
chewing
of the feet and/or nails. Other compulsive behaviors noted in feline
patients
may be categorized as in canine patients as hallucinatory (e.g. prey
chasing
or searching, air batting), locomotor (e.g. paw shaking, head shaking,
pacing), vocalization (e.g. repetitive howling / crying), or neurotic
(e.g. vicious self-
biting, spontaneous aggression to humans).

A diagnosis of self-injurious behavior may be established independent
of
compulsive behavior. In the author's experience, a significant
percentage
of cases referred for consultation on potential compulsive grooming
behavior
do not meet the criteria for compulsive disorders. Behavioral
conditions
presenting with dermatologic signs exclusive of compulsive disorders
include
some attention-seeking behaviors, feline hyperesthesia, and certain
anxiety-
related behaviors.

Anxiety may be defined as an apprehensive anticipation of future danger
or
misfortune accompanied by a feeling of dysphoria and/or somatic
symptoms of
tension. Anxieties may be internally or externally focused and may be
in
response to real or perceived stimuli. Anxiety may result from
motivational
states of conflict (the tendency to simultaneously perform more than
one type
of activity) or frustration (engagement in a sequence of behaviors
which cannot
be completed because of physical or psychological obstacles).

Because of contributory factors of stress, pain, and pruritus
associated with
many lesions, a primary diagnosis of a behavioral disorder should only
be made
after thorough dermatologic and medical evaluation. Even with a
presumptive
behavioral diagnosis, after medical causes are ruled out, secondary
dermatologic sequelae may develop as a result of chronic trauma to the
skin.

Neurochemistry

Although anxiety, panic, and phobia disorders are related, different
neuroanatomic models have been proposed for each. Complex neurochemical
mechanisms involving dopaminergic, serotonergic, GABA-ergic,
noradrenergic,
and opioid systems may be involved in the manifestation of these
disorders.

Numerous clinical studies and case reports have explored
pharmacological
manipulation of the above neurotransmitter systems in patients with
anxiety-
related conditions with varying results. Differences in responses to
pharmacotherapy may be reflective of individual variations in
neuroanatomic
and neurochemical function. Therefore, it is important that the
clinician
consider the underlying motivational state and possible neurochemical
correlates
when assigning behavioral diagnoses and recommending pharmacologic and
behavioral management.

Clinical Presentations

Evaluation of patients presenting for dermatological conditions with
suspected psychogenic components or origins should incorporate not only

a broad-based medical work-up but also a careful review of the
behavioral
history and direct observation of the patient. Table 1 provides a list
of
important considerations to address in the behavioral history. A
videotape
of the patient exhibiting any relevant problem behaviors recorded by
the
owner can provide valuable clues to the practitioner.

Stressful Environmental Conditions

It is not uncommon for both veterinary clients and practitioners to be
concerned about "boredom" as a cause for compulsive,
self-injurious, or
anxiety related behaviors. While an assessment of boredom is
anthropomorphic
and most likely an oversimplification of the stresses a patient may be
experiencing in relation to its physical and social environment, it is
important and frequently contributory to the patient's presentation.

Stressors, which may contribute to the manifestation of
anxiety-related,
compulsive, and self-injurious behaviors, are noted in Table 2.
Behaviors
that may be elicited in response to stress include changes in appetite,

grooming behaviors, elimination patterns, social interaction, and
activity.

Attention-Seeking Behavior

A significant percentage of cases referred for evaluation of compulsive

or self-injurious behaviors are ultimately diagnosed as
attention-seeking
behaviors. Animals can readily learn that not only disruptive behaviors

(e.g. barking, jumping, pawing, nuzzling), but also less directly
demanding
behaviors (e.g. limb/foot/preputial licking, chewing, scratching,
sucking,
pawing) often effectively get the client's attention. The clients may
have
historically tried a variety of approaches to discourage such
behaviors;
often such attempts include: varying degrees of physical and verbal
corrections, comforting the patient with physical touch and verbal
reassurances, banishment
with physical and social isolation, and ignoring the behavior to
varying degrees.

As the animal persists in the behavior, clients typically report that
they
eventually provide some form of attention; in so doing, the behavior
can
quite effectively be reinforced. It is important for the client to
recognize
that any form of attention, even physical punishment, may serve to
reinforce
the problem behavior.

In establishing a diagnosis of attention-seeking behavior, a careful
review
of the history should reveal that the patient will only demonstrate the
problem
behavior in the immediate presence or close proximity of the client.
Observation
of the patient at the time of consultation should reveal the behavior
is dramatically reduced or non-existent when the clients (or, in some
cases, all parties including
the clinician) are absent.

Feline Psychogenic Alopecia (Over grooming)

Psychogenic alopecia is characterized by excessive self-grooming that
is
initiated or intensified by non-organic causes, or which persists
beyond
resolution of an organic cause. The predominant clinical sign is
alopecia -
particularly in the area of the medial forelegs, caudal abdomen,
inguinal
region, tail, and/or dorsal lumbar areas - in which medical causes
have
been ruled out. Because cats may groom reclusively, excessive licking,
biting, scratching, or rubbing may or may not be observed by the
client.
Barbering and/or frank alopecia may be the only dermatologic signs.

In other cases, self-mutilation with possible secondary bacterial
infection
may be evident. Symmetrical alopecia of the caudomedial thighs and
ventrum
may be observed. Lichenification and hyperpigmentation may develop in
chronic
cases. A dermatitic form (atypical neurodermatitis) characterized by
bright red, elongated, oval streaks or plaques may result from
extensive grooming behavior.

Physical examination reveals: (1) short, broken hairs which are readily

palpated by stroking the affected area against the normal angle of hair

growth; (3) remaining hairs do not epilate easily; (4) microscopic
evaluation
of hairs reveal broken shafts; (5) hair re-growth occurs normally and
lesions
heal with placement of an Elizabethan collar, (6) significant amounts
of hair
upon fecal examination.

Licking of the hair and skin, nibbling, biting, facial rubbing of the
forepaws,
and scratching may all be observed in cats exhibiting normal grooming
behavior.
Although they regularly self-groom, specific times and percentages
relative to
other behaviors are unknown for household cats. Beyond such basic
purposes as
cleansing, removal of parasites, and thermoregulation, grooming in cats
may
occur as a displacement behavior (an activity that is performed out of
context
as a result of frustration) in response to social or environmental
stressors. Displacement grooming may be rooted in anxiety and may serve
to lower arousal,
deflect aggression from other individuals, or provide some distraction
for the cat.

While the occurrence of such behavior in feral or wildcat species is
not known, incidences of psychogenic alopecia have been noted in
captive wild cats. Psychogenic alopecia is reported to be more
prevalent in strictly indoor cats. A possible common variable in both
captive wild cats and indoor cats predisposing them to psychogenic
alopecia may be limited environmental stimulation. A seasonal
incidence, even in indoor cats, can result as a result in changes in
environmental and social stressors (e.g. accessibility / visibility of
other cats).

Feline Hyperesthesia Syndrome

Feline hyperesthesia syndrome refers to a complex of behaviors which
may
include: (1) behaviors similar to those observed in estrous females
(e.g.
increased motor activity, rolling, crouching with elevation of the
perineal
region, vocalizations); (2) excessive licking, plucking, biting, and/or
chewing, particularly at the tail, flank, anal, or lumbar areas; (3)
rippling of the skin,
muscle spasms, or twitches (especially dorsally), which may be
accompanied by vocalization, running, jumping, possible hallucinations,
or self-directed
aggression. Affected cats tend to be difficult to distract from the
behavior,
or, if successfully distracted, remain so for only a short period of
time.

As with feline psychogenic alopecia, environmental and social stressors
have
been associated with this disorder. The cues or changes precipitating
the
behavior may be endogenous. Cats may present with clinical signs
consistent
with hyperesthesia without evidence of alopecic or other dermatologic
lesions.

Review of the behavioral history may further support a lack of
excessive grooming.
Such cases support the hypothesis that this complex of behaviors may
represent a
number of discretely different phenomena. While not currently discussed
in the veterinary literature, based on clinical syndromes observed in
human patients, it
may be worthwhile to consider hallucinatory, rheumatologic, or
neurogenic origins
in future research.

Canine Acral Lick Dermatitis/Granuloma

While acral lick dermatitis (ALD/ALG) may be organic or psychogenic in
origin, this discussion will limit consideration to psychogenic
considerations.
A strong association appears to exist between licking and anxiety in
dogs. Other psychogenic associations include inadequate social
interaction, environmental stimulation, and opportunity for aerobic
activity. As with over-grooming in cats,
ALD may also be associated with displacement grooming in response to
social or environmental stressors.

Compulsive behavior or states of anxiety may contribute to ALD in some
patients. As with feline psychogenic alopecia, the occurrence and
incidence
of correlative behaviors to ALD in feral and wild canines is not known.
Among
domestic dogs, certain breeds appear to be over-represented -
Labrador retrievers,
Great Danes, Doberman pinchers, German shepherds, and some northern
breeds - with
some evidence of familial inheritance. This may be reflective not only
of a genetic component, but also selection pressures placed on these
breeds reflecting their affiliative work and social relationships with
humans.

Other Presentations

Other behaviors focusing on specific body parts which may be of
psychogenic
origin include tail biting, flank sucking, preputial licking,
self-nursing,
licking in the anal region, and foot licking. Based on the evidence to
date,
these conditions represent the result of a heterogeneous array of
underlying
conditions, rather than specific dermatologic or behavioral diagnoses.
Attention seeking, displacement, self-injurious, compulsive, and other
anxiety-related
behaviors may lead to the establishment of these behaviors. Seizure
activity
involving the amygdala and ventro-medial hypothalamus can result in
stereotypic, self-directed, aggressive behaviors. The physiological
sensation of pruritus
may share common biochemical origins with some anxiety states, which
support
consideration of neuropsychodermatological etiologies.

Clinical Management

Considering the heterogeneous and potentially multifactorial origins of
compulsive, self-injurious, and anxiety-related behaviors, clinical
management should incorporate consideration of environmental stimuli,
social stimuli, the motivational state of the animal, and underlying
neurophysiological mechanisms in developing a treatment plan. A
hypothesis incorporating the above, which can account for the
patient's dermatological and behavioral manifestations, provides a
rational starting point from which a program of environmental,
behavioral, and pharmacological management can be based.

Environmental Management

Since the patient's environment may frequently contribute to the
establishment
of OCD, SIB, and anxiety-related behaviors, it is important to
manipulate the environment so as to eliminate stressors and
conflict-producing stimuli. If
this is not possible, systematic desensitization should be employed to
minimize
the effect of the environment. Client resistance is often encountered
and creativity
is often needed when proposing environmental changes. The client must
be committed
to proposed changes in the environment before employing behavioral and
pharmacological management.

Behavior Modification

Counter-conditioning and desensitization provide the framework of
behavior
modification. Counter-conditioning consists of teaching the patient new
behaviors which are incompatible with the problem behavior. Since SIB,
compulsive disorders, and related behaviors are often based in anxiety,
it
is often most effective to select for behaviors which encourage
relaxation.

Desensitization consists of reinforcing the selected new behaviors
while
very gradually introducing provocative circumstances and environments.
Clients commonly wish to progress more rapidly than the patient can
effectively
accept. Patience, consistency, and commitment on the part of the client
are
critical for success to effectively support performance of the new
behaviors
in the face of increasingly provocative stimuli. For desensitization to
be
effective the patient must accept the direction and leadership of the
client.

Deference to the client can be established through routine and regular
reinforcement of leadership on a daily basis. This can be effectively
and gently achieved through asking the animal to sit for all routine
interactions with the client (i.e. receiving attention, love, meals and
treats; grooming and petting; interactive play; going outdoors / coming

inside).

Withdrawal of attention is an effective, gentle correction for failure
of deference. In all phases of counter-conditioning and
desensitization,
appropriate responses are effectively supported with encouragement and
small food rewards as positive reinforcement. Rewarding the patient at
any time when he/she is not exhibiting the problem behavior and is
relaxed
can further support counter-conditioning. Massage therapy, when the
patient
is relaxed, can further facilitate relaxation and encourage appropriate

interaction between the animal and client. The above techniques are not

limited to application in dogs, but can be effectively employed with
cats
and other species with appropriate modification.

Client responses to the patient, particularly when they are performing
the
problem behavior, can be problematic. Despite their history and
experience
of the problem behavior, the client should never express their
frustration
in any way in the presence of the patient. Doing so may reinforce any
anxiety
which the animal may be experiencing. Neither should the client provide
any
measure of comfort - verbal, physical, or emotional - to the
patient while
performing the problem behaviors. Attention-seeking behaviors are based
on
the response of the client or, in some cases, other people. Attempts to

distract the behavior or even aversive responses may be preferred by
some
animals and may reinforce the observed behavior.

Interactive activity and opportunities for aerobic exercise can be
critical
components of behavioral modification. Exercise and mental stimulation
in
cats can be encouraged with a bit of creativity. Opportunities for
environmental
and social enrichment may include: augmenting accessible three
dimensional space;
adding window perches, sisal wrapped scratching posts, and "kitty
condominiums";
varying the location and availability of limited resources (e.g.
resting places); providing an ample variety of both purchased and
homemade toys; scattering food
into small portions throughout the house or employing intermittent
feeding devices; playing with clients utilizing "fishing lure" type
toys, laser pens, and other stimulating games; and training "trick"
behaviors through shaping with a secondary reinforcer (e.g. clicker).

Agility, fly ball, and freestyle provide dogs the opportunity for
interactive,
aerobic activity with the clients beyond traditional activities such as
field
work, sheep herding, Frisbee tossing, ball retrieving, and running /
jogging.

Interactive exercise can facilitate desensitization to anxiety
producing
situations by expose the dog to a variety of potentially provocative
stimuli
while providing something else on which to focus. Interaction with the
dog in
such activities also provides something to which he/she can look
forward,
encourages mental and physical agility, and serves to enhance the
relationship
between the dog and the client.

Pharmacologic Support

Rational use of pharmacologic support can substantially enhance the
effects
of behavioral and environmental modification in patients with
anxiety-related
behaviors, compulsive disorders, and SIB. Management of patients
diagnosed with attention-seeking behavior should be limited to
behavioral and environmental
modification unless the underlying motivation is based in anxiety.

Pharmacotherapeutic agents should be selected to specifically address
the
motivational state of the patient and a proposed underlying
neurophysiological
mechanism of action. With few exceptions, the application of
psychotropic
medications to veterinary behavioral medicine constitutes extra-label
use.

It is important to note that extra-label use requires compliance with
pre-
medication data bases routinely used in human medicine. Hepatic
metabolism
and renal clearance of these compounds further supports pre-medication
assessment of serum biochemistry, CBC, and thyroid function.
Psychotropic
medications, as a category, may affect thyroid hormone concentrations,
potentiate cardiac arrhythmias, potentiate epileptiform seizures, and
increase
hepatic enzyme activities (particularly SAP). Practitioners are well
advised to
become familiar with the specific indications, contraindications, side
effects
and pharmacodynamics of psychotropics which they wish to employ.

Amitriptyline (Elavil®) and doxepin (Adapin®, Sinequan®) are
tricyclic antidepressants (TCA's) which are utilized in human and
veterinary medicine as an anxiolytics. Both exert their primary
clinical effects by inhibiting the pre-synaptic reuptake of serotonin
and norepinephrine to varying degrees. Both have antihistaminic
properties brought about by their ability to block H1 and H2 receptors.
Amitriptyline equally affects H1 and H2 receptors while doxepin is much
more selective for H1 receptors. These medications, particularly
amitriptyline, also effectively block muscarinic cholinergic receptors
resulting in anticholinergic side effects. Additional reported side
effects include weight gain, transient sedation (particularly in cats),
gastrointestinal disturbances, potential cardiac conduction
disturbances and a suggested role in sick euthyroid syndrome at higher
doses. Contraindications may include hepatic, renal, or cardiac
disease. This class of drugs should not be administered concurrently
with MAOI's, selegiline (Anipryl®), or L-tryptophan. Amitriptyline
is a first choice medication for anxiolytic therapy because of the
relative cost and rate of clinical response relative to most
psychotropic medications. It has distinct disadvantages of having a
particularly bitter taste and a narrow therapeutic index associated
with a high rate of toxicity with overdose. For patients in which
dermatitis, neuralgia, or pain is associated with an anxiety related
condition, the antihistaminic properties of these compounds combined
with their noradrenergic effects (and the potential role of
norepinephrine in managing neurogenic inflammation) can prove to be
quite effective in managing clinical signs.

Clomipramine (Clomicalm®) is a TCA which is relatively more
serotonergic and less anticholinergic than previously mentioned
medications. Clomicalm® has been approved by the FDA for use in dogs
in the management of separation anxiety and may be an effective aid in
the management of other anxiety-related behaviors. Clomipramine is also
the only TCA which has documented efficacy in the management of
compulsive behaviors in both humans and animals. As a tricyclic
antidepressant, potential side effects and contraindications of
clomipramine are similar to those of other medications in that class.

Fluoxetine (Prozac®) and paroxetine (Paxyl®), as selective serotonin
reuptake inhibitors (SSRI's), share a common mechanism of action of
being serotonergic without substantially affecting the reuptake of
norepinephrine or dopamine. The relatively specific action of SSRI's
is associated with fewer side effects. Adverse effects reported with
SSRI's include increased anxiety, restlessness, insomnia, weight
loss, gastrointestinal disturbances, and alterations in cardiac
conduction. Despite the relative serotonin specificity of SSRI's
compared to clomipramine, they appear to be equally effective in the
management of OCD. As with TCA's, SSRI's should not be administered
concurrently with MAOI's, selegiline, or L-tryptophan.
Contraindications may include hepatic, renal, or cardiac disease.
Paroxetine is the most potent SSRI available, but it does have some
anticholinergic effects. Metabolism of paroxetine is unique in that
almost no active metabolites are produced. This feature may favor the
administration of paroxetine in elderly patients or animals with liver
or kidney disease.

Table 1: Important Considerations in the Behavioral History Detailed
description
of the patient's behavior immediately prior to, during, and after
eliciting problem behavior Chronology, incidence, and progression of
problem behavior. Ease with which problem behavior may be interrupted
and tendency for return to behavior
Locations, circumstances, and potential eliciting stimuli associated
with the problem behavior Review of other problem behaviors Review of
home environment including all persons and animals in household
Presence of the client(s), other people, and other animals in relation
to animal when behavior occurs Responses of the client(s), other
people, and other animals in relation to the problem behavior
Patient's background including adoption source, familial history,
early temperament/behavior of patient,
and history of obedience work.

Interactions with familiar and unfamiliar household guests Dietary
history including consideration of who feeds patient and review of
feeding schedule Daily routine of patient in relation to other human
and animal members of household Specific types,
amount, and frequency of exercise Specific form, duration, and
frequency of interaction with client(s) and other people Notation of
sleeping location and favorite resting places Review of medical history
with notation of any current medications being administered

Table 2: Potential Environmental & Social Stressors Inadequate mental
stimulation
Inadequate aerobic exercise Inadequate interaction with family or other
pets
Limited access to essential resources Social Isolation Overcrowding
Status-related conflicts Territorial-related conflicts  Addition or
loss of family members or pets
Changes in health status of family members or pets Changes in daily
routine of family members or pets New home / environment Changes in
physical environment Boarding
Hospitalization

mat,--roky is a dog!