Good evening everybody and welcome to another Thursday night members webinar. My name is Bruce Stevenson, and it is my pleasure to be able to chair this session tonight. I think we have a couple of new members in tonight, so just a little bit of housekeeping.

If you want to ask any Questions, just move your cursor over the screen. The control bar pops up normally at the bottom and there's a little Q&A box. Just click on that, type in your questions.

They'll come through to me and we will hold those over to the end, and Sarah has agreed to answer as many as we have time for. Don't be shy, ask a question. It, it really is interactive and as I say, Sarah is great, so she will help us and answer those questions.

Sarah spent 4 years in mixed general practise before setting up a behavioural referral veterinary practise in 1992. She's an RCVS and European veterinary specialist in behavioural medicine and was made a fellow of the Royal Veterinary College, at the Royal College of Veterinary Surgeons in 2018. 2019 saw Sarah gaining her postgraduate certificate in veterinary education, and she became a fellow of the Higher Education Authority.

She is a certified clinical animal behaviourist under the ASAB accreditation scheme and registered as a veterinary behaviourist with the Animal behaviour and Training Council. She sees both clinical cases across the whole of the Northwest of England. In 2002, Sarah became a founding diplomat of the European College of Animal Welfare and behavioural Medicine.

Sarah has a special interest in the interplay between emotional and physical illness in dogs and cats, and particularly in their role in pain. Sarah, welcome to the webinar vet, and it's over to you. Good evening, Bruce.

Good evening, everybody. Thank you very much indeed. Thanks for those of us of you who are attending live this evening, and hi to those who are listening to the recording as well.

So, tonight, we're going to be talking about emotional and physical health and the connection. So, I thought I'd start off with just some learning outcomes and the sorts of things we hope we're going to cover this evening. So, looking at what the link is between emotional and physical health.

Looking at how we can recognise presentations of physical health, which indicate some sort of potential for emotional, an emotional component. And also to think about how we need to take histories in a chronological order. So we look at the changes over time, so that that can help us to detect these links between physical health and behaviour change.

So, if we look at the effects of disease on behaviour to start with, we look at our counterparts in human medicine, and we know that there's a lot of work being done to investigate how mental, as it's taught to, talked about in the human field or emotional, as, as we tend to refer it to, to it, and physical health impact on one another in the human animals. So there's a lot of information about that in the literature within the field of human medicine. But until recently, this link between physical disease in our non-human animal patients and the behavioural changes that they show has really been very poorly appreciated.

And we've tended to think, especially in the dog field, about behaviour change only in terms of cognition, in terms of training or learning, and thought of it more as a training problem. Obviously now we have a much better understanding of the fact that behavioural output comes from the underlying emotional motivations of the individual, and it's those emotions that are so inextricably linked with physical health. And of course, it's a two-way street, so this link works in both directions.

And again, if we look at the evidence from our human colleagues, we find that the presence of physical disease affects the likelihood or the risk factor for developing mental or emotional health issues. But also, those individuals who suffer with emotional health issues can also have an added risk factor for developing physical disease. And I guess one of the areas that's quite often talked about in the human medicine field is that of pain.

And pain is something I am particularly interested in. It's not the only area, of course, where there is a link. What we know in humans that have, conditions such as osteoarthritis, causing pain and mobility challenge, that there is a, a very, established link between those conditions and the onset of emotional health issues.

We also know that having emotional health issues can change your perception of pain and therefore the significance of pain to the individual, and here I'm talking about humans. So if we think about veterinary implications, this interplay, as we've just said, has largely been overlooked and ignored within our profession until relatively recently. And now we know that this emotional state is more relevant than we considered beforehand.

And I I've put a picture here of a cat with FIC feline idiopathic cystitis. So, because of the fact that that was probably the first of the conditions of the physical health conditions, to be written about in the veterinary literature by medics, so, by internal medical, Specialists talking about the fact that emotions and behaviour were relevant to these cases. And that was quite a turning point in our profession, because these were people who were working in a recognised veterinary discipline at the time, behavioural medicine was still in its infancy, and struggling to be recognised by the profession.

But here were people working in internal medicine saying, Hang on a minute, there is a link with the emotional health of this animal. And the other picture I've put here is of a cholic dermatitis in a dog. Another condition where we started to see people, again, working in dermatology, talking about the fact that there was a link with the fact that these animals had emotional compromise.

So now, much more readily, we see, cooperation and collaboration between those working in perhaps the more traditional veterinary disciplines, like dermatology, internal medicine, etc. And those of us working in veterinary behavioural medicine. So, how do we maximise the detection of potential physical health influences when we're looking at a behavioural presentation?

So if someone comes to the practise of an animal and is asking about advice for behaviour change, we need to think about a combination of a medical and a behavioural history. So of course, yes, we need. To ask questions which are traditionally associated with the, with the behavioural side of veterinary medicine.

So, or the origins of the animal, or where it was bred, how it was reared, and all of those sorts of questions, alongside our physical health history. And to do so in a way that has a chronological approach. So that we can then look at the history that we have just taken on both dimensions, so, medical and behavioural, and then look at the examination of the animal in the here and now.

So your physical examination in your consulting room, and the description of the behaviour that's happening in the here and now. And then evaluate that history in the light of the examination. So we're looking at what's happened previously, looking at what's happening now, and looking at whether there is a link between them.

And we're going to also think about maximising our detection of underlying disease. So if there is doubt, so if we take that history, we start to see clusters, and we tend to take histories using a timeline, just means a, a line on a piece of paper. And you can put the behavioural history on the bottom of the line, the medical or physical health history on the top of the line, and then look for clustering of events.

So is there any evidence that things are coinciding over time? And if there's doubt that comes from that history taking, as to whether the origins of this behaviour change might actually come from a phys underlying disease, then we may, of course, go on to do our more traditional veterinary examination in terms of things like neurological examination. Taking bloods, for hem and biochem, and also thinking about urinalysis.

And those are commonly used in cases that are presented with behavioural change in order to rule out or rule in the potential for underlying physical disease. I've also put on this list diagnostic imaging, X-ray, CT MRI. Is that helpful in these cases?

Well, yes, certainly, we do have situations where we may go down the, imaging route, but wouldn't say that that was being done at the beginning of the investigation. So, once we get into diagnostic imaging, We're probably going to have done quite a lot more work up, from a behavioural point of view, taking that history and analysing the emotional health of the individual before we're going to go into these, slightly more involved tests, like diagnostic imaging or more specialised tests like ECGs, EEGs, etc. So the challenge for us is that many cases where pets are actually referred as a result of unwanted behavioural change, as a general practitioner, you may not be aware of the behavioural significance of that medical history.

So, sometimes there can be links in time in the past, so where we've. Got past illnesses, or an animal's had a previous accident, or they have an ongoing medical condition, where actually, that does have an influence on the emotional health of the individual, but may not seem to be significant. And particularly the ones that are passed in terms of the fact that they're not in in front of you in the consult room at this moment.

And the caregiver may also have forgotten that this animal had maybe an RTA when it was younger, or had a bout of, an infectious disease when it was a puppy or a kitten, which resulted in it being isolated. These sorts of things may have happened quite a long time ago. And so it's.

Really important when referring cases for behavioural change, to provide a full medical history, so that those who are working in the behavioural field, who maybe are slightly more aware of the potential for there to be a link, have got the whole medical history to go back and look at. Now, of course, another challenge that we have when we're dealing with behaviour cases is that often vets are referring to non-veterinary certified clinical animal behaviourists. So then, they don't have veterinary behaviourists, in their area, because sadly, we're still, quite low in numbers.

It is definitely improving, and we've got a, a few, new diplomats over the last couple of years, and each. Diplomat that qualifies, obviously has the potential to take on residents, and so it will improve. But, at the moment, we do have a lot of need to refer to non-veterinary CCABs.

Now, the Certified Clinical Animal behaviour scheme through ASAB, is a way of finding someone who has got the right skills to help you, and non-veterinary colleagues have a a lot to offer in terms of working alongside our profession to help these patients and their caregivers. But it's really important to remember that the physical health potential to be involved with these individuals' behavioural problem is something that is our responsibility to detect as a veterinary profession. So, it's really important to develop a mutually Respectful relationship, because you need to have dialogue.

It's not just a case of referring, particularly if you refer to a non-vet. It's, it's not just a case of referring and then washing your hands of the case, but maintaining that contact so that potential physical health influences can continue to be considered as the history of, from a behavioural point of view, continues. And it's important that non-vets who are working, in this field work on veterinary referral.

And those who belong to reputable organisations and those who have adequate and appropriate qualifications will only work on veterinary referral, which is obviously is in keeping with the idea of the vet led team approach. And this is Absolutely crucial from a welfare perspective, because of the fact that only the veterinary surgeon is able to make sure that this animal is clinically, physically well, but also, we are responsible for the emotional health of the individual as well. So, if the animal is unwell, it's really important that we are involved.

Now, a clinical examination should probably be carried out before any referral to a non-vet. If you're referring to a veterinary, behavioural specialist, then it's likely there will be some element of, examination. Certainly, observation and taking history in a more clinical way.

But a clinical examination before referral is important. And any additional tests that are justified. So again, we would probably wouldn't get as far as into the more in-depth investigations like imaging, but certainly we may have taken a urinalysis or bloods if we're suspicious, for example, in our cats that have got FIC for example.

And the other way in which referrals can come about is because you know there's a physical disease, that's, been diagnosed. So it's not that there's any doubt as to whether there's a physical disease. We know there is one, but we also are aware that there is an emotional impact of that physical disease.

That's another reason for referring for work, to help the animal with the emotional component. And obviously, once referral has been made, particularly to this non-vet avenue, then they would be contacting you if they had concerns because the behavioural signs were progressing, or because the clients made some comment, regarding the physical health of their pet in the past, that may not have been, in the immediate, timeline that you've been involved with. So, maybe even when they were at another practise, so they've moved house since then, and they've.

Haven't mentioned, something in, in their history. So there's all sorts of reasons. And when you're spending more time in a more involved behavioural medicine style of consultation, it's surprising how often the clients tell us things that they haven't told their general practitioner, not because they were withholding information, but because they just weren't in a, a context where it was, easy to chat, and therefore, this information is more likely to come forward.

So there may be added information that the non veterinary behaviourists or even the veterinary behaviourists that you've referred to can come back to you with. And obviously, if the response to conventional positive behavioural modification techniques is not as expected, then it's really important not just to continue down that avenue, but to think about whether potentially there could be some other component. So an ongoing dialogue between the professionals involved is absolutely essential so that we optimise the welfare of the individual patient.

So I want to look at this link between emotional and physical health in two directions. Firstly, the potential for emotional health to affect physical disease. And so, emotion, as we say, can influence disease, and it can work the other way around.

And any emotional disorder, so that's when the emotional health of the individual is outside of normal limits, leads to a physiologically stressed state. So, particularly if an individual is in an exaggerated bias towards the protective emotions. So, fear, anxiety, frustration, pain, panic, grief, those emotions.

That are about protecting the individual. If those are being stimulated, in an abnormal manner, over and above the need to protect, then the physiological stress that results from those emotions can be a predisposing factor for changes in the physical body and can affect the perception of pain. So, the really important when we're thinking about pain is the individual's understanding of its own pain.

Likewise, if you've got a physical health state that leads an animal to be debilitated, so for things that cause, changes in ability to be mobile, for example, that may compromise an individual's ability to use avoidance. So, if they're protective in their emotion, they want to move away from something they consider to be harmful, but they have a physical disease state, which is limiting their mobility, then that will obviously exacerbate that level of emotional. And equally, if the animal's in a debilitated state, so it has things like chronic skin disease, or has things like chronic orthopaedic conditions, which are causing chronic pain, then it's likely that those are going to be influencing emotion by creating more protective emotional bias.

So, you're more likely to feel the need to protect yourself when you're unwell and uncomfortable and debilitated. And that, in turn, can influence behavioural output. So the outward manifestation of a behavioural change is dependent on the threshold of response to the stimulus.

So, if the animal is showing a behavioural reaction, for example, to noises, then the threshold of the response to that noise and the salience or the relevance to the individual of that noise will determine their behaviour. Output. But in addition, that behavioural output is dependent on the emotional state of the individual in terms of arousal.

So we talk about in emotional terms, in two ways. We talk about valence. So that's whether the emotion is protective or engaging.

And we talk in terms of arousal, which is, if you like, the amount of the emotion that's present. And, those of you who've heard me, speak before may be familiar with the sync analogy I developed, back in 2010. And basically, in terms of arousal, we're talking about the amount of emotion in the metaphorical sink.

So, anything that increases that level of residue, the amount of motion. Emotion that's sitting in the sink of the individual makes it more likely that when another tap gets turned on, so another stimulus is encountered, that that individual is not going to have enough capacity to deal with the additional input, and is more likely to flood, is more likely to, be in a state where they're not able to cope. And that residue that sits in the sink may be coming directly from an emotional health issue.

So, an animal that has an anxiety disorder or something similar. It could be because of the emotional effect of a physical health issue, as we just talked about the debilitating or mobility. Restricting illnesses.

And also remember, from pain point of view, that has both physical and emotional components. So it may be filling up the sink because of the effect on mobility, and also filling up the sink because there's an emotional component to the pain. And so we end up with less emotional capacity.

So, thinking about this idea of physiological stress, so this is where the body is, is reacting through chemical changes within the body that have the potential to then impact on physical health. And one of the signs of chronic physiological stress is the repetition of health presentations. So, a recurrent history of ill health.

And you're probably going to think, immediately of things like FIC. So we talk about some diseases that we encounter in our internal medicine experience as being prone to so-called flare-ups or being prone to recurrent presentations. And that would be a real red flag to consider whether there may be emotional factors involved in that recurrent pattern.

Other things that would lead us to think about whether physiological stress is a component would be where there are diseases associated with a breakdown of mucosal integrity. So, where we've got issues, for example, with the bladder wall integrity in RFIC cases, or with gas, with the gastro. Spinal tract in terms of gastrointestinal disease presentations related to things like diarrhoea and chronic diarrhoea, unexplained or unresponsive diarrhoea, or flare-ups of diarrhoea in these individuals.

You may also see it, of course, in breakdown integrity of skin, and therefore, in dermatological cases. We also know that in the immune function of an individual can be influenced by this physiological stress. So, when we have diseases like infectious diseases or autoimmune conditions, again, taking the history that takes into account emotional health as well as physical So these animals are physically ill.

They're presenting with a physical disease process, but we need to expand our history taking to consider whether there is some, exaggerated, presence of physiological stress because of emotions, and pain-related conditions as well. So I thought I'd just quickly give some examples of sort of common disease-related indicators. So, certainly, dermatological conditions are up there.

So we often see a link between individuals with dermatological conditions and emotional disturbance. And so, they often present as dermatology. That's why they come into the veterinary practise, and then get referred on to us to investigate the emotional component.

Or we see them, for the, because of behavioural presentation. And then we detect changes in dermatological health during our examination. So we may see things like stress related grooming patterns, particularly, thought about in cats, where grooming can become a displacement behaviour.

But dogs will also use self licking as a displacement behaviour associated with high emotional arousal. Or if we have repetitive licking, so foci of, of, of skin disturbance, where the individual is licking repeatedly, or situations where we have changes in immune function. So, just some pictures of cats with, Dermatological change associated with, grooming patterns.

So often has this more, symmetrical pattern, more in keeping with normal grooming behaviour, but being, carried out at more excessive intensity or for more excessive duration. And then we see things like the aqua lips, which we talked about, or focal changes in skin, irritation, and alopecia as a result. Or individuals like this cat, Polly, who had an autoimmune skin disease.

That was diagnosed. There was definitely, that condition. But the resolution was, not as expected to conventional medical treatment for the condition.

So, I was asked to do a house visit, and then we detect this cat is actually, suffering from quite a, a high level of, protective emotional bias because of other cats in the neighbourhood that are causing a lot of tension, and particularly staring in at her through windows, from walls, and from the top of a car on a driveway, for example. And then we have our, cases of things like ATP, and we do see, a lot of atopic dogs who have behavioural change because of this two-way street that the the irritation associated with ATP can also be debilitating emotionally, and, of course, because of the fact that physiological stress may be affecting their immune function. In terms of urinary tract conditions, then feline idiopathic cystitis, as I've already mentioned, is a, a really good example of this interplay between the natural behaviour of the cat, so, often associated with water being provided in inappropriate, places or not being provided in the right sort of receptacles and decreasing water intake as a result, or having water too close to food, or those sorts of things.

The, their emotional state is affected through anxiety because of intercat tension in the household, or problems with other cats in the neighbourhood, and then having this physical disease. And it's been shown that in, in various studies, many of them published, that stress, that physiological response to protective emotional bias, is a risk factor for FIC. And we're very grateful to the work of, Tony Buffington, Dennis Chu, Jody Westro, people, from Ohio State, who started publishing on this particular topic.

And recent research has shown that these cats who suffer from foetal idiopathic cystitis actually respond differently to stress. Their physiological response is different. So, they have, FIC because when they're emotionally challenged, they are reacting to that emotional challenge in an abnormal way.

They show more displacement behaviour. They have the beginning of a normal stress response, so an increase in their activity in their locus sullius. And then they get more sympathetic tone, which we would expect, but they don't have an increase in their plasma ACTH, and cortisol levels.

And what that basically means is that the HPA axis, the hypothalamic pituitary adrenal axis, is not completing its work to deal with that protective emotional bias. And this so-called uncoupling of the HPA axis is also talked about in the human literature, particularly in things like chronic pain syndromes. So of course, FIC cases may present with medical signs, so straining to urinate, hematuria, periuria, for example, but others may actually come to us with much more obvious behavioural signs, so things like unacceptable house soiling.

Or sometimes even with over grooming. Now this is something I see far less commonly now because FIC is so well recognised within the profession and so well dealt with at a general practise level that generally we see FIC cases. This is because the the clinician has already diagnosed the condition, the condition is being treated, but we are involved to look at the potential stresses.

What is it that is happening in this animal's environment, which is leading to this physical condition. Behavioural investigation is necessary so that we can fully treat effectively the medical condition. Particularly understanding these things such as feline social groupings and feline relationships, potential for interca tension, resource distribution, particularly things like communal eating, which is particularly stressful for cats, but very, very common, because caregivers are humans, and therefore, they tend to put human perceptions of feeding onto their.

Pets and think it would be nice for them all to feed together. And sometimes, sadly, they've been given very bad advice from a behavioural perspective and been told to feed their cats closer and closer together in order to get them to like each other. That's actually quite a common piece of advice, from certain internet-based, people claiming to be cat behaviourists.

And that is very detrimental. We then see these cats becoming more and more, in conflict over food, more and more frustrated, and so yes, they will come closer together in order to gain access to the food, because they need to, but they will also become more hostile to each other at other times, or manifest with these sorts of physical health manifestations. Other things that we need to think about are the gut.

I mentioned that earlier, that, obviously, the mucosal integrity of the gut can be affected by physiological stress. And we have, obviously, a physical response to that. So things like, diarrhoea, as we talked about earlier.

But also remember that the gut is so crucial in the functioning of the gut brain axis. So we have the potential for abnormality in gut function, and particularly where dysbiosis is created for there to be a change in the kurinase pathways and therefore, in the production of serotonin. This is the effect on tryptophan degradation.

And tryptophan is a precursor, of course, of serotonin. And we know that about 95% of the body's serotonin is produced in the gut. So if we have, emotional issues that influence gut motility and gut function, we may also start to see changes in gut function in relation to serotonin production, and that can have a looping effect on the underlying emotional disorders.

So, these things interplay. The other thing where there's an area of, necessity to think about emotional health when you're presented with the clinical presentation is obesity. Now, we know more and more about obesity, thanks to the work of people like Alex German at at Liverpool Vet School, and the weight Management clinic there, and Georgia as well.

So, the that sort of work has been inc incredibly important in increasing our understanding of Obesity as a physical disease process. But also, we have a better understanding of how the emotional state of the individual can influence that disease of obesity in terms of changing the utilisation of nutrition. So, if we have animals who are eating in a protective emotional bias, so they have higher levels of protective emotion while consuming food, then it is likely they are going to lay down glycogen storage deposits rather than utilise that food.

And so there's a link, and that's been very well established in humans, of course, if you think about the weight loss programmes of things like Weight Watchers or Slimmer's World or any of those sorts of, Weight Watching programmes, they talk not only about what you eat. Eat your food consumption and your exercise, so your output of energy, but they also talk about your emotional state, about eating when you're calm and when you're relaxed, and not eating when you're in a hurry, and not eating when you're worried about something. These sorts of factors are well established, and now we have a lot more information about that in our non-human species as well.

And then pain, we have to talk about the influence of emotion on pain. And certainly, in terms of things like neuropathic pain. So an illustration here of, feline or a facial pain syndrome, recognised in Burmese originally, but now recognised in orientals, oriental crosses, and cer in certain families as well.

And of course, if I show you a picture, of A cavalier King Charles Spaniel, then you're immediately going to think about syringomyelia chia malformation. And so these, again, are conditions that are neurological conditions. So we know about the abnormality of the, of the skull in the, cavalier, and we think about the trigeminal nerve neuralgia in these feline orofacial pain syndrome cats.

So yes, there is a neurological condition, but it is influenced by the emotional state of the individual. And so if we're going to treat them effectively, we need to consider looking at their lifestyle, looking at their social interactions to reduce the level of physiological stress by creating a better, more engaging emotional bias in these individuals. And environmental effects can also influence emotional state and then have a knock-on effect on physical disease.

So, if an individual is living in a socially or a physically suboptimal environment that doesn't cater for their species specific behavioural needs, they're more likely to be in this protective emotional state, more likely to be suffering from physiological stress. And that may be very. Obvious.

So an example that we can see here in this picture, everybody would go, this animal is obviously in a welfare compromised environment. But it may be that the, household that they're living in is compromising from a, from a physical or a social environment point of view, but isn't on the face of it, a welfare issue until we start to think about the environment from a species-specific perspective. Other things that may influence your bias towards protective emotion is where environmental factors affect natural behaviour.

So I mentioned earlier about the provision of water. So it's common for water for cats to be put near to food or to be given in plastic containers, or to be given in containers that are too too deep, so they can't get to the meniscus of the water. Anything that reduces the cat's natural drinking behaviour or compromises it, of course, risks reducing water intake and that may be a risk factor for certain diseases, for example, renal disease.

And then, of course, if we think about multi-cap households where we've got levels of high levels of social pressure, that may be restricting access to resources, food, or water. For food, it may mean that they are eating that food in a sympathetic state, sympathetic predominance, and we talked about obesity, and if they are unable to gain access to water, then the sorts of things we've just talked about of renal disease being affected. And so we've seen that the emotional health of an individual can have a direct impact on their physical functioning through the physiological changes associated with stress and also that if they are compromised emotionally through the environment that they live in, that that may also have an effect on their physical health.

In fact, In humans, adverse childhood events is a term that's related to, children who suffer emotional trauma during childhood, and adverse childhood events are a risk factor for cardiac and respiratory disease in adult humans. Years and years after the trauma that the individual experienced as a child. They can have physical health complications as a result.

And we are exploring more and more in non-human animals about this link as well. So if we have puppies and kittens who have emotionally traumatic puppy and kitten hoods, that that may actually be a risk factor for physical disease later on down the line once they enter adulthood. So, I just want to now turn and look the other way.

Look at the influence that physical disease can have on emotional health. And again, it's a, a link that works in both directions. So, I want now to think about this animal that has a physical disease state and then has an emotional consequence of that.

And we can think of it in 3 areas. So, where it's developmental. Touched on that a little bit, just then, when I was talking about early puppyhood and early kittenhood.

It could be immediate, so the disease the animal is suffering from has an immediate impact on the emotional health of the individual. Or we can start to get into the area where cognition involved. So, I often talk about the tri the triad of, healthcare, and the idea that the veterinary profession needs to be involved in looking after physical, emotional, and cognitive health.

And so, when we look at this learned potential for there to be a link, then we start to see the input of cognition. So, in terms of developmental link, I have touched on this already. So, if we have severe illness in those first few weeks, That can have implications because those first few weeks are so important in terms of behavioural development.

So those kittens or puppies that are very sick, maybe we have to have them hospitalised and therefore they're isolated from normal socialisation and non-social environmental learning. So they're not in a domestic environment, they're in the veterinary hospital. They're not in their home learning about normal stimuli in their domestic environment.

And so that may be a risk factor for them going on to develop behavioural challenges later. Also, they may need to be nursed in certain ways that create negative associations with handling. So the way in which we have to administer treatment may lead to negative associations, and that may compromise their emotional health.

In the cases that we talk about here, where it's early, influences, the behavioural change may not occur until quite a long time afterwards. Sometimes weeks, sometimes months. And by then, those early health issues may have been forgotten.

So, obviously, very worrying at the time for a small puppy or a small kitten to be hospitalised because of, illness. But if we don't start to see the behaviour. Change until they're 69, 1218 months of age, then it may well be that we have forgotten, or the caregivers have forgotten about the fact that the puppy or kitten was very sick and when it was, when it was younger.

And we come back to taking our history in a chronological manner and using a timeline to gather that history, so we don't miss these potential connections. And again, that adequate and appropriate early learning. So, we've got cognition here, where they're making appropriate associations between their emotional state and the environment that they live in, is really essential for emotional control.

So, being able to To have a functional HPA access. So, if we have compromise in those early environments through the presence of physical illness, then it's likely that that's, going to be, as I say, a risk factor, later on in life. And the concept of, of adverse childhood, events I just spoke about.

So, when we're nursing puppies and kittens, or when we are dealing with sick puppies and kittens, it's really important to remember that, yes, we, of course, we're treating the disease in the here and now, but we also need to be thinking about the future of these individuals, and maybe giving more specific advice to the caregivers about how they could optimise their emotional health as they grow older. Immediate links between current disease and behaviour are where there's an underlying medical disease which leads to behavioural change directly. And there, in other words, you may even think that this is more, the behavioural change is a sign or or a symptom of the medical condition.

And in some of these situations, it's, it's very, very obvious, whereas in others, it may be much more subtle. So, let's look at the obvious ones. And probably the most obvious one that springs to mind is where you have a condition that causes acute pain, and then you have a confer.

Or behavioural response. So an animal with a broken leg and you have to manipulate it, and the cat hisses at you or the dog snaps at you, then it's very likely that you're going to immediately make a connection between that disease process and that behavioural output. Perhaps not quite as obvious, but still immediate, is where you've got an animal that has some physical health reason for polydipsia or polyuria.

So, for example, a diabetic patient, and that then leads to the presentation of house soiling, which obviously is directly linked. Also, we may see obvious links in terms of, neurology. So quite a strong overlap, of course, between, neurology and behavioural medicine as branches of veterinary medicine.

They both involve, understanding of the brain and understanding of the nervous system and how that influences, obviously, emotional state for behavioural medicine and the full range of body functions from a neurological point of view. And when signs are consistent with neurological involvement, then obviously our differentials are things like abnormal electrical activity, or epilepsy, or space occupying lesions. So anything that is causing pressure on parts of the nervous system could result in very specific behavioural change, or if we have congenital abnormalities or inflammatory processes within that nervous system.

If we think more about more subtle links between current disease and behavioural change, then we've got many disease states which have an impact on emotion. So if we think about the endocrine disorders, and the endocrine disorders are often linked with, changes in emotional bias towards anxiety. So we're thinking about things like Cushing's or Addison's.

And if you think about things like hyperthyroidism in your elderly cats, I'm sure you're very familiar with these. Individuals presenting with behavioural change because of the, the imbalance of their thyroid, mechanisms and that leading to behavioural change, like changes in confrontational behaviour, for example, in some of these individuals. We also know that there's a relationship between hypertension and behavioural change.

So anxiety is associated with hypertension. Now of course, that may be cardiac related, or it may be in elderly cats where you have renal disease. Very important to check for hypertension from a physical health point of view, but also remembering that if they are in a hypertensive state, that may also influence their emotional bias.

And we tend to think about pain being associated with confrontational behaviour. So, we think about that cat that hisses or the dog that snaps. But we can also have non-aggressive responses to pain as well.

So pain can doesn't only result in confrontation, it can lead to increased levels of protective. Of bias, it can lead to increased appeasement behaviour. So individuals who are in pain can appear more clingy or more needy in terms of interaction with the caregiver because they need more support and more information, or they may become more avoiding and more withdrawn because of the consequences of pain.

So pain is incredibly important in behavioural medicine, not only because of the fact that we can have acute pain responses, so short term practical consequences of pain. So we can have animals again, who respond through confrontation, but also respond through more, passive responses, like inhibition. So animals who become inhibited when they're in a protective state, may show that response when they're in pain.

We may think about those individuals as being more stoical in their nature. So, you Yes, of course, there are differences in pain thresholds between individuals and between breeds. But when we think about the fact there are some breeds that, again, are renowned for stoic, and some that are renowned for having a so-called excessive reaction to pain, this may also be linked to their emotional health, as well as to the presence of the pain itself.

And we also need to think about species differences, so we know that in cats, they often express pain in a far more subtle way, because they are more likely to, select the protective emotional behavioural responses of inhibition or avoidance. Yes, of course, when we see them in a veterinary context, we may be more likely to see the more confrontational responses, because. We've taken away those other options.

But when they're at home, we often find that they show passive responses to pain, which makes it very difficult for caregivers to identify that there's a problem of pain, so they lack vocalisation. They don't resent palpation, or, or you can pick them up and move them quite readily, more readily than you could a dog that was in pain. And also, they don't really show the same changes.

In motility, mobility, so they don't tend to see the animal limping as they may do in our canine patients. And so underreporting of chronic pain is a real issue in the feline world. And sometimes these are individuals who come via our service.

They come through behavioural referral because they start showing behavioural change before anyone has actually picked up on the fact that there's chronic pain. And also, the long term consequences of pain are something we also need to think about because of this link with cognition, the potential for associative learning, which can maintain the behavioural signs, even when that acute episode is over. Because classical conditioning will occur.

Classical conditioning happens when any interaction or event coincides with something else. So, if it coincides with the experience of pain. So, being in the presence of another, of, of a dog is associated with being sat on and hurting, then that presence of the dog can become associated with the pain.

And, of course, we know all too well that the context of the veterinary practise often becomes associated with pain in this, the, in this way through classical conditioning. And that leads to how important it is to control pain, particularly pain when they're in the veterinary context. When I talked about non-aggressive behavioural consequences of chronic pain, we can have things like limitations of mobility and then having a presentation of something like indoor toileting.

We can also get more avoidance strategies, or a decrease in social play, a decrease in social interaction, the animal not wanting to engage. With individuals because of the fact that they're in pain, so they're withdrawing from normal social interaction and it may be the change in greeting behaviour that the client is experiencing, or a change in relationship with another animal in the household that actually leads them to consider that to be a problem. And in cases where the individual has developed so-called, behavioural coping strategies, we also may see a link between pain and so-called compulsive or repetitive behaviours.

So if we have a situation where an animal's in chronic pain, they may engage in things like circling behaviour, or a Repetitive chewing behaviour, or repetitive, exiting behaviours into gardens, so they follow certain paths. When I see ritualised compulsive behaviour, and I must admit that chronic pain is very often, top of my differentials list. That's the thing I really want to rule out before investigating other potential reasons.

Is for the compulsion. Now, of course, compulsion is linked to anxiety as a coping strategy, but pain and anxiety are of the same emotional route. So pain is an emotional response, but it is a form of the fear anxiety response.

So, therefore, it's likely there could be a link to these anxiety-related compulsive behaviours. And then, final category that I wanted to talk about was this learned potential for there to be a link between behaviour and disease. So if we have an onset of a confrontational response, to people or to dogs because there was pain in the past, so if you got stood on by somebody, wearing these sorts of shoes and black trousers and a white t-shirt, and you, were in pain as a result, through.

Through the process of generalisation, you may start to see behaviour towards individuals of that appearance, even though they haven't actually come anywhere near the individual, or certainly have not caused any pain, but because of the fact there's this learned component, learned association, that you start to see the behavioural response as if pain were present. And this is something that, again, the chronological history taking can help to identify. So behavioural conditions can be related to natural species specific behaviours.

They can also be related, of course, to compromised emotional health, and they can also result from unintentional learning, so compromised cognitive health. But from our perspective as a veterinary profession, remember that the other part of that health triad is physical health. And so excluding physical health factors always needs to be considered if we have a behavioural presentation so that we can, not miss potential compromised physical health.

So, I would say that if we've got, a presentation of behavioural change, then the potential for that to have an underlying medical reason should be thought about, particularly if the behavioural signs are certainly in onset or they show an unexpected form of progression, or if they're not responding to normal conventional behavioural modification. But equally, if we have a medical change presented to us, we shouldn't ignore the possibility of emotional or cognitive reasons for that, particularly when the disease is recurrent or we're having a flare-up presentation or when they are. Having concurrent changes in their behaviour or where there's a poor response to medical therapy.

So what we thought would be a normal conventional way of dealing with this from a physical health treatment perspective is not being successful. And I want to just finish tonight by also thinking about the fact that not only does emotional and physical health interplay in the ways we've considered already, but also emotional health interplays with our clinical decision making. So, having an understanding of this triad of emotional, physical, and cognitive health all being linked together, It becomes important in certain clinical decision scenarios.

And I've got some examples here, which I'll just go through very briefly. But just to leave you with that idea of how we, we do need to think about emotion, even when we're doing what is very conventional, veterinary work, there may still, in these cases, be an emotional component. So let's start with false pregnancy.

Obviously, we need to think about the fact that these animals have got physical health, like lactation, potential for mastitis, all of those sorts of, considerations. But of course, there's an emotional, basis to a false pregnancy. It comes from the care system, and that leads to the gathering of things like toys to look after through that motivation.

And if we only think in terms In terms of the physical health, we may be tempted to say, I'll take all the toys away, because we know if we remove them, we'll dry up that lactation more quickly. But if we do that, we remove all us ability to care for something, then that emotional system has nowhere to go, and frustration is likely to be triggered, and frustration can then go on to have other consequences, particularly confrontational behaviour. We also need to remember that the prolactin that's involved in that false pregnancy has an influence on emotional state.

So, under the influence of prolactin, an individual will be more anxious and also perceive the, resources necessary to rear, rear puppies to be of more value. So, if you have a more anxious individual who Frustrated because they've had their care objects taken away. They may also have more value put on things like food and things like shelter and bedding, then there's a higher risk of a behavioural influence, in terms of confrontation, as I say, towards caregivers.

And it's really important as well to think about that prolactin level in terms of making a decision as to when to spay that individual, because we really want those levels of prolactin to be down to as low a level as possible so that we can then ensure that we don't get set in a, in a cycle of elevated anxiety because of hyperallactinemia. And so the other thing to think about is potentially the use of cabergoline pre-spraying so that we reduce prolactin levels. So again, a consideration of emotional and physical health helps us to give a more comprehensive treatment programme.

Another area is the castration of male dogs, so we're often, asked to castrate for reasons of behavioural presentation, or we're asked to castrate early on in male dogs just for, overpopulation prevention. But it's important when we're making a decision as to whether to castrate, of course, we're gonna look to see whether those testicles are. Descended.

We're going to think about physical health considerations, but also, we need to consider the emotional state of that individual, it's level of emotional maturity. Or if they're presented for castration to solve a behavioural problem, have we actually got an accurate diagnosis of the emotion that's underlying that behaviour before we think about castration? We know that testosterone increases self-confidence and decreases anxiety in individuals.

So if we have a behaviour that's actually rooted in anxiety, it's possible that castration could be a complicating factor. So, castration of male dogs is a day to day routine part of veterinary medicine, but there is an emotional aspect to it. Treatment of cancer patients is another area where there are emotional health implications.

That comes from the disease itself, maybe having an influence on the emotional state of the patient. The implications emotionally of the treatment protocol or the side effects of that treatment protocol also may need to be considered. And so as well as our expertise in surgical correction of tumours or amputation of affected limbs, for example, as illustrated here, or the administration of the correct chemo regime, we may also need to think about how we care for these patients from their emotional perspective.

And then the final example I gave was the potential to administer medication pre surgery and also pre-visits, for example. So, visits to the veterinary practise. So appropriate premedication or sedation for our fearful and anxious patients, so that we are limiting the impact.

Emotionally, of coming into the veterinary experience. So, we need to, again, think about our patients, not just those who are, in pain. That's one good example, where there's an interplay or in a situation where they're just coming in for routine work, but they are highly emotionally challenged by coming into the environment.

Remember, there may be safety implications for your staff and safe. Implications for your caregivers while they're in your premises if the animal is in the negative emotional bias. So it's not just the welfare of the patient, it may be the safety of your staff and your clients as well.

And so, appropriate use of pre-visit medication. So, I'm sure you're familiar with things like gabapentin in cats and trazodone in dogs, use or sometimes as well, of course, of the benzodiazepines, which is another option. So, there are various options.

And if anyone, is interested in, sedation and pre-bed protocols for emotionally challenged individuals, if you want to contact the practise behaviour referrals, we do have, some, sheets of protocols that we've worked on with Matt Gurney, from Zero Pain Philosophy. To look at ways that we can, appropriately, sedate individuals who are emotionally challenging. But it's just another example of how emotional health impacts on your daily work, in general practise.

So, in conclusion, what I've talked about this evening is an interplay, an interplay between the three aspects of the health triad, emotional, cognitive, and physical health. And seeing that, hopefully, considering that triad is something that will be foremost in your mind, not only when you're investigating changes in behaviour, but also when you're dealing with physical health. And making clinical decisions.

So, thank you very much indeed for listening. And Bruce, if we've, got time, then I'm very, very happy, to take some questions. I don't know if anything's come in, in the chat box.

Sarah, thank you so much for that. I, it's fascinating because this is a lot of stuff that, and I found myself sitting listening to you going, I knew that, but I don't always think about it. Or, oh, hell, yes, there was that case that I didn't think about that.

And so, you know, it's, it's, it's lovely to hear it sort of brought to the fore and and tied together. So thank you very much for a, a very thought provoking presentation tonight. It's pleasure.

We haven't had any questions come through, and, I think that's because everybody is probably sitting with the same thought processes that I have of, oh, yes, that case and this case. And so, yeah, it was absolutely fascinating and, and really, great information. And, I'm sure it's going to make a significant difference to our patients going forward.

So once again, Sarah, thank you so much for your time tonight. Folks, thank you for attending. I really appreciate it and once again to Dawn, my controller in the background, thank you so much for all your help and from the webinar vets and myself, Bruce Stevenson, it's good night.