OK, so the topic we've got for today is to talk about behavioural medicine and the question of what makes it a day one skill for veterinary students. So I want to start off just by putting, behavioural medicine within the context of the topic of healthcare. And so, if we think about healthcare, there's a triad to the way in which we approach healthcare, whether that's of human animals or of non-human animals as we deal with.

And that triad has three equally important components. So, we have physical health, emotion, cognitive health and emotional health. So 3 equally important components, which are interrelated with each other.

And that's illustrated a little bit here by this photo, these photographs, because what I've done is I've selected, we've just got dogs on here. We'll look at cats as well as we go through this presentation. But with dogs, examples here, if you look at the photo at the top right, Obviously used to illustrate physical health, but you can see from the facial expression of this dog that it also has an emotional response to being in the veterinary practise context.

You've got some, furrowing here, some tension across the head, a little bit of staring here. And you've also got a cognitive experience, because this dog is learning what from being in that environment and could be potentially building up. Negative emotional connections.

Here, we've got a dog engaging in fly ball, this little jack, and you can see again, there's cognition involved here, and that's what I used it to illustrate, because it's learned to engage in fly ball in this way. But we can also see that there's an emotional component to this activity as well. In fact, frustration is very strong in these animals who are, engaging.

In fly ball. And it's one of the ways in which they get them to go faster and to be more intense in wanting to gain access to that ball. But there's also a potential, if we look at the way this animal is hitting that plate repeatedly during this activity, there could be physical health complications or implications from engaging in this activity on a regular basis in terms of joints and musculature.

And then we have the example that I chose for illustrating emotional health, where we can see, again, the facial expression, ear position, this whale eye here, associated with a protective emotional bias in this dog. But we can also see that there is some cognition. So it's learning about the person behind the camera.

And this dog may also present with, physical health issues, things like intermittent diarrhoea, for example. So all of these things are interrelated to one another, and healthcare involves all three components, your physical, your cognitive, and your emotional health. So, what is behavioural medicine in a veterinary context?

Well, basically, it's a discipline of veterinary science, which recognises this triad in non-human animals, promotes equal consideration of both physical, emotional, and cognitive health, and works to optimise all those parts of the triad so that animals have the most optimal welfare when they are living in a domestic human dictated environment. And so when you think about veterinary behavioural medicine, you might think primarily about the diagnosis and treatment of emotional illness. And we'll see there are some restrictions to how much that is carried out within a general practise context.

But what behavioural medicine is, is far broader than that, and it also involves this identification of links between emotional and physical health. And that is the aspect that really does make it a day one skill. So let's have a look at what the barriers are to thinking about practising behavioural medicine in general veterinary practise.

Some practises don't have a behavioural medicine service, and one of the reasons why they might not feel that it is part of their, remit. I think one of the big problems with behavioural medicine is that people are worried about the knowledge that they need in order to work in this field. Knowledge about natural behaviour, for example, of the species that we deal with, primarily dogs and cats, but also other species as well.

They might be concerned about whether they understand enough about cognition, about learning. And that is important in behavioural medicine, because it's about understanding how behavioural behaviours develop. And some of the treatment programmes involve cognition and learning and changing associations.

But certainly, all of behavioural medicine is not rooted in the, learning theory aspects. We also have concerns whether we know enough about human psychology. We certainly know that when we look at specific individual behavioural problems, that there may be a strong component associated with the family dynamics or the social environment that the animal's living in.

And an understanding of human psychology is important. So I think that knowledge is certainly something that people are concerned about, worried about whether also they know enough about psychopharmacology. Are they going to be able to understand using medications that are related to changing emotional bias and changing neurotransmitters that affect that?

The other thing people are concerned about, I think, is experience. So we get very familiar with certain aspects of veterinary practise quite quickly once we qualify. So you do a lot of, certain types of interactions.

So you start to be able to quite. Rapidly diagnose certain conditions that you see on a regular basis. But with behavioural medicine, I think people are worried about not having experience with specific individual cases and therefore, feeling that they're not getting experienced in behavioural medicine.

And then one of the biggest arguments is that it's too time consuming. Well, if we think about the time-consuming component, certainly, dealing with individual cases is time consuming. There's the whole part of the history taking, and then the diagnosis.

There's also the need to implement a treatment plan, and then also to, give enough an appropriate follow-up support. And that can take a lot of time. But that doesn't mean that this is not a day one skill of the general veterinary practitioner.

Because, although fully investigating a behavioural presentation takes a long time, and for that actual part of behavioural medicine, you may want to refer to a veterinary behaviourist, certainly if you have one locally to you, or with the new arrangements during COVID-19. More availability of online remote access to that sort of help. You may also want to get support from adequately and appropriately qualified non-veterinary behaviourists who can be extremely helpful, but do be careful when you get out there into general practise, that you look for someone with appropriate qualifications.

Look for the initials CCAB, the cert. By clinical animal behaviourists, roll through AA and look on the website of the association, the, Animal behaviour and Training Council, the AEBTC, because they hold a register as well of people with recognised qualifications or members of recognised, organisations. So it is important to get help from the right place.

But even if you are going to get help for those individual cases from outside of your practise, the actual con contribution of behavioural medicine to general practise is really significant. So behavioural practise is part of. Veterinary practise.

Vets and nurses on a daily basis, consider behavioural factors, often without realising it. And I hope I'm gonna just illustrate the ways in which behavioural medicine is part of everyday general practise, as we talk today. And also being aware of emotional and cognitive as well as physical health is also a necessity in terms of optimising the way in which we do our job.

So, I wanted to, very quickly, cause we've not got long today, just look at 5 potential reasons why behavioural medicine is a day one skill. So let's start off with behavioural change being commonly reported by caregivers. So, just some examples of the sorts of behavioural changes that are reported, and that can be indicative not only of physical health issues, but also emotional compromise.

So, for example, changes in appetite. When we have animals presented with a change of appetite, of course we're gonna think of gastrointestinal diseases, things like pancreatic disease. But also consider the fact that reactions to food may also be influenced by levels of fear anxiety.

Desire seeking is the motivation that drives us to eat, but if fear anxiety, the protective emotional bias is higher, then these animals may be reluctant to eat, maybe due to social tension in the household, or it may be due to other forms of fear, anxiety triggers such as sounds in the environment. We may get the reporting of changes in exercise tolerance, and of course we will think about cardiac and respiratory disease and the potential of course for pain to be involved in that. But also from an emotional perspective, animals suffering from high levels of fear, anxiety with what's called a negative emotional or protective emotional bias may also be reluctant to go for walks.

They may walk only in certain environments, or they may walk for short distances and then show a need to go back home. Also, we may get reports of onsets of more unusual behaviours. Those unusual behaviours might lead us to think about neurology, or leading us to think about pain as well.

But we can also get compulsion behaviours, so things like tail chasing or shadow staring, which are associated with, again, a protective emotional bias of fear, anxiety, and also coupled with frustration, which leads to these behaviours being done in a repetitive fashion. So it's important to also consider the animal's emotional health. Other changes that are indicative of either compromised physical or emotional health might include alterations in social interaction or play.

These may occur through physical problems such as pain. We also might see alterations in social interaction. When we have got the onset of endocrine disorders.

But fear anxiety as well may also be something to consider, as well as frustration if they're not able to engage in social play or desire seeking motivated behaviours and become frustrated by that. An onset of confrontational interactions can also have medical causes, pain, and endocrine disorders, but also, we might get hormonal changes, things like false pregnancies, and fear, anxiety and frustration are differentials. So that's one way in which there's an interplay with a day one skill.

The other one is where we have this interplay between physical and emotional health. So these are inextricably linked in both directions. We have a lot of information about this in human medicine, where the presence of physical disease affects mental health, and where having mental health issues is a risk factor for developing physical disease.

In a similar way with our non-human animals, we need to consider that physical health conditions impact on their emotional health. For example, if we have a patient with sensory compromise, they may become disorientated and increased in anxiety, and therefore show behavioural signs. If we have cognitive dysfunction, where there's a decrease in functioning of the ability to, function in a social environment, we get, we may again get increased anxiety, where cognitive dysfunction is a neurological condition with anatomical changes in the central nervous system, but leads to behavioural presentation.

We may also get things like polyphagia, where we then get frustration of desire seeking, if they're polyphagic for a medical reason, they may start to show behavioural change, which is what the client notices because they're frustrated. We also, when we have kittens and puppies who are poorly with physical health in those first few weeks of life, that can compromise their socialisation, their introduction to the world, particularly into a domestic world where people predominate. And that can lead to compromised development, in terms of emotions, compromised learning through socialisation and through non non-social environmental learning.

And then lead to increased problems of fear, anxiety, or the potential for panic grief, where panic grief is the emotional reaction to being unable to access your caregiver. So, if you have increased nurturing care because of caring for a young puppy or kitten when they're physically ill, that can then influence their emotional development and make them more prone to problems related to panic grief later. We also have the potential for gut illness, gut dysbiosis, for example, to affect behaviour and emotion because of the high levels of serotonergic production within the gut.

If we have alterations in that serotonergic action, then we can get an increase, in fear, anxiety because of depleted levels of serotonin, and therefore a direct effect on emotions and behaviour through a physical illness. Emotional health also impacts on physical health. So I said it's a two-way street.

And so we know that chronic negative emotional bias, so where we have an individual who has high levels of the protective emotions, fear, anxiety, pain, frustration, panic grief, those emotions, if they are predominant, particularly over a long period of time, then there will be a physiological response to that, emotional state. And that physiological response can then have an effect on the physical body. For example, we can have an effect on mucosal integrity.

That can affect various systems within the body. We can have presentations of disease related to bladder compromise, things like feline idiopathic cystitis. Or we may have gastrointestinal effects, things like irritable bowel syndrome, and, presentations of changes in faecal consistency.

We can also have skin changes associated with physiological stress, as well as oral health conditions. So changes to the integrity of oral mucosa and problems of gingivitis and things, those sorts of diseases. Particularly in cats, and if any of you have ever, vetted in at a cat show, you might know that it's quite common to have high levels of, oral health conditions in some of these cats related to the levels of, pardon me, physiological stress, maybe related to long car travel to get to the cat show, for example.

The other thing that can happen when we're in a physiologically stressed state as a result of emotional compromise that it has an impact on our immune system and the same for our patients. So we may have presentations of diseases such as cat flu. And you may be familiar as well with the term kennel cough for the infectious disease of dogs, but, of course, it's not only related to kennels, it has that name because of the fact that it's been recognised that being in a novel environment, or such as a kennels, where there are higher levels of, physiological stress because the animal is more anxious.

May be more frustrated through confinement, which is not normal compared to their normal everyday life, that that can lead to that physiological stress impacting on their immune system. Obviously, in the case of kennel cough, combined with being in an environment where there's a potential for an increased load of the infectious agent because of the close proximity of other dogs. But outbreaks of cat flu are common, of course, in Qataris and in rescue centres, but also in multi-cat households.

We can have problems of chronic stress, chronic emotional challenge because of living in a suboptimal social environment. If we don't understand the Necessity to create safe environments for each of the, social groups in that household, and then we can get outbreaks of immune, related diseases, infectious diseases, maybe things like cat flu, FIV, FELV, etc. Also, we have to think about the fact that there's a potential for emotional health to impact on pain perception.

Pain is perceived and processed within the brain. There is a common pathway between the anxiety and emotional pathways and those of pain, because pain is an emotional experience as well as a physical one. And so, we also have the potential for enhanced.

Perception of pain, increased significance of pain to individuals who have compromised emotional health. So we that may be manifested to us in a general practise setting with cases such as illustrated here with the cavalier King Charles Spaniel, with syringomyelia chiari malformation. But there are also, of course, other examples.

Feline or a facial pain syndrome is another condition, which is a neurological condition associated with discomfort and pain, with the trigeminal nerve being involved. But in situations where cats are emotionally compromised, we may see an onset of those physical signs, and they will be presented in a general practise setting. Another very common area where there is an interplay between emotional health and physical health is in the area of weight management.

Primarily, we think about obesity, and certainly, if we have animals who are consuming food in a compromised emotional situation, then that will lead to a higher level of sympathetic activity during consumption and an increased tendency to lay down glycogen storage deposits. But we also have the potential that emotional compromise can impact as well, leading to hyperexia, and maybe even to a situation of anorexia, which may be presented to you within the veterinary practise. And of course, in order to get full resolution of that problem, you're then going to need to think about the emotional health of your patient as well as their physical signs.

Other ways in which emotional compromise can lead to problems in terms of physical health is when the behavioural responses to those emotions impact on physical health. So, some examples of that might be responses to fear anxiety. If the response to that fear or anxiety is avoidance, leading to things like bolting, those animals may be at increased risk of things like road traffic accidents.

Or if they engage in repulsion responses, they may get engaged with altercations with members of their own species, as illustrated here, with a cat wound from a cat fight. They may get themselves into situations in dogs where they are more prone to get. Physical injury if they start using repulsion responses to fear anxiety.

So if we don't resolve the emotional component, the fear anxiety that led to those behavioural responses, we're going to limit our success in dealing with the physical disease. Desire seeking can also lead to an impact on physical health when it is, misplaced or when it leads to ingestion of things like toxins or foreign bodies. And also, if we have frustration, so frustration is the emotion that occurs when you cannot achieve an expected outcome.

If animals are placed in situations where they become frustrated, so, for example, if they have a desire-seeking motivation for, for a social company and they are not able to achieve that, they may become frustrated, and they may become injured. This is a, for example, a claw being torn out in a dog that's put in a crate because of a separation problem, and then becomes frustrated by that confinement, and then has a clawed injury that would be brought again to you in a general practise setting. And then in social tension cases, particularly, we think about multi-cat households, if that social tension is leading to compromise of their access to their resources because of not being able to go past another cat or being worried about the other cat being present, then we may get problems such as, Obesity, hyperexia, as we've already thought about.

We also might get restriction of access to water with the implications for feline patients in terms of renal disease, or limiting their access to litter trays and problems of urinary retention, increased possibility of urinary tract infections, for example. So we can see that this interplay happens between physical and emotional health in a way that highlights the importance of understanding emotion as a day one skill in general practise. The fourth way in which we can have an interplay is where compromised emotional health adversely affects your ability to perform your clinical examination or your diagnostic tests.

So, for example, if an animal has a protective emotional bias, they come to the vet. In practise, feeling, those emotions of fear, anxiety, and also potentially pain. That may lead to what we term repulsion behavioural responses, where they aim to get rid of the perceived threat.

And that, of course, can make clinical examination challenging. And it can also mean that even if we do a clinical examination, our outcome from that, our information may not be reliable. We also need to think about the fact that caregivers may actually be reluctant to bring their pet in the first place for a veterinary visit, if they perceive a problematic behavioural reaction.

And that may not only be being repelling in behaviour, it may also be those animals who use avoidance. So the cat who shows distress during the veterinary visit, or the dog as well. Who's reluctant to come into the practise.

And therefore, caregivers may delay coming to ask for our assistance, and that can be really problematic in leading to us having a delayed diag diagnosis of physical disease. And we see that particularly in our feline patients, where they can be quite advanced in physical disease before we actually diagnose it, because we don't see them. We also need to remember that physiological stress at the time of sampling for blood samples, for example, can lead to altered biochemistry.

We can have elevated glucose, changes in leukocyte and neutrophil counts, or neutrophil lymphocyte ratios. We can also have changes in things like creatinine kinase readings. So, when we have an animal who has compromised emotional health, we need to be aware of that if we're going to accurately interpret our lab results.

And then finally, I thought about the potential for there to be an impact of our treatment approaches on the emotional health of our patients. So, when we have patients who are hospitalised, that has not only, a benefit to us in terms of being able to offer better physical treatment, making sure we can monitor their progress and their physical disease, we also need to think about the potential for there to be impact on their emotions. They may feel fear anxiety because of being in a novel location.

Of course, there's also within that context, the, the emotion of pain, which is a form of fear anxiety. We may get panic grief if they are separated from their caregivers and they have a strong, either a strong attachment. To them, so it's a panic grief response.

Or they may just be frustrated by lack of access to social contact. That may be exacerbated if they have anxiety and they need social contact in order to resolve their anxiety, they're more likely to become frustrated by being hospitalised. We also may have the potential for our patients to have emotional impact from advice such as confinement.

So if we confine because of surgery or injury, we ask people to keep them restricted within, particularly, an indoor crate, for example. We need to think about the potential for there to be an emotional impact of that and how we might mitigate that. For example, if it's an elective surgery, we may want to train that animal prior to going into that situation.

So they have a positive expectation of being in the crate. We also might give advice, such as restricted exercise for our canine patients that may involve on lead exercise only. If that dog has a high expectation of social play with other dogs on his walks, generally, we may start to induce, again, frustration for that individual.

And we need to be aware of these potentials when we're giving out treatment advice to make sure that we're also giving advice as to how to deal with the potential emotional impact. And then we might think about the fact that we give advice to clients to administer medication at home. We give them tablets or eardrops, or eye drops, and we expect them to be able to give those to their patients in the home environment, to follow our instructions.

But have we asked about the emotional Health of that patient. If they have problems of fear, anxiety, or if they have a prone, a tendency to become frustrated, we may actually be asking clients to do things that are incredibly difficult to do, and we may need to modify our advice or even our treatment approach. So, behavioural medicine is about welfare.

I said at the beginning, it's about optimising all three parts of the health triad to give optimal welfare. And that is undoubtedly within the remit of the veterinary surgeon, because when we take our oath on entry to the Royal College, we actually say that above all, my constant endeavour will be to ensure the health and welfare of animals committed to my care. And welfare encompasses emotional, cognitive and physical aspects of their health.

So behaviour is a veterinary responsibility, and behavioural medicine is a day one skill. So in conclusion, the general veterinary practise consultation doesn't offer enough time to thoroughly investigate individual behavioural cases. And you may need to either refer those or dedicate specific time.

But within the veterinary practise context, there are many opportunities to practise behavioural medicine. To give preventative behavioural advice and to consider emotional health during the veterinary visit experience itself and during your diagnostic process, whether that is for physical health or for emotional health, or for situations where there's a combination of the two. So, understanding the health triad and this interplay between physical, emotional, and, sorry, cognitive health, the typo there, I apologise.

So, physical, emotional and cognitive health is a day one veterinary skill. It improves our understanding of our patients, and it also improves our understanding of their welfare, whether that's during the veterinary visit or during their experience of a health problem. And it increases our ability to successfully diagnose and treat disease.

Thank you.