interplay between emotional and physical health

maximising detection of physical health influences on behavioural change

A combination of physical and behavioural history

A chronological approach to the gathering of this information

Evaluation of the history in light of the physical and emotional assessment of the patient

Where doubt still exists about the origins of the behavioural changes a range of further investigations can be carried

challenge

In many cases when the concern raised by a caregiver is in relation to behavioural change the significance of the physical health history can be overlooked

Past illness, previous accidents and ongoing physical conditions should be considered as potential influencing factors

In the context of shelter medicine often the history of these events may not be available

the link

interplay between emotional and physical health - related to

influence of emotional health on physical disease

• physiological stress

• behavioural responses

influence of physical disease on emotional health

physiological stress

peripheral expression of stress response is modulated via 2 systems

• sympatho-adreno-medullary axis

• hypothalamic-pituitary-adrenal axis

SAM axis

The SAM axis mediates the initial rapid response to an immediate stressor

Activation of the sympathetic nervous system leads to release of catecholamines (adrenaline and noradrenaline)

The result is a state of physiological readiness for response

Manifestations of SAM axis activation include

• mydriasis

• increased heart rate

• increased blood pressure

• cutaneous vasoconstriction

• an alert state

• increased plasma glucose and free fatty acid concentrations

Behavioural responses of flight, fight and freeze

HPA axis

The HPA axis mediates the slower response to a stressor, with effects in minutes to hours or days

Hypothalamus - release of corticotropin releasing hormone and arginine vasopressin

Stimulate the release of adrenocorticotropic hormone from the pituitary gland

Leads to production and release of GCs from the adrenal glands.

Peripherally circulating GCs, cortisol and corticosterone, provide negative feedback

Behavioural responses of repulsion, avoidance, inhibition and appeasement

allostasis

Mediators associated with physiological stress protect the body in the short term and promote adaptation by the process known as allostasis

In the long run allostatic load causes changes in the body that can lead to disease

allostatic load

Allostatic load is “the cost to the individual of chronic exposure to elevated or fluctuating endocrine or neural responses resulting from chronic or repeated challenges that the individual experiences as stressful”

It is the individual interpretation of events which is most important in determining their impact

effects of physiological stress on physical health

Physiological change due to emotional challenge can impact on physical health

A common sign of chronic stress is repeated ill health

If there is a history of recurrent illness it is essential to ask questions about potential emotional health factors

It is important to investigate the potential for physiological stress to be a factor in

• diseases associated with breakdown of mucosal integrity

• physical health issues related to altered immune function

• cases involving weight management

• issues of pain perception

common physical disease related indicators of physiological stress incl

dermatological conditions

• stress related grooming patterns

• repetitive licking

• immune function factors

urinary tract conditions

• Feline idiopathic cystitis

= This disease is a great example of the interplay between natural behaviour, emotional state and physical disease

= It has been shown by various studies that “stress” is a risk factor for FIC

= Recent research has also suggested that those cats suffering from FIC have a difference in the way in which they respond to “stress”

GI conditions

• impact of physiological stress on mucosal integrity

• influence of stress related mediators such as cytokines on gut pathways

= Kynurenine pathway (KP) - major route of tryptophan catabolism influencing serotonin availability

• impact of microbiome on gut-brain axis function

weight management

• obesity

= influence of sympathetic/ parasympathetic balance on glycogen storage deposits

• hypo/anorexia

immune function effects

• viral/ bacterial/ protozoan impact

• parasitic impact

issues of pain perception

acute

• surgical

• accidental

chronic

• inflammatory pain

• neuropathic pain issues

feline idiopathic cystitis

In clinical terms many of these cats may present with clearly medical symptoms such as straining to urinate

Others may present with behavioural signs such as unacceptable house soiling or overgrooming

Behavioural investigation is necessary in order to fully treat the physical health condition

In particular, an understanding of feline social groups, resource distribution and resulting stress issues for cats must be understood

Environmental effects on emotional state can influence physical disease

When environments, both social and physical, do not cater for species specific behavioural needs this leads to negative (protective) emotion and resulting physiological stress

Some environmental factors can have a direct effect on physical disease risk and progression

Human misperceptions may lead to presentation of water in ways that make it unattractive cats thus limiting their water intake

Restricted water intake can be a factor in renal disease

When patients are in a protective emotional bias they display behaviours of repulsion, avoidance, inhibition and appeasement

These responses have the potential to influence physical health eg

• Repulsion leading to injury or transfer of infectious agents through salivary exchange

• Avoidance leading to bolting and RTAs or leading to social avoidance which influences access to vital resources

• Inhibition leading to physical vulnerability or reduction in self-care

• Appeasement leading to physical vulnerability

An engaging emotional bias leads to behaviours of approach and interaction which can also impact on physical health eg

• Desire-seeking related object play leading to stick injuries

• Desire-seeking approach leading to ingestion of toxins eg chocolate and raisins

When patients are in high state of emotional arousal, regardless of valence, they will display displacement and drainage behaviours

These have the potential to interplay with physical health eg

• Drainage – chewing leading to dental damage or ingestion of foreign bodies

• Displacement – self licking leading to dermatological issues

what is the link between physical and emotional health may be related to

influence of emotional health on physical disease

influence of physical disease on emotional health

heath model

capacity - sink size

input - valence

drainage - resilience

emotional arousal can be thought of as the result of balance betwen capacity, input and drainage

it is represented by level of emotion in sink

emotional health considerations

The outward manifestation of behavioural change is dependent on the valence of emotion triggered by the stimulus as well as the threshold of response to the stimulus and the salience of that stimulus – which tap is turned on and the flow rate of that emotional input

However it is also dependent on the emotional state of the individual in terms of arousal – the amount of emotion present in the emotional sink and the efficiency of emotional drainage

The level of arousal and the valence of emotion and can be influenced by physical ill health

examples residue

due to an emotional health issue

due to emotional effects of a physical health issue

due to pain - which has both physical and emotional components

emotional valence

Presence of physical ill health can also influence emotional valence

• Limitations of mobility can lead to a more protective emotional bias

• Physiological consequences of physical disease can influence emotional bias, for example as a result of endocrine disorders

• Neurological compromise can influence emotional motivation

developmental link between physcial health and behavioural change

Severe illness in the first few weeks of life can have serious implications in terms of behavioural development

Kittens and puppies that are ill may be isolated from adequate socialisation and “habituation”

They may also develop negative associations with certain forms of handling due to the necessity for medication and nursing intervention

In such cases behavioural change may not be evident until weeks or months after the physical problem

The early health issues may be long since forgotten by caregiver and veterinary surgeon alike

Chronological history taking is therefore important

In the shelter context early life history may not be available

Developmental link between emotional and physical health

The link between emotional development and physical disease is a two-way street

Adequate and appropriate early learning is essential for successful development of emotional control mechanisms

Poor emotional control and lack of emotional intelligence increases risk of protective emotional bias and high emotional arousal both of which can influence physical health

Where emotional development is compromised and young animals experience emotional trauma there is evidence that this can predispose individuals to a range of physical health conditions later in life

This concept is well established in the field of human medicine – Adverse childhood event (ACE)

This connection also needs to be considered in the context of veterinary medicine and the effects of early behavioural development considered in physical health conditions

immediate link between current physical disease and behavioural change

Cases where underlying physical health conditions are directly responsible for the behavioural change

The behavioural change is a sign of the physical health condition

In some cases the link may be obvious

In others the link is more subtle

Acute pain and confrontational behaviour – the dog that snarls and

snaps or cat that hisses and scratches when its fractured limb is manipulated

House soiling as a result of polydypsia and polyuria from a medical cause – the diabetic that is obviously drinking excessively

obvious link between current physical disease and behavioural change

One area of significant overlap between physical health and behavioural change lies in the field of neurology

When signs are consistent with neurological involvement it will lead to consideration of differentials such as:

• Epilepsy

• Space occupying lesions

• Congenital neurological defects

• Inflammatory processes within the nervous system

subtle link between current physical disease and behavioural change

In some cases the association between the physical disease state and the presentation of the behaviour may be less obvious, for example:

• Onset of anxiety as a result of endocrine imbalance

• Relationship between hypertension and behavioural change

• Non-”aggressive” responses to pain

learned association between current physcial disease and behavioural change

Onset of repulsion and avoidance responses to stimuli, such as people

or dogs, which have been linked with pain through association

In the early part of the association process the link may be obvious

With time a process of generalisation may lead to expression of

problematic behaviours in decreasingly obvious contexts