Recognizing Behavioral Signs of

P a i n an d D i s e a s e :
A Guide for Practitioners

Diane Frank, DVM

KEYWORDS
 Anxiety  Pain  Discomfort  Behavioral changes  Dog  Cat

KEY POINTS
 There is significant overlap in nonspecific signs of medical conditions, pain, and anxiety
disorders.
 Lip licking, lip smacking, panting, pacing, trembling, aggression, agitation, hiding, with-
drawal, and vocalizing can be seen in patients that are anxious, sick, or in pain.
 Sudden appearance of new behaviors (pica; aggression; anxious behaviors), especially in
middle-aged or older animals, points to an underlying medical condition.
 Neuropathic pain is often worsened by stimuli that evoke a sympathetic response, such as
the startle response and emotional arousal (stressful situations).
 Obtaining an accurate and complete history to collect all subtle signs and behavioral
changes will help the veterinarian establish if the signs are more compatible with a medical
condition, a behavioral disorder, or both.

INTRODUCTION

Disease is always associated with changes in behavior such as disappearance of

normal behaviors or appearance of new behaviors. These changes are often consid-
ered abnormal behaviors, indicating illness and/or pain. Differentiating between
normal and abnormal behaviors can be based on several aspects such as appropri-
ateness of specific behaviors in a given context, appropriateness of the frequency,
the severity or the duration of a behavior in a given context, and the behavioral
sequence (normal or altered). The context in which the behavior occurs allows the
clinician to distinguish between appropriate and inappropriate behaviors. Aggression,
for example, can be an appropriate response in some contexts,1 and serves different
purposes depending on context. Aggression serves as normal communication in cats
or dogs, signaling “stop,” “leave me alone,” or “stay away.” Aggression in response to
a threat as self-defense would also be considered normal. Behavior is generally

Department of Clinical Sciences, Centre Hospitalier Universitaire Vétérinaire, 1525, rue des
Vétérinaires, Saint-Hyacinthe, Quebec J2S 7C6, Canada
E-mail address: [email protected]

Vet Clin Small Anim 44 (2014) 507–524

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0195-5616/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
508 Frank

a sequence of actions and reactions. A normal behavioral sequence of aggression in

dogs would include (1) initiation, (2) pause, (3) response by the recipient, (4) end or
further action, and (5) end of sequence. Initiation is the warning phase, such as a growl
followed by a pause. The animal has communicated and is waiting for a response. If
the recipient gives the desired response, the aggressive interaction may end at this
early stage. The recipient may not always respond as desired by the instigator, in
which case the instigator may proceed to bite (further action) and then release volition-
ally, signaling the end of the sequence. The bite may be single or multiple. In the
context of communication, the aggressive behavior is generally controlled or inhibited
(ie, one bite without teeth marks or injury). Inhibited aggression does not cause phys-
ical injury, and these aggressive behaviors would be considered normal given the
context of communication. In the case of self-defense, the greater the fear, the
more severe the injuries could potentially become. Behavior definitely becomes
abnormal if some of the steps from the sequence are omitted or altered. A dog
growling and biting simultaneously without any prior warning signal has an altered
sequence because of the absence of clear initiation and pause. Such a sequence
could not be considered normal, and thus becomes indicative of illness. Illness
includes medical conditions and behavioral (mental) disorders. The aim of this article
is to illustrate some examples of cases that might present as behavioral disorders but
are in fact medical conditions.

ANXIETY DISORDERS
Dogs
Fear and anxiety result in a common stress response.2 The range of responses to
stressors seen in dogs can include avoidance, defensive aggression, panting, sali-
vation, pacing, excessive activity, visual scanning, elimination, dilated pupils, vocal-
ization, hiding, seeking out human contact, seeking out contact with other dogs or
pets, attention-seeking behaviors such as pawing at a person, lowered body
posture, flattened ear position, low tail position, anorexia, and digging. One study
reported increased performance of tongue out, snout licking, paw lifting, and
body shaking along with a lowered body posture3 as well as increased heart rate
and saliva cortisol in one dog subjected to noise (95 dB). The investigators
concluded that these behaviors could indicate stress. In another study,4 re-
searchers found that dogs subjected to different types of stimuli (pushing the dog
down by pressing on the neck and back, pulling the head of the dog down to the
ground via a rope/bar system, opening an umbrella, dropping a bag filled with paper
from the ceiling, noise, or an electric shock) performed more body shaking, crouch-
ing, oral behaviors (tongue out, tip of tongue briefly extended, snout licking, swal-
lowing, smacking), yawning, and restlessness, and also presented a low posture.
Dogs subjected to harsh training methods (physical corrections) exhibited mouth
licking and front paw lifting, pulled their ears back, and had lowered standing or
sitting postures5; they also vocalized, whereas dogs trained with rewards did not.
A third study reported that dogs housed in the greatest degree of social isolation
spent the most time moving, performed the greatest number of abnormal move-
ments, and vocalized the most.6 Many of these signs, though associated with
various stressful stimuli, can also be associated with disease. Lip licking, repeated
swallowing, and smacking can occur in animals that are nauseous.7 Trembling
can be seen in animals with fever (shivering) or neurologic disorders (tremors).8,9
Restlessness, pacing, or increased activity can be seen in dogs with painful10 or
neurologic conditions.11,12 Increased activity is associated with hyperthyroidism in
 Behavioral Signs of Pain and Disease 509

31% of cats.13 In one retrospective study of 97 dogs diagnosed with brain tumors,
circling was reported in 23% of cases, pacing in 10%, nonspecific behavioral
changes or mentation changes in 7%, aggression in 5%, and wandering in 5%.12
Vocalization can also be observed in some patients in pain.
The most common complaints in cases of canine separation anxiety are destruc-
tive behavior directed at the home, inappropriate elimination (defecation, urination),
increased and repetitive motor activity (pacing, circling), and excessive vocalization
(whining, barking, or howling) in the owner’s absence.14 Destructive behavior
(chewing, digging, and scratching) can be directed at exit points such as doors,
windows, and gates,15 and specific objects in the home are scratched, chewed,
or torn apart. Owners will not necessarily distinguish between destruction and
pica. It is therefore crucial to question the owner specifically because in the author’s
opinion, pica is more likely a sign of gastrointestinal disorder than a behavioral
disorder.
One study filming the behaviors of dogs diagnosed with separation anxiety when
home alone16 showed that dogs spent most of their time (22.95%) vocalizing
(barking 11%, whining 10%, howling 1.95%), and a similar proportion of time
(21%) remaining vigilant (expressed as oriented to the environment). Panting and
destructive behavior were exhibited respectively for 14% and 6% (5% scratching
at the cage, door, environment; 1% oral destruction of items or cage) of the time.
Hourly average for lip licking and yawning was 27 and 3, respectively. None of these
anxious dogs played during owner absence, 2 dogs trembled, and 3 dogs elimi-
nated. Based on videotape records, panting tended to increase over time. Again,
many of these nonspecific signs may also be seen in medical conditions. Panting
can be associated with thermal regulation, fever, cardiovascular disease, metabolic
disease, endocrine diseases such as hyperadrenocorticism,17 hypertension, or
painful conditions.18 Anxiety will elicit behaviors that enable the animal to approach
a source of perceived threat19 by increasing attention and triggering risk assess-
ment.20,21 During risk assessment, nondefensive behaviors such as environmental
exploration, self-grooming, feeding, and social interaction are inhibited,22–24 and
the degree of suppression of these behaviors may be used as an indirect index
of defensiveness or anxiety.24 Exploration can in fact be partially or completely
inhibited by anxiety; therefore, reduced exploration might represent an indirect
measure of anxiety.21,25 In the previously reported study of dogs16 with separation
anxiety, self-grooming was never observed and exploratory behavior was observed
only for short periods. These changes were compatible with a state of anxiety
during owner absence. Similarly sick animals will generally not play, explore, self-
groom, or interact socially.

Cats
The range of responses to stressors seen in cats can include avoidance, hiding, low-
ered body posture, defensive aggression, reduced activity, vocalization, elimination,
flattened ear position, dilated pupils, pacing, seeking out human attention, visual
scanning, anorexia, climbing, vigilance, spraying, and a reduction in maintenance be-
haviors such as sleeping, grooming, eating, and eliminating.2 Lip licking and repeated
swallowing can be seen in stressed cats during physical examination in the veterinary
setting, and are observed during cat fights (chomping motion).26 Again, several of
these signs are also compatible with disease or pain. Lip licking and repeated swal-
lowing are seen in nauseous cats.27 Panting (increased respiratory rate), a sign of anx-
iety in the hospital environment28 or during car rides, can also be a sign of acute pain29
or hyperthyroidism.13
510 Frank

BEHAVIORAL SIGNS OF NEUROLOGIC DISEASE AND PAIN

Changes in behavior may occur with neurologic signs, but in some cases behavioral
changes precede the other clinical signs by weeks or months.
Lysosomal storage diseases in cats and dogs are rare. In addition to neurologic
signs animals may show behavioral changes, loss of learned behavior, or stereotypical
behaviors.30
Sometimes dramatic hydrocephalus may be present, and owners will report few
clinical signs other than slowness to learn.31 Owners may report that a puppy is
hard to house train or that the puppy was house trained but now is eliminating in
the house again. Close attention to the animal’s mentation and physical examination
may reveal a neurologic disorder rather than a behavioral disorder.
Lissencephaly in dogs is rare. A case series32 in Lhasa Apso dogs described that in
one case, the owners had been unable to house train their 11-month-old female. Their
dog was apprehensive of people, and on several occasions the dog was aggressive
and failed to recognize its owner. The dog developed seizures at about 10 months
of age. The other Lhasa Apso, a 1-year-old male, had a history, starting at 3 months
of age, of sudden personality changes manifested as unprovoked attacks on the
owner and other people.
Neuropathic pain is typically attributed to injury or disease that damages the axon
or soma of sensory neurons or disrupts the myelin sheath of axons.33 One of the
most common causes of neuropathic pain is intervertebral disc herniation resulting
in persistent or intermittent pain. Spinal cord injury (trauma, ischemia, hemorrhage,
or extradural compression) can result in somatic or visceral neuropathic pain.
Radicular (referred) pain is observed with impingement of nerve roots. Signs of cen-
tral pain (secondary to central nervous system tumors or congenital/developmental
lesions) highlight the importance of history taking with respect to changes in
behavior (obvious and subtle). Behaviors such as scratching motion without
touching the skin (Chiari-like malformation), continually biting or attacking an area
on the body, frequently turning (looking) at the same area, or yelping for no reason
should alert veterinarians to potential neuropathic pain. Cats that have undergone
onychectomy may experience chronic neuropathic pain. Signs (within days to
months after the surgery) can include obvious pain of the paw or paws as well as
other nonspecific behavioral changes such as decreased activity, decreased appe-
tite, or increased aggression. A multimodal perioperative analgesic plan is essential
to prevent this type of chronic pain.34 Some of the repetitive behaviors labeled as
obsessive-compulsive disorders such as flank sucking, self-mutilation, and check-
ing could in fact be secondary to somatic or visceral neuropathic pain. Anecdotally,
the author has encountered a few cases of dogs with self-mutilation of the prepuce
and penis that had back pain and improved significantly when treated with
gabapentin.
Zulch and colleagues35 reported the case of a 30-month-old Labrador retriever
presented for acute tail biting leading to self-mutilation. On examination of the tail,
an irregularity was noted midway on the dorsal surface. Radiographs of the tail
showed soft-tissue swelling and presence of an ossicle between the midcaudal verte-
brae. Analgesic treatment consisting of tramadol and paracetamol was implemented.
Analgesia was discontinued after approximately 6 weeks.
In the case of aggression, it is important to always distinguish between appro-
priate, or normal, aggression and inappropriate, or abnormal, aggression. The latter
will always be associated with a medical condition or behavioral disorder. Inappro-
priate aggression as a behavioral condition (mental disorder) is generally observed in
 Behavioral Signs of Pain and Disease 511

young animals.36 If inappropriate aggression appears as a new behavior in a middle-

aged dog or cat, neurologic disease should be considered before a behavioral
disorder.

Dogs
Clinical signs of tumors affecting the rostral cerebrum in 43 dogs,37 ranging in age
from 5 to 15 years (mean of 10 years), revealed that 5 dogs had recently reported
abnormal behaviors (dementia, aggression, alterations in established habits) as a
sole sign, 22 had seizures as their only initial sign, and 4 had seizures and behavioral
changes. Thirty-one of these 43 dogs had normal neurologic examinations on initial
presentation, but 25 eventually developed persistent neurologic deficits.
A published case of simultaneously occurring oligodendroglioma and meningioma
in a 12-year-old neutered male Boxer reported a 3-week history of stumbling over ob-
jects, reluctance to climb stairs, standing in corners, and circling.38 Three days before
presentation, the dog became very agitated and started urinating inappropriately.
In a case report of clinical findings in 3 dogs with polycystic meningiomas,39 an
8-year-old spayed female Labrador retriever was presented after a 1-month history
of changes in behavior that included an initial increase in aggression toward people,
a significant decrease in response to the owner, and increasing episodes of house
soiling, panting, pacing, circling to the right, head pressing, and nightly vocalizations.
A 9-year-old castrated Golden retriever was presented after a 3-week history of
abnormal behavior and pacing and a 1-week history of right-sided circling and head
pressing. In the third case, the dog had a 6-month history of seizures.
A case report40 described progressive, abnormal signs observed before 9 months
of age in a Dachshund diagnosed with ceroid lipofuscinosis. Changes in behavior
included increased nervousness, decreased interactions with the other dogs in the
household, a severe loss in the ability to recognize or respond to commands or his
name, a loss of ability to recognize the owner or other people in the household, an
increased sensitivity to loud noises, circling behavior, increasing inappropriate vocal-
ization, loss of ability to climb stairs or other obstacles, tremors, loss of coordination,
severe loss of vision, persistent head movements, and bumping into obstacles.
Dogs diagnosed with spinal meningiomas11 have histories of clinical signs compat-
ible with chronic discomfort. In one report, there was a prolonged delay between the
onset of clinical signs and diagnosis (10 of 13 dogs), with an average 5.8 months for all
dogs (range 3 days to 14 months). Owners reported signs such as restlessness, diffi-
culty finding a comfortable sleeping position, and irritability. These signs preceded the
appearance or recognition of limping or lameness by weeks or months.
One case report described a Boxer that had always growled and snarled41 if
owners disciplined the dog either verbally or physically, disturbed it when it was
sleeping, tried to move it from furniture, or when petting the dog. However, the dog
never bit in such circumstances. The aggression was appropriate for the contexts
(the dog communicated that it did not want to be disturbed while resting, did not
like physical contact, was feeling threatened when disciplined, and so forth). At
8 years of age, the dog was resting in a corner of the living room and suddenly entered
the kitchen. He jumped at one of the adults and without warning bit her multiple times.
The aggression was not triggered by any interaction on the part of the person. This
aggressive behavior was novel, clearly inappropriate for the context, and the behav-
ioral sequence was altered, thus pointing to an underlying medical condition. In addi-
tion, the dog had presented with seizures every 2 to 3 months during the 2 years
before presentation. Following medical investigation and necropsy, the final diagnosis
was a microcystic meningioma.41
512 Frank

A recent case report of abnormal behaviors42 described a 5-year-old female spayed

Cocker Spaniel presented with a history of intermittent episodes of vocalization and
apparent fear since the age of 6 months. These episodes could happen at any time
of day or night. Before the onset of vocalization (2–24 hours), the dog would appear
fearful and quiet, and would hide under furniture, avoiding all interaction. Following
these initial behavioral changes, the dog would start vocalizing and would exhibit a
low head carriage. She would refuse to eat or drink. Occasionally she would also sali-
vate excessively, swallow frequently, or vomit. Vocalization initially lasted 2 to 4 hours
but progressed over time for to up to 3 days. The initial frequency was 1 to 2 episodes
yearly progressing to 1 to 2 episodes monthly. After the episode of vocalization, she
remained quiet for 1 to 2 days before returning to an apparently completely normal
state. The owner of the dog was unable to identify any specific triggers. Physical,
neurologic, and behavioral examinations were unremarkable. Blood analyses, bile
acids, magnetic resonance imaging (MRI) of the brain, and cerebrospinal fluid analysis
were all within normal limits. Thoracic radiographs and abdominal ultrasonography
were normal. None of the initial pharmacologic treatments attempted were successful:
opioids (morphine, methadone), diazepam, acepromazine, nonsteroidal anti-
inflammatory drugs (carprofen, meloxicam), and phenobarbital. The dog was also pre-
sented during one episode that lasted over 2 days. She vocalized, and appeared
photophobic and phonophobic. Physical and neurologic examinations were again un-
remarkable apart from a low head carriage with no detectable spinal pain. MRI of the
entire spine was performed and was normal. Acetaminophen/codeine and pregabalin
were prescribed but were unsuccessful at alleviating the signs. A migraine-like disorder
was then suspected, and topiramate was prescribed. Clinical signs improved mark-
edly. The dog continued to experience these episodes, but the duration was reduced
to 1 to 3 hours. The intensity was also reduced as the dog would remain quiet, no longer
vocalize, and be keen to go for walks, eat, and drink normally. The dog also no longer
appeared to be photophobic and phonophobic. Eighteen months later she continued
to respond well. The frequency of the episodes was reduced from 2 episodes monthly
before the medication (topiramate) to 1 episode every 2 to 3 months.

Cats
A published case of intracranial meningioma in a 7.5-year-old cat43 reported a
10-month history of visual impairment and altered behavior without specifying the
changes. Following surgery, normal behavior was restored. A published case of extra-
cranial expansion of a meningioma in a 13-year-old cat reported a 1-year history of
behavioral changes with the first signs being reluctance to play and episodic lethargy,
followed by episodes of aggressiveness.44 The owner had noticed pain reactions
when touching the head of her animal only 3 months before presentation. Behavioral
changes thus preceded the signs of pain. Some geriatric cats diagnosed with menin-
gioma are presented to their veterinarian as “just not being themselves.”45 Signs are
typically present for 1 to 3 months in cats before diagnosis.
In one report of clinical features in 11 cats with Cuterebra myiasis of the central ner-
vous system,46 changes in behavior were reported in 2 of 11 cats but were not spec-
ified, other than aggression in 1 case. Depressed mentation was noted in 6 of 11 cats.
The sequence of appearance of clinical signs was not specified.
A report on feline leukemia virus (FeLV)-associated myelopathy in 16 cats47 indicated
that clinical signs of some cats included abnormal vocalization (n 5 1), fly biting (n 5 1),
undefined abnormal behavior (n 5 1), catatonic behavior (n 5 2), and pica (n 5 1), along
with other signs such as ataxia, hyperesthesia (n 5 4), and paresis progressing to
paralysis. Three cats presented with urinary incontinence and 1 cat had recurrent
 Behavioral Signs of Pain and Disease 513

constipation. Signs generally progressed over the course of 1 year, but the article does
not specify if the behavioral signs preceded the neurologic signs.
Lissencephaly with microencephaly in Korat cats has been reported, and is associ-
ated with signs of abnormal behavior and self-mutilation.48

BEHAVIORAL SIGNS OF UROGENITAL DISEASE AND PAIN

Cats
Numerous medical conditions (bacterial urinary tract infection, calculi, neoplasia) can
result in urination outside the litter box49 and urine spraying49 in cats. One publication
looked at urinalysis results in spraying and nonspraying cats, and found no difference.50
However, the minimum data base should not only include urinalysis (with urinary spe-
cific gravity) but also abdominal radiographs if signs of lower urinary tract disease are
present for more than 7 days.49 A urine culture may be needed to rule out urinary tract
infection in older cats. Urinary history should specify whether periuria (urinating outside
the litter box) occurs on a vertical or horizontal surface, and a detailed environmental
history should also be obtained.49 In cats with recurrent episodes of lower urinary tract
signs and in cats older than 10 years, serum thyroxine concentration in addition to
serology for FeLV and feline immunodeficiency virus (FIV) should be performed because
hyperthyroidism, FeLV, or FIV infection can result in abnormal urinary behavior.49 Some
cases will require ultrasonography to visualize uroliths larger than 2 mm in diameter, or
contrast urethrocystography to evaluate the urethra and bladder.
Neuropathic pain is often worsened by stimuli that evoke a sympathetic response,
such as the startle response and emotional arousal.33 Feline interstitial cystitis (FIC) is
associated with visceral neurogenic (neuropathic) pain. Treatment of FIC includes
recommendations to decrease stress factors in the environment. One study reported
that when looking at multicat households, cats with FIC were more likely than cats in
the control population to be in conflict with a housemate.51

BEHAVIORAL SIGNS OF GASTROINTESTINAL DISEASE AND PAIN

Signs of esophageal disease include regurgitation, dysphagia, odynophagia, saliva-

tion, retching, gagging, and repeated swallowing.52 Signs of gastric disease include
nausea, salivation, vomiting, hematemesis, melena, unexplained breath changes,
and anorexia. Clinical signs associated with large bowel diseases include, among
others, dyschezia, tenesmus, and constipation. Signs of gastrointestinal foreign
body include salivation, regurgitation, odynophagia, dysphagia, forceful retching,
anorexia, and intermittent vomiting (free-floating gastric foreign body). Signs of gastric
motility disorders in addition to gastric distension, food retention, and vomiting include
belching and pica.53
Flatulence is excessive accumulation of gas in the gastrointestinal tract54 and may
be associated with eructation, borborygmus, or flatus. Eructation is the expulsion of
gas from the stomach. Borborygmus is a rumbling noise caused by the propulsion
of gas through the gastrointestinal tract, and flatus is the anal passage of gas. Flatu-
lence and borborygmus are often considered normal for owners54 but should not be
dismissed too rapidly as insignificant,7 as they can occasionally signal diseases of
the intestine or pancreas.54 Owners may report their dog having a tendency to bloat
with or without belching, taking an arched stance (cramps?), and excessive expulsion
of flatus. These behaviors may be associated with aerophagia (excitement; eating too
rapidly), or eating foods that produce gas. However, in some cases a more serious dis-
order in dogs may be present, such as gastric hypomotility or gastric outflow obstruc-
tion. These dogs may experience intermittent to frequent signs of nausea.7 Early in the
514 Frank

course of the disease there may be minimal signs, but as the disorder progresses
there may be significant discomfort. Dogs with inflammatory bowel disease (IBD) or
irritable bowel syndrome may also experience abdominal discomfort caused by
gas.7 The symptom complex of bloating, fullness, and significant abdominal discom-
fort is recognized to occur in dogs but can be difficult to detect because of the
nonspecific or subtle signs. In addition, restlessness (discomfort), changing position
(discomfort), and lip licking (nausea) can all be confused with signs of anxiety.
IBD is frequently diagnosed in dogs and cats. Some anecdotal reports33 of amitrip-
tyline use in cats already adequately treated for their IBD, but still uncomfortable
according to their owners, indicated improvement in behavior, thus suggesting a
potential neuropathic component to IBD.
Flatulence is reported more commonly in dogs than in cats.54 Borborygmi are rarely
heard in cats.7
Anecdotal unpublished cases of IBD have been reported in both dogs and cats
presenting with pica. Although more studies are needed, the author believes that in
some species, conditions labeled as oral stereotypies or oral compulsive disorders
are more likely signs of gastrointestinal disease than behavioral disorders. These
repetitive behaviors in dogs include fly biting, excessive licking of surfaces, air licking,
star gazing, flank sucking, and pica. IBD may in some cases be causing anal sac dis-
ease.55 Therefore, checking behavior reported in Miniature Schnauzers should include
gastrointestinal disease in the differential. These dogs may be experiencing pain and
are therefore looking repeatedly at their hind end. Repetitive behaviors in cats, often
labeled as obsessive-compulsive, include pica. In the author’s opinion, pica in cats
is more likely a gastrointestinal disease than a behavioral disorder, although further
research is needed.

Dogs
One dog was referred to the behavior service for separation anxiety because of
destruction during owner absence. However, when the dog was filmed home alone
he showed no signs of anxiety. The dog also had a history of intermittent diarrhea,
and the destruction was in fact associated with pica. The dog underwent medical
investigation and was diagnosed with IBD. Both a change in diet and prednisone
were required to treat the diarrhea and pica. When the prednisone dosage was
decreased, the dog resumed pica. Gastrointestinal biopsies should always be taken
when performing surgery for removal of a gastrointestinal foreign body in dogs or
cats, especially in cases of repeat offenders.
In the author’s opinion and based on preliminary studies,56,57 gastrointestinal
disease can manifest itself with unusual behavioral signs such as excessive licking
of surfaces, fly biting, and star gazing. In general there are other subtle signs of gastro-
intestinal disease, such as presence of flatulence, borborygmus, belching, lip licking,
swallowing, or drooling, though not always. Owners will not necessarily report these
gastrointestinal signs unless asked specifically. It is therefore important to ask! In a
study of 19 dogs licking surfaces excessively,56 14 dogs had gastrointestinal disorders
including eosinophilic (n 5 5) or lymphoplasmacytic infiltration (n 5 3) of the gastroin-
testinal tract, delayed gastric emptying (n 5 7), irritable bowel syndrome (n 5 1),
chronic pancreatitis (n 5 1), giardiasis (n 5 1), and gastric foreign body (n 5 1).
Mean duration of the behavior problem (ie, how long the dog had been licking
surfaces) was 32 months (range 0.08–82 months). Sixteen of the 19 dogs exhibited
daily licking of surfaces such as floors, walls, blankets and sofas. Following treatment
of the underlying condition, complete resolution was achieved in 53% (9 of 17) after
90 days and in 59% (10 of 17) after 180 days.56 Three additional dogs showed a
 Behavioral Signs of Pain and Disease 515

decrease (more than 50%) in both duration and frequency of licking bouts at 180 days.
Therefore, 76% of dogs (13 of 17) improved significantly clinically over the 6-month
follow-up. Of the 5 dogs without gastrointestinal abnormalities and treated nonspecif-
ically (hypoallergenic diet), 2 dogs stopped licking by day 90. One of the licking dogs
was also “air licking”, retching, and squinting. A painful facial expression in dogs can
include ears back or down, eyes wide open with dilated pupils, or eyes partially
closed.10 Squinting with lowered head is also recognized as a sign of pain in cats.58
This particular dog had a 12-inch piece of rope in his stomach for approximately
6 months before presentation. The owners were unaware that their dog had ingested
the rope. Treatment included removal of the foreign body via endoscopy and a switch
to a hypoallergenic diet. Air licking, surface licking, retching, and squinting all ceased
once the foreign body was removed and the dietary change implemented.
A study on medical investigation of 7 fly-biting dogs57 revealed that the age of the
dogs at the onset of fly biting varied between 6 months and 10 years. Dogs had
exhibited this behavior at the time of presentation from 6 days to 4 years. Frequency
of bouts varied from once daily to once every hour. Duration of a single bout varied
from seconds to 1 hour. At home, fly biting was more frequent following feeding in
3 dogs. The most significant finding in the fly-biting study was the occurrence of
head raising and neck extension preceding jaw snapping in all dogs. In some cases,
raising the head and extending the neck occurred more frequently than snapping
(2 of 7). Underlying medical abnormalities included gastric and/or duodenal eosino-
philic (n 5 2) or lymphoplasmacytic infiltration (n 5 4), and delayed gastric emptying
(n 5 2). Gastroesophageal reflux was observed on endoscopy in 2 dogs. One dog
had no histologic abnormalities but presented a very flaccid and distended stomach
on ultrasonographic and endoscopic examination. Medical treatment of the specific
underlying gastrointestinal disease resulted in complete resolution of the fly biting in
5 of 6 dogs (within 30 days for 4 dogs, including 1 dog that had been fly biting for
2 years). Four dogs also presented behavioral changes compatible with anxiety (pac-
ing, panting, hiding, increased attention-seeking) along with the fly-biting episodes.
One dog paced continuously during the entire behavioral assessment. These signs dis-
appeared once the underlying gastrointestinal disease was treated, and therefore were
perhaps associated with pain or discomfort rather than strictly anxiety. Anxiety may
also occur secondary to pain. One study59 on postanesthetic esophagitis in dogs
described clinical signs of esophageal pain that included extension of the neck during
swallowing and abnormal posturing with the neck extended (possibly similar to the
raised head and neck extension seen in fly-biting dogs).
Flank sucking in Doberman Pinschers is characterized by repetitive mouthing and
sucking of the flank, resulting in consequences ranging from a dampened coat to
alopecia and even raw open skin lesions. A study looking at blanket and flank sucking
in 77 Doberman Pinschers60 reported that 55 dogs only sucked blankets, 14 only
sucked their flank, and 8 did both. Twenty-two of these dogs (18 blanket sucking
and 4 flank sucking) exhibited pica as well, ingesting a wide variety of nonfood
substances (fabrics; dirt; twigs and leaves; paper products; plastic, vinyl, and metal
objects). Although more research is needed, the author hypothesizes that flank suck-
ing and blanket sucking are more likely a sign of an underlying digestive problem (and
possible neurogenic pain) than a strictly behavioral disorder.
In hindsight, when reading case reports of stereotypic motor behavior some of the
abnormal behaviors described may have been associated with gastrointestinal
discomfort. In one report,61 a 4-year-old castrated male Rottweiler was evaluated
for unusual behavior that was common at night, but could occur at any time during
the day if someone scratched his back. At the start of his bouts, the dog would extend
516 Frank

its neck and lick its lips (compatible with esophageal discomfort and nausea). The dog
would swallow repeatedly and explore the room snuffling. During exploration, any ob-
jects encountered were ingested and could include plastic, pens, paper, paperclips,
and toys. During bouts the dog would become excited, pace, circle, and ingest items.
If restrained the dog would whine, become agitated, rock back and forth, and continue
its ingestive movements (aerophagia). The dog had already had 2 gastrotomies within
18 months to remove foreign bodies. Biopsies were taken during the second gastro-
tomy, and a presumptive diagnosis of eosinophilic gastritis was made. No changes in
behavior were seen with a change of diet. However, there is no mention of medication
to treat the gastritis, and this dog may have also had gastric reflux. The report states
that the drug clomipramine controlled the behavior, but does not specify if there was
complete resolution of all the signs. Response to clomipramine in this case report may
have been the result of neuropathic pain alleviation in a case of IBD. It is presumed that
norepinephrine and serotonin reuptake inhibitors attenuate neuropathic pain. Blocking
synaptic reuptake of norepinephrine and serotonin increases the postsynaptic levels
of these neurotransmitters, which then sustain the activation of the descending pain
inhibitory pathway. These actions result in alleviation of pain.33
Fecal incontinence can be divided into 2 main categories, reservoir incontinence
and sphincter incontinence. In reservoir incontinence the colon and rectum are unable
to retain feces.62 The dogs will posture properly, but there is an urgency to defecate;
they may therefore defecate excessively or in inappropriate areas. Diseases associ-
ated with reservoir incontinence include colitis and neoplasia.

Cats
Dyschezia is difficult or painful evacuation of feces from the rectum.63 Tenesmus is
ineffectual and painful straining at defecation or urination. Cats with tenesmus or dys-
chezia commonly vocalize or defecate outside the litter box.63 It is therefore crucial in
cases of defecation outside the litter box to question owners about the elimination
behavioral sequence and all other associated behaviors prior to and during defeca-
tion. Tenesmus after defecation suggests irritation or inflammation. In the author’s
experience, cats with dyschezia or tenesmus often appear anxious or restless before
defecation. If these cats use the litter box intermittently they will race out of the box
after defecation, most likely because of pain or discomfort.
Pica in cats has been reported as a sign of FIV,64,65 a sign of gastric motility disor-
der,53 and to be associated with chronic anemia.66 Cats may eat kitty litter or may lick
concrete or ceramics. Compulsive licking at concrete, carpeting, or other cats was
also reported in 3 of 16 cats with chronic feline infectious peritonitis (FIP).65 Two
were house soiling and one was incontinent (fecal and urinary).65 Personality changes,
although not specified, are also reported with FIP.65

BEHAVIORAL SIGNS OF DERMATOLOGIC DISEASE AND PAIN

Self-mutilation should always alert the veterinarian to pain, which can be local or
neurogenic in origin.

Dogs
Infection is almost always present in acral lick dermatitis (ALD),67 and antibiotics are
one of the most important aspects in the treatment of ALD. These agents should be
used systematically, and therapy may need to be as long as 4 to 6 months. Shumaker
and colleagues68 conclude that “lesions associated with ALD warrant tissue bacterial
cultures as the majority of cases yielded positive growth of bacteria differing from
 Behavioral Signs of Pain and Disease 517

superficial culture and often resistant to empirical drugs.” Current text books and
dermatology conference notes highlight that ALD should be considered as a primary
disease that is complicated by perpetuating factors. Entrapped free hair shafts are
very painful and most likely contribute in perpetuating the dog’s licking behavior.
Atopy, food allergy, and secondary deep pyoderma are among the most common dif-
ferentials. In a case series,69 6 dogs presented with ALD-like lesions were diagnosed
with various underlying causes, namely lymphoma, an orthopedic pin, deep pyo-
derma, mast cell tumor, leishmaniasis, and (presumptive) sporotrichosis. The author
has personally not seen a single case of strictly anxiety-related ALD in 15 years of
behavioral medicine practice. Other underlying causes have always been identified.

Cats
Feline symmetric alopecia (FSA) is a clinical reaction pattern whereby cats present
with symmetric alopecia over the thorax, flanks, ventral abdomen, or pelvic regions.70
Initially it is important to determine if the overgrooming is associated with pain or a
medical condition. Excessive grooming of the ventral abdomen may indicate abdom-
inal pain, particularly of the bladder. Radiographs may reveal arthritic changes in
older cats, particularly intervertebral arthritis. Resolution of the overgrooming and
regrowth of the hair following the treatment of pain provide compelling evidence
that pain can be a trigger for overgrooming.70 True behavioral causes of overgroom-
ing are rare. A case series of 21 cats with presumptive psychogenic alopecia71
showed medical causes of pruritus in 16 cats. Three cats had a combination of psy-
chogenic alopecia and a medical condition, and 2 were found to have psychogenic
alopecia.

BEHAVIORAL SIGNS OF ENDOCRINE DISEASE

Dogs
Behavioral manifestations have been attributed to hypothyroidism, but there is no
strong evidence of a causal association.72 A study comparing thyroid analytes in
31 dogs aggressive to familiar people and in 31 nonaggressive dogs found no signif-
icant differences in the complete blood cell (CBC) count, serum chemistry panel, total
thyroxine, free thyroxine by equilibrium dialysis, total triiodothyronine, free triiodothy-
ronine, triiodothyronine autoantibodies, thyroid-stimulating hormone, and thyro-
globulin autoantibodies.73 Significant differences were found only with thyroxine
autoantibodies. Levels were increased in the aggressive dogs but were still within
normal reference range.

Cats
Hyperthyroid cats may be restless, vocal, and anxious looking. Night yowling can be
associated with hyperthyroidism, hypertension, both hyperthyroidism and hyperten-
sion, and cognitive dysfunction.13
A 14-year-old spayed female cat was presented for a 1-year history of aggression
toward other cats and urine spraying.74 The cat’s urine had recently developed a
strong “tom cat” smell. The cat was diagnosed with hyperadrenocorticism, resulting
in oversecretion of sex steroid hormones. In a similar case,75 a 13-year-old neutered
male domestic shorthair was evaluated for urine spraying that had a strong odor and
aggressive behavior. The cat had been spraying urine and was aggressive for approx-
imately 2 years before presentation. The owner had also noticed that the cat’s face
appeared larger. A mass associated with the right adrenal gland was found, and the
adrenal gland and mass were removed during laparotomy. Final diagnosis was an
518 Frank

adrenocortical adenoma. Eight weeks after surgery, the cat was no longer spraying
urine and the strong odor had resolved.
A 15-year-old spayed female domestic shorthair cat was evaluated76 for cyclic
intermittent estrous behavior of 1 year’s duration. Clinical signs reported were
posturing, licking the vulva, vocalizing, rolling on the ground, and head rubbing. These
behaviors occurred every 2 weeks and were similar to estrus behaviors exhibited by
this cat at 6 months of age. The cat was diagnosed with an adrenocortical carcinoma.
A 12-year-old castrated male domestic longhair cat with a 2-year history of urine
spraying was diagnosed with a functional ectopic interstitial cell tumor.77 In addition
to the spraying behavior, the cat had a round and full head with a general muscular
body condition, similar to the appearance of a sexually intact male.
A 1-year-old female spayed Birman cat was presented to the referring veterinarian
for inappropriate urination and defecation 1 month before presentation at a referral
center.78 Initially urinalysis revealed high levels of whole red blood cells (sediment
and dipstick) and the CBC count revealed thrombocytopenia. One week later the
cat became lethargic, had a decreased appetite, and was “more clingy” than usual.
Following medical investigation, a diagnosis of atypical hypoadrenocorticism was
made.
Diabetic neuropathy is a well-recognized cause of neuropathic pain in people.33
Many cats with diabetes exhibit an aversion to being petted and cuddled. Owners
refer to them as “cranky and aloof.” Many of these cats also do not like to have their
paws touched. Amitriptyline may help alleviate these pain-associated behaviors.

BEHAVIORAL SIGNS OF DENTAL DISEASE OR PAIN

In cases of dental disease or pain the animal is hesitant to pick up, chew, or swallow
food. The animal may drop food, toys, or training articles from the mouth. Quivering of
the jaw or chattering of the teeth may be reported. Oral pain can also cause pawing,
tilting, bobbing, shaking, and sliding of the head and mouth along the floor. Chronic
ptyalism or drooling may be seen and is most commonly caused by an inability or
reluctance to swallow.79
Feline orofacial pain syndrome (FOPS) is considered to be an episodic neuropathic
pain disorder, caused by a dysfunction of central or ganglion processing of sensory
trigeminal information.80 Affected cats usually exhibit exaggerated licking, unusual
chewing movements, and pawing at the mouth. Mutilation of the tongue, lips, and
labial and buccal mucosa may also be noted. Sensitization of trigeminal nerve endings
from tooth eruption or oral disease and environmental stress are most likely important
contributing factors in the etiology of the disease. Social incompatibility, if present in
a multicat household, should be addressed as part of the treatment plan of this syn-
drome. In a retrospective study of 113 cases of FOPS,81 the investigators stated
that external factors could influence the disease. One or more FOPS events were
directly linked to anxiety in 24 cats. In 14 cases, social incompatibility in a multicat
household was listed as a source of stress. In 8 of these cats, stressful events included
stay at a cattery, builders in the environment, death of the primary carer and moving
house.

BEHAVIORAL SIGNS OF OSTEOARTHRITIS OR PAIN

Dogs
The most common sign of osteoarthritis in dogs is lameness.82 Owners will report loss
of normal performance (early signs) but will only seek veterinary care once their dog is
lame. Stiffness after rest is a cardinal sign of joint disease, and is often present before
 Behavioral Signs of Pain and Disease 519

onset of overt lameness. Stiffness will last only a few minutes. Anecdotally, dogs in
constant joint discomfort can also exhibit increased nervousness, aggression, depres-
sion, and loss of appetite.82 Muscle atrophy in some or all muscle groups of the legs
can be a sign that the dog has stopped bearing weight evenly and/or is not exercising
its limbs as it normally would. This type of muscle loss may occur slowly and develop
before any overt lameness.

Cats
Changes in lifestyle and behavior are the main clinical features of osteoarthritis in cats.
One study83 used a questionnaire to identify lifestyle or behavioral changes noticed by
owners that could be associated with chronic pain in 23 cats aged 9.4 to 19 years
(mean 13.4 years). The changes were scored on a scale of 1 (minor) to 10 (severe).
Owners rated the behaviors observed before and after analgesic therapy (meloxicam).
Behaviors were grouped as mobility, activity, grooming, and temperament changes.
The mobility category included jumping, height of jump, gracefulness, and changes
in elimination behaviors (reluctance to go outside or use the litter pan; difficulties using
the pan; missing the pan; and so forth). Activity included sleeping habits, playing, and
hunting. Temperament addressed tolerance to owner or other animals and general
attitude. There was a statistically significant reduction in owner scores in all cate-
gories, with the greatest reduction in the activity category. An earlier prospective study
of 28 cats with osteoarthritis had already reported84 that alterations in the ability to
jump (20 of 28 cats or 71%) and height of jump (19 of 28 cats or 67%) were the
most frequent signs of the disease. Data on demeanor, lameness, food intake,
behavior, lifestyle, and other orthopedic parameters before and after analgesic admin-
istration (meloxicam) were recorded. Behavioral characteristics such as seeking
seclusion, resentment, vocalization or aggression when handled, abnormal elimination
habits, and lifestyle alterations such as unwillingness to jump and/or reduced height of
jump and abnormal gait were all recorded. There were statistically significant improve-
ments in willingness to jump, height of jump, stiff gait, activity level, and lameness.
There were no significant changes in behaviors such as seeking seclusion, vocaliza-
tion, resentment, or aggression when handled. The latter signs were present in a small
number of cats (n 5 6–10); the lack of improvement following analgesic treatment may
simply indicate that the cat did not like being handled, and seeking seclusion may
have been normal for that given individual. Lameness is rarely a sign of osteoarthritis
in cats, and was absent in 15 of the 28 cats.84 Stiffness after resting was reported in
8 of 50 cats in a study of owner-perceived signs of feline osteoarthritis.85 Five owners
reported a change in posture for claw sharpening (ie, the cat scratched a horizontal
instead of a vertical surface).85 Changes in how cats performed jumping included hes-
itation, stumbling or falling, or doing small jumps at a time. Stair use was described as
climbing a few stairs at a time instead of the entire flight. This study also reported more
specifically on changes in litter-box use. According to owners, 11 cats were elimi-
nating outside the litter box because of either an inability to reach the box in time
(urgency to urinate) or reluctance to climb stairs. Nine of these cats were thought to
have difficulty maneuvering in the litter box.85 No study to date has clearly shown
house soiling as a consequence of osteoarthritis. Other medical conditions seen in
older cats could also account for changes in litter-box use.

SUMMARY

Observing and collecting complete histories of obvious and subtle changes in

behavior will help veterinarians identify and define more precisely all of the signs
520 Frank

associated with medical and painful conditions as well as those associated with
behavioral disorders. Pain identification remains a challenge in veterinary medicine,
and should always be considered in the list of differential diagnoses when patients
are presented with behavioral changes.

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