Vet Clin Small Anim

33 (2003) 231–251

Behavioral dermatology
Vint Virga, DVM
Behavioral Medicine for Animals, Veterinary Healing Arts, Inc., PO Box 219,
Newport, RI, 02840–0219, USA

The practice of behavioral dermatology encompasses the management of

any dermatologic condition for which there is a substantive behavioral
or emotional component. It is estimated that emotional factors are
an important consideration in the effective management of at least one
third of human patients presenting for dermatologic conditions [1,2]. It is
reasonable to assume that a similar incidence occurs in companion animal
species. Integral to the clinical incidence of behavioral dermatoses is an
underlying neurophysiologic basis for psychodermatologic conditions. Both
the central nervous system (CNS) and integument are derived from the
embryonic ectoderm. Although the CNS and skin are differentiated during
fetal development, a substantial number of hormones, neuropeptides, and
receptors are common to both [46]. Physiologic changes that can be
clinically observed, such as pruritus, vascular flushing, and sweating, are
related to underlying actions of psychoneuroendocrinoimmunologic medi-
ators, such as enkephalins, endorphins, substance P, and vasoactive
intestinal peptide, on the CNS, integument, and immune system [4–6].
The skin is the primary organ of tactile stimulation and communication
in the body. Underscoring the integral relation between the integument
and behavior is the finding that cutaneous contact and stimulation during
postnatal development may substantially influence cell growth and differ-
entiation, CNS maturation, neurosensory responses, immune function, and
the incidence of behavioral problems (eg, aggression and anxiety-related
behaviors) in a variety of species [6–10]. Meriting further consideration,
a number of forms of psychotherapy (eg, biofeedback, hypnosis, cognitive
therapy) have been used effectively to manage human patients with a num-
ber of dermatologic disorders [11–14]. Together, these findings present a com-
pelling picture of the intrinsic relation between the brain, emotions, and skin.

E-mail address: vvirga@att.net

0195-5616/03/$ - see front matter
2003, Elsevier Science (USA). All rights reserved.
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232 V. Virga / Vet Clin Small Anim 33 (2003) 231–251

Using the framework established for human psychodermatology,

behavioral dermatoses in animals may be classified into four categories
of phenomena: psychophysiologic disorders, primary behavioral disorders,
secondary behavioral disorders, and cutaneous sensory disorders [15,16].
Although these groupings may provide a useful framework for discussion
and clinical management, individual patients may present with features
characteristic of more than one of these categories of psychodermatologic
disease.

Psychophysiologic disorders
Psychophysiologic disorders are primary dermatologic conditions that
can be affected by emotional stress. A substantial number of conditions,
particularly chronic dermatoses (eg, acne, urticaria, atopic dermatitis,
psoriasis, rosacea, seborrheic dermatitis), that meet this criterion have been
identified in human patients [15–17]. Of primary concern in animals, con-
ditions in this category include atopic dermatitis, chronic inflammatory
dermatoses, and acral lick dermatitis (ALD). Although many cases of ALD
respond to standard dermatologic treatment, some refractory cases should
be considered as primary behavioral disorders.
With psychophysiologic disorders, the activation of psychoneuroendo-
crinoimmunologic mediators may contribute to an exacerbation of clinical
signs. By means of vasoactive mediators, emotional stress can precipitate
or perpetuate the ‘‘itch-scratch cycle’’ associated with psychophysiologic
disorders [18]. It has been documented clinically and physiologically that
emotional stress can trigger or exacerbate pruritus by activating the release
of neuropeptides distributed to the skin by means of hypophyseal portal
vessels and peripheral circulation as well as by descending autonomic fibers
[19,20]. Sensory nerves can act not only afferently, conveying sensory input
to the CNS, but efferently in a neurosecretory fashion. Thus, neuropeptides
mediating a behavior along CNS pathways may also contribute sensation
(eg, pruritus, pain) and manifestation of a behavior (eg, scratching, licking,
biting) peripherally [4].
The physiologic sensation of pruritus may share common biochemical
origins with some anxiety states, which supports consideration of neuro-
psychodermatologic etiologies [21]. An association between atopic derma-
titis and emotional reactivity has been well established in human beings.
Reduced coping strategies, irritability, hostility, depression, anxiety, and
aggression are common concomitant behaviors in human atopic patients
[4,13,22]. Excitability and inadequate stress-coping skills, particularly,
correlate with elevated serum IgE levels in atopic patients [22]. Not only
are certain behaviors more likely to manifest in atopic patients, but certain
behavioral characteristics may predispose individuals to atopic dermatitis.
In human beings, a well-documented relation has been demonstrated to
exist between maternal rejection and atopic dermatitis [4].
 V. Virga / Vet Clin Small Anim 33 (2003) 231–251 233

Based on psychophysiologic research to date, it is likely that veterinary

patients with clinical atopic disease and other chronic inflammatory diseases
may be predisposed to behavioral sequelae, particularly reduced coping strat-
egies and increased reactivity, anxiety, and aggression. Stressors (environ-
mental or social) may contribute to the exacerbation of clinical signs or, in
a quiescent state, may lead to the recurrence of clinical signs. Thus, environ-
mental or social stress may contribute toward a patient reaching the
pruritic threshold in the same manner as specific antigenic stimuli. Fur-
thermore, chronic stress may exacerbate dermatologic management by ef-
fectively bringing the patient closer to the pruritic threshold. Concurrent
behaviors that may be elicited in response to stress include changes in
appetite, grooming behaviors, elimination patterns, social interaction, and
activity [23]. Potential environmental and social stressors that should be
considered are as follows:
 Inadequate mental stimulation
 Inadequate aerobic exercise
 Inadequate interaction with family or other pets
 Limited access to essential resources
 Social isolation
 Status-related conflicts
 Territorial-related conflicts
 Addition or loss of family members or pets
 Changes in health status of family members or pets
 Changes in daily routine of family members or pets
 New home/environment
 Changes in physical environment
 Boarding
 Hospitalization

Primary behavioral disorders

Conditions for which the primary problem is related to behavior in
nature and secondary skin manifestations are self-induced are classified
as primary behavioral disorders. In human beings, primary psychiatric
disorders presenting as dermatologic complaints include delusional behav-
iors (eg, delusions of parasitosis), obsessive-compulsive disorder (OCD,
including some cases of trichotillomania and neurotic excoriations),
dermatitis artefacta, dysmorphic disorder, and psychogenic pruritus. Pri-
mary behavioral disorders in animals include ALD, compulsive behav-
iors, excessive grooming behaviors (psychogenic alopecia), and psychogenic
pruritus.
Self-injurious behavior (SIB) refers to any volitional behavior that results
in self-mutilation or damage [24]. A diagnosis of SIB in small animals must
meet the criteria of barbering or removal of hair and/or abrasion;
234 V. Virga / Vet Clin Small Anim 33 (2003) 231–251

petechiation; or ulceration of any body part using the teeth, tongue, claws,
or an external substrate (eg, rubbing against a wall). A condition for a diag-
nosis of SIB is that these behaviors must be demonstrated repeatedly and
consistently in the absence of any primary dermatologic or physiologic
condition [24]. It is important to recognize that a diagnosis of SIB does
not necessitate or imply that the behavior is compulsive, only that it
is volitional.
The essential features of OCD in human beings are recurrent obsessions
or compulsions that are severe enough to be time-consuming or cause
marked distress or significant impairment. Obsessions are defined as per-
sistent ideas, thoughts, impulses, or images that are experienced as intru-
sive and inappropriate and that cause marked anxiety or distress. Common
obsessions reported in people include repeated thoughts about contami-
nation (eg, by shaking hands), specific repeated doubts (eg, having left a
door unlocked), a need to have things in a particular order (eg, intense
distress from disorder or asymmetry), and aggressive or horrific impulses.
These thoughts, impulses, and images exceed simple worries about real-life
problems and are unlikely to be related to a real-life problem. Compulsions
in human beings are defined as repetitive behaviors (eg, hand washing,
checking) or mental acts (eg, praying, counting), the goal of which is to
prevent or reduce anxiety or distress rather than to provide pleasure or
gratification [25].
In veterinary behavioral medicine, sequences of movements that serve
no obvious purpose or function and occur repetitively, out of context, at
an excessive frequency or duration exceeding that necessary to achieve a
real or potential goal, and in a relatively unvaried fashion are termed
stereotypic behaviors [23,26]. In most cases, they are derived from behaviors
that are part of the animal’s normal behavioral repertoire. Most stereotypic
behaviors are not compulsive in nature. To establish a diagnosis of
a compulsive disorder, the behavior must interfere with the patient’s abil-
ity to function normally in its social environment [26,27]. Because any evi-
dence of obsessive behavior in nonhuman species is problematic and
must be inferred, the term compulsive disorder more accurately describes
these behaviors in our companion animal species. As in human medicine,
a compulsive disorder should be considered a manifestation of an anxiety
disorder. In the author’s experience, most patients referred with suspected
compulsive behaviors do not meet the criteria for a compulsive disorder.
Accurate data denoting the incidence of compulsive disorders or the relative
percentage of compulsive SIBs in the general canine or feline population are
not currently available.
Considering these criteria, it is evident that some patients presenting
to the small animal practitioner may meet the conditions for both SIB
and compulsive disorder. Compulsive behaviors associated with dermato-
logic signs are most commonly classified as grooming compulsive disorders,
although some may be neurotic in origin. In canine patients, these may
 V. Virga / Vet Clin Small Anim 33 (2003) 231–251 235

include ALD/granuloma, flank sucking, tail chewing (which may or may not
be associated with tail chasing), excessive chewing of the feet and/or nails, and
excessive scratching. Other compulsive behaviors observed in canine pa-
tients may be classified as hallucinatory (eg, fly/light chasing, prey search-
ing, staring), locomotor (eg, circling, tail chasing, fence running), eating/
drinking (eg, fabric sucking, psychogenic polydipsia, some picas), vocal (eg,
rhythmic barking, barking at food or inanimate objects), or neurotic (eg,
vicious self-biting, spontaneous aggression to human beings) [23,26]. In
feline patients, compulsive behaviors associated with grooming include
psychogenic dermatitis, feline hyperesthesia syndrome, tail sucking, and
excessive chewing of the feet and/or nails. As with canine patients, other
compulsive behaviors noted in feline patients may be categorized as
hallucinatory (eg, prey chasing or searching, air batting), locomotor (eg,
paw shaking, head shaking, pacing), vocalization (eg, repetitive howling/
crying), or neurotic (eg, vicious self-biting, spontaneous aggression to hu-
man beings) [23].
Independent of compulsive disorders, anxiety may lead to the develop-
ment of a variety of other behavioral dermatoses. Anxiety may be defined as
an apprehensive anticipation of future danger or misfortune accompanied
by a feeling of dysphoria and/or somatic symptoms of tension [24]. Anxieties
may be internally or externally focused and may be in response to real
or perceived stimuli. Anxiety may result from motivational states of conflict
(the tendency to simultaneously perform more than one type of activity)
or frustration (engagement in a sequence of behaviors that cannot be
completed because of physical or psychologic obstacles) [23]. In human
psychiatry, anxiety disorders are subcategorized into a number of discrete
diagnoses (eg, OCD, agoraphobia, posttraumatic stress disorder, general-
ized anxiety disorder) [25].
Nonspecific behaviors directed toward specific body parts that may be of
psychogenic origin include tail biting, flank sucking, preputial licking, self-
nursing, licking in the anal region, and foot licking. Based on the evidence
to date, these behavioral patterns represent a heterogenous array of under-
lying conditions rather than specific dermatologic or behavioral diagno-
ses. Attention-seeking, displacement, self-injurious, compulsive, and other
anxiety-related behaviors may lead to the establishment of such behavioral
patterns. Seizure activity involving the amygdala and ventromedial hypo-
thalamus can result in stereotypic self-directed behaviors [24].

Canine acral lick dermatitis (acral lick granuloma)

ALD is characterized by firm, raised, ulcerative plaques preceded by
erosion of the skin secondary to chronic or intense licking. Most cases
present with single unilateral lesions on the cranial carpus or metacarpus.
Additional sites include the cranial radius, metatarsus, and tibia [28,29].
Secondary bacterial infection is common, may contribute to these lesions
236 V. Virga / Vet Clin Small Anim 33 (2003) 231–251

being intensely pruritic in nature, and may necessitate prolonged anti-

microbial therapy. As noted previously, ALD may be dermatologic or
psychogenic in origin. It has been estimated that psychogenic and idiopathic
ALD combined may comprise as many as 50% of cases [59]. A strong
association seems to exist between licking and anxiety in dogs. It has been
reported that as many as 70% of dogs diagnosed with ALD have concurrent
fear- and/or anxiety-based conditions (eg, noise phobia, separation anxiety,
anxiety-related aggression) [31]. It is not uncommon to find evidence of
salivary staining of the carpi in dogs presented for signs of separation
anxiety. As with overgrooming in cats, ALD may also be associated with
displacement grooming in response to social or environmental stressors.
Other possible psychogenic associations include attention seeking; compul-
sive behavior; and limited opportunity for social interaction, environmental
stimulation, or aerobic activity.
The occurrence and incidence of correlative behaviors to ALD in
feral and wild dogs is not known. Among domestic dogs, certain breeds
seem to be overrepresented (Labrador Retrievers, Great Danes, Doberman
Pinchers, German Shepherds, and some northern breeds), with some evi-
dence of familial inheritance [29,31,32]. This may be reflective not only of a
genetic component but of selection pressures placed on these breeds for
selected work duties and social relationships with human beings.

Psychogenic alopecia (excessive grooming)

Psychogenic alopecia is characterized by excessive self-grooming that is
initiated or intensified by nonorganic causes or persists beyond resolution
of an organic cause [30]. Although cases are more typically identified in
feline patients, it is possible for psychogenic alopecia to occur in dogs in
the absence of discrete lesions of ALD. The predominant clinical sign is
alopecia, particularly in the area of the medial forelegs, caudal abdomen,
inguinal region, tail, and/or dorsal lumbar areas, in which medical causes
have been ruled out. Because cats may groom reclusively, excessive lick-
ing, biting, scratching, or rubbing may or may not be observed by the client.
Barbering and/or frank alopecia may be the only dermatologic sign.
In other cases, self-mutilation with possible secondary bacterial infection
may be evident. Symmetric alopecia of the caudomedial thighs and
ventrum is possible. Lichenification and hyperpigmentation may develop
in chronic cases. A dermatitic form (atypical neurodermatitis) can develop
from abnormally prolonged or intense grooming behavior. In the der-
matitic form, bright red and elongated oval streaks or plaques may result
[28].
Physical examination reveals (1) short broken hairs that are readily
palpated by stroking the affected area against the normal angle of hair
growth, (2) remaining hairs that do not epilate easily, (3) broken hair shafts
detected by microscopic evaluation, (4) hair regrowth that occurs normally
 V. Virga / Vet Clin Small Anim 33 (2003) 231–251 237

and lesions that heal with placement of an Elizabethan collar, and (5) sig-
nificant amounts of hair on fecal examination [28,29].
Licking of the hair and skin, nibbling, biting, facial rubbing with the
forepaws, and scratching may all be observed in cats exhibiting normal
grooming behavior. Although they regularly self-groom, specific times and
percentages relative to other behaviors are not well-documented in house-
hold cats [31,33]. Studies in farm cats and colony-housed domestic cats
have reported grooming to occupy 15% and 4% of the total time budget,
respectively [34,35]. Beyond such basic purposes as cleansing, removal of
parasites, and thermoregulation, grooming in cats may occur as a displace-
ment behavior (an activity that is performed out of context as a result of
conflict or frustration) in response to social or environmental stressors.
Displacement grooming may be rooted in anxiety and may serve to
lower arousal, deflect aggression from other individuals, or provide some
distraction for the cat [23,24]. Although the occurrence of such behavior
in feral or wild cat species is not known, incidences of psychogenic alopecia
have been noted in captive wild cats [36]. There is some evidence to date that
psychogenic alopecia occurs in captive wild cats secondary to inadequate
environmental or social enrichment (V. Virga, unpublished data). Similarly,
it is possible that domestic cats with limited environmental or social
stimulation may display excessive grooming. Psychogenic alopecia is re-
ported to be more prevalent in strictly indoor cats [31]. A seasonal inci-
dence, even in indoor cats, can result from changes in environmental and social
stressors (eg, accessibility/visibility of other cats) [37].

Self-directed attention-seeking behavior

In the author’s experience, a significant percentage of cases referred for
evaluation of compulsive or SIBs are ultimately diagnosed as attention-
seeking behaviors. Animals can readily learn that not only disruptive
behaviors (eg, barking, jumping, pawing, nuzzling) but less directly de-
manding behaviors (eg, limb/foot/preputial licking, chewing, scratching,
sucking, pawing) often effectively get the client’s attention. The clients may
have historically tried a variety of approaches to discourage such behaviors;
such attempts often include varying degrees of physical and verbal cor-
rections, comforting the patient with physical touch and verbal reassur-
ances, banishment with physical and social isolation, and ignoring the
behavior to varying degrees. As the animal persists in the behavior, clients
typically report that they eventually provide some form of attention; in
so doing, the behavior can quite effectively be reinforced as a result of
a variable and high ratio-reward schedule [38]. It is important for the client
to recognize that verbal or physical punishment, particularly if intermittent,
may serve to reinforce the problem behavior.
In establishing a diagnosis of attention-seeking behavior, a careful review
of the history should reveal that the patient demonstrates the problem
238 V. Virga / Vet Clin Small Anim 33 (2003) 231–251

behavior only in the immediate presence or close proximity of the client.

Observation of the patient at the time of consultation should reveal that the
behavior is dramatically reduced or nonexistent when the client (or, in some
cases, all parties, including the clinician) is absent.

Psychogenic pruritus
Pruritus is defined as an unpleasant sensation that provokes the desire to
scratch [39]. Typically, the term pruritus is used synonymously with itching.
Although it is difficult to determine if dogs are scratching because of a
sensation of itching, by definition, they experience pruritus by virtue of some
stimulus that initiates scratching. It has been well established that human
beings may experience psychogenic pruritus (ie, pruritus in the absence of
primary dermatologic lesions or significant metabolic, endocrine, neuro-
logic, or other medical findings) [17,18,40]. Based on similar psychoneu-
roimmunoendocrinologic mediators and physiologic mechanisms, it is
reasonable to assume that psychogenic pruritus may occur in animals.
A diagnosis of psychogenic pruritus in animals must be made after
exclusion of other potential causes for scratching. In assessing an animal
for pruritus in the absence of dermatologic lesions, it is important to
identify any contexts, environments, social interactions, or temporal as-
sociations with the incidence of pruritus. As noted earlier, scratching (or
other self-directed behaviors) occurring only in the presence of selected
individuals is strongly suggestive of attention-seeking behavior. Scratching
limited to certain specific contexts or in the presence of selected stimuli
may be a manifestation of displacement behavior secondary to conflict or
frustration.

Secondary behavioral disorders

Secondary behavioral disorders may result from dermatologic conditions
that adversely affect the normal behavioral patterns and social function-
ing of the animal. It is well documented that pruritus in human beings
can significantly influence emotional reactivity and sleep patterns [41,42].
Furthermore, anxiety and depression have been well substantiated as
common concomitants of pruritus [19,40,43]. Although secondary psychi-
atric disorders in human beings are frequently associated with emotional
responses secondary to disfiguring conditions, it is difficult to determine if
animals suffer similarly from disfigurement. Based on sensory stimuli (eg,
pain, pruritus, hyperesthesia, allodynia) typically associated with a variety
of dermatologic lesions, it is likely that the behavioral patterns and social
functioning of animals may be affected. As with stressful environmental
and social stimuli, sensory stimuli associated with pain or discomfort may
result in reduced coping strategies and increased reactivity, anxiety, or
aggression.
 V. Virga / Vet Clin Small Anim 33 (2003) 231–251 239

Cutaneous sensory disorders

Cutaneous sensory disorders are conditions for which the patient
experiences a purely sensory complaint without clinical evidence of a
dermatologic, neurologic, or medical condition. By definition, the patho-
genesis is typically not identifiable and diagnostic tests prove unremarkable.
Humans with cutaneous sensory disorders most commonly report sensa-
tions of stinging, burning, or itching [44]. The persistence of clinical signs in
the absence of significant diagnostic tests suggests an underlying neuro-
pathic phenomenon. The pathologic findings and clinical signs may be
generalized or specific to certain body parts [44,45].
Cases may present with no diagnosable behavioral problem or with
significant behavioral findings that may or may not be related to the
cutaneous sensory disorder. It is well documented that some human patients
with depression and anxiety disorders perceive pain or itching sensations in
an exaggerated manner. As such, these cases could be considered primary
psychiatric disorders with a secondary neurosensory component; however,
among patients with no diagnosable psychiatric finding, there is sufficient
evidence to consider that these patients have a primary neurosensory
disorder. In the absence of significant clinical findings, the clinician is
dependent on the patient’s description of the phenomena he or she ex-
periences [44]. As such, although it is problematic to confirm a diagnosis in
animals, cutaneous sensory disorder should be carefully considered if the
patient exhibits (1) a response as if experiencing pain to nonnoxious stimuli,
such as touch, mild pressure, mild heat, or mild cold (ie, allodynia); (2) a
markedly exaggerated response to a stimulus that is typically painful (ie,
hyperalgesia); (3) behaviors that subjectively seem to be in response to or
avoidance of an unpleasant stimulus (ie, dysesthesia); or (4) excessive self-
directed behavior (eg, grooming, licking, biting, chewing, rubbing, scratch-
ing, rolling) of an intensity suggesting that the animal may be responding to
a sensory stimulus. The behavior may directed toward specific body parts or
generalized to multiple foci.

Feline hyperesthesia syndrome

Feline hyperesthesia syndrome refers to a complex of behaviors that may
include (1) behaviors similar to those observed in estrous females (eg,
increased motor activity, rolling, crouching with elevation of the perineal
region, vocalizations); (2) excessive licking, plucking, biting, and/or chew-
ing, particularly at the tail, flank, anal, or lumbar areas; and (3) rippling
of the skin, muscle spasms, or twitches (especially dorsally), which may be
accompanied by vocalization, running, jumping, possible hallucinations, or
self-directed aggression [23,24]. Affected cats tend to be difficult to distract
from the behavior or, if successfully distracted, remain so for only a short
period. The occurrence of signs may be episodic in nature, accompanied by
variable periods of unremarkable behavior.
240 V. Virga / Vet Clin Small Anim 33 (2003) 231–251

As with feline psychogenic alopecia, environmental and social stressors

have been associated with this disorder. The cues or changes precipitating
the behavior may be exogenous or endogenous [24]. Cats may present with
clinical signs consistent with hyperesthesia or allodynia without evidence of
alopecic or other dermatologic lesions. Review of the behavioral history
may further support a lack of excessive grooming. Such cases support the
hypothesis that this complex of behaviors may represent a number of
discretely different phenomena. Although not currently discussed in the
veterinary literature, based on clinical syndromes observed in human
patients, it may be worthwhile to consider hallucinatory, rheumatologic, or
neurogenic origins in future research.

Clinical management
Diagnostic approach
Because of the heterogenous and potentially multifactorial origins of self-
directed behaviors, clinical evaluation should include a thorough clinical
examination (general, dermatologic, and neurologic), complete blood cell
count (CBC), serum chemistry profile, and urinalysis. Any potentially sig-
nificant clinical findings should be pursued by appropriate laboratory and
diagnostic tests so as to rule out any organic causes before considering
primary behavioral disorders. Patients presenting with clinical signs sug-
gestive of psychogenic alopecia or a cutaneous sensory disorder of the
ventral abdomen should be evaluated for lower urinary tract disease. Pa-
tients presenting with clinical signs suggestive of psychogenic alopecia or a
cutaneous sensory disorder of the perianal region should be evaluated for
anal sac disease or distension.
Psychophysiologic, primary behavioral, secondary behavioral, and
neurosensory disorders should carefully be considered even with significant
dermatologic or neurologic findings. This is particularly true for patients
with a history of being refractory to standard courses of treatment. Behav-
ioral evaluation should incorporate a review of the behavioral history and
direct observation of the patient, including consideration of environ-
mental stimuli, social stimuli, the motivational state of the animal, and
underlying neurophysiologic mechanisms in developing a treatment plan.
Important considerations to consider in the behavioral history include the
following:
 Detailed description of the patient’s behavior immediately before,
during, and after eliciting problem behavior
 Chronology, incidence, and progression of problem behavior
 Ease with which problem behavior may be interrupted and tendency for
return to behavior
 Locations, circumstances, and potential eliciting stimuli associated with
the problem behavior
 V. Virga / Vet Clin Small Anim 33 (2003) 231–251 241

 Review of other problem behaviors

 Review of home environment, including all persons and animals in
household
 Presence of the client(s), other people, and other animals in relation to
animal when behavior occurs
 Responses of the client(s), other people, and other animals in relation to
the problem behavior
 Patient’s background, including adoption source, familial history, early
temperament/behavior of patient, and history of obedience work
 Interactions with familiar and unfamiliar household guests
 Dietary history, including consideration of who feeds patient and review
of feeding schedule
 Daily routine of patient in relation to other human and animal members
of household
 Specific types, amount, and frequency of exercise
 Specific form, duration, and frequency of interaction with client(s) and
other people
 Notation of sleeping location and favorite resting places
 Review of medical history with notation of any current medications
being administered
Although a videotape of the patient’s behavior does not preclude direct
observation, it can provide valuable clues toward accurate diagnosis, be-
cause the cat can be observed in its home environment. A hypothesis in-
corporating the above, which can account for the patient’s dermatologic and
behavioral manifestations, provides a rational starting point from which
a program of environmental, behavioral, and pharmacologic management
can be developed.

Environmental management
Because the patient’s response to its environment may contribute to the
establishment of behavioral dermatoses, it is important to manipulate the
environment so as to eliminate or reduce exposure to stressors. If this is
not possible, counterconditioning and systematic desensitization should be
used to minimize the response to provocative environmental stimuli. Client
resistance to appropriate environmental changes may be encountered, and
creativity is often needed when presenting the management plan. The client’s
commitment to proposed environmental changes should be assessed before
determining behavioral and pharmacologic management.

Behavioral modification
Counterconditioning and desensitization provide the framework for
behavioral modification. Counterconditioning consists of teaching the
patient new behaviors that are incompatible with the problem behavior.
242 V. Virga / Vet Clin Small Anim 33 (2003) 231–251

Because self-directed behaviors are often based on emotional states of stress,

anxiety, arousal, conflict, or frustration, behavioral modification can serve
to minimize the stress response when the animal is exposed to these stimuli
[15,46]. It is often most effective to select for behaviors that encourage
relaxation [12]. Desensitization consists of reinforcing the selected new be-
haviors while gradually introducing progressively more provocative cir-
cumstances and stimuli. In the author’s experience, clients commonly wish
to progress more rapidly than the patient can be expected to tolerate.
Patience, consistency, and commitment on the part of the client are critical
for success to support performance of the new behaviors in the face of
increasingly provocative stimuli. The willingness of the patient to follow the
leadership of the client can, in some cases, facilitate counterconditioning and
desensitization. Deference to the client can be established through routine
and regular reinforcement of leadership on a daily basis. Withdrawal of
attention is an effective gentle correction for failure of the animal to follow
the client’s leadership. In all phases of counterconditioning and desensiti-
zation, appropriate responses should be supported with encouragement,
affection, and small food rewards as positive reinforcement. Rewarding the
patient at any time when it is not exhibiting the problem behavior and is
relaxed can augment active counterconditioning. Massage therapy, when
the patient is relaxed, can further facilitate relaxation and encourage ap-
propriate interaction between the animal and the client. These techniques
are not limited to application in dogs but can be effectively employed with
cats and other species with appropriate modification.
Client responses to the patient, particularly when it is performing the
problem behavior, can be problematic. Despite the history and experience of
the problem behavior, the client should avoid expressing frustration in any
way in the presence of the patient. Doing so may reinforce or exacerbate
any anxiety that the animal may be experiencing. The client should further
avoid offering any measure of comfort (verbal, physical, or emotional) to
the patient when it is exhibiting the problem behavior. Attention-seeking
behaviors are based on the response of the client or, in some cases, other
people. Attempts to distract the behavior or even aversive responses may be
rewarding to some animals and may reinforce the observed behavior.
Interactive activity and opportunities for aerobic exercise can be critical
components of behavioral modification. Agility, fly ball, and freestyle ex-
ercises provide dogs the opportunity for interactive aerobic activity with the
clients beyond traditional activities, such as field work, sheep herding,
Frisbee tossing, ball retrieving, running/jogging, hiking, and walking.
Interactive exercise can facilitate desensitization by exposing the dog to a
variety of potentially provocative stimuli while providing something else on
which to focus. Interaction with the dog in such activities also provides
something to which it can look forward, encourages mental and physical
agility, and serves to enhance the relationship between the dog and the
client. Additional opportunities for environmental and social enrichment for
 V. Virga / Vet Clin Small Anim 33 (2003) 231–251 243

canine patients may include providing interactive devices and toys on a

variable rotating basis, massage therapy, social grooming, and social play
with other dogs as well as people.
Environmental enrichment for cats may provide opportunities for mental
and physical stimulation, serve as a form of distraction from potentially
provocative stimuli, and offer some degree of control over their physical and
social environment. Opportunities for environmental enrichment for feline
patients may include providing access to elevated sites and window perches
on which to explore and rest; offering substrates to encourage marking by
rubbing, rolling, and scratching; limiting free access to food and distributing
food and treats to encourage exploration; and providing an ample variety
of interactive devices and toys available on a variable rotating basis.
Opportunities for social enrichment for cats may include social play,
massage therapy, social grooming, and facilitating selected and interactive
behaviors through shaping with a secondary reinforcer (eg, clicker).

Pharmacologic support
When behavioral dermatoses are considered, it is likely that a hetero-
geneous array of neurophysiologic mechanisms involving dopaminer-
gic, serotonergic, GABA-ergic, and noradrenergic systems may be
involved in the manifestation of these disorders. Numerous clinical studies
and case reports have explored pharmacologic manipulation of these
neurotransmitter systems in patients with behavioral dermatoses with
varying results. Differences in responses to pharmacotherapy may be
reflective of individual variations in neuroanatomic and neurochemical
function. Therefore, it is important that the clinician consider the underlying
motivational state and possible neurochemical correlates when assigning
behavioral diagnoses and recommending pharmacologic and behavioral
management.
Pharmacologic support with anxiolytics may be necessary to effect a
clinical response, particularly in cases where sufficient environmental and
social modification is problematic. Even with pharmacologic support,
however, it is worth noting that behavioral and environmental manage-
ment may enhance the efficacy of standard dermatologic treatments and
effectively reduce the dosage regimen and duration of treatment with
medications [12,16]. Pharmacotherapeutic agents should be selected
specifically to address the motivational state of the patient and a proposed
underlying neurophysiologic mechanism of action.

Tricyclic antidepressants
Amitriptyline (Elavil) and doxepin (Adapin, Sinequan) are tricyclic
antidepressants (TCAs) that are used in human and veterinary medicine as
an anxiolytics. Both exert their primary clinical effects by inhibiting the
244 V. Virga / Vet Clin Small Anim 33 (2003) 231–251

presynaptic reuptake of serotonin and norepinephrine to varying degrees.

Blocking norepinephrine and, to a lesser degree, serotonin reuptake
prolongs the inhibitory action of these neuropeptides, released from the
brain stem by pain-modulating systems, on spinal cord neurons involved in
transmitting pain [47–49]. Amitriptyline has been shown to function as a
partial antagonist of N-methyl-D-aspartate (NMDA) receptors, which may
become activated secondary to peripheral nerve injury or inflammation
[48,50]. By virtue of these properties, amitriptyline and doxepin can be
effective analgesics for neuropathic pain. Both compounds have substantial
antihistaminic properties brought about by their ability to block H1 and
H2 receptors. Amitriptyline equally affects H1 and H2 receptors, whereas
doxepin is much more selective for H1 receptors [51]. Compared with other
antihistamines, doxepin has an affinity for H1 receptors 56 times that of
hydroxyzine and 775 times that of diphenhydramine. These antihistaminic
properties have made these TCAs useful in treating pruritic conditions
refractory to traditional antihistamines [50].
Both amitriptyline and doxepin effectively block muscarinic cholinergic
receptors, which may result in anticholinergic side effects. Additional
reported side effects include increases in appetite, weight gain, sedation
(particularly in cats), gastrointestinal disturbances, anxiety, aggression,
alopecia, pruritus, urticaria, photosensitivity, potential cardiac conduction
disturbances, lowered seizure threshold, and a suggested role in sick
euthyroid syndrome at higher doses [23,51,52]. Contraindications may
include hepatic, renal, or cardiac disease. This class of drugs should not be
administered concurrently with monoamine oxidase inhibitors (MAOIs)
selegiline (Anipryl), or L-tryptophan. Amitriptyline has the distinct dis-
advantages, particularly in cats, of having a particularly bitter taste and a
narrow therapeutic index associated with a high rate of toxicity with over-
dose. By virtue of the mechanism of action of TCAs, it is important to allow
at least 3 to 4 weeks of TCA administration before evaluating the patient’s
clinical response at any given dosage. For patients in which dermatitis,
neuralgia, pain, or pruritus is suspected to be contributory to the patient’s
clinical signs, the antihistaminic, analgesic, and anxiolytic properties of
these compounds can prove to be quite effective in managing clinical signs.
Clomipramine (Clomicalm) is a TCA that is relatively more serotonergic
and less anticholinergic than previously mentioned medications. Clomicalm
has been approved by the US Food and Drug Administration (FDA) for use
in dogs in the management of separation anxiety and may be an effective aid
in the management of other anxiety-related behaviors. Clomipramine is
also the only TCA that has documented efficacy in the management of
compulsive behaviors in both human beings and animals [32,51,53]. As a
TCA, potential side effects and contraindications of clomipramine are similar
to those of other medications in that class [51]. For patients with stress,
anxiety-related, or compulsive behaviors and no neurosensory component,
clomipramine may be an effective means of pharmacologic support.
 V. Virga / Vet Clin Small Anim 33 (2003) 231–251 245

Selective serotonin reuptake inhibitors

Fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) are
selective serotonin reuptake inhibitors (SSRIs). They share a common
mechanism of action of being serotonergic without substantially affecting
the reuptake of norepinephrine or dopamine. The relatively specific action
of SSRIs is associated with fewer side effects. Adverse effects reported
with SSRIs include increased or reduced appetite, weight loss, gastrointes-
tinal disturbances, anxiety, aggression, restlessness, sleep disturbances, and
alterations in cardiac conduction [15,54]. Despite the relative specificity of
SSRIs compared with clomipramine, they seem to be equally effective in
the management of OCD [55,56]. As with TCAs, SSRIs should not
be administered concurrently with MAOIs, selegiline, or L-tryptophan.
Contraindications may include hepatic, renal, or cardiac disease. A min-
imum of 4 to 6 weeks of administration should be allowed so as to ob-
serve and evaluate the clinical effects at any given dosage. Paroxetine is the
most potent SSRI available, but it does have some anticholinergic ef-
fects. In the author’s experience, this is of primary concern in the cat, where
constipation is common. Metabolism of paroxetine is unique in that no
active metabolites are produced. This feature may favor the admin-
istration of paroxetine in elderly patients or animals with liver or kidney
disease.

Additional anxiolytics
The benzodiazepine tranquilizers, including diazepam (Valium), alpra-
zolam (Xanax), lorazepam (Ativan), oxazepam (Serax), and clonazepam
(Klonopin), are effective as short-term anxiolytics and, as such, may be
beneficial for acute or time-limited stress [15,57]. Benzodiazepines potentiate
the action of gamma aminobutyric acid (GABA) and, as such, act not only
as anxiolytics but also as tranquilizers. Unlike phenothiazine tranquilizers,
which are dopamine receptor antagonists, the benzodiazepines are not
neuroleptics. A primary benefit of benzodiazepines is their immediate onset
of action relative to the TCAs and SSRIs. An advantage of alprazolam,
clonazepam, and lorazepam is their sustained clinical effect relative to
diazepam; although variable from patient to patient, their duration of
clinical effect is typically 8 to 12 hours. The benzodiazepines may potentially
interfere with short-term memory and learning [58,59]. Other potential side
effects include increased appetite, physiologic dependency, paradoxic
excitement, anxiety, sleep disturbances, and hepatocellular toxicity in cats
[15,58].

Other psychotropics
Naltrexone (ReVia) is a pure opioid antagonist that may be readily
absorbed via oral administration. Although its clinical applications are
limited, one open-ended trial evaluating the efficacy of naltrexone in the
management of ALD demonstrated that it may substantially reduce or
Table 1 246
Psychotropic medications commonly used in the management of behavioral dermatoses
Typical dosage range in feline
Medication Form supplied patients Typical dosage range in canine patients
Amitriptyline 10-, 25-, 50- 75-, 100-, 0.5–1.0 mg/kg PO q 12–24 hours 1–4 mg/kg PO q 12 hours, beginning 1–2 mg/kg PO q 12 hours · 2–3
(Elavil) 150-mg tablets (allow 3–4 weeks for initial trial) weeks, › by 0.5–1 mg/kg PO q 12 hours · 2–3 weeks up to maximum
dosage PRN; if no clinical response fl by 0.5–1 mg/kg PO q 12 hours
· 2 weeks until at initial dosage) (allow 3–4 weeks for initial trial)
Doxepin 10-, 25-, 50-, 75-, 100-, 0.5–1.0 mg/kg PO q 12–24 hours 1–5 mg/kg PO q 8–12 hours, beginning at 1 mg/kg PO q 12 hours · 2–3
(Adapin 150-mg capsules; 10- up to 25–50 mg per cat (allow weeks, › by 0.5–1 mg/kg PO q 12 hours · 2–3 weeks up to maximum
Sinequan) mg/mL oral solution; 3–4 weeks for initial trial) dosage PRN; if no clinical response fl by 1 mg/kg PO q 12 hours · 2
5% (4.43%) topical weeks until at initial dosage) (allow 3–4 weeks for initial trial)
cream
Clomipramine 20-, 40-, 80-mg tablets 0.5–1.0 mg/kg PO q 24 hours, 1–3.5 mg/kg PO q 12 hours, beginning at 1 mg/kg · 3–4 weeks, › by
(Clomicalm) (scored) beginning at 0.5 mg/kg · 3–4 0.5–1 mg/kg PO q 12 hours · 3–4 weeks up to maximum dosage
weeks, › by 0.5 mg/kg PO q 24 PRN; if no clinical response decrease by 1 mg/kg PRN q 12 hours ·
hours · 3–4 weeks (allow 4–6 2 weeks until at initial dosage) (allow 3–4 weeks for initial trial)
weeks for initial trial)
Fluoxetine 10-, 20-, 40-mg capsules; 0.5–1.0 mg/kg PO q 24 hours 1 mg/kg PO q 12–24 hours (allow 4–6 weeks for initial trial)
(Prozac) 10-, 20-mg tablets (allow 4–6 weeks for initial trial)
tablets (scored); 5-mg/
mL oral solution
Paroxetine 10-, 20-, 30-, 40-mg 0.5–1.0 mg/kg PO q 24 hours 1 mg/kg PO q 24 hours (allow 4–6 weeks for initial trial)
(Paxil) (scored); 2-mg/mL (allow 4–6 weeks for initial trial)
V. Virga / Vet Clin Small Anim 33 (2003) 231–251

oral solution
Sertraline 25-, 50-, 100-mg tablets 0.5–1.0 mg/kg PO q 24 hours 1 mg/kg PO q 24 hours (allow 4–6 weeks for initial trial)
(Zoloft) (scored) (allow 4–6 weeks for initial trial)
Diazepam 1-, 2-, 5-, 10-mg tablets; 0.2–0.4 mg/kg PO q 12–24 hours 0.55–2.2 mg/kg PO PRN
(valium) 1-mg/mL, 5-mg/mL
solutions
Alprazolam 0.25-, 0.5-, 1-, 2-mg 0.025–0.2 mg/kg PO q 12–24 hours 0.05–0.25 mg/kg PO q 12–24 hours
(Xanax) tablets (scored)
Lorazepam 0.5-, 1-, 2-mg tablets; 0.025–0.2 mg/kg PO q 0.025–0.25 mg/kg PO q 12–24 hours
(Ativan) 2-mg/mL solution 12–24 hours
Oxazepam 10-, 15-, 30-mg capsules; 0.2–0.5 mg/kg PO q 0.2–1.0 mg/kg PO q 12–24 hours
(Serax) 15-mg tablets 2–24 hours
Clonazepam 0.5-, 1-, 2-mg tablets 0.025–0.2 mg/kg PO q 0.05–0.25 mg/kg PO q 12–24 hours
(Klonopin) (scored) 12–24 hours
Melatonin 0.3-, 1-, 3-mg tablets/ 3–6 mg PO q 3–12 mg PO q 12–24 hours
capsules 12–24 hours
With few exceptions, the application of psychotropic medications to veterinary behavioral medicine constitutes extralabel use. It is important to note that
extralabel use requires compliance with premedication databases routinely used in human medicine. Hepatic metabolism and renal clearance of these
compounds further support premedication assessment of serum biochemistry, complete blood cell count, and thyroid function. Psychotropic medications, as a
category, may affect thyroid hormone concentrations, potentiate cardiac arrhythmias, potentiate epileptiform seizures, and increase hepatic enzyme activities
particularly serum alkaline phosphatase (SAP). Practitioners are well advised to become familiar with the specific indications, contraindications, side effects,
and pharmacodynamics of the psychotropics they wish to use.
Abbreviations: PO, per os; q, every; fl, decrease; ›, increase; PRN, as needed.
V. Virga / Vet Clin Small Anim 33 (2003) 231–251
247
248 V. Virga / Vet Clin Small Anim 33 (2003) 231–251

eliminate clinical signs in some cases [59]. Potential side effects of naltrexone
can include severe pruritus and gastrointestinal disturbances [3,51,60].
Melatonin is a naturally occurring indole amine hormone produced by
the metabolism of serotonin and secreted by the pineal gland. In both
nocturnal and diurnal animals, the relative levels of serotonin and
melatonin in the pineal gland are inversely related during the daily
photoperiod (ie, during daylight hours, serotonin levels are high and
melatonin levels are low; during nighttime, hours melatonin levels are high
and serotonin levels are low) [61,62]. Beyond applications for some primary
dermatologic conditions, melatonin may be effective as an anxiolytic in
some patients [63–65]. Melatonin has been reported to be serotonergic
(possibly as a result of its derivative and inverse relation with serotonin) and
may also function as a GABA-ergic agonist [64,66]. Potential side effects of
melatonin include gastrointestinal disturbances and somnolence; however,
no data on long-term side effects have been collected on companion animal
species [67].
Table 1 reviews the dosages of more commonly used psychotropics
previously discussed.

References
[1] Koo JYM, Chantal T. Psychodermatology: practical guidelines on pharmacotherapy. Arch
Dermatol 1992;128:381–8.
[2] Savin JA, Cotterill JA. Psychocutaneous disorders. In: Champion RH, Burton JL, Ebling
FJG, editors. Textbook of dermatology. vol. 4. 5th edition. Oxford: Blackwell Scientific
Publications; 1992. p. 2479–96.
[3] White SD. Naltrexone for treatment of acral lick dermatitis in dogs. JAVMA
1990;196:1073–6.
[4] Panconesi E, Hautman G. Psychophysiology of stress in dermatology. Clin Dermatol
1996;14:399–422.
[5] Pert CB, Ruff MR, Weber RJ, et al. Neuropeptides and their receptors: a psychosomatic
network. J Immunol 1985;135(Suppl):S820–6.
[6] Rassmussen JE. Psychosomatic dermatology. Arch Dermatol 1990;126:90–3.
[7] Field TM, Schanberg SM, Scafid F, et al. Tactile kinesthetic stimulation effects on preterm
neonates. Pediatrics 1986;77:654–8.
[8] Meier GW. Infantile handling and development in Siamese kittens. J Comp Physiol
Psychol 1961;54:284–6.
[9] Paul J, Kuhn CM, Field TM, et al. Positive effect of tactile and kinesthetic or vestibular
stimulation on neuroendocrine and ornithine decarboxylase activity in maternally deprived
rat pups. Life Sci 1986;39:2081–7.
[10] Solomon GF, Levine S, Kraft JK. Early experience and immunity. Nature 1968;220:821–2.
[11] Bar LHJ, Kuypers BRM. Behavioral therapy in dermatological practice. Br J Dermatol
1973;88:591–8.
[12] Fried RG. Nonpharmacologic treatments in psychodermatology. Clin Dermatol 2002;
20:177–85.
[13] Koblenzer CS. Successful treatment of a chronic disabling dermatoses by psychotherapy.
J Am Acad Dermatol 1986;15:390–3.
 V. Virga / Vet Clin Small Anim 33 (2003) 231–251 249

[14] Surman OS, Gottleib SK, Hackett TP, et al. Hypnosis in the treatment of warts. Arch Gen
Psychiatry 1973;28:439–41.
[15] Gupta MA, Gupta AK. Psychodermatology: an update. J Am Acad Dermatol
1996;34:1030–46.
[16] Koo JYM, Do JH, Lee CS. Psychodermatology. J Am Acad Dermatol 2000;43:848–53.
[17] Koblenzer CS. Cutaneous manifestations of psychiatric disease that commonly present to
the dermatologist—diagnosis and treatment. Int J Psychiatry Med 1992;22:47–63.
[18] Koo JYM, Lebwohl A. Psychodermatology: the mind and skin connection. Am Fam
Physician 2001;64:1873–8.
[19] Koblenzer CS. Itching and the atopic skin. J Allergy Clin Immunol 1999;104(Suppl):S109–13.
[20] Tobin D, Nabarro G, Baart dela Faille H, et al. Increased number of immunoreactive
nerve fibers in atopic dermatitis. J Allergy Clin Immunol 1992;90:613–22.
[21] Shanley K. Pathophysiology of pruritus. Vet Clin North Am Small Anim Pract
1988;18:971–81.
[22] Scheich G, Florin I, Rudolph R, et al. Personality characteristics and serum IgE level in
patients with atopic dermatitis. J Psychosom Res 1993;37:637–42.
[23] Overall K. Fears, anxieties, and stereotypies. In: Clinical behavioral medicine for small
animals. St. Louis: Mosby-Year Book; 1997. p. 209–50.
[24] Overall K. Self-injurious behavior and obsessive-compulsive disorder in domestic animals.
In: Dodman NH, Shuster L. editors. Psychopharmacology of animal behavior disorders.
Malden (MA): Blackwell Science; 1998. p. 222–52.
[25] American Psychiatric Association. Diagnostic and statistical manual of mental disorders.
4th edition. Washington, DC: American Psychiatric Association; 1994.
[26] Luescher UA, McKeown DB, Halip J. Stereotypic or obsessive-compulsive disorders in
dogs and cats. Vet Clin North Am Small Anim Pract 1991;21:401–13.
[27] Overall K. Terminology in behavioral medicine: necessary and sufficient conditions for
behavioral diagnoses. Newsletter of the American Veterinary Society of Animal Behavior
1995;17:3–7.
[28] Scott DW, Miller WH, Griffin CE. Psychogenic skin diseases. In: Small animal
dermatology. 5th edition. Philadelphia: WB Saunders; 1995. p. 846–58.
[29] Shanley KS, Overall KL. Psychogenic dermatoses. In: Kirk RW, Bonagura JD, Current
veterinary therapy XI: small animal practice. Philadelphia: WB Saunders; 1992.
p. 552–8.
[30] Young MS, Manning TO. Psychogenic dermatoses (dog and cat). Dermatol Rep
1994;3:1–8.
[31] Moon-Fanelli AA, Dodman NH, O’Sullivan RL. Veterinary models of compulsive self-
grooming: parallels with trichotillomania. In: Christenson GA, Stein DJ, Hollander E,
editors. Trichotillomania: new developments. Washington, DC: American Psychiatric
Press; 1999. p. 63–92.
[32] Rappaport JL, Ryland DH, Kriet M. Drug treatment of canine acral lick: an animal model
of obsessive-compulsive disorder. Arch Gen Psychiatry 1992;49:517–21.
[33] Houpt KA. Aggression and social structure. In: Domestic animal behavior for
veterinarians and animal scientists. 3rd edition. Ames (IA): Iowa State University Press;
1998. p. 33–81.
[34] Eckstein RA, Hart BL. The organization and control of grooming in cats. Appl Anim
Behav Sci 2000;68:131–40.
[35] Panaman R. Behaviour and ecology of free-ranging female farm cats. Zeitschrift
Tierpsychologie 1981;56:59–73.
[36] Kenny DE. Use of naltrexone for treatment of psychogenically induced dermatoses in five
zoo animals. JAVMA 1994;204:1021–3.
[37] Beaver BV. Animal behavior case of the month. JAVMA 1993;203:651–2.
[38] Houpt KA. Learning. In: Domestic animal behavior for veterinarians and animal
scientists. 3rd edition. Ames (IA): Iowa State University Press; 1998. p. 251–85.
250 V. Virga / Vet Clin Small Anim 33 (2003) 231–251

[39] Scott DW, Miller WH, Griffin CG. Structure and function of the skin. In: Muller & Kirk’s
small animal dermatology. 5th edition. Philadelphia: WB Saunders; 1995. p. 1–54.
[40] Gupta MA, Gupta AK, Schork NJ, et al. Depression modulates pruritus perception:
a study of pruritus in psoriasis, atopic dermatitis, and chronic idiopathic urticaria.
Psychosom Med 1994;56:36–40.
[41] Dahl RE, Bernhisel-Broadbent J, Scanlon-Holford S, Sampson HA, Lupo M. Sleep
disturbance in children with atopic dermatitis. Arch Pediatr Adolesc Med 1995;149:
856–860.
[42] Stores G, Burrows A, Crawford C. Physiologic sleep disturbance in children with atopic
dermatitis: a case control study. Pediatr Dermatol 1998;15:264–8.
[43] Ginsburg IH, Prystowsky JH, Kornfeld DS, Wolland H. Role of emotional factors in
adults with atopic dermatitis. Int J Dermatol 1993;32:656–9.
[44] Koo JYM, Gambla C. Cutaneous sensory disorder. Clin Dermatol 1996;14:497–502.
[45] Backonja MM, Gaylor BS. Pain assessment and evaluation in patients who have
neuropathic pain. Neurol Clin 1998;16:775–89.
[46] VanNoorden S, Polak JM, Negri L, et al. Common peptides in the brain, intestine, and
skin: embryology, evolution, and significance. J Endocrinol 1997;75:33–4.
[47] Dubner R, Bennett GJ. Endogenous pain control mechanisms: review and hypothesis.
Ann Neurol 1978;4:451–62.
[48] Karlsten R. How do drugs relieve neurogenic pain? Drug Ther 1997;5:398–412.
[49] Max MB, Lynch SA, Muir J, et al. Effects of desipramine, amitriptyline, and fluoxetine
on pain in diabetic neuropathy. N Engl J Med 1992;326:1250–6.
[50] Tennyson H, Levine N. Neurotropic and psychotropic drugs in dermatology. Clin
Dermatol 2001;19:179–97.
[51] Kaplan MD, Sadock BJ. Tricyclics and tetracyclics. In: Pocket handbook of psychiatric
drug treatment. 2nd edition. Baltimore: Williams & Wilkins; 1996. p. 170–83.
[52] Garnis-Jones S. Dermatologic side effects of psychopharmacologic agents. Clin Dermatol
1996;14:503–8.
[53] Overall KL. Use of clomipramine to treat ritualistic stereotypic motor behavior in three
dogs. JAVMA 1994;205:1733–41.
[54] Kaplan MD, Sadock BJ. Serotonin-specific reuptake inhibitors. In: Pocket handbook
of psychiatric drug treatment. 2nd edition. Baltimore: Williams & Wilkins; 1996.
p. 146–61.
[55] Freeman CPL, Trimble MR, Deakin JFW, et al. Fluvoxamine versus clomipramine in the
treatment of obsessive-compulsive disorder: a multi-center, randomized, double blind,
parallel group comparison. J Clin Psychiatry 1994;55:301–5.
[56] Greist JH, Jefferson JW, Kobak KA, et al. Efficacy and tolerability of serotonin
transport inhibitors in obsessive-compulsive disorder. Arch Gen Psychiatry 1995;52:
53–60.
[57] Koo JYM, Gambla C. A psychopharmacology for dermatological patients. Clin Dermatol
1996;14:509–23.
[58] Overall K. Behavioral pharmacology. In: Clinical behavioral medicine for small animals.
St. Louis: Mosby-Year Book; 1997. p. 293–322.
[59] White SD. Management of acral lick dermatitis (ALD, lick granuloma). In: Proceed-
ings of the Fourth World Congress of Veterinary Dermatology, San Francisco. 2000. San
Francisco: World Congress of Veterinary Dermatology Association. p. 126–28.
[60] Schwartz S. Naltrexone-induced pruritis in a dog with tail-chasing behavior. JAVMA 1993;
202:278–80.
[61] Nelson RJ. The endocrine system. In: An introduction to behavioral endocrinology. 2nd
edition. Sunderland: Sinauer Associates; 2000. p. 35–96.
[62] Nelson RJ. Hormones and mood. In: An Introduction to behavioral endocrinology. 2nd
edition. Sunderland: Sinauer Associates; 2000. p. 627–58.
[63] Aronson L. Animal behavior case of the month. JAVMA 1999;215:22–4.
 V. Virga / Vet Clin Small Anim 33 (2003) 231–251 251

[64] Pierrefiche G, Zerbib R, Laborit H. Anxiolytic activity of melatonin in mice: involve-

ment of benzodiazepine receptors. Res Commun Chem Pathol Pharmacol 1993;82:
131–142.
[65] Van Moffaert M. Psychodermatology: an overview. Psychother Psychosom 1992;58:
125–136.
[66] Mills KC. Serotonin syndrome: a clinical update. Crit Care Clin 1997;13:763–83.
[67] Paradis M. Melatonin in canine alopecias. In: Proceedings of the Fourth World Congress
of Veterinary Dermatology, San Francisco. 2000. p. 52–9.