Transcript Toxoplasma gondii - Ontario ACT Association

CATS, OTHER PETS
AND
COMMUNITY PSYCHIATRY
Dr Martin Feakins
Psychiatrist / Assistant Professor
Community High Intensity Treatment Team (CHITT)
ACKNOWLEDGEMENT: DR VALERIE GOFF
INTRODUCTION
•
14/ 69 Chitt patients own pets (20%)
•
1 goldfish
•
6 dogs (4 owned by one patient and family)
•
15 cats (4 owned by one patient and family)
•
What do we need to consider in looking after these patients?
CATS %HOUSEHOLDS m = million with CATS
AUSTRALIA
3m
JAPAN
8m
UK
8m
CANADA
4.5 m
SWEDEN
1.3 m
NEW ZEALAND .9 m
GERMANY
7m
SWITZERLAND 1.2 m
25%
11%
25%
38%
21%
47%
14%
35%
http://answers.google.com/answers/threadview/id/244443.html
CONTENT
•
Introduction and prevalence
•
Ethics
•
Problems of cat/ pet ownership
• Diseases
• Risks to owner / others
• Risks to cat
•
Costs and responsibilities of cat / dog ownership
•
Benefits of cat / pet ownership
•
How to assess a cat – owning patient
•
How safely to approach a cat, and dog
•
What to do if there are concerns
ETHICS
•
Some self evident statements:
•
Psychiatric patients have as much right to keep pets as anyone
•
Pets are widely regarded to be therapeutic
•
As healthcare professionals we are in a unique position
• Our primary responsibility is to the patient
• But we also have a human duty to pets they are responsible for
• Through our treatment of patients we become involved in the welfare of their pets
GANDHI
•
“The greatness of a nation and its moral progress can be judged by the way its
animals are treated”
THE DALAI LAMA
•
“Now, with regard to animals, they not only have life, but feelings of pleasure and pain
too. We should treat their lives with respect.”
JESUS
•
“The lion of Judah” Revelation 5:5
•
“The lamb of God”
•
Used animals in teaching; birth was amongst, and witnessed by, animals
•
“and
he was in the desert forty days, being tempted by Satan. He was with the wild
animals, and angels attended Him.” Mark 1:13
OLD TESTAMENT
•
"The righteous man regards the life of his beast." Proverbs 12:10,
•
"I will make a covenant with you and with all living creatures." Genesis 9
•
"If you see an animal that is overburdened, you should lighten its load to help it."
Deuteronomy 22, Exodus 23,
•
"Ask the birds, ask the beasts and they will teach you.“ Job 12: 7-10,
MOHAMMED
•
Several references to kindness to animals being advocated.
•
"Whoever is kind to the creatures of God, is kind to himself." (Wisdom of Prophet
Mohammad(s); Muhammad Amin; The Lion Press, Lahore, Pakistan; 1945).
IS CAT OWNERSHIP ASSOCIATED WITH
ANY PSYCHIATRIC DISORDER?
•
Stereotype of “Crazy cat lady”
•
http://www.youtube.com/watch?v=GkMvKeX7erI
•
Pubmed search of “psychiatric illness prevalence and cats’ yields no results
•
But….
TOXOPLASMA GONDII
TOXOPLASMOSIS
•
Toxoplasma gondii
•
Cat ingests infected prey (or other infected raw meat)
•
Parasite released into the cat's GI tract and multiplies in the wall of the small intestine
•
Oocysts produced and then excreted in feces 3 - 10 days later
•
Continue excreting for 10 - 14 days, during which time millions of oocysts may be
produced.
•
Oocysts are resistant and may survive for over a year.
TOXOPLASMOSIS IN HUMANS
•
Generally asymptomatic
•
Flu – like syndrome if symptomatic
•
Pregnant mothers – 30% transmission to foetus, 3rd > 2nd > 1st trimester
•
Usually asymptomatic in mother
•
The majority of infected infants will show no symptoms of toxoplasmosis at birth.
•
Blindness, mental retardation, deafness, stillbirth/ abortion, death
TOXOPLASMOSIS AND SCHIZOPHRENIA
•
Kraepelin speculated in 1896 that dementia praecox might be caused by a focal infection
of bodily organs that then affected the brain.
•
Bleuler subsequently suggested that “the connection of the disease to infectious
processes equally needs further study … many writers assume that schizophrenia is
caused by some physical weakness or possibly even by some infectious disease.”
•
Infectious research on schizophrenia has focused on bacteria and viruses (eg influenza)
•
T. gondii is a protozoa.
• Plasmodium (malaria)
• Trypanosoma (sleeping sickness).
•
Schizophr Bull. 2007 May; 33(3): 727–728.
TOXOPLASMOSIS: TORREY ET AL
•
42 studies comparing prevalence of antibodies to T. gondii in schizophrenia vs normal
population. 23 met selection criteria.
•
The combined odds ratio (OR) was 2.73 (95% confidence interval, 2.10 to 3.60)
•
Seven studies that included only patients with first-episode schizophrenia (OR 2.54) did
not differ significantly from 16 studies that included patients in all clinical phases (OR
2.79).
•
Patients with schizophrenia have an increased prevalence of antibodies to T. gondii
•
Although the OR of 2.73 is modest, it exceeds that for genetic or other environmental
factors.
• Torrey EF, Bartko JJ, Lun ZR, Yolken RH. Antibodies to Toxoplasma gondii in patients
with schizophrenia: a meta-analysis. Schizophr Bull. November 3,2006.
TOXOCARA CATI
TOXOCARA CATI
•
Similar lifecycle to toxoplasma
•
Mature nematodes in cat’s intestine produce eggs
•
After ingestion by humans, the eggs hatch into larvae, which penetrate intestinal lining
and enter systemic circulation. They do not develop further or reproduce.
•
Lymphadenopathy, flu like symptoms.
•
Characteristic eosinophilia. Resolves within weeks.
•
10,000 clinical cases are seen a year in the U.S., with ten percent being OLM.
•
Two serious possible complications:
• Visceral larva migrans depends on organs affected
• Ocular larva migrans
•
Review of Optometry Online: Handbook of Ocular Disease Management. Toxocariasis: Ocular Larva
Migrans". 26 Jan. 2009
•
Stewart, JM, LD Cubillan, and ET Cunningham, Jr. Prevalence, clinical features, and causes of vision loss
among patients with ocular Toxocariasis. Retina. 2005 Dec;25(8):1005-13
TOXOCARIASIS: SERIOUS COMPLICATIONS
•
•
Visceral Larva Migrans:
•
Pallor, fatigue, weight loss, anorexia, fever, headache, rash, cough, asthma, chest
tightness, increased irritability, abdominal pain, nausea, and vomiting.
•
In rare cases of hypersensitivity, epilepsy, myocarditis, pleural effusion, respiratory
failure, death
Ocular Larva Migrans:
•
Characteristically one eye only
•
Larvae inside orbit. Progressive blindness. Various other ocular signs.
•
Treatment with corticosteroids / surgical removal.
•
Laser photocoagulation for ocular complications
Holland, Celia and H.V. Smith. Toxocara: The Enigmatic Parasite. Wallingford, UK and Cambridge, MA: CABI
Publishing, 2006. 26 Jan. 2009
Huh, Sun and Sooung Lee. eMedicine from WebMD. “Toxocariasis.” 20 Aug. 2008. 26 Jan. 2009
Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, Division of Parasitic
diseases. "Fact Sheet: Toxocariasis." 5 Nov. 2007. 19 Jan. 2009
BARTONELLA BACTERIUM
CAT INFECTIONS: CAT SCRATCH DISEASE
• Described by Henri Parinaud (1844 – 1905) in 1889
• Regional lymphadenopathy
• Mild fever, headache, backache, abdominal pain
• Usually manifests 7 – 14 days after scratch or bite
• Generally benign and self limiting
• Uncommon complications in immunocompromisation:
• Optic neuritis
• Skin lesions
• Encaphalitis
HARM TO PATIENTS:
FALLS AND CATS/ DOGS
•
Center for Disease Control, March 27, 2009 / 58(11);277-281
•
Annual injury rate of 30 / 100,000 population from 2001 – 2006
•
Falling over pet, causing fracture, was the most common injury
•
Charts on subsequent slides
CDC: DOG ATTACKS
•
368,245 pts treated for dog bite--related injuries in 2001 (rate: 129.3 per 100,000)
•
Injury rate was highest for children aged 5--9 years and decreased with increasing age.
•
16,526 (4.5%) dog bite injuries were work-related (e.g., occurred to persons who were
delivering mail, packages, or food; working at an animal clinic or shelter; or doing home
repair work or installations).
•
Fatal dog attacks roughly 30 – 35 / year in US but statistics collation is difficult
CAT ATTACKS
•
Few publications
•
25% of animal bites in a 1990 study in Dallas
• (Wright, JC. Public Health Rep. 1990 Jul-Aug;105(4):420-4.)
•
25% of bite / scratch attacks in Switzerland in 1998
• (Matter HC, Eur J Epidemiol. 1998 Jul;14(5):483-90.)
COST OF CAT OWNERSHIP
•
Estimates vary widely around the figure of $500/ year.
•
First year and final year more expensive.
• http://www.peteducation.com/article.cfm?c=1+2137&aid=1542
Product/Service
Cost 1st Year
Low
High
My Cost
Cost
Cost
Yearly Cost
Low
High
My Cost
Cost
Cost
Purchase Price
Food
Spay/Neuter
Litter Box
Cat Litter
Furniture
Window Perches
Cat Bed
Cat Door
Cat Carrier
Scratching Post
Food Bowls
Grooming Tools
Hair Removing Tape
Stain Removers
Flea Control
Heartworm Prevention
Training Aids
Vet Bills
Vaccines
Ear/Dental Care
Vitamins/Fatty Acids
Treats
Toys
Boarding
0
120
50
8
70
0
0
0
0
18
5
7
5
0
8
50
0
20
50
45
0
0
0
10
25
50
175
95
10
120
0
25
0
25
20
5
8
7
7
25
60
0
20
50
55
0
10
5
15
75
750
200
200
50
150
200
60
45
75
45
45
25
40
10
75
150
40
150
300
85
65
50
40
75
200
0
100
0
1
70
0
0
0
0
0
1
1
0
0
1
50
0
0
50
10
0
0
0
1
25
Totals
$491.00
$862.00
$3125.00 $310.00
Total over the life of a 14 year old cat
0
175
0
1
120
0
3
0
3
0
1
1
1
7
3
60
0
0
50
10
0
10
5
2
75
0
200
0
5
150
20
6
5
8
0
5
3
4
10
8
150
40
15
200
35
7
50
40
8
200
$527.00
$1169.00
Low Cost My Cost
$4,521.00 $7,713.00
High Cost
$18,322.0
COSTS OF DOG OWNERSHIP
COSTS OF DOG OWNERSHIP
•
Much more variation due to size of dog
•
Also more time intensive
Yearly Expense
Type of
Expense
Food and Treats
250 - 700
Toys
Beds
25 - 150
50 - 200
Leashes and Collars
20 - 50
Grooming
30 - 500
Routine Veterinary Care
500 - 1000
Preventive Medications and Supplements
100 - 300
Training Classes or Resources
25 - 300
Petsitters or Boarding
100 - 300
Yearly Total $1100-3500
Average Monthly Cost of Owning a Dog $90-290
http://dogs.about.com/od/becomingadogowner/a/costofdogs.htm
ESTABLISHED BENEFITS OF PET OWNERSHIP
•
Psychiatric benefits demonstrated in numerous trials since 1960’s
•
Improve motivation, mood, well being, reduce psychiatric symptoms
•
Companionship and affectional bond for isolated patients
•
Emerging field of pet therapy
•
Also publications on cardiac benefits,
HOW TO APPROACH A DOG
•
http://www.youtube.com/watch?v=XfRDuPk3xas
HOW TO APPROACH A DOG
•
Ask owner
•
Assess his temperament and state of mind by looking at his body language.
•
Is his tail tucked? Is he backing away from your presence instead of moving toward you? Is
some of the hair on his back standing up? Growling / barking?
•
These can lead to aggression if approach is continued. Retreat slowly (don’t run).
•
If absent:
•
Crouch – puts you on dog’s level
•
turn your body to the side – non threatening.
•
Try and get the dog to approach you first.
•
Avoid looking the dog in the eye. Direct eye contact is confrontational.
•
Look over his head, or just to the left or right of him.
•
Keep your voice calm and cheerful.
HOW TO APPROACH A DOG
•
While still in crouched position, try to coax the dog toward you.
• Extend your hand, making sure that it never goes above the height of the dog's nose.
Any movements or gestures above the nose put you in a dominant posture, and that
may feel threatening to the dog.
• Do not try to pet the top of his head, or stand up and bend over him until you are
certain he is ready.
•
After you have made contact, stay crouched on the floor until you feel the dog is relaxed
and comfortable with you touching him. Avoid making any sudden movements or loud
noises in these initial stages. Continue to keep your voice very calm and upbeat.
How to Approach a Dog | eHow.com http://www.ehow.com/how_4576016_approach-adog.html#ixzz2QZPhUcs0
HOW TO APPROACH A CAT
•
Ask owner
•
Assess his temperament and state of mind by looking at his body language.
•
Is his tail tucked or switching from side to side? Fur standing up? Is he backing away from your
presence instead of moving toward you? Growling / wailing/ hissing?
•
These can lead to aggression if approach is continued. Retreat slowly.
•
If absent:
•
Crouch – puts you on cat’s level
•
Turn your body to the side – non threatening.
•
Try and get the cat to approach you first.
•
Avoid looking the cat in the eye. Direct eye contact is confrontational.
•
Look over his head, or just to the left or right of him.
•
Keep your voice calm and cheerful. Chirp.
HOW TO APPROACH A CAT
•
While still in crouched position,
• Extend your hand, making sure that it never goes above the height of the cat's nose.
Any movements or gestures above the nose put you in a dominant posture, and that
may feel threatening to the cat.
• Do not try to pet the top of his head, or stand up and bend over him until you are
certain he is ready.
• If the cat wants to be friends, he will sniff your fingers, then rub part of his face
against it. Change your finger to a gentle scratching or stroking motion and allow cat
to move face or body against your fingers.
•
Stay crouched on the floor until you feel the cat is relaxed and comfortable with you
touching him. Avoid making any sudden movements or loud noises.
•
Do not be alarmed if cat approaches you first, or jumps on lap.
CATS HISSING AND CHIRPING
•
http://www.youtube.com/watch?v=xXUF3N3G5Pk
•
http://www.youtube.com/watch?v=z3U0udLH974
HARM TO PETS
•
Deliberate (good data)
•
Neglect (subcategory of “willful neglect” identified) (no data)
•
Accidental (poor data)
POTENTIAL FOR HARM
TO PETS OWNED BY PSYCHIATRIC PATIENTS
•
No publications
•
Canvassing views indicates risks of:
•
Neglect
•
Forgetting
•
Smoking
•
Not buying provisions
•
Denial of problems with pet
•
Not perceiving the need for treatments, eg flea protection, vaccines
•
Bizarre behaviour driven by hallucinations / delusions
•
Deliberate cruelty (good data)
• Always compare with “normal”
SUGGESTIONS FOR HIGHER RISK DIAGNOSES
•
Antisocial personality trait / disorder
•
Marked negative syndrome
•
Positive symptoms concerning pet
•
Profound depression
•
Marked developmental delay
•
Eating disorder
•
Nicotine dependence
•
Drug / alcohol dependence
Smoking and Cats
• Feline lymphoma the most common cancer in domestic cats
• GI tract or nasopharynx
• Moore et al 180 cats treated at Tufts' Foster Hospital for Small Animals
between 1993 and 2000. Eighty of those cats were treated for lymphoma
and 100 were treated for renal failure.
• 2.5x incidence of lymphoma for cats exposed to any household tobacco
smoke vs cats not exposed. The risk increased according to the duration
and level of the cat's tobacco exposure
• 2x incidence for cats living with one smoker
• 4x for cats living with two or more smokers.
• 3x for cats living with humans smoking a pack or more a day
Am J Epidemiology 2002 Aug 1;156(3):268-73.
Environmental tobacco smoke and risk of malignant lymphoma in pet cats.
Bertone ER, Snyder LA, Moore AS
UNUSUAL CASE EXAMPLE
•
39-year-old woman with a history of bipolar affective disorder
•
Found dead on her living room floor by neighbors.
•
Hands covered in scratches
•
Pet cat was found disemboweled in the kitchen with its tail hacked off.
•
On autopsy her stomach was found to be full of cat intestines, adipose tissue, and strips
of fur-covered skin.
•
An intact left kidney and adipose tissue were found lodged in throat just above epiglottis.
•
Cause of death was determined to be asphyxia by smothering due to animal tissue.
• An unusual case of smothering secondary to ingesting raw pet cat.
• Redpath M, Sauvageau A, Laboratoire de Sciences Judiciaires et de Medicine
Légale, 1701 Parthenais Street, Montreal (Quebec), Canada. Am J Forensic Med
Pathol 2011 Jun;32(2):190-2.
CRUELTY TO ANIMALS
•
Treatment of animals that causes gratuitous, unwarranted or unjustifiable suffering or
harm (including death)
•
Well known link to antisocial personality traits
•
DSM-III-R incorporated animal cruelty as a diagnostic criterion for Conduct Disorder and
Antisocial Personality Disorder in 1987
•
Correlates of Cruelty to Animals in the United States: Results from the National
Epidemiologic Survey on Alcohol and Related Conditions. Vaughn, MG et al, J
Psychiatr Res, 2009 Oct 43(15) 1213 - 1218
POSITIVE CORRELATES OF ANIMAL CRUELTY
•
Correlates of Cruelty to Animals in the United States: Results from the National
Epidemiologic Survey on Alcohol and Related Conditions. Vaughn, MG et al, J
Psychiatr Res, 2009 Oct 43(15) 1213 – 1218
History of Cruelty to Animals
No History of Cruelty to Animals
(N = 728)
(N = 41,203)
Sociodemographic Characteristics and
Other Psychiatric Disorders
% (95% CIa)
% (95% CI)
AORb (95% CI)
32.77 (28.38-37.48)
16.58 (15.89-17.29)
1.27 (0.75-1.69)
19.57 (15.80-23.98)
11.71 (9.40-14.49)
5.50 (5.18-5.84)
4.23 (3.95-4.53)
0.99 (0.70-1.39)
1.17 (0.81-1.70)
7.49 (5.46-10.21)
13.84 (11.07-17.16)
16.81 (13.88-20.22)
10.75 (8.29-13.83)
4.03 (3.77-4.32)
4.93 (4.55-5.35)
9.49 (8.89-10.13)
4.12 (3.79-4.48)
0.89 (0.59-1.34)
1.13 (0.82-1.55)
1.03 (0.76-1.38)
1.14 (0.75-1.72)
Alcohol use disorder
Nicotine dependence
Marijuana use disorder
63.69 (58.71-68.38)
36.16 (31.39-41.21)
27.90 (23.87-32.32)
29.77 (28.28-31.30)
17.56 (16.63-18.54)
8.15 (7.62-8.71)
1.56 (1.20-2.03)
0.93 (0.71-1.22)
1.05 (0.77-1.44)
Other illicit drug use disorder
19.92 (16.38-24.01)
5.02 (4.63-5.44)
1.05 (0.77-1.43)
Comorbid Psychiatric Disorder
Mood disorders
Major depressive disorder
Bipolar disorder
Dysthymia
Anxiety disorders
Panic disorder
Social phobia
Specific phobia
Generalized anxiety disorder
Substance use disorders
Psychotic disorder
Conduct disorder
Personality disorders
Avoidant
Dependent
Obsessive-compulsive
3.63 (2.19-5.95)
8.29 (5.66-11.98)
0.74 (0.64-0.86)
0.94 (0.83-1.08)
1.14 (0.59-2.22)
9.53 (6.07-14.97)
9.89 (7.26-13.33)
2.66 (1.39-5.01)
26.56 (22.53-31.01)
2.27 (2.06-2.51)
0.46 (0.38-0.57)
7.74 (7.30-8.21)
1.50 (0.97-2.30)
0.76 (0.33-1.71)
1.65 (1.24-2.20)
Paranoid
Schizoid
Antisocial
Histrionic
18.09 (14.79-21.93)
9.54 (7.17-12.59)
35.84 (31.53-40.40)
10.69 (8.12-13.94)
4.27 (3.98-4.58)
3.09 (2.85-3.35)
3.13 (2.88-3.40)
1.72 (1.56-1.90)
1.34 (0.93-1.94)
0.70 (0.44-1.12)
6.68 (5.05-8.85)
1.62 (1.14-2.31)
ASSESSMENT OF PET OWNING PATIENTS
CONTRIBUTIONS FROM DR VALERIE GOFF
ASSESSMENT OF PET OWNING PATIENTS
•
Direct observation of cat
• Mobilising normally (not limping, not languid, not agitated)
• No weight changes, appears of healthy weight
• Fur clean, grooming
• Eyes clear
• Not scratching excessively.
•
Direct observation of home
• Litter cleanliness
• Food and water
• Overall reasonable hygiene
ASSESSMENT OF PET OWNING PATIENT
•
Informal conversation about pet
•
Look for signs of attachment – smiling when discussing, sad if separating
•
Discuss pet’s needs and how they are met
• Changing litter
• Buying food
• Reacting to illness promptly, which vet to call and how to get there.
• Playing
• (Dogs – walking)
WARNING
CASE EXAMPLE
•
Middle aged male with active negative symptoms of schizophrenia
•
Lives alone with cat
•
Feeds cat regularly and cleans litter.
•
Cat usually appears energetic and displays interest in visitors
•
Seen regularly for med delivery by community psychiatric team
•
Lately the cat appears to be losing weight, and only raises its head sleepily when team
visits
•
Discussed with patient who initially acknowledged a problem, but said he had no money
for vet.
•
Team discussed with vet who agreed to see cat free, and euthanise if necessary
•
Patient then said cat was fine and dismissed interventions
•
Cat died.
CASE EXAMPLE – SMOKING / HYGIENE
•
Middle aged male, schizophrenia with thought disorder
•
Lives with 5 cats in 6 th floor apartment, no balcony
•
Heavy smoker
•
On medication delivery visits, all cats immediately run out of opened apartment door and
require herding to return at end of visit
•
Patient dismisses concerns about effects of smoking on cats
•
Team reviewed case in multidisciplinary discussion
•
Varying views
•
People who have no psychiatric dx do the same thing
•
Duty to act as healthcare professional
•
Case discussed on anonymous basis with Humane Society
•
Status quo ante
HELP FROM PSYCHIATRIC TEAM
•
Buying litter and food can be incorporated into therapeutic grocery trips
•
Psych team has a role in assisting when there is a pet emergency
•
Trusting relationship with psych team is important
WHAT TO DO IF THERE ARE CONCERNS
•
Concerns are unusual. Most patients take excellent care of pet.
•
Discuss with patient
•
Suggest options and problem solve, eg
• Vet visit
• Facilitate advice from other professionals eg Humane Society
•
Suggest surrendering pet to Humane Society if these measures are not enough
• http://www.kingstonhumanesociety.ca/
WHAT TO DO WITH CONCERNS
IF PATIENT DOES NOT AGREE
•
Depends on severity
•
Duty of disclosure does not apply if no consent
•
Animals are legally regarded as property
•
However raising the alarm anonymously may be an option
•
If there is a substitute decision maker for finances, s/he can make decisions with advice
from the vet.
TOXOPLASMOSIS DIAGNOSIS / TREATMENT
•
Difficult to distinguish from llymphoma,.
•
Diagnosis is often made by trial of therapy: antimalarials and antibiotics
•
Detection of T. gondii in human blood samples may also be achieved by polymerase chain
reaction. Inactive cysts may exist in a host which would evade detection.
•
Lymph nodes affected by Toxoplasma have characteristic changes.
WEBS
•
http://www.youtube.com/watch?v=GkMvKeX7erI
•
http://www.youtube.com/watch?v=XfRDuPk3xas how to approach a dog
•
http://www.youtube.com/watch?v=xXUF3N3G5Pk cat hissing
http://www.youtube.com/watch?v=z3U0udLH974 cat chirping