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Compendium March 2007 (Vol 29, No 3)

Understanding Behavior: "White Coat Syndrome: Prevention and Treatment"

by Sharon L. Crowell-Davis, DVM, PhD, DACVB

    One of the great paradoxes of veterinary medicine is that most of us enter this profession because we love animals, but because of our profession, our patients often fear us or, worse, exhibit fear aggression. These reactions can be caused by the sight of a white coat, stethoscope, or metal examination table; the smell of the hospital; or anything else that patients associate with unpleasant, uncomfortable, or sometimes painful experiences, such as being stuck by a needle, having objects placed in their rectum, or being handled by strangers when they are not well. Through classical conditioning, any stimulus associated with an unpleasant experience can become a conditioned stimulus for a response of anxiety or fear (see "Classical Conditioning: Learning by Association," June 2006, p. 472).

    Some fearful animals respond with submissive signaling, urination, avoidance, cringing, whining, and other behaviors that indicate their distress but do not present an immediate hazard to veterinary staff, whereas other animals become aggressive, attempting to defend themselves. Patients in the latter group are not trying to dominate the hospital staff but are simply trying to actively defend themselves from a perceived threat, and the underlying motivation for their growling, snapping, and biting is fear. For both types of patients, aversive stimuli such as yelling, hitting, and pinching are contraindicated because they only increase an animal's fear. In some cases, such actions may cause a patient to briefly freeze, making it possible to administer some treatment or perform a partial examination; however, in the long term, this approach will be counterproductive because such experiences can increase a patient's fear of the hospital and its staff.


    White coat syndrome is more easily prevented than treated. If a stimulus reliably predicts that an animal will experience pain, the development of fear is more likely than if that same stimulus often predicts a pleasant outcome. The following can all be used to help prevent white coat syndrome:

    • Puppy and kitten socialization classes in a veterinary hospital
    • "Fun" vet visits
    • Habituation of puppies and kittens to clinical items (e.g., white coats, stethoscopes) at socialization classes at locations other than a veterinary hospital

    Fun Vet Visits

    Even if your clinic does not conduct socialization classes, fun vet visits can be offered to help "immunize" puppies and kittens from developing fear. These visits can be scheduled for a day and time that the practice is least busy. Whether these visits are offered for free or at a nominal charge, they can pay off in the long term by producing patients that are easier to handle when they are ill or injured. Toys, treats, and fun are essential during these visits. Some puppies and kittens may also benefit from exposure to D.A.P. (dog-appeasing pheromone; Veterinary Products Laboratories) or Feliway (Veterinary Products Laboratories), respectively. The owner should first introduce the puppy or kitten to the hospital lobby and some personnel and then take the "patient" to an examination room. The owner should allow the pet to explore the room while giving it treats and toys and playing with it. The pet should eventually be placed on an examination table, and the pleasant experiences should be continued. If it is feasible to have a veterinary technician or assistant enter the room, he or she should be wearing standard examination clothing and handle the pet in ways that mimic a physical examination. While this is being done, treats should be offered continuously. Squirting some cheese product or peanut butter onto a tongue depressor and offering it to the "patient" to lick is often a very effective technique. If puppy or kitten socialization classes are offered at the practice, at least one of the sessions should include a fun practice examination. The pet should be allowed to sniff stethoscopes, thermometers, otoscopes, and other paraphernalia.

    Carriers and Car Rides

    Sometimes, a patient's fear of the veterinary office begins with preparing to go to it. Cats most commonly fear a carrier, whereas dogs most commonly fear getting in a vehicle. Cats with this problem may run and hide as soon as they see the carrier and, once found and caught, struggle violently against being placed it. Dogs with this problem may struggle violently as soon as the owner opens the vehicle door or leads them toward the vehicle. In the worst cases, attempts to get the dog in the vehicle can lead to the owner being bitten. These problems are more easily prevented than treated. Cat carriers should be brought out frequently and left open with a treat or favorite toy inside. The owner can also occasionally shut the cat in the carrier, briefly carry it around, set the carrier down in an appropriate location, let the cat out, and give it a treat. If this is done frequently when the cat is young and periodically throughout the cat's life, the carrier will not become predictive of painful and unpleasant experiences.

    The same principle should be followed with puppies and rides in vehicles. Dogs that are put in a vehicle only to go to the animal hospital become afraid of vehicles. Puppy owners need to start by periodically playing with the puppy in a stationary vehicle and giving the puppy treats and special toys. Dogs should be wearing a seatbelt harness in a moving vehicle. Owners can familiarize their puppies with a seatbelt harness by occasionally putting it on them while they are indoors. The harness should be associated with treats and favorite toys. For initial vehicle rides, two people are needed: one to drive, and one to sit with the puppy. The person sitting with the puppy should attach the puppy's harness to the seatbelt according to the product's instructions and should continually give the puppy treats while the vehicle is driven a short distance. Initial trips should not be longer than about one-quarter of a mile. Trip length can gradually be increased over time. Once the puppy is back at the house, it should be allowed to run and play. If the puppy is driven to a nearby dog park, vehicle rides can become predictive of going to the park and playing.



    For animals that are already afraid of the veterinary office and related stimuli, treatment follows many of the same principles as prevention but takes longer and may require more planning and greater frequency. If the pet is clearly afraid of specific stimuli, such as stethoscopes or personnel in scrubs or white laboratory coats, the owner may have to acquire these items and expose the pet to them at home. Although toy stethoscopes may be an economical option, they may not adequately mimic real stethoscopes. Ordering inexpensive brands of medical clothing and stethoscopes from clearance sales on the Internet is probably the least expensive option for many owners. The objects can initially be left where the pet can investigate them on its own. If the pet completely avoids the objects, a trail of treats leading to the objects may encourage the pet to take a closer look. Once the pet is comfortable with the objects, the owner can pick up the objects or put them on and slowly initiate pleasant interactions with the pet.

    The pleasant experience depends on what the pet best responds to and its specific fear. For example, for dogs that like to chase Frisbees but are afraid of stethoscopes and staff in white laboratory coats, owners can put on a white laboratory coat and pick up a Frisbee. The dog does not need to be next to the owner for a game of Frisbee and may follow him or her into the yard when it sees the Frisbee. After successive tosses and returns, the owner should gradually increase his or her interaction with and direct handling of the dog when it returns the Frisbee. Once the dog is clearly comfortable, the owner should start wearing a stethoscope around his or her neck. After a while, the dog should be offered the stethoscope to sniff when it returns the Frisbee. Once the dog does this, the owner should try touching the dog with the stethoscope and only toss the Frisbee after the dog allows this. Eventually, the owner should place the earpieces in his or her ears and touch the bell to the dog's chest before tossing the Frisbee. Over time, the dog should be required to stand still while being touched with the stethoscope for increasingly longer periods before the Frisbee is thrown. In this example, the dog will have learned that standing still for a person in a white coat with a stethoscope is predictive of a Frisbee toss. During an actual examination or treatment, it may help to periodically reward the dog with a Frisbee.

    Fear Aggression

    In managing cats that have developed fear aggression toward veterinarians, it is commonly said that less is more because the more these cats are restrained, the more they fight. When a visit from one of these patients is expected, careful planning is important. Syringes for all injections should be drawn and ready before the cat is brought into the examination room, and adequate assistance should be ready. The longer a fear-aggressive cat is in a frightening situation, the more likely it is to become aggressive. Many of these cats do better if environmental stimuli are minimized (i.e., the lights should be dimmed, if possible, and hospital personnel should avoid making loud noises). A technician who is skillful with cats can be soothing the cat while injections are quickly administered, an approach that may produce better results than the traditional approach of scruffing and pinning the cat.

    Fear aggression in dogs, especially medium-sized to large dogs, presents a special problem because of the significant harm they can inflict on personnel. While it is best to treat veterinarian-directed fear aggression in the long term, short-term management is essential for safe and effective treatment. The disadvantage of muzzles that keep a dog's mouth fully closed is that they can be used only briefly because dogs cannot drink or pant while in these muzzles. If a dog is a fear aggressor, the owner should obtain a correctly fitting basket muzzle, which allows the dog to pant. These muzzles can be made of plastic or wire and must be the correct length and circumference for the dog. The dog can be trained at home to associate the muzzle with pleasant consequences. The owners should initially put a food the dog likes, such as cream cheese or peanut butter, on the interior of the muzzle and let the dog stick its nose in and lick up the treat. When the dog is comfortable licking the interior of the muzzle, the owner should buckle the neck strap that goes behind the ears and then give the dog treats (e.g., beef jerky) through the openings in the muzzle, take the dog for a walk, or do something else that the dog perceives as pleasant. Over time, the muzzle can be left on for increasingly longer periods. Dogs correctly trained in this manner will not resist being muzzled and may even voluntarily put the muzzle on themselves if it is placed on the floor with the open end up, only requiring that the owner buckle the neck strap.

    While wearing a basket muzzle, a dog can pant, bark, eat stick-shaped food stuck through the openings and drink with the front of the muzzle under water. Dogs wearing a basket muzzle can attempt to bite but cannot make tooth contact. Therefore, if the owner puts the muzzle on the dog before bringing it to the clinic, the clinic staff will be safer and the fear aggressor will be as comfortable as possible. In the short term, a basket muzzle makes it possible to perform necessary medical procedures with minimal discomfort to the dog. In the long term, the dog can repeatedly be brought to the clinic wearing its muzzle to have pleasant experiences and gradually overcome its fear of the hospital and veterinary personnel.


    White coat syndrome cannot always be prevented or treated. Extremely timid and fearful animals that undergo severely traumatic and painful experiences, such as being treated for vehicular trauma, may never be totally relaxed and comfortable at an animal hospital. However, with the proper approach by the owner and hospital staff, most cases of white coat syndrome can be prevented and treated.

    See the Key Points box.

    NEXT: Web Sights (March 2007)


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