Graduation Day: The VetBeh Recheck that Almost Happened

Maisy had an appointment scheduled for today with her veterinary behaviorist, Dr. Duxbury. Key word: had. We ended up cancelling it, on Dr. Duxbury’s advice.

Things normal dogs do: play, then nap.

 

 

Quick recap: At our last appointment a year ago, Dr. Duxbury was so pleased with Maisy’s progress that she gave me the option of transferring her care back to our primary vet. I chose not to do this because I wanted to maintain a relationship with Dr. Duxbury in case things worsened.

Things have changed since then. Not only is Maisy doing even better than she was a year ago (to the point that I now think of her as normal), but I also now count Dr. Duxbury- Margaret- as a friend. This means that she has seen Maisy regularly over the past year, thus alleviating my concerns about continuity of care. Still, I scheduled the appointment because I was concerned that the sudden thunderphobia that started last summer would continue this year. It hasn’t (she’s slept through the last several thunderstorms), leaving me with absolutely zero concerns about Maisy’s behavior. Margaret and I agreed that it seemed silly to bring a normal dog in.

Maisy will continue on her current medication regime because it continues to be the best thing I’ve ever done for her. I decided long ago that I would not change something that’s working so well. Of course, I will continue to run regular lab work to make sure the meds aren’t impacting her negatively, but so far, so good.

And so ends our (professional) involvement with the Veterinary Behaviorist. I will be forever grateful for what she’s done for both Maisy and for me. Margaret is an amazing clinician and an even more amazing person. The world is truly a better place with her in it, and I am so fortunate to be able to call her a friend.

Follow Up with the Veterinary Behaviorist

A few weeks ago, Maisy had a follow up appointment with our veterinary behaviorist, Dr. Margaret Duxbury. I almost forgot to post about it because it was a pretty anticlimactic visit. Unlike past visits, where I've come armed with logs and graphs and charts and videos, I didn't have much to show her. Maisy is... well, pretty much normal.

I brought two videos as proof of her normalcy. The first is of her playing with other dogs. Maisy loves the little white and brown dog, and plays with her often, but while she has met the Aussie before, they've never played together.



The second video made Dr. Duxbury incredibly happy. The video looks like nothing- it's just the three of them lying around- and it's that nothingness that makes it so wonderful. Those of you have followed Maisy and I since the beginning know that this ability to relax was nonexistent only two years ago.



We chatted for a bit during the appointment, and as we did, Maisy simply laid down at my feet. Again, that sounds like nothing, but it's such a huge deal for a dog who was constantly restless and hypervigilant. (Here's a link to the before and after videos I posted last year.)

At the end of the appointment, Dr. Duxbury gave me a choice: I could either transfer Maisy's care back to our primary vet, or I could choose to do annual visits with her. I chose annual visits. I'd like to maintain the relationship we have in case things deteriorate in the future.

It's been twenty months since we first met Dr. Duxbury, and I am really just so happy that we did. Like she said, Maisy was the ideal candidate for medication, and she has responded beautifully to treatment. I will always be incredibly grateful to Dr. Duxbury for her kindness, her compassion, and her expertise. It has made such a difference in both Maisy's life and my own.

One Year on Meds: Recheck with the Veterinary Behaviorist

So Maisy's been on meds for a bit over a year now. The difference between the way she was then and the way she is now is nothing short of miraculous to me. Of course, it's not a miracle at all, it's simply the fact that the biochemistry in her brain is not correct, and the addition of paroxetine makes it so. Whatever. The point is, medication has made such a huge impact on our lives that I am absolutely awestruck when I think about it- like when we have an appointment with our veterinary behaviorist, Dr. Duxbury.

Our appointment this time around was actually pretty short and sweet. We didn't discuss behavior logs (although I took them, and I'll share them here today), and we only watched one video. We talked about what daily life is like now- uneventful, really, but that's a good thing in this case. We also talked about some of the challenges we still face- children, mostly, as well as our disastrous (if you're a chicken, anyway) Thanksgiving. But really we just admired how well Maisy is doing.

Here's a link to the behavior logs/charts from a year ago. At baseline, before medication, she was averaging 3.58 incidents (defined as overreacting to unnoticeable or mild stimuli when at home) per day. About a third of these happened during the night, and frequently woke me up. It was not uncommon for these incidents to include prolonged scanning of the environment/general vigilance, up to and including leaving the room to investigate. After six weeks on medication, this was down to 1.33 incidents per day.

Although this was a great improvement, we decided to increase Maisy's medication slightly. I took another set of behavior logs (link here), and after eight weeks at the new dose, we were down to 1 incident a day, on average.

Things have improved since then, and honestly, it's not even worth making a chart. I kept logs for seven days. Over the course of six of these days, I saw a grand total of three incidents, which makes for an average of 0.5 incidents per day. It involved stuff like “Maisy was lying in my lap while we were watching Star Trek. She heard a car go by with loud bass. She lifted her head and growled.” No vigilance, low intensity, and just all around typical dog behavior.

That seventh day, though? Was awful. She had four incidents that day, mostly because my husband was wrong about everything and forced me to yell at him. Okay, not really, but for some reason we were just really crabby with each other that day, and I was amazed by the impact it had on Maisy. Including the seventh day, her logs shoot up to an average of 1 incident a day. Marital bliss is good for more than just the people involved, I guess.

I also took logs after we got home from Thanksgiving. Every year, we spend five days at my parents' house in South Dakota. It's a significant disruption to her routine, there are tons of cats and dogs and horses and chickens, and it's just hard on her. I also took logs last year after we got home, which means I can compare how she recovered both times:

Her stress recovery period actually took longer than I expected, although it's still an improvement over last year.

The coolest thing about all this doesn't come from the numbers, but rather from her general behavior. The video below was taken back in October. I had left work early to do some much needed yard work. It was a very windy day (that white thing you'll see bouncing around is a styrofoam cooler lid), and across the street you can just barely make out approximately 50 elementary school-aged children playing during recess. And through it all, she did this:



Maisy's behavior was not in any way cued or encouraged by me. She chose to lie down. As Dr. Duxbury noted, Maisy's acting like a normal dog. Who knew she had it in her?

Miraculous or not, both Dr. Duxbury and I are quite pleased with Maisy's progress. In fact, the sum total of Dr. Duxbury's advice to me was to continue to be alert to both the environment and Maisy's body language, and to remove her from situations where she might be triggered, but before she reacts. I think I can do that.

Recheck with the Veterinary Behaviorist: Plans for the Future

After all my blathering on, I still haven't gotten to the crux of the appointment: where do we go from here? So today I'm going to share what Dr. Duxbury and I agreed to do next.

Medication
Not ones to mess with a good thing, we are not changing Maisy's paroxetine. She will remain on a daily 10mg dose for the forseeable future. I don't know when/if we'll ever take her off it, but for now, it remains effective and awesome.

However, given how traumatic her recent vet visits were, and considering that Maisy will be staying at a boarding kennel for the first time in her life next month, we decided that we do want have a little something for special occasions.

We did try trazodone at her ultrasound, and I was unimpressed with it then. Still, that day was weird- she was already stressed from her appointment the day before, and the city was doing ripping out the sidewalk in front of our house that day. Plus, Dr. Duxbury really prefers trazodone over the alternatives (it's typically less addicting and seems to have fewer side effects, including paradoxical effects), so we agreed to give it another try, this time on a day when nothing was going on.

Training
Based on the feedback Dr. Duxbury received from our reactive dog class trainer, we discussed the possibility of trying more conventional training classes. (I'm thinking I'll try an advanced rally class, but I might try an advanced obedience class, too- depends on what works best in our schedule, really.)

We're going to take it slow, though.

Maisy and I will remain in our current reactive dog class, but only attend every other week. Dr. Duxbury said we could start taking regular classes immediately, but I think I'm going to take it a bit slower instead. My plan is to go to the club where I plan to take classes every other week and set up Maisy's crate and do the same stuff as we do at reactive dog class: mostly chill in the crate, but have her come out to heel, work on a perch, etc., near the other dogs. I'll probably spend two to three months doing the every-other-week thing before actually signing up and attending a class.

The purpose of doing reactive dog class every other week is to give us a barometer of how Maisy is doing. If Maisy gets reactive in the regular class, but not in reactive dog class, we'll know that she's not ready for the regular class yet. If she gets worked up in the regular class and the reactive dog class, we know there's an issue, but that it's probably not related to the class schedule.

Beyond classes, though, we have two additional assignments: first, I am to condition Maisy to wear a muzzle. This was mostly my idea, but Dr. Duxbury did fit Maisy for a muzzle because I couldn't figure out what size she needed. (As it turns out, she's between sizes.)

 
Second, I am to condition Maisy to love being picked up. She doesn't care for this right now, but if she finds being picked up pleasant, it will make it easier to move her through crowded doorways and spaces without increasing her stress level. It's meant to be a management strategy, to prevent stress, as opposed to something I do in response to stress.

Trialing
Because Maisy did so well just hanging out at the last trial, Dr. Duxbury said we could enter the next one! However, we both agreed that the best course of action is to play it by ear. I'll go, hang out, and if Maisy's doing well, do a day-of-show entry. And then, depending on how she's doing as we enter the ring, I am to seriously consider purposely NQing, and either do just one to two signs, or have a “cookie run” instead of trying to actively compete. Either way, we've been given permission to enter the ring, and I'm happy about that!


Both Dr. Duxbury and I are thrilled with how Maisy's doing. We'll return in three to six months to reassess things again, and I am very excited to see where she's at then.

Recheck with the Veterinary Behaviorist: More Videos

I hope you all don't mind more videos! The difference between the two videos in my last post is so dramatic that I didn't want to detract from them by including extra ones, but I have more that I want to share!

Bike Reactivity
One of Maisy's triggers has always been motion- whether it's a dog running or a bike whizzing past, it's usually unsettling. In the interest of full disclosure, this was one of the areas where we'd made great progress with behavior mod alone. Still, she occasionally had trouble with motion, as this video from last fall indicates:



Since adding medication to the mix, though, she's doing much better with bikes. She's still not entirely comfortable with them (notice how her body stills when she sees them, and how her tail goes up as the pass), but she doesn't feel the need to lunge at them anymore!



Encountering Novel Objects
Maisy has also always struggled with novelty and sudden environmental changes. I was fortunate enough to catch this on tape last fall when we went on our usual walk through the neighborhood only to discover a couch on the side of the road! As you'll see, she's quite cautious to approach the couch, and normal road noises (which she didn't usually find upsetting) caused her to jump.



Compare that to this video I took just a few weeks ago. In it, we encounter a large waste bin in our alley that hadn't been there before. Although she's still cautious, it's much less pronounced than it was with the couch. She approaches, checks it out, and that's that.



Strange/Trigger Dogs
I don't have any good before video, but I have two great videos of Maisy around “trigger dogs.” Maisy was pretty reliably unnerved by large, dark dogs with prick ears- Dobermans, German Shepherds, and Bouviers, for example. In fact, the first dog she ever demonstrated reactivity toward was a Great Dane, so I consider them the ultimate challenge. As it happened, I was going for a walk with a friend, and she had invited another friend with a Great Dane.

It did not end in disaster like I thought it might, although Maisy did lunge at the dog once. It felt horrible at the time, but when I reviewed the video, it didn't seem that bad at all. No barking or growling, and she recovered pretty quickly. In fact, she even laid down about 90 seconds later! She wasn't entirely comfortable (her body is tense, her tail is low, and she's panting mildly), but I still think this is a pretty big deal.



And here's a second video, about 45 minutes later. She's still alert, but more relaxed than in the previous video. She also deserved WAY MORE COOKIES for her behavior here- total mom fail. It was kind of funny, actually, because as we were watching this video at Maisy's appointment, I sighed and said, “I needed to give more cookies,” and Dr. Duxbury kind of laughed and said, “I was just thinking that!”



I am so, so proud of how my little dog is doing. She's improved so much since beginning meds that I can't believe it sometimes. We are now able to do things that I never dreamed possible- hanging out in a group? Unreal. And yet very real. Medication has changed our lives.

Recheck with the Veterinary Behaviorist: Before and After Videos

It probably wasn't fair to leave the last post hanging like that, mostly because Dr. Duxbury and I didn't really discuss the logs. She thanked me for bringing them in, but the bulk of our appointment was spent watching videos.

Because she had three students in the room with her, I showed the “before” videos that complemented the "after" videos so they had a frame of reference. I'm really glad it happened like this, because I don't think we would have watched the before videos otherwise. Why would we have? We both were there, we both remember what Maisy was like... right?

The truth is, when I watched the before videos, my jaw dropped. I didn't remember Maisy being that anxious, that vigilant, that slow to bounce back from stress. What I remember is Maisy being herself, and that she'd improved a lot through the training we'd already done.

Here's the before video. For context, this was taken at my reactive dog class last fall. We were pushing Maisy a little bit harder than usual because we wanted to make sure we got good video for the initial appointment. (I was later told that wasn't necessary, so I do not recommend you do the same thing.)



And here is the after video. There are some differences between the two videos- different location, different dog, different orientation- but not enough to cause the drastic change you will see in Maisy's behavior.



Amazing, right? Let me tell you, if I had had any doubts about whether or not medication was the right choice for my dog, well... they're gone now. Instead, I turned to Dr. Duxbury and said, “Why didn't I do this sooner?”

Recheck with the Veterinary Behaviorist: Behavior Logs

It seems hard to believe that Maisy has been on medication for eight months now. Sometimes it feels like just yesterday that we started this journey, and at others, it feels like it was a lifetime ago. On Monday, we had Maisy's six-month recheck with her veterinary behaviorist, and once again, I must take this opportunity to highly recommend Dr. Duxbury at the University of Minnesota Behavior Department. As always, I absolutely adored working with her. She's full of great insight and is absolutely masterful at reading body language. She has tons of experience, which leaves me feeling very comfortable with her recommendations. And it doesn't hurt that I really like her.

Anyway, I have so much that I want to share about Maisy's progress, about Dr. Duxbury's reactions, and about what the future holds that this will probably take multiple posts. Today's entry will take a look at the behavior logs I kept in the past couple of weeks. (Click here to see past behavior logs.)

Usually, I keep a week or two of logs to get an idea of how Maisy is doing. Her pre-medication baseline was 3-4 anxiety episodes per day, so I was pretty excited to see how she was doing. This set of behavior logs were different, though. You see, right before I planned to start keeping the logs, Maisy ended up in the doggie ER. She then had two back-to-back appointments with a specialist, which she found incredibly stressful. I kept logs anyway knowing that they wouldn't be an accurate representation of how she's doing in general, but feeling like it was my duty. Then I remembered that I have logs from the last time she had a stressful event (five days at my parents' house at Thanksgiving), so I laid them out side by side (click the image to enlarge it):

As you can see, I have data from the day of the stressful event (in both cases, I started keeping logs in the late afternoon), as well as for the subsequent week. The initial response is the same: 3 instances of anxiety vocalizations or startles on the day of the stressful event. And, I'd say that her recovery time is about the same for both sets of data- three full days after the stressful event, although I'd definitely say there was residual stress for a couple days beyond that both times. 

I have to admit, I was a bit disappointed by this. One of my goals was really for Maisy to bounce back quicker after a stressful event, and that has not happened. In fact, now I'm not sure it can happen; I don't know that it's possible to hurry stress hormones out of the body.

However, I am thrilled by how much better she's doing in handling the stress. I mean, check out that graph! The red lines are so much lower than the blue lines! Before, over the full seven-day period, she had an average of 2.86 instances of anxiety per day. Now, that's just 1.14. Before, over the three-day primary recovery period, she had an average of 4 instances per day, and now it's only 2 per day. More than that, the quality of those anxious outbursts has changed. The intensity and duration have gone way down.

So, even though these aren't exactly conventional behavior logs, they are incredibly interesting, and I'm quite happy with Maisy's progress. I absolutely love what Paxil has done for Maisy's quality of life. Of course, now the question is... did Dr. Duxbury agree that the Paxil has been helpful? Was she as impressed by the results of our logs? I'll let you know in my next post...

Rethinking Normal

Maisy chilling at my husband's office- a relatively unfamiliar environment.

This behavior is normal now, but it wasn't six months ago...

Last week, I wrote a post in which I shared a video of Maisy in a fairly busy, novel environment. I was pleased by that big helicopter tail and her willingness to interact with people. I was happy that she was willingly entering the seminar room, and even pulling me to get in. And mostly, even though I knew she was a bit stressed, I was just thrilled with how well she was handling it. She could never have done that six months ago.

So I was quite surprised when Dr. Duxbury, Maisy's veterinary behaviorist, responded to my happy email by saying that she didn't like seeing Maisy so stressed. Now, I knew that Maisy was stressed in the video- she was moving slightly quicker and tighter than usual- but I thought it was pretty subtle. I guess I should be glad that I have a veterinary behaviorist that is skilled enough to see more than I can, but mostly I was embarrassed. After all, while she may be the expert on dog behavior, aren't I supposed to be the expert on my dog?

After several phone calls to trusted trainers (and friends), and what might be a potentially unhealthy level of obsession, I think I've figured out why I missed it. The key was in what Dr. Duxbury said- that Maisy was “on hyperdrive” in the video. In other words- all that moving around? Stress. Even though I know that excessive movement or pacing can be a sign of stress- heck, it was discussed at the very seminar where I took the video- I didn't recognize it as such because I thought it was normal for Maisy.

As Maisy begins to stabilize on medication, I'm learning a very hard lesson: I have no idea who she really is. Sure, I have some clues- she loves playing ball and chasing chickens, for example- but her base personality? Well, it's possible that I'm just now seeing it for the first time.

You see, when Maisy was a puppy, I thought she was a social butterfly. In puppy class, she flitted around on the end of leash, going from person to person, and she never stopped moving. I thought she was simply excited and happy to see everyone. Meanwhile, at home, she had a never-ending source of energy. I never saw her sleep until she was almost six months old, and then only because she'd just been spayed. She was constantly on the go, getting into things and climbing up the stairs obsessively.

As she grew older, the sociability morphed into leash reactivity, while her energetic nature began to express itself in constant scanning and pacing. Although I knew the reactivity and hypervigilance was a problem, I thought the rest was just part of her personality. She's a herding dog mix, after all, and aren't herding breeds known for being sensitive and high-energy?

This explains why I looked at that video and saw Maisy acting normal, and Dr. Duxbury looked at it and saw a stressed dog. For awhile, I played with the idea that she was wrong, that she just doesn't know Maisy as well as I do, that she has no idea who Maisy is. But when I thought about, I realized that wasn't right at all. When I take an honest look at the dog Maisy has become, I am convinced that all that excitement was a symptom of her anxiety.

These days, Maisy is a pretty laid-back little dog. She no longer gets the nightly “zoomies” like she used to, and she isn't constantly dropping a tennis ball in my lap anymore... or chasing the cats... or just wandering around aimlessly. As I write this, she is flopped out on her side next to me on the couch, which is pretty much the norm now. This isn't to say that she's drugged or lethargic; on the contrary, she can go for a two hour off-leash hike, and still be begging for more while I'm dragging my sorry butt back to the car. Even out in public, she's pretty relaxed. For example, when we hung out at the rally trial recently, she spent most of that afternoon in my lap or rolled over onto one hip. And while she was pretty excited to see some of her human friends, it wasn't with the same frantic abandon that she demonstrated in that seminar video.

The truth is, there are enough red flags in Maisy's puppyhood that I believe she suffered from anxiety from an early age. Just because certain behaviors might seem normal for her doesn't mean they're part of her true, non-anxious personality. I can't compare her behavior only to who she was. While it's important to do so in order to recognize how much she's improved, it also leaves me with some pretty big blind spots. I need to check those areas, and instead of assuming that something is simply part of who she is, I need to consider how the average dog would react, and ask myself, “Could this be stress?”

Of course, I know that Maisy is an individual, and as such, she will never conform perfectly to the notion of what a normal dog is, but then, no dog can. Therefore, I also need to compare her behavior to how she acts in familiar environments. Although this might apply to a wide variety of places, she's most comfortable at home, so I need to think about how she might react if we were there instead. If the behavior would seem odd in a familiar context, I need to consider that it might be stress, no matter how often I've seen her do it in the past.

Really, I'm saying that I need to rethink normal. I can't simply pass something off as part of of her personality because I don't really know what that is. Maisy is growing and changing every day, and I'm constantly surprised by what she's capable of now. I can't limit that growth by fixating on a “normal” that's no longer true. Instead, I need to be willing to challenge my assumptions about who she is, and accept who she becomes. Only when I do that can I help her move forward and realize her full potential. It's going to be hard, and I won't always get it right, but it's going to be worth it in the end.

Medication Update: 8 weeks at 10mg

Maisy has now been on the increased dose of paroxetine for 8 weeks, which means that it should be at its full effectiveness. At our recheck appointment with the veterinary behaviorist, Dr. Duxbury commented that the level of improvement Maisy had shown would probably be enough for most people. I, being greedy, wanted more, which is why we increased the medication. I am glad we did, because I’m thrilled with the additional improvement I’ve seen in Maisy.

As you may remember, before beginning the medication, Maisy was averaging 3.58 incidents per day in which she would startle, bark, or growl at mild or undetectable stimuli. About a third of these would happen overnight, waking us both up. These behaviors were pretty intense: approximately 1 in 4 lasted longer than a minute, and she would scan the environment and/or or leave the room to look for the trigger roughly 1 in every 3 times.

After seven weeks on the 8mg dosage, she was averaging 2 incidents per day, and thankfully, the number at night had reduced dramatically, happening roughly 1 time out of 10. Similarly, the duration of her behaviors shortened, and she wasn’t showing any vigilance. You can see the logs for the first two months of medication here.

Now? Well, at 8 weeks on the new dose, she’s averaging 1 incident per day, although it’s honestly hard to label some of them as incidents. For example, on Sunday, she simply looked up and softly “wuffed.” I wrote it down to be consistent, but that sort of thing doesn’t concern me in the least. The average duration of her behaviors is 5.7 seconds, which shows that her vigilance has greatly reduced, and that she recovers quickly. And the absolute best thing? She isn’t waking me up at night anymore.

Here’s the chart for the last two months (click to embiggen):


As you can see, it’s been up and down. She actually did the best at four weeks, with a rough spot at six weeks. I saw a similar trend the first time around, and I’m beginning to wonder if this is just a normal reaction to SSRIs. At any rate, it's clear that the increased dose has had positive behavioral effects.

These effects have carried over to Maisy’s behavior outside our house, as well. Recently, I took Maisy to a pet store on a Saturday afternoon, and it was fairly busy inside. There were rude dogs, men in funny hats and unpredictable children, and yet she handled herself well. In the 45 minutes that we were there, she only had one outburst, a very quick bark at a large golden on a flexi, literally dragging a child wearing clompy boots down the aisle towards us. I can hardly blame her for her reaction! I think the best thing about the visit, though, was that I wasn’t actively managing her. I wasn’t requesting behaviors or shoving treats in her mouth, which is a huge change from how it used to be.

Needless to say, I’m thrilled. After consulting with Dr. Duxbury, we agreed to keep Maisy on this dose. Going forward, I’ll take behavior logs once a month, and then return for a follow-up appointment in June.

Even more exciting… Dr. Duxbury said I could work towards getting Maisy ready for trials again! I've been given orders to take things very slow, so I will be very purposeful about the level of stimulation I expose her to. I am working on a training plan to follow so that I don’t accidentally push Maisy too hard, and I’ll share it with you all soon. If there’s anyone with experience with this, I’d love to hear what you did.

For now, I just want to say that I’m so grateful for the knowledge and experience that Dr. Duxbury has shared with me, the support I’ve gotten from you all, and best of all, my newly relaxed dog. It’s been a crazy journey, but it’s been worth it!

Re-check with the Veterinary Behaviorist

Maisy had her eight week re-check with Dr. Duxbury, her board-certified veterinary behaviorist, on Monday. This appointment lasted longer than I expected- almost two hours- and we reviewed the behavior logs and the charting that I had done. We also discussed my general observations, as well as my goals and hopes for Maisy. I guess I still don’t know if Maisy’s response has been “typical,” but Dr. Duxbury did say that for most people, the level of improvement we’ve seen in Maisy is “enough.”

I don’t want to undermine Maisy’s progress- it’s been phenomenal, and I’m thrilled. In fact, Maisy was incredible in the exam room yesterday. At our first appointment, Maisy alternately paced and sought out interaction. She settled only when I asked her to, and it was very clearly an operant behavior, not a truly relaxed one.

This time around, Maisy was much calmer. She spent most of the time on her mat, and she had a very soft, heavy-lidded look to her eyes. Incidentally, I’ve heard people talk about this look on email lists before, but never really understood what they meant. Now I do, and I must have pointed it out to Dr. Duxbury half a dozen times because I was so amazed. Although she did get up from time to time, her body movements were soft and fluid instead of quick and frantic. She wasn’t pacing so much as she was bored. She was truly a different dog. Dr. Duxbury even said that she wished she’d taken video at Maisy’s initial consult!

With that said, I want more progress. Maybe that makes me greedy, I don’t know, but like Dr. Duxbury said, we won’t know how much more is possible without trying. She certainly didn’t seem to think I was being unreasonable, and I completely trust that she would say something if I was.

We discussed my goals for Maisy. Dr. Duxbury wasn’t surprised that Maisy had a hard time when we were at my parent’s house, but she was a bit concerned by how long it took Maisy to recover. (I actually feel like a three to four day recovery period is a big improvement for her, but I don’t have any data to back that up.) We agreed that a short-acting, as needed medication is probably in Maisy’s best interest. We discussed both trazodone, which is a serotonin modulator, and alprazolam (Xanax), which is a benzodiazepine. Since we don’t have any big events planned for several months, we decided to wait until we’ve decided what to do with her routine meds.

Because I want to see the number of anxiety-provoked reactions around the house reduced from the current average of two per day to something like three or four per week, we agreed to increase Maisy’s paroxetine. Currently, she’s on 8mg (1mg/kilo of body weight), and we decided to increase it to 10mg (1.25mg/kilo). I will continue to keep intermittent behavior logs, and we’ll consult again in four to six weeks. At that time, we’ll discuss increasing to a max of 12mg (1.5mg/kilo) and/or adding a second medication (probably clonidine, a centrally acting alpha-agonist).

Speaking of behavior logs, I totally got a gold star. I’m glad they were useful, because they are an awful lot of work. Honestly, I’m not looking forward to doing more of them, but I can’t deny their importance. Dr. Duxbury’s student analyzed them for patterns (she thought maybe Maisy was having a series of lower-intensity behaviors that culminated in a high-intensity one, but that theory didn’t pan out). We also discussed the fact that some of the stimuli that Maisy is reacting to is reasonable- for example, someone at the door- while some of it isn’t. My new task is to start coding my logs in an effort to pinpoint which type of stimulus is causing most of her reactions.

I will also start doing some desensitization and counter-conditioning around the house. I decided to focus primarily on interactions with the cats, mostly in an effort to help reduce the stress in their lives, too. Dr. Duxbury also recommended giving a treat when Maisy startles but doesn’t go over the top. Obviously, being consistent with this will yield the best results, so I’m going to have to pay close attention to what’s going on. I will also need to have treats close by, which may result in my being mugged for a few days. This could be interesting!

Like I said, it was a great appointment, and I was absolutely thrilled with the professionalism, respect and attention we received. Seriously, if anyone in the area needs a vet behaviorist, I can’t recommend Dr. Duxbury enough.

Medication Update: 8 Week Re-Check

Maisy has a re-check appointment with Dr. Duxbury, her veterinary behaviorist, this week. We are going to evaluate her response to Paxil, the current dosage, and consider if an additional medication might be helpful. I’ve kind of been freaking out about this. I have no idea if Maisy’s response to the meds is typical; maybe the average dog is doing better (or worse) at this point. But I guess this is why I hired a professional, right?

There is much less preparation to be done this time around; no form to fill out and no videos to be taken. Because I’m a geek, I have been keeping behavior logs, although the behaviorist didn’t request them. Instead, I was told to be ready to share my general impressions of how Maisy’s doing, and the areas of continuing difficulty.

I find this incredibly overwhelming. I think she’s doing well, and I’m happy that I chose to put her on medication. But she’s not doing as well as I hoped, and I have no idea how much improvement is reasonable to expect. I don’t think Maisy will ever be “normal,” but how close can we get without overmedicating her?

After several days of panic, and many scribbled pages of notes, I realized that it would be easiest to think in terms of goals. How would I like to see Maisy behave? What do I want to see change? In the paperwork I filled out prior to her consult, I identified two goals: for Maisy to be able to relax, and (if possible) to be able to take her to trials again. Although I still have these goals, I’ve expanded on them so that I have a better idea of what I’m looking for. I’ve also prioritized them, because it’s far more important that she can relax at home than at a trial. I’ve listed these goals below, along with my comments on her progress.

1. Ability to relax at home. Specifically, I want Maisy to be able to hang out and/or take naps without startling over undetectable or minor environmental stimuli. Overall, she’s improved. Her vigilance has reduced, as well as frequency of outbursts. The outbursts are lower intensity and lower duration. She is less restless, and is choosing to nap instead of seek constant interactions with others. She is sleeping more often and more soundly, and is demonstrating increased impulse control around the cats.

2. Ability to settle in low-stimulation environments. If I take her to a friend or family member’s house, I’d like for her to feel comfortable enough to lie down and chill instead of pacing or wandering around. Although my parents thought Maisy did well at their house over Thanksgiving, and commented that she seemed calmer, I think that her vigilance and outbursts were on par with baseline data, or possibly even higher. (I wish I’d done behavior logs at their house.) Also, she paced the entire time we were at my grandparents’ house one afternoon, and couldn't settle, even when there were treats involved.

3. Ability to sleep in low-stimulation environments, especially for overnight trips to a family member’s house, but also at hotels. Maisy didn’t sleep the first night at my parents’ house, instead pacing most of the night, punctuated with barking outbursts. After about 12 hours, she seemed to get used to the environment, and was sleeping better than she had prior to medication (even at home), but not as well as she had been when I did the logs for the six-week update.

4. Ability to recover from stressful events within 24 to 48 hours. Maisy had an average of 3.75 outbursts a day for approximately four days after returning home from my parents’ house, at which point they reduced to the six-week levels, or maybe even a bit better. Despite the frequency of outbursts, 40% were silent (compared to 14% at baseline), which seems good. She was able to sleep (and absolutely crashed the night we got home), although not as well as she’d been doing prior to the trip.

5. Ability to go to trials without demonstrating reactivity. Bonus points if she can relax in her crate at a trial, or can do full days and/or multiple days. Obviously, we haven’t tried this yet. We’ll continue to wait and watch to see if it’s appropriate. It may not be, but I would really like to be able to do at least a single run at a small trial once or twice a year. That said, I do recognize that it’s not likely that she’ll ever be in it for the long haul.


Overall, while I’m pleased with Maisy’s progress, I’m hoping for more. I’m looking forward to discussing everything with Dr. Duxbury, and can't wait to tell you guys about the appointment. It's sure to be interesting!

Marydale Park

I think I’ve discovered one of the greatest ironies in owning a reactive dog: the daily walk.

The exercise inherent in a walk seems to reduce anxiety, which means that walking is a vital part of helping my dog feel better. I certainly noticed a correlation between exercise (or the lack of it) and subsequent behavior in my behavior logs. At the same time, walks can really set a cautious or fearful dog back. After all, you can’t control what you encounter, like loose dogs. In fact, I’ve found that when such unpredictable events happen, Maisy needs at least a week to recover, and even then, I think the effects are longer lasting.

This became a point of conversation at Maisy’s recent appointment with her veterinary behaviorist. Since April, we have encountered many loose dogs while walking in our neighborhood, and we’ve had several close encounters. Three required the use of citronella spray, two were reported to animal control, and all left me feeling panicky. As a result, I began to seek out alternative places to walk, but had little success. The best option I’d found was walking at Como Lake, a beautiful but popular destination that was just too busy to be relaxing.

This week, on a whim, I stopped off at a small park, with an even smaller lake, halfway between Como and my house. I’ve driven past it dozens of time without a second thought, both because of its size and its proximity to its more popular cousin. As it turns out, though, this makes it perfect for us. We rarely encounter any one else at this park, and so far, we’ve never seen another dog, on-leash or otherwise. Better yet, the probability that we will encounter a loose dog seems quite low; only two of the four streets surrounding the park are residential, and those have a minimum of 50 feet between the path and the road.

Although the lake is small, the walking path around it is just over half a mile in length. This really is ideal, because it means that on the nights I’m in a hurry/tired/lazy/the weather sucks, we can bang out a quick walk in almost no time. Or, we can loop the lake two or three times and have a respectable walk. Hopefully, this repetition will not get boring, but hey- I’ll take boring and safe over interesting and unpredictable any day.

I’m pretty excited by this find, naturally, and I hope that it really is as amazing as it seems. In case it isn’t, though… where do the rest of you with reactive dogs take them for walks? Are you fortunate enough to live in a quieter area? Do you drive your dog somewhere so you can take her for a walk? Do you do something else entirely for exercise? I’d love to hear how others handle this daily challenge.

Small Changes Yield Big Results

She might have her chin down, but she's sure not relaxed!

I’ve known for a long time that Maisy is very sensitive to my moods. At her appointment with the veterinary behaviorist on Monday, Dr. Duxbury saw that, too. She said in her report that during the appointment, “Maisy was exquisitely responsive to [me] but most of her 'relaxed behaviors' (e.g. resting her head on floor, laying on one hip) appeared to be highly reinforced operant responses vs. truly relaxed.”

She went on to acknowledge that this is a tricky area in which to work; while you need to start somewhere, it’s easy to fall into the trap of operantly relaxed, where it’s clear that Maisy is “on” and working, and not actually relaxing. With that in mind, Dr. Duxbury made some suggestions on how I can tweak my current handling in order to promote real relaxation as the medication begins to work.

Relax
Unsurprisingly, Dr. Duxbury said that because Maisy takes so many cues from me, I need to be make sure I’m relaxed. She advised me to make a conscious effort to breathe and relax my neck and shoulders. This is much easier said than done!

Slow down
Dr. Duxbury told me that I need to slow down both my physical and verbal interactions with Maisy. She highly recommended that I don’t use a marker with Maisy because it “keeps the response very operant,” and “interrupts and… ends the behavior.” I quit using a clicker for behavior modification long ago, but I think I will reduce my use of a verbal marker, too. I will still praise Maisy occasionally, but Dr. Duxbury cautioned me thatI need to slow down and speak softly so that I’m not so exciting that it encourages Maisy to get up.

Likewise, I need to be mindful of how I deliver food rewards. She said I need to be much slower in my hand movements, because I have a tendency to be “so quick with [my] food rewards that [I] encourage quickness in her response.” A lot of my quickness has developed because I want to get the treat to Maisy while she’s still performing the behavior. Dr. Duxbury acknowledged that I’m right to be concerned about this timing, but recommended using negative punishment- that is, the removal of the food treat if Maisy tries to leave her relaxed position- to help ensure I’m rewarding the position I want.

I tried this out in my reactive dog class on Tuesday, and it worked fabulously. I put Maisy in her crate, and when she moved into a more relaxed position, such as lying her chin on the floor, I very softly said “gooooooood giiiiiiirl.” I then offered her a treat, using slow, fluid motions. Predictably, she would lift her head or even jump up. When she did, I (slowly) moved my hand away. When she put her chin down, I again moved (slowly, fluidly) to give her the treat. Initially, I allowed very small movements to get the treat, but by the end of class, Maisy was able to lie much quieter as she took the treat. Incidentally, she also rolled over flat on her side, and was possibly the most relaxed I’ve ever seen her at class- even her legs (which usually stick straight out without touching the ground) were becoming soft and loose.

Rest
Dr. Duxbury said that while it has previously been necessary for me to manage Maisy by providing her with a lot of stimulation (such as through training or playing ball), I need to be careful that this doesn’t prevent her from resting. I will need to reduce the amount of management I do, especially the number of treats I give, and I will need to start allowing her to entertain herself.

To that end, while I should continue the relaxation protocol, I need to do it both in her crate and outside of her crate/on a mat. She said these should be considered two completely separate exercises. Further, she recommended routinely encouraging Maisy to rest quietly on her mat for 20-30 minutes a day instead of trying to keep her engaged in an activity. As the medication begins to take effect, I will hopefully see Maisy shift over into actual resting instead of operant relaxation. When I see this, she advised me not to interrupt her because “rest is also its own reward, and [I] can just allow it to happen.”

Balance
Finally, I need to remain attentive to Maisy’s needs. If there is a lot going on in the environment, I may need to switch back to management temporarily. As she wrote, “it is appropriate for [me] to move her away [from the situation] and fire treats at her as rapidly as necessary to reward her for mentally staying with [me].”


I really appreciated that Dr. Duxbury took quite a bit of time during our appointment to help me practice these steps. I learn best by doing, so even though all of this is stuff I’ve been told to do before, having her coach me on how and when to give treats was very helpful.

I am very encouraged by the success we had at class this week, and so I think I’m going to start over with the relaxation protocol. Maisy’s response has been very operant, and that is not at all what I want with it. Instead of following the program so rigidly by treating at the completion of each exercise, I will try to treat only for relaxed responses. I’ll continue with the slow, fluid treat delivery, too. I’m very excited to see how this goes!

Why, yes, she does.

Recently, I wondered if Maisy might have Generalized Anxiety Disorder. As a result, I scheduled an appointment with a board-certified veterinary behaviorist to find out. The short answer is yes. But the long answer is probably more interesting…

So, Maisy had her appointment with Dr. Duxbury yesterday. Before I go any further, let me just say that I really enjoyed working with Dr. Duxbury. Since she has so much education and experience, I was nervous that she might be one of those ego-driven specialists you run into from time to time, but nothing could be further from the truth! I really felt that Dr. Duxbury took the time to listen to what I was saying, and she was very respectful of me and the work I’ve done with Maisy. If anyone in the Twin Cities metro area needs a veterinary behaviorist, I would highly recommend her. It was an expensive appointment, but it was worth it.

The actual appointment was about 90 minutes long. Dr. Duxbury complimented me on the pre-appointment questionnaire I had sent in advance; I gave enough details that she had a really good picture of who Maisy is. This ended up saving a lot of time because she didn’t need to take much history from me. In fact, apparently I described things so well that she didn’t even review our behavior logs! Instead, we jumped right into watching videos.

I had about an hour’s worth of video that I had taken at home, in class, while on walks, and even at trials. I really enjoyed watching the videos with her, mostly because she found them so interesting. In fact, she ended up copying all of the videos I brought in so she can use them with her advanced students. She said Maisy is an excellent example of a “complicated case,” and that it will be very helpful for her students to see the video.

I think the video she liked best was the one below. It’s long- 10 minutes- but this is a very typical snapshot of Maisy “relaxing” at home. (The action starts around two minutes in.) Dr. Duxbury was especially interested in the interactions with the cats you see towards the end of the video, especially the stereotypic tail chasing.



Dr. Duxbury’s assessment of Maisy, after viewing the videos, and interacting with her in person, is that she is “functionally anxious.” Dr. Duxbury complimented me on the work I’ve done with her, and said that Maisy might not have been functional at all had circumstances been different for her. Here’s what she wrote in her report:
You have done a wonderful job trying to help Maisy learn to relax and to not react to other dogs and other environmental stimuli. Her continued reactivity and vigilance even in her 'safest' environments (e.g. at your home) suggests that she is generally anxious. This is likely related to her very limited early environment.

I also appreciated that Dr. Duxbury saw Maisy’s good qualities. Most people are quite charmed by Maisy when they meet her- she’s cute, of course, but she has a personality that just doesn’t stop. In fact, it is sometimes hard for people to see that she has issues because she is so functional. Dr. Duxbury described her as “outgoing and social and very eager to play and to work on training, but at the same time she seems overly attentive to subtle stimuli in her environment and reacts… to other dogs.”

Ultimately, Dr. Duxbury diagnosed Maisy as follows:

• Fear related aggression (lunging, barking, growling only -- no bites) to unfamiliar dogs and certain unfamiliar people.
• Resource guarding - directed towards the cats.
• Generalized anxiety - increased sensitivity to environmental stimuli, exaggerated startle response, hypervigilance, long recovery after arousing events.

The main component of the treatment plan was, as I’d hoped, medication. Dr. Duxbury prescribed paroxetine (also known as Paxil). She said she’s had really good results with paroxetine for dogs like Maisy, and felt that it would be the best choice for her given her particular set of issues. The only downside to paroxetine is the dosage- Maisy will be taking 8mg a day, and it generally comes in 10mg tabs. Since that would be very difficult to split accurately, it will need be ordered from a compounding pharmacy, which increases the cost. (Of course, the upside to that is that it will be salmon flavored, which will make it much easier for us to give!)

Dr. Duxbury didn’t have any further suggestions for types of behavior modification. She said that about the only thing I haven’t tried is BAT, which she didn’t feel would be helpful for Maisy (although she didn’t rule it out for the future). She said that I should continue to do what I’m doing, including my classes with my current trainer, Robin Sallie.

She did have some suggestions on how I carry out the behavior modification. These suggestions are relatively small changes to how I do things, and probably things Robin has told me to do a million times before (in fact, I actually asked her if she’d talked to Robin in advance, it sounded so much like her!). Despite being fairly minor revisions to our training, I suspect that they will, in conjunction with the medication, make a huge impact on Maisy. Because of that, I’ll dedicate a separate post to the topic.

Anyway, Maisy will start her medication as soon as it arrives from the pharmacy. We probably won’t see any changes in her behavior until she’s been on it for 4-6 weeks, so she’ll have a recheck with Dr. Duxbury in about 8 weeks. At that appointment, we’ll discuss the medication, the dosage, and whether or not we want to add a second med to the mix (something which Dr. Duxbury said may be needed for Maisy). While I don't believe Maisy will ever be "normal," I am pretty excited to see how this will help.

Behavior Logs

When you schedule an appointment with a veterinary behaviorist at the U of M, you’re asked to do a number of things. First, there’s a 12 page history form, which I found both frustrating (I don’t do well with rating things according a numerical scale), and perplexing (Is Maisy my best friend? Does she understand me better than anyone else in the world? What are they hoping to learn about us by asking these things?). You also have to get video of the problem behaviors, and while I thought this would be the hard, but ended up with nearly an hour of footage within two days. But the most difficult task, at least for me, is completing a behavior log.

The idea seemed simple in theory: every time Maisy showed a problematic behavior, I was to note the date, the circumstances, who was around, where we were, what she did, and what I thought caused the behavior. Since I love charts and checklists, I mocked up handy chart in Excel and printed it out.

Filling out the chart was difficult, though. I knew which behaviors I wanted to track, but underestimated how tricky it is to categorize some of the things Maisy does. For example, where’s the line between being startled by something reasonable and overreacting? How large must the reaction be, or how often must you see it, before you can write down that she was jumpy?

I also didn’t realize just how often she engaged in weird and potentially troublesome behaviors- I quickly ran out of room on the chart I’d printed up and had to revise it. Besides, should I list each individual jump, or is it better to capture the number of instances in a set amount of time? And of course, what exactly is “normal” quirky and what is “bad” quirky? Which things are worth writing down, and which are inconsequential?

I ended up with a lot of data, and even then, I know I didn’t capture everything. I don’t mean the fact that I couldn’t write down what I didn’t see, while I was at work or while I was asleep. I found that I’m so used to Maisy’s odd habits that I took them for granted. I saw things that I’d never really noticed before. And even then, things still slipped past me; it wasn’t until the last day of charting that I realized, hey, maybe carrying around a stuffed bunny head and whining every night for five minutes isn’t the most normal behavior.

Despite the difficulties, the behavior logs revealed some very interesting things about a dog who I thought I knew very well. After reviewing my logs, I’ve refined the way I describe her, I’ve learned things I didn’t know before, and I’ve begun to see patterns in her behavior. This is just an overview of what I learned:

Maisy is better described as “restless” than “jumpy.”
A lot of what I had previously described as fear was less about being startled by something and more about being unable to relax. For example, during a 45 minute nap one day, there were 11 times that Maisy lifted her head and looked around for up to two minutes following a soft noise. The longest I saw her remain resting during the week was 15 minutes. Maisy just can’t tune out environmental stimuli the way normal dogs can. Yes, she does have moments where she’s startled by something (legitimately or not), but more often, she’s just having trouble tuning out normal things.

Maisy wakes up frequently during the night.
I kept the log on my bedside stand, which is a good thing, because in the mornings, I’d look at it, read my barely legible notes, and think to myself, “I do not remember that happening.” But indeed, she woke me up growling or barking multiple times a night. Considering the fact that she’s so restless during low-key times of the day, this really isn’t that surprising. Still, I’m amazed that I didn’t remember it in the mornings. And hey- now I understand why I feel so tired all the time.

Maisy’s relationship with our cats is far more complicated than I realized.
I was even more surprised that she has so many cat issues. I knew that she does some resource guarding towards them, but I never thought much about it. Those cats are relentless in their quest for food, so I wasn’t surprised that Maisy needed to fend them off from time to time. But I didn’t realize that this behavior has carried over to “disciplining” the cats when they’re naughty. I have no idea if that’s what she’s actually doing, but that’s sure what it looks like. She will rush at the cats and nip them if they do something wrong, by which I mean, stuff that we’ve yelled at them for in the past like scratching furniture and jumping on the counter.

Maisy’s leash reactivity tends to happen when the other dog is already retreating.
I was surprised by how often Maisy’s reactivity happens after the fact- eight out of eleven documented instances happened after the person/dog was leaving, not as they were approaching. (I was surprised that she had so many instances of reactivity, too, but then I realized almost half were deliberate set ups in class so that we could capture video. Still- there were a number of small reactions that I probably wouldn’t have thought much about if it weren’t for the fact that I’m paying such close attention.)


Those first two things really confirmed that this appointment is the right thing to do. Maisy is clearly on edge much of the time. If the veterinary behaviorist recommends medication, I will have no objections to giving it. Given her restlessness, and given the fact that I documented 43 instances of barking or growling over very minor or undetectable stimuli, it almost seems inhumane not to give her some chemical support.

The behavior logs also helped me see some training opportunities. For example, there is a lot I can do to promote a more harmonious relationship between Maisy and our cats now that I know it’s a problem. The logs have also given me a nice baseline. I wish I had them from a year ago, back when we were first starting the hardcore behavior mod work. I’m glad I’ll have some basis for comparison in the future.

All in all, keeping a behavior log, though challenging, was incredibly eye-opening, and I highly, highly recommend that any of you with “quirky” dogs keep a log for a week or so, too.

What is Generalized Anxiety Disorder? (And Does Maisy Have It?)

This is what puppy-hood was like. Endlessly.

Maisy has never been a “normal” dog. Most of my pictures of her as a puppy have motion blur, and not just because I have a cheap point-and-shoot. She just never slept. At three months, she became overly upset at the appearance of a soda can in the bathroom. And when she took her CGC test at eight months, the evaluator wrote on the form, “seems a little nervous.”

“Little” was an understatement. Although Maisy is generally a very outgoing and curious dog, she is also very cautious and worried about new experiences. I know this sounds contradictory, but to a certain degree, I think this is normal for many reactive dogs- they feel conflicted about what’s going on around them, and react accordingly. But Maisy sometimes seems even more conflicted about things. For a long time, I simply thought she was “quirky,” but when a friend shared a handout on Generalized Anxiety Disorder with me, I began to think differently.

So, what is Generalized Anxiety Disorder (GAD)? It is when a dog consistently overreacts to things, is more active than would be seen in a normal dog, and is excessively vigilant to its surroundings. The key here is the extreme nature of the dog’s reactions; these reactions will be seen even when there isn’t a “truly provocative stimulus.” Further, there is rarely a pattern to the things that cause this overreaction. For example, if a dog overreacts only to thunderstorms, it may still be anxious, but it would not be diagnosed with GAD.

Dogs with GAD are typically wary of things or startle at things in a way that seems out of proportion with the actual stimulus. Even when a reaction seems to be justified, the reaction is still more intense than what would be expected. They are often very light sleepers who awaken easily. They may be destructive, but there’s no true pattern to their destructiveness. They might have some general reactivity to unfamiliar people or places. Physically, they may demonstrate regular vomiting, diarrhea, itchiness or rashes.

Does Maisy have GAD? Well… it sure sounds like her. Incredibly active? Check. Overreacts to things? Check. Vigilant about her environment? Check. She is definitely a light sleeper, and she certainly startles often. She had some of the physical symptoms as a puppy. But other things don’t fit the diagnosis. For example, she’s never been destructive. While Maisy has always demonstrated a lot of caution with new objects, she’s actually pretty friendly and interested in meeting most new dogs and people.

I don’t know if she actually meets the diagnostic criteria for GAD. GAD is considered a diagnosis of “last resort”- most anxiety can be categorized in some other way, such as separation anxiety or thunderstorm phobia. Still, she is anxious in general, so in order to resolve this mystery, Maisy has an appointment next week with Dr. Duxbury, one of only 51 board-certified veterinary behaviorists in the US and Canada.

I am both excited and nervous about this appointment. Dogs with GAD do not easily learn to ignore the things that upset them, and as a result, medication is often needed. I don’t know if Maisy needs medication, but I’ll be honest: I think I am approaching the limits of my abilities. Maisy has improved incredibly in the year-and-a-half that I’ve been doing behavior modification with her, but she still seems so uncomfortable in her own skin sometimes. So, even though I’m not crazy about the idea of medications- I trend more holistic most of the time, after all- I can’t help but wonder if it isn’t the kindest thing I can do for her.

(Note: the handout, and this post, is based on Dr. Karen Overall’s Clinical Behavioral Medicine for Small Animals, 2nd Ed..)