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Exercise as an Effective Treatment for Reducing the Signs and Symptoms of Anxiety Disorders, Specifically Panic and Generalized Anxiety Disorder

Lily MocharyU.S. Adult Mental Illness Surveillance ReportMeasured prevalence of mental illness in the United Sates25% U.S. adults have a mental illness Nearly 50% will develop a mental illness during their lifetimeYear 2002- $300 billion economic burden Released on September 2011, the US Mental Illness Surveillance Report measured the prevalence of mental health in the United States. Based on population surveys and Health care surveys.

Mental illness is a blanket term for all diagnosable mood disorders. Characterisitics of mental illness include sustained abnormal thinking, mood or behavior patterns. Mental illness is very dibilitating and impairs daily function affecting ones personal, social, and occupational life. And leads to premature death2Mean Number of Mental Unhealthy Days during the past 30 days

http://www.cdc.gov/mentalhealthsurveillance/images.html2009 * Survey question: "Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the last 30 days was your mental health not good?"3More from the reportMore disability in developed countries than any other group of illnesses (cancer or heart disease)Associated with increase risk for chronic diseasesAssociated with lower use of medical careHigher risk for self injury. Conclusions- most of the efforts of the report focused on depression. Although, anxiety disorders have very similar characteristics. More efforts need to be made at the state and national level to document anxiety disorder in the US. 4Anxiety DisorderAnxiety disorders are the most common mental illnesses among adults in the United States. Characterized by excessive and unrealistic worry about everyday tasks or events, maybe specific objects; lasting for at least 6 months

Not like the anxiety you feel before public speaking, or taking a test. Anxiety disorder is diagnosed by having feelings of fear last for at least 6 months and they can get worse if they go untreated. 5

http://www.nimh.nih.gov/statistics/1ANYANX_ADULT.shtmlFor Anxiety Disorder Specifically 6Anxiety DisordersPanic disorderObsessive-compulsive disorder (OCD)Post-traumatic stress disorder (PTSD)Social phobiaSpecific phobiasGeneralized anxiety disorder (GAD)

These are the 6 different diagnosable anxiety disorders. Although they all have specific characteristics, they all center around an excessive feeling of fear and dread. Anxiety disorders can often overlap and/or occur alongside other mental illnesses or substance/alcohol abuse. The substance or alcohol abuse can mask the symptoms of anxiety disorder or make them worse. Most of the the time the other illnesses or underlying cause of the anxiety needs to be treated first.

Panic disorder- sudden attacks of terror, pounding heart, faintness, weakness, sweatiness, a sense of doom, extreme fear, think they are having a heart attacl, cannot predict when they will happen and experience extreme anxiety in between attacks ( waiting for it to happen )- affects about 6 million Americans - can lead to agoraphobia ( fear of open spaces) if not treated, person starts to fear where they the panic attack occurred ex: elevator - really restrict their lives - often goes undiagnosedOCD- use rituals to control anxiety - affects 2.2 millionPTSD- develops persistent anxiety after a traumatic event, has flashbacks (war, rape, fatal accident)-7.7 million americans Social phobia- afraid of scoial situations, always think they are being crtiticized and judged by others - 15 million americans Specific phobias intense irrational fear of something often involving closed spaces -19.2 million americans GAD- worries excessivley about a variety of every day problems, anticiapte disaster, overly concerned about daily issues - cant relax, have trouble concentrating, have trouble falling sleep - Physical symptpms fatigue, muscle cramps, head aches, muscle tension, trembling, twitching, irritability, sweating, nausea, - develops gradually, highest risk between childhood and middle age- genes play a modest role - 6.8 million americans

7TreatmentMedication and/or psychotherapyCommon medications:Antidepressants (SSRIs, Tricyclics, MAOIs)Anti-anxiety (Benzodiazepines) Beta blockersPsychotherapyCognitive Behavioral Therapy

Exposure techniques 8ProblemsAdverse side effects Easy to build a tolerance (drug abuse)Benzodiazepines are often prescribed to patients for only a short period of timeAnxiety can abruptly return after the medication is stopped, and patient often experience withdrawal symptomsExercise and Mental HealthEpidemiological StudiesCorrelationsRegular PA associated with decreased risk for mental illnessMore likely to recover from mental illness if engaging in PAIn the general population, several epidemiological studies have found significant cross-sectional correlations between mental health and PA levels. In an adult US population, regular PA is associated with a significantly decreased prevalence of current major depression, panic disorder, agoraphobia, social phobia, and specific phobia [2]. A study from Norway confirmed this negative cross-sectional association between depression and leisure-time PA of any intensity (not work-related PA), and pointed out that social factors such as social support, rather than biological markers, play an important role [3]. Recently, a Dutch study replicated this finding, reporting lower rates of any affective, anxiety, or substance use disorder in subjects who exercised at least 1 h/wk, without finding a linear dose-response relationship [4].Prospectively, the overall incidence of mental disorders and co-morbid mental disorders, as well as the incidence of anxiety, somatoform, and dysthymic disorder, decreases by PA [5]. Furthermore, a four-year prospective study revealed that PA decreases the incidence rates of depressive and anxiety disorders in older adults [6]. Finally, ten Have et al. reported in their epidemiological study that patients engaging in regular PA were more likely to recover from their mental illness at a three-year follow-up [4].10MechanismsIncreases neurotransmittersSerotonin, endorphinsExercise has neuroprotective effects Balances levels of brain-derived neurotrophic factor (BDNF)

Other psychological benefits- positive health attitudes/behaviors, body image, coping strategies

Hypothesis Is Exercise an Effective Treatment for Reducing the Signs and Symptoms of Anxiety Disorders, Specifically Panic and Generalized Anxiety Disorder?

StudyBroocks A, Bandelow B, Pekrun G, George A, Meyer T, Bartmann U, et al. Comparison of aerobic exercise, clomipramine, and placebo in the treatment of panic disorder. Am J Psychiatry 1998; 155: 6039.

Key TermsClomipramine- tricyclic antidepressantUsed to treat OCD, depression, chronic pain, bulimia, sleep disorders, and panic disorderSide effects: dry mouth, upset stomach, nausea, loss of appetite, decreased sex drive, constipation, dizziness, drowsiness, tired PurposeThe purpose of this study was to examine the anxiolytic effects of aerobic exercise compared to pharmocotherapy and a placebo in patients with panic disorder. Design46 patients with Panic DisorderRandomly assigned to 10 week treatmentPlacebo (control) (15)Clomipramine, 37.5 mg (15)Tapered dosage of 1 per day to 3 per dayExercise (16)4 mile walk, 3-4 times per week for first 2 weeksEncouraged to be able to run entire route by end of treatmentMet with trainer for group run once a weekPatients- recruited by physician referral from an Outpatient Anxiety Disorders Unit of the Department of Psychiatry in Gottingen, Germany- diagnosed by the structural clinical interview for DSM III-R- exclusion pregnant, severe major depression, psychotic symptoms, drug dependency, eating disorder, or regular aerobic exercise During treatment- not allowed additional psychological treatment, but could talk to any of the therapists at any time, met once a week with therapist, then once every 2 weeks interaction restricted to general support (no CBT) - had to stop medication 3 weeks before, only promethazine was allowed for severe attacks

Exercise- based on general reccomendations for the public - emphasis put on completion of the route rather than being able to run it, at least 3 times a weekAll patients had to complete activity diaries 17Measures2, 4, 6, 8 and 10 weeksPrimary Tests The Hamilton Anxiety Rating ScalePanic and Agoraphobia Scale (observer and patient rated)Clinical Global Impression

Panic and Agoraphobia scale- measures severity in patients, 14 items with a Likert scale- intensity and frequency of panic attacks- agoraphobia- anticipatory anxiety- disability- health related concerns

Clinical Global Impression improvement scale, measures how the illness has improved or worsened since baseline 18

Drop out rate- 31% for exercise- 27 % for placebo- none for drug group

Significant effects of clomipramine at 4 weeks BOTTOM LEFT AND UPPER RIGHT - even more significant at 6, 8, and 10 weeks in all 4

Exercise significantly different from placebo at 8 weeks and at the end in all except BOTTOM RIGHT

Clomipramine signifacntly more effective than exercise at 4 6 and 8 in all 4, but ONLY more significant at the VERY END of the BOTTOM LEFT

SIDE EFFECTS- exercise muscle joint and pain but dissapeared as the treatment went on- clomipramine- SINGIFCANTLY more side affects, dry mouth, sweating, mild tremor, dizziness, tachychardia, constipation, diahrea, imparied sexual function 20ConclusionsExercise had significant improvements in all primary measure outcomes when compared to placeboClomipramine also highly effective, improved symptoms more significantly than exercise and earlier in treatment CritiqueProsConsLarge sample sizeCompared exercise to pharmocatherapy High drop out rateShort duration Specific participant criteriaNot truly blindExercise too variableNo anaerobic exerciseToo many variablesSocial interactionspromethazineMechanism?

Herring MP, Jacob ML, Suveg C, O'Connor P. Effects of short-term exercise training on signs and symptoms of generalized anxiety disorder. Ment Health Phys Act. 2011;4(2):7177.StudyKEY TERMSTrait anxiety tendency to experience anxiety, referring to characteristic anxiety disorder (not STATE anxiety) Effect size- measures the strength of a relationship between two variablesPurposeTo compare the effects of resistance training and aerobic training on the signs and symptoms of generalized anxiety disorder Design30 sedentary women clinically diagnosed by DSM- IV with generalized anxiety disorderThree groups Resistance Exercise Training (RET):2x per wk, 6 wksLeg press, curl, extension7 sets, 10 reps, 50% 1 RMAerobic Exercise Training (AET):Cycling 2x per wk, 16 minWait ListNo treatmentStill completed outcomes

Participants- recrutied from around Athens GA- severity rating greater than 4 on the Anxiety Disorders Interview Schedule test - required to have HIGH worry symptoms and be inactive - inactivity based on 7 day recall could not exceed 260 kCal per day

RET: consisted of only lower body exercise, 2x per week, for 6 weeks - leg press, leg curl, leg extension- 7 sets, 10 repetitions each - 50% 1 RM, increasing by 5 % each week- warm up set 10 reps of each exercise, 35% 1 RM first week, then increasing by 5 %

AET- matched RET in time, intensity and part of body- 2x a week, cycled 16 min, for 6 weeks - intensity increased by 5% each week26Outcome Measures Difficulty with concentration, trait anxiety, symptoms of depression, anxiety-tension, low vigor, fatigue and confusion, irritability, muscle tensions and painHR and RPE (secondary measures)RET: after each exercise and end of sessionAET: 2, 7, and 15 min and end of session

Trait anxiety was measured by the Trait Anxiety Inventory. Anxiety tensions, vigor, fatigue and confusion were measured by the Profile of Moos States-Brief form. Irritability was measured by the Irritability Questionnare. Depression was measured by the Beck Depression Inventory. Concentration was measured by a psychomotor vigilance task. A bullseye would appear on a screen and patients had to react by pressing a button. Finally, muscle tension was measured by physiological tremor; patients were asked to draw on the body where they felt pain. 27

RESULTS

WEIGHT LIFTING GROUPSignificant improvement in pain intensity at WEEK 4

AET GROUPSignificant improvement in pain intensity at WEEK 2 AND 4Mean reaction time at WEEK 6

29

RET FREQUENCY AND INSTENSITY OF IRRITABILITY AT WEEK 6 FOR 30

RET

Anxiety- tension at WEEK 631

Comparing the effects RT and AET have on specific signs/ symptoms

RET condition resulted in six-week Hedges d effect sizes of 0.36 in trait anxiety, depression, concentration, fatigue, vigor and pain intensity, while the AET condition resulted in improvements of this magnitude intrait anxiety, concentration, fatigue, vigor, irritability and muscle tension

MEANING: RET and AET have similar effects on trait anxiety, concentration, fatigue, and vigor32ConclusionsShort-term RET and AET can improve signs and symptoms associated with GAD especially:IrritabilityAnxietyLow vigorPain

CritiqueProsConsClinically diagnosed with GADMatched RT and AETOutcomes measured were specific to GAD signs and symptomsAll women, small sample sizeNo drug therapy to compareRPE different for each exerciseMechanisms?Statistical jargon Too many tests Merom D, Phongsavan P, Wagner R, Chey T, Marnane C, Steel Z, et al. Promoting walking as an adjunct intervention to group cognitive behavioral therapy for anxiety disorders: a pilot group randomized trial. J Anxiety Disord. 2008;22(6):959968.

PurposeTo compare a home-based walking intervention adjunct a group cognitive behavior therapy treatment with group cognitive therapy treatment adjunct educational sessions Design85 patients from outpatient anxiety disorder clinic with GAD, Panic Disorder or Social PhobiaGCBT90 min session 1x/wk for 8 wksGCBT + EXGCBT + ED

85 patients from an outpatient anxiety clinic in South Western Sydney participated in this study. Each participant was diagnosed with either General Anxiety Disorder, Panic disorder or Social Phobia by the Structured Clinical Interview for the DSM-IV. The participants were informed about the walking program by a letter which told them it was an optional program. Once the researchers had 8 people with the same disorder, they were randomly assigned to either the GCBT+EX treatment group or the GCBT+ ED treatment group. The participants also completed self report physical activity measures from the Active Australia Questionnaire prior to and post treatment.

Sessions- facilitated by a clinical psychologist and a student trainee- consisted of standard techniques along with disorder specific techniques based on 3 manuals created by the clinic

11 groups formed by disorder, 6 groups to intervention, 5 groups to comparison 37

Intervention Group: GCBT + ExerciseExercise trainer At-home based GOAL: engage in 30 min of moderate exerciseEND GOAL- at least 150 min per week or at 5x per week38 patients totalAvg age 30GAD: 29%PD: 34%Social Phobia: 37%Pedometers were given to each participant to monitor their steps and a logbook to record the number of walks they did, the number of daily steps (or steps for each walk) and any other exercise they did in addition to walking.

Each participant got a weekly target of frequency and durationFirst 3 weeks, GCBT extended 30 minutes to talk about pedometers, exercise, HR and so on 39Comparison Group: GCBT + ED3 educational meetings at 2nd, 3rd and 6th GCBT meetings to match other group Focused on healthy eating and nutrition 36 patients totalAvg age 39GAD: 42%PD: 36%Social phobia: 22%Results

the GCBT+EX group experienced greater decline in depression score (=6.2, p=0.001), in anxiety score (=3.41, p=0.002), and in stress score (=5.4, p=0.022) than the GCBT+ED control group

Significant reductions in depression, anxiety, and stress scores were documented for all clients with completed post-treatment measurements. Clients with generalized anxiety disorder (n=13) experienced the greatest mean changes for depression (8.7, 95% CI: 15.5; 1.8) for anxiety (8.8, 95% CI: 10.9; 6.6) and for stress (7.1, 95% CI: 9.5; 4.6) compared to the other two diagnoses

The added benefits of the intervention were most marked for clients with social phobia, with results for clients with panic disorder or generalized anxiety disorder remaining questionable.41CritiqueProsConsStandardized GCBTCompared different disordersNo drug treatmentMissing self reportsShort duration of exercise program 8 wks Overall ConclusionsIs Exercise an Effective Treatment for Reducing the Signs and Symptoms of Anxiety Disorders, Specifically Panic and Generalized Anxiety Disorder?

YESFuture ResearchDrug therapy + exercise therapy Long term studies (lifetime)Comparing anxiety disorders Mechanisms Adherence to exercise how?Correlations between exercise and obesity Nutrition and mental health Different exerciseRun, swim, bike, dance?

Referenceshttp://www.cdc.gov/features/mentalhealthsurveillance/Zschucke E, Gaudlitz K, Strohle A. Exercise and physical activity in mental disorders: clinical and experimental evidence. Journal of preventive medicine and public health = Yebang Uihakhoe chi. Jan 2013;46 Suppl 1:S12-21.http://www.nimh.nih.gov/health/publications/anxiety-disorders/introduction.shtmlGoodwin RD. Association between physical activity and mental disorders among adults in the United States. Prev Med. 2003;36(6):698703.Pasco JA, Williams LJ, Jacka FN, Henry MJ, Coulson CE, Brennan SL, et al. Habitual physical activity and the risk for depressive and anxiety disorders among older men and women. Int Psychogeriatr. 2011;23(2):292298Seifert T, Brassard P, Wissenberg M, Rasmussen P, Nordby P, Stallknecht B, et al. Endurance training enhances BDNF release from the human brain. Am J Physiol Regul Integr Comp Physiol. 2010;298(2):R372R377.Strhle A, Stoy M, Graetz B, Scheel M, Wittmann A, Gallinat J, et al. Acute exercise ameliorates reduced brain-derived neurotrophic factor in patients with panic disorder. Psychoneuroendocrinology. 2010;35(3):364368Fumoto M, Oshima T, Kamiya K, Kikuchi H, Seki Y, Nakatani Y, et al. Ventral prefrontal cortex and serotonergic system activation during pedaling exercise induces negative mood improvement and increased alpha band in EEG. Behav Brain Res. 2010;213(1):19DeBoer, Lindsey B. Exploring exercise as an avenue for the treatment of anxiety disorders. EXPERT REVIEW OF NEUROTHERAPEUTICS, AUG 2012Broocks A, Bandelow B, Pekrun G, George A, Meyer T, Bartmann U, et al. Comparison of aerobic exercise, clomipramine, and placebo in the treatment of panic disorder. Am J Psychiatry 1998; 155: 6039.Herring MP, Jacob ML, Suveg C, O'Connor P. Effects of short-term exercise training on signs and symptoms of generalized anxiety disorder. Ment Health Phys Act. 2011;4(2):7177.Merom D, Phongsavan P, Wagner R, Chey T, Marnane C, Steel Z, et al. Promoting walking as an adjunct intervention to group cognitive behavioral therapy for anxiety disorders: a pilot group randomized trial. J Anxiety Disord. 2008;22(6):959968.

Questions?Other anxiety disorders and exerciseSocial phobia had the leastOCD has quite a bitPTSD not so much46