Lily Mochary

1. Exercise as anEffective Treatment for Reducing the Signs and Symptoms of Anxiety Disorders, Specifically Panic and Generalized Anxiety Disorder Lily Mochary

2. U.S. Adult Mental Illness Surveillance Report Measured prevalence of mental illness in the United Sates 25% U.S. adults have a mental illness Nearly 50% will develop a mental illness during their lifetime Year 2002- $300 billion economic burden

3. Mean Number of Mental Unhealthy Days during the past 30 days http://www.cdc.gov/mentalhealthsurveillance/images.html

4. More from the report More disability in developed countries than any other group of illnesses (cancer or heart disease) Associated with increase risk for chronic diseases Associated with lower use of medical care Higher risk for self injury

5. Anxiety Disorder Anxiety 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

6. http://www.nimh.nih.gov/statistics/1ANYANX_ADULT.shtml

7. Anxiety Disorders Panic disorder Obsessive-compulsive disorder (OCD) Post-traumatic stress disorder (PTSD) Social phobia Specific phobias Generalized anxiety disorder (GAD)

8. Treatment • Medication and/or psychotherapy • Common medications: • Antidepressants (SSRIs, Tricyclics, MAOIs) • Anti-anxiety (Benzodiazepines) • Beta blockers Psychotherapy • Cognitive Behavioral Therapy

9. Problems Adverse side effects Easy to build a tolerance (drug abuse) Benzodiazepines are often prescribed to patients for only a short period of time Anxiety can abruptly return after the medication is stopped, and patient often experience withdrawal symptoms

10. Exercise and Mental Health • Epidemiological Studies • Correlations • Regular PA associated with decreased risk for mental illness • More likely to recover from mental illness if engaging in PA

11. Mechanisms • Increases neurotransmitters • Serotonin, endorphins • Exercise has neuroprotective effects • Balances levels of brain-derived neurotrophic factor (BDNF) Other psychological benefits- positive health attitudes/behaviors, body image, coping strategies

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

14. Study Broocks 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.

15. Key Terms • Clomipramine- tricyclic antidepressant • Used to treat OCD, depression, chronic pain, bulimia, sleep disorders, and panic disorder • Side effects: dry mouth, upset stomach, nausea, loss of appetite, decreased sex drive, constipation, dizziness, drowsiness, tired

16. Purpose The purpose of this study was to examine the anxiolytic effects of aerobic exercise compared to pharmocotherapy and a placebo in patients with panic disorder.

17. Design • 46 patients with Panic Disorder • Randomly assigned to 10 week treatment • Placebo (control) (15) • Clomipramine, 37.5 mg (15) • Tapered dosage of 1 per day to 3 per day • Exercise (16) • 4 mile walk, 3-4 times per week for first 2 weeks • Encouraged to be able to run entire route by end of treatment • Met with trainer for group run once a week

18. Measures • 2, 4, 6, 8 and 10 weeks • Primary Tests • The Hamilton Anxiety Rating Scale • Panic and Agoraphobia Scale (observer and patient rated) • Clinical Global Impression

21. Conclusions Exercise had significant improvements in all primary measure outcomes when compared to placebo Clomipramine also highly effective, improved symptoms more significantly than exercise and earlier in treatment

22. Critique Pros Cons • Large sample size • Compared exercise to pharmocatherapy • High drop out rate • Short duration • Specific participant criteria • Not truly blind • Exercise too variable • No anaerobic exercise • Too many variables • Social interactions • promethazine • Mechanism?

23. 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):71–77. Study

24. KEY TERMS Trait anxiety – tendency to experience anxiety, referring to characteristic anxiety disorder (not STATE anxiety) Effect size- measures the strength of a relationship between two variables

25. Purpose To compare the effects of resistance training and aerobic training on the signs and symptoms of generalized anxiety disorder

26. Design • 30 sedentary women clinically diagnosed by DSM- IV with generalized anxiety disorder • Three groups • Resistance Exercise Training (RET): • 2x per wk, 6 wks • Leg press, curl, extension • 7 sets, 10 reps, 50% 1 RM • Aerobic Exercise Training (AET): • Cycling • 2x per wk, 16 min • Wait List • No treatment • Still completed outcomes

27. Outcome Measures • Difficulty with concentration, trait anxiety, symptoms of depression, anxiety-tension, low vigor, fatigue and confusion, irritability, muscle tensions and pain • HR and RPE (secondary measures) • RET: after each exercise and end of session • AET: 2, 7, and 15 min and end of session

29. RESULTS

33. Conclusions • Short-term RET and AET can improve signs and symptoms associated with GAD especially: • Irritability • Anxiety • Low vigor • Pain

34. Critique Pros Cons • Clinically diagnosed with GAD • Matched RT and AET • Outcomes measured were specific to GAD signs and symptoms • All women, small sample size • No drug therapy to compare • RPE different for each exercise • Mechanisms? • Statistical jargon • Too many tests

35. 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):959–968.

36. Purpose To compare a home-based walking intervention adjunct a group cognitive behavior therapy treatment with group cognitive therapy treatment adjunct educational sessions

37. Design • 85 patients from outpatient anxiety disorder clinic with GAD, Panic Disorder or Social Phobia • GCBT • 90 min session 1x/wk for 8 wks • GCBT + EX • GCBT + ED

39. Intervention Group: GCBT + Exercise • Exercise trainer • At-home based • GOAL: engage in 30 min of moderate exercise • END GOAL- at least 150 min per week or at 5x per week • 38 patients total • Avg age 30 • GAD: 29% • PD: 34% • Social Phobia: 37%

40. Comparison Group: GCBT + ED • 3 educational meetings at 2nd, 3rd and 6th GCBT meetings to match other group • Focused on healthy eating and nutrition • 36 patients total • Avg age 39 • GAD: 42% • PD: 36% • Social phobia: 22%

41. Results

42. Critique Pros Cons • Standardized GCBT • Compared different disorders • No drug treatment • Missing self reports • Short duration of exercise program 8 wks

43. Overall Conclusions Is Exercise an Effective Treatment for Reducing the Signs and Symptoms of Anxiety Disorders, Specifically Panic and Generalized Anxiety Disorder? YES

44. Future Research • Drug 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 exercise • Run, swim, bike, dance?

45. References • http://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 = YebangUihakhoe chi. Jan 2013;46 Suppl 1:S12-21. • http://www.nimh.nih.gov/health/publications/anxiety-disorders/introduction.shtml • Goodwin RD. Association between physical activity and mental disorders among adults in the United States. Prev Med. 2003;36(6):698–703. • 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. IntPsychogeriatr. 2011;23(2):292–298 • Seifert T, Brassard P, Wissenberg M, Rasmussen P, Nordby P, Stallknecht B, et al. Endurance training enhances BDNF release from the human brain. Am J PhysiolRegulIntegr Comp Physiol. 2010;298(2):R372–R377. • Ströhle 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):364–368 • Fumoto 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):1–9 • DeBoer, Lindsey B. Exploring exercise as an avenue for the treatment of anxiety disorders. EXPERT REVIEW OF NEUROTHERAPEUTICS, AUG 2012 • Broocks 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: 603􏰄9. • 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):71–77. • 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):959–968.

46. Questions?