Psychology Textbook Chapter 16 Physical Activity and Exercise for the Prevention and Management of Anxiety

Chapter 16 Physical Activity and Exercise for the Prevention and Management of Anxiety Felipe , Brendon , and of Sports Methods and Techniques , Federal University of Santa Maria , Brazil of Psychiatry , Psychology and Neuroscience , King College London , UK Foundation Trust , UK Division of Psychiatry , University College London , UK Please cite as , A . 2021 ) Physical activity and exercise for the prevention and management of anxiety . In Jones ( Essentials of exercise and sport psychology An open access textbook ( Society for Transparency , Openness , and Replication in Kinesiology . Attribution 40 International This content is open access and part of Essentials of Exercise and Sport Psychology An Open Access Textbook . All other content can be accessed at Chapter Overview Anxiety disorders are a leading cause of the global disability burden . The of treatment for anxiety disorders are pharmacological and psychological interventions . Although a growing number of pharmacological treatments are available , about the half of patients do not respond adequately and require additional approaches for the prevention and treatment of anxiety disorders . Observational studies have demonstrated that physical activity is associated with a lower risk of incident anxiety at a population level . Randomized controlled trials have found that exercise , a subset of physical activity , can reduce anxiety and stress symptoms in people with anxiety disorders . The effect of exercise is observable following a single bout of exercise or a training program of aerobic resistance training over several weeks . The mechanisms underlying the effects of exercise are not fully understood , but some neurobiological factors , such as changes on neurogenesis , inflammation , and regulation of the autonomic system , are potential candidates . In addition , psychological factors , such as reduction of anxiety sensitivity , increases in , and mastery may help to explain this effect . In the present chapter , we provide an overview of the use of physical activity and exercise for the prevention and treatment of anxiety . For correspondence

Chapter 16 Prevention and Management of Anxiety Physical Activity and Anxiety Anxiety disorders are highly prevalent disorders in most cultures across the world ( World Health Organization WHO , 2017 ) In 2015 , an estimated of the global population had anxiety disorders . Some variation can be seen in different countries across the world , ranging from ( Vietnam ) to ( Brazil WHO , 2017 ) Anxiety disorders are the sixth leading cause of global disability with considerable economic costs ( WHO , 2017 ) The core features of anxiety disorders include persistent , intense , and excessive fear or worry ( American Psychiatric Association APA 2013 WHO , 1992 ) Each disorder has its specific presentation , but the most common symptoms of anxiety across all disorders are feeling restless , or edge , fatigued , irritable , muscle tension , with difficulties concentrating , difficulties in controlling feelings of worry , and sleep problems . Although anxiety symptoms are present in daily life , for a clinical diagnosis these symptoms must ( a ) persist for a certain period of time , which varies from disorder to disorder ( months for generalized anxiety disorder GAD ) cause significant problems in areas of life ( social interactions , school , and work ) and ( not be a consequence of substance use . The diagnosis must be made by a psychiatrist or psychologist . In addition to the profound burden on mental health and , people with anxiety disorders experience poorer physical health ( Firth et , 2019 ) For example , people with anxiety disorders are at increased risk of cardiovascular disease ( et , 2016 ) diabetes ( Smith et , 2018 ) and metabolic syndrome ( Tang et , 2017 ) Also , anxiety disorders are associated with a 77 increase in all risk and a 177 increase in cardiovascular mortality risk ( et , 2009 ) The main treatments for people with anxiety disorders consist of antidepressants and ( et , 2014 ) While antidepressants are typically more efficacious than placebo ( de et , 2018 ) the benefits are mostly modest for those with symptom severity , and eventually , the ratio may be unfavorable for these patients due to the side effects ( de et , 2018 ) Also , adherence to antidepressant treatments is not optimal , and dropout rates can be four times higher compared to dropout with placebo pills ( et , 2018 ) mostly due to common side effects , including weight gain , increased diabetes risk , and sexual dysfunction . Some of these side effects can potentially contribute to poor physical health for people with anxiety disorders . Psychological therapies , such as cognitive behavioral therapy , have moderate positive effects for people with anxiety disorders ( Carpenter et , 2018 ) but without improving physical health . In addition , dropout from can be up to 29 , which is substantially higher than control groups ( 17 Carpenter et , 2018 ) Given the considerable individual and societal burden of anxiety disorders , there is an urgent need to identify modifiable risk factors and additional intervention strategies to mitigate this burden . Emerging evidence indicates physical activity ( PA ) and exercise can reduce the risk of developing anxiety disorders and be useful strategies for the treatment of anxiety disorders by reducing anxiety symptoms . In the present chapter , we provide a brief overview of the current evidence for ( a ) the role of PA and exercise as protective factors against incident anxiety , and ( the use of PA and exercise as therapeutic strategies for people with anxiety disorders . We highlight the use of exercise as a strategy for acute management of symptoms , the effects of different types of exercise training , neurobiological mediators between exercise and anxiety , and issues related to exercise prescription , adherence , and dropout . Can Physical Activity Protect Against Incident Anxiety ?

Incident anxiety refers to the occurrence or development of new cases of anxiety . sectional studies have shown that people with higher levels of PA present a decreased risk of having anxiety . For example , evidence using data from the World Health Survey , accounting for individuals from 47 countries , demonstrated that those with low levels of physical activity were 370

, at 32 increased risk for having anxiety ( odds ratio OR , 95 confidence interval CI , et , 2017 ) Also , findings reveal that those spending more time in sedentary behavior are 48 more likely to have anxiety , even when the analyses are adjusted for and factors ( OR , 95 CI , Allen et , 2019 ) A limitation of studies is the inability to infer directionality . However , these associations seem to be bidirectional . For example , there is a higher prevalence of low physical activity ( da Silva et , 2014 , et , 2017 ) and high sedentary behavior in people with anxiety disorders ( de Wit et , 2011 ) Likewise , data from prospective cohort studies , which followed people free from anxiety for at least one year , demonstrate that people with higher PA levels are at 26 lower odds of developing meaningful anxiety symptoms and disorders ( OR , 95 , et , 2019 ) However , the evidence that PA protects against anxiety is mostly based on questionnaires that are more likely to suffer from social desirability and recall bias ( et , 2019 ) More recently , some evidence has shown that people with low cardiorespiratory fitness and muscular strength , two objectively assessed measures of physical capacity largely influenced by PA levels , have 60 higher risk ( 95 CI ) of presenting anxiety compared to those with higher cardiorespiratory fitness and muscular strength ( et , 2020 ) Exercise as a Treatment for Anxiety Exercise can be used to alleviate anxiety symptoms in people with anxiety disorders . The effects of exercise on anxiety symptoms can be both acute , following a single bout of exercise , as well as chronic , following a period of weeks of intervention . Acute Bouts of Exercise for Managing Symptoms Current evidence has demonstrated that a single exercise bout results in a small reduction in state anxiety ( et , 2015 ) However , this notion has changed over the last five decades . In the , some believed that exercise would elicit increased anxiety symptoms in those prone to anxiety episodes ( et , 2000 ) This fear seems to have been borne from an experiment conducted by and McClure ( 1967 ) who demonstrated that the infusion of sodium lactate induced symptoms of anxiety in people with anxiety neurosis . It is that exercise results in an increased secretion of lactate . Therefore , the increase in lactate levels caused by exercise was thought to trigger panic attacks . This fear was reinforced because exercise results in bodily responses similar to somatic symptoms of anxiety , such as sweating , increased heart rate , and respiratory frequency . However , these findings were not supported by later evidence . A study in people with panic disorders observed only panic attacks in 444 exercise bouts ( performed in the laboratory ( et , 2000 ) In addition , further evidence has demonstrated that exercise is not only safe for people with panic disorders but also helps to alleviate acute state anxiety symptoms ( et , 2009 ) Exercise Training for Managing Symptoms Diverse studies have attempted to discuss and synthesize the evidence on the effects of exercise training in healthy people ( Conn , 2010 ) people with multiple chronic conditions ( Herring et , 2010 ) and people with anxiety disorders or elevated anxiety symptoms ( et , 2018 et , 2013 et , 2014 et , 2017 ) Overall , small effects were observed for people with and without chronic health conditions ( Conn , 2010 Herring et , 2010 ) For people with anxiety disorders or elevated anxiety , there was some divergence in the magnitude and direction of the effects . et al . 2013 ) synthesized data from seven randomized controlled trials and found no effect of exercise in people with anxiety disorders . However , this included studies comparing exercise versus relaxation plus ( et , 2010 ) strength exercises 371

Chapter 16 Prevention and Management of Anxiety ( et , 1989 ) or cognitive behavioral therapy ( et , 2013 ) The inclusion of such studies in a is problematic because the control group interventions are largely effective . As such , to become effective , exercise effects would have to overcome the treatment effects of the control groups . For example , in the et al . 2010 ) study , the authors compared the effectiveness of four interventions , namely ( a ) exercise ( relaxation ( placebo exercise and ( placebo relaxation , showing no differences between groups . However , all groups improved significantly and with a large effect on anxiety symptoms ( exercise , Cohen relaxation , Cohen placebo exercise , Cohen placebo relaxation , Cohen ) In the study of et al . 1989 ) aerobic exercise ( walking and jogging ) was compared to a combination of strength exercises , flexibility , and relaxation . At the end of the intervention , both groups improved without having any statistical differences between them . Lastly , et al . 2013 ) compared cognitive behavioral therapy versus exercise and found that cognitive behavioral therapy , a and known intervention , is more effective than exercise for anxiety symptom reduction . The inclusion of such comparison groups likely results in a reduction of the estimated effect of exercise . To address this , the authors explored the role of the type of control group in a subgroup analysis , showing that exercise has a large effect compared to placebo or waitlist control groups . et al . 2017 ) revisited the same topic in a more recent that included six randomized controlled trials . In this , studies did not include comparisons against other forms of exercise or other established treatments ( antidepressants or ) et al . 2017 ) found a moderate effect of exercise on anxiety ( 95 CI , The literature investigated the effects of exercise training in multiple anxiety disorders , and some heterogeneity in the effects can be observed across disorders . This can potentially mean that exercise may be more effective for some anxiety disorders compared to others . Due the small number of studies , it is not clear if the differences in the effects between studies are related to the diagnosis or to other methodological aspects , such as weekly frequency , exercise intensity and type , trial duration , comparison group , or other factors related to the sample , such as age , gender , symptom severity , or use of other treatments . For example , the seminal study lead by et , 1998 ) found a very large effect of aerobic exercise on anxiety symptoms in patients with panic disorder . The exercise sessions were held three to four times per week , for eight weeks , while Herring et al . 2012 ) in another seminal study found a moderate effect of strength training , held two times per week , for weeks in people with GAD . A brief summary of some existent studies by anxiety diagnosis is given in Table . Exercise Prescription The American College of Sports Medicine ( recommends the use of the frequency , intensity , time , and type ( principle as a strategy to guide the exercise prescription ( American College of Sports Medicine , 2013 ) However , the literature exploring how the ' characteristics relate to the effects of exercise in people with anxiety disorders remains scarce . 372

, Table Randomized Controlled Trials on Exercise as a Treatment Study Disorder Sample Exercise type Mental health Duration comparison outcomes et al . 2017 ) 28 Aerobic Usual treatment Health No differences Exercise weeks Education between 28 control groups ( both improved ) et al . 2018 ) 39 Aerobic , Anxiety Exercise Exercise weeks exercise symptoms 38 control et al . 1998 ) 16 Aerobic to None Placebo pill , Anxiety and Exercise Exercise weeks ( depressive symptoms 15 placebo et al . 2015 ) 24 Aerobic , Anxiety Exercise Exercise weeks exercise symptoms 23 control et al . 2018 ) 21 Resistance About 40 of Waitlist , Exercise Exercise weeks participants were control symptoms Aerobic taking psychiatric 26 control exercise drugs 373

Chapter 16 Prevention and Management of Anxiety Table ( continued ) Herring et al . 2012 ) GAD et al . 2008 ) GAD , Plan et al . 2020 ) GAD Powers et al . 2015 ) et al . 2015 ) 10 10 10 control 38 36 control 17 16 control control 42 39 control Aerobic Resistance Exercise Aerobic Exercise Aerobic Exercise ( High intensity interval training ) Aerobic Exercise Resistance Exercise Aerobic exercise ( walking ) weeks Unknown frequency 10 weeks Every second days weeks weeks Some patients were also using antidepressants Stable doses of antidepressants and were allowed ET Usual treatment Waitlist control Educational sessions exercise ET Alone Usual treatment alone , Worry symptoms , Anxiety , depressive , and stress symptoms , Anxiety , depressive , stress symptoms , somatic and worry symptoms symptoms , depressive , stress symptoms Note . Abbreviations Cognitive Behavioral Therapy , ET Exposure Therapy , GAD Generalized Anxiety Disorders , Group Behavioral Therapy , OCD Obsessive Compulsive Disorder , Panic Disorder , Stress Disorder , Social Phobia 374

, Most of the literature is based on aerobic exercises . However , a recent has shown that forms of exercise , such as resistance training , are also capable of reducing anxiety symptoms in healthy people and people with a chronic condition ( Gordon et , 2017 ) Early head trials comparing aerobic versus exercises found no difference between the two interventions ( et , 1989 ) When taken together , there is evidence that both aerobic and exercises are effective . The optimal dose of exercise intensity , frequency , or volume remains unclear . Most randomized controlled trials investigating this topic have shown the effectiveness of exercise ( et , 2017 ) Still , there is a paucity of trials investigating whether the same benefits could be achieved with lower . The optimal weekly frequency and optimal weekly volume for achieving the greatest reductions in anxiety symptoms is also unclear . In order to maximize exercise engagement and reduce dropout , and exercise professionals should consider that exercise should be rewarding and enjoyable , and autonomous motivation seems to be a key element for exercise engagement and maintenance ( et , 2015 ) Autonomous motivation leads someone to engage in exercise behavior for its own sake and intrinsic rewards , such as challenge and enjoyment ( also see Chapter et , 2021 ) Accordingly , every aspect related to the exercise prescription should consider personal preferences and make the exercise the most enjoyable . Hence , it might be viable to prescribe moderate exercise or exercise . For example , exercising at and below the ventilatory threshold are more likely to be linked to positive affective responses . In contrast , higher are more likely linked to a negative affective responses in people with lower physical activity levels ( Brand , 2018 also see Chapter 11 Jones , 2021 Chapter 12 , 2021 ) In addition to intensity , it is also important to consider other personal preferences such as music listening , time of day , the presence of friends or family , and exercise setting . All these aspects should be considered and discussed with the exerciser . Including the exerciser in the process should increase the sense of autonomy ( et , 2015 ) Potential Mediators ( Mechanisms ) of the Effects of Exercise Potential mechanisms underpinning the effects of exercise may be related to changes in biological markers and factors . Some biological markers are candidates to explain the effects of exercise . We do not intend to provide an exhaustive list instead we briefly mention those with supporting evidence . It is believed that neurotrophic factor ( potentially counteracts the impact of stress hormones on the hippocampus ( et , 2013 ) However , this protective mechanism seems to be impaired in people with anxiety , given that levels are reduced in this group ( 2013 ) Exercise , in turn , releases the secretion of in humans ( et , 2015 ) A previous study has found an increase in serum levels following a single exercise bout ( et , 2010 ) However , no study has evaluated the response to interventions in people with anxiety disorders ( to the best of our knowledge ) A second potential explanation is the regulation of the autonomic system ( AS ) functioning . Some people with anxiety have impaired AS functioning , marked by decreased heart rate variability ( et , 2016 ) In turn , exercise improves AS functioning in patients with anxiety and AS dysfunction ( et , 2013 et , 2006 ) Lastly , the hypothesis proposes that the system is responsible for linking and integrating the perception of external and internal stimuli with psychological outcomes , such as anxiety , allowing the adaptation to its constantly changing environment ( Lutz et , 2015 ) Acutely , exercise promotes an increase on peripheral levels , an in women with major depressive disorder , and this increase was associated with lower state anxiety ( Meyer et , 2019 ) However , there is a paucity of 375

Chapter 16 Prevention and Management of Anxiety studies showing that effects of exercise are related to adaptations , instead of transient increases , in levels . One potential psychosocial mechanism relates to anxiety sensitivity . The systematic and deliberate exposure to somatic symptoms , such as increased heart rate , respiratory frequency , and sweating through exercise , has been shown to reduce the fear of bodily sensations related to anxiety ( et , 2008 ) Second , physical activity and exercise have been associated with increased esteem , improved , and increased . For example , a study with young college women demonstrated that PA is inversely associated with symptoms of social phobia , GAD , and disorders . Among the factors that explained these associations were and ( Herring et , 2014 ) Lastly , exercise might lead to an increased sense of mastery and , especially when associated with marked increases in physical capacity and functioning , body composition changes , or when mastering a new set of techniques ( 2010 ) Conclusions PA can reduce the risk of anxiety symptoms and disorders in the general population . In addition , among people with anxiety , acute and repeated exercise is safe and can alleviate symptoms . Exercise also has cardiovascular and metabolic benefits that may reduce the physical health risks that are associated with anxiety disorders . The mechanisms related to the effects of exercise are not fully understood but likely include both neurobiological and psychosocial factors . Exercise prescription should consider the participant motivations , expectations , barriers , and preferences to promote autonomous motivation and adherence . Learning Exercises physical activity associated with a reduced risk of incident anxiety ?

What is the magnitude of the effect ?

Does exercise induce panic attacks ?

Can exercise be used as a complementary treatment for anxiety disorders ?

Explain how exercise could reduce anxiety . Further reading Firth , Allan , Carney , Curtis , Heald , Jackson , 2019 ) The Lancet Psychiatry Commission A blueprint for protecting physical health in people with mental illness . The Lancet Psychiatry , Firth , 2017 ) An examination of the effects of exercise for people with anxiety and disorders A . Psychiatry Research , 249 , 376

, Herring , Rebar , Firth , 2018 ) Moving to beat anxiety Epidemiology and therapeutic issues with physical activity for anxiety . Current Psychiatry Reports , 20 ( White , Richards , Bennie , A . 2020 ) Do we need physical activity guidelines for mental health What does the evidence tell us ?

Mental Health and , 18 , is supported by the ( Brendon is supported by a Clinical Lectureship ( jointly funded by Health Education England ( HEE ) and the National Institute for Health Research ( Brendon is part funded by the Biomedical Research Centre at South London and Foundation Trust . Brendon also holds active grants with the Medical Research Council ( and calls ) and Guys and St Thomas Charity ( Brendon has honorarium from Europe . The views expressed are those of the author ( and not necessarily those of the partner organisation , the , the , the Department of Health and Social Care , the or . Felipe is Supported by de de de Superior ( CAPES ) Grant 001 . References , Brown , Strong , Yip , 2017 ) A pilot randomized controlled trial of aerobic exercise as an adjunct to OCD treatment . General Hospital Psychiatry Psychiatry , 49 , Allen , Walter , Swann , 2019 ) Sedentary behaviour and risk of anxiety A systematic review and . Journal of Affective Disorders , 242 , I . 2016 ) Autonomic nervous system dysfunction in psychiatric disorders and the impact of psychotropic medications A systematic review and . Journal Neuroscience , 41 ( American College of Sports Medicine ( 2013 ) AC exercise testing and prescription . Williams Wilkins . American Psychiatric Association ( 2013 ) Diagnostic and statistical manual disorders ( American Psychiatric Association . Powers , Otto , A . 2013 ) get physical a contemporary review of the effects of exercise for anxiety and its disorders . Depress Anxiety , 30 ( Small , Bower , 2018 ) Exercise in the treatment of clinical anxiety in general practice a systematic review and . Health Services Research , 18 ( Hay , 2013 ) aerobic exercise for the treatment of anxiety disorders . Progress in and Biological Psychiatry , 45 , Bot , van , 2016 ) Anxiety and new onset of cardiovascular disease Critical review and . British Journal , 208 ( 377

Chapter 16 Prevention and Management of Anxiety , Wieder , A . 2018 ) Running for extinction ?

Aerobic exercise as an augmentation of exposure therapy in panic disorder with agoraphobia . Journal of Psychiatric Research , 101 , Brand , 2018 ) Theory of physical inactivity and exercise . German Journal of Exercise and Sport Research , 48 ( George , Meyer , 1998 ) Comparison of aerobic exercise , and placebo in the treatment of panic disorder . American Journal of Psychiatry , 155 ( 2013 ) Sex and stress hormone influences on the expression and activity of neurotrophic factor . Neuroscience , 239 , Carpenter , Andrews , Witcraft , Powers , 2018 ) Cognitive behavioral therapy for anxiety and related disorders A of randomized trials . Depression Anxiety , 35 ( Turner , Higgins , Egger , 2018 ) Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder A systematic review and network . Lancet , 391 ( 10128 ) 17 ) Conn , 2010 ) Anxiety outcomes after physical activity interventions findings . Nursing Research , 59 ( da Silva , Costa , 2014 ) Somatic , but not cognitive , symptoms of anxiety predict lower levels of physical activity in panic disorder patients . Journal Disorders , 164 , de , de , 2018 ) Initial severity and antidepressant efficacy for anxiety disorders , disorder , and posttraumatic stress disorder An individual patient data . Depression and Anxiety , 35 ( de Wit , van , 2011 ) Are sedentary television watching and computer use behaviors associated with anxiety and depressive disorders ?

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, Firth , Allan , Carney , Curtis , Heald , Jackson , 2019 ) The Lancet Psychiatry Commission A blueprint for protecting physical health in people with mental illness . Lancet Psychiatry , 19 ) A . 2015 ) Aerobic exercise training facilitates the effectiveness of cognitive behavioral therapy in panic disorder . Depression Anxiety , 32 ( 2006 ) Assessment of the influence of exercise on heart rate variability in anxiety patients . Letters , 26 , Cohen , Barnes , Silver , Talbot , A . 2018 ) Veterans group exercise A randomized pilot trial of an integrative exercise program for veterans with posttraumatic stress . Journal Disorders , 227 , Gordon , Lyons , Herring , 2017 ) The Effects of Resistance Exercise Training on Anxiety A and Analysis of Randomized Controlled Trials . Sports Medicine , 47 ( 12 ) Herring , connor , 2014 ) associations of physical activity with anxiety in college women . Medicine Science in Sports Exercise , 46 ( 10 ) 21863 Herring , Jacob , 2012 ) Feasibility of exercise training for the treatment of generalized anxiety disorder A randomized controlled trial . Psychotherapy and Psychosomatics , 81 ( 000327898 Herring , 2010 ) The effect of exercise training on anxiety symptoms among patients A systematic review . Archives Medicine , 170 ( 2013 ) Comparing physical exercise in groups to group cognitive behaviour therapy for the treatment of panic disorder in a randomized controlled trial . Behavioural and Cognitive Psychotherapy , 41 ( 2014 ) Exercise for anxiety disorders Systematic review . British Journal Medicine , 48 ( Jones . 2021 ) Strategies to facilitate more pleasant exercise experiences . In Jones ( Essentials of exercise and sport psychology An open access textbook ( Society for Transparency , Openness , and Replication in Kinesiology . A . Choi , Hayes , 2020 ) Individual and combined associations between cardiorespiratory fitness and grip strength with common mental disorders A prospective cohort study in the UK . Medicine , 18 ( Van , the Canadian Anxiety Guidelines Initiative Group on behalf of the Anxiety Disorders Association of des troubles and University . 2014 ) Canadian clinical practice guidelines for the management of anxiety , posttraumatic stress and disorders . Psychiatry , 14 ( 379

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