(p. 53) Exercise for Stress, Worry, and Panic
■ Copy of patient workbook
■ Teach the patient how to recognize and defer worries
■ Prepare to target fear of somatic arousal with exercise
■ Fine-tune the exercise prescription for fears of anxiety sensations
■ Monitor exercise avoidance and anxiety sensitivity
Using Exercise to Target Stress, Worry, and Panic
As outlined in Chapter 1, there is substantial empirical support for the use of exercise to target stress, worry, and panic. As a way to enhance outcome expectancies and increase motivation for the intervention, initial discussion with patients who suffer from anxiety or panic should focus on the effectiveness of the exercise prescription for achieving their goals. Particularly with patients who hold strong beliefs that their anxiety problems stem from a chemical imbalance, it is important to also share results of studies that indicate that the effect of exercise on neurotransmitters mimics that of many antidepressant medications commonly prescribed for anxiety disorders.
(p. 54) Although anxiety disorders differ significantly in their presentation, they share in common worry and/or hypervigilance, as well as the tendency to avoid. Many of the anxiety disorders, and particularly panic disorder and post-traumatic stress disorder (PTSD), are also characterized by fears of anxiety symptoms. The sections that follow discuss strategies to complement and fine-tune the exercise prescription to help target these core features of anxiety disorders.
Teaching Patients to Recognize and Defer Worries
To help patients better target their worry patterns for change, it is helpful to sensitize patients to the core features of these patterns. In particular, you will want to help the patient differentiate worry from problem solving. Problem solving is solution focused, where multiple potential solutions are reviewed relative to a well-defined topic for change—the problem. On the other hand, worry is a repetitive cognitive activity that focuses attention on potential problems without consideration of the probability of these problems or potential solutions. A core feature of worry is the “what if” thinking format that keeps the thoughts future- and catastrophe-oriented. Discuss this form of worrisome thoughts and help the patient to understand that worry does not generate useful action, but it does generate anxiety and physical discomfort. To illustrate this process, you may say something like the following:
As you get better at identifying worry, you will likely notice a wide range of “what if” thoughts. What if I get fired? What if my partner breaks up with me? What if the kids get sick? What if my friend is mad? What if the report is flawed? What if things get worse? And if you are worrying, you rarely stop to consider whether these “what if” outcomes are likely or whether you could cope with these outcomes should they occur. Most commonly, anxious individuals identify a “what if” thought, feel anxious, and then quickly jump to a different “what if” thought. Also, the more anxious you are, the more easily these worries about the future come to mind and the more believable the “what if” thoughts become. I want you to be aware of these patterns so that you are more able to identify worry as unproductive and work actively to defer worry thoughts.
(p. 55) One role of exercise is to create a break from these unproductive thoughts. With vigorous-intensity aerobic exercise, many patients will report a reduction in anxious and ruminative thinking patterns, as well as relief from the feelings of stress and anxiety associated with such worry. Indeed, a break from worry thoughts can help patients regain perspective and shift their thinking style to generate potential solutions (in the case of worries about probable events or threats) or gain perspective that further consideration of an unlikely “what if” thought is unproductive and not worth the investment of time and anxiety. As such, one strategy for reducing worry is to defer it until after vigorous exercise. You may use the following sample dialogue to describe this strategy:
How do you get out of an unproductive cycle of worry and increasing anxiety? Creating breaks is one strategy. A break will often allow you to regain perspective on the situation. Ideally, you would use exercise as soon as you find yourself in a worry rut, but this is unlikely given your schedule. Instead, I would like you to defer worry whenever possible. After all, worrying is not problem solving, so there is no hurry to worry. In deferring worry, you may ask yourself: “Do I really need to think about this now, and is my thinking leading to solutions?”I recommend that you then set the goal of focusing on the present—events going on right now—so that you can stay free of “what if” thoughts until your exercise session later in the day. During the exercise, look forward to the way in which exertion can lead to a worry-free period and create a sense of calmness to help you stay worry-free for hours after exercise.
■ You will need to assess whether the patient needs problem-solving training to supplement worry interventions. ■
Preparing to Target Fear of Somatic Arousal With Exercise
A number of studies have implicated the tendency to fear anxiety and its related bodily sensations (i.e., anxiety sensitivity) in the onset and maintenance of panic disorder (cf. McNally, 2002) and other anxiety disorders (Schmidt, Zvolensky, & Maner, 2006). Individuals who (p. 56) have a high level of anxiety sensitivity respond to benign bodily sensations (e.g., racing heart, rapid breathing, and sweating) with fear because they are concerned that these sensations have harmful (physical, social, and mental) consequences. Growing evidence suggests that targeting anxiety sensitivity may be critical to overcoming panic disorder, and initial evidence suggests that reducing anxiety sensitivity may also improve outcomes for other anxiety disorders such as PTSD, as well as anxiety-related health behaviors such as smoking.
Because exercise induces arousal-related bodily sensations, individuals with a high level of anxiety sensitivity (e.g., patients with panic disorder) are likely to avoid exercise and may therefore be hesitant to initiate or maintain an exercise program without additional coaching from their therapist. Prior to providing the exercise prescription to patients with panic disorder, you should provide education on the role of fears of anxiety sensations in panic disorder and the efficacy of exposure to bodily sensations (through exercise) for overcoming anxiety sensitivity. Be sure to address the following points:
1. Panic attacks are part of a natural alarm signal
A panic attack is an intense rush of fear accompanied by a host of symptoms, including dizziness, numbness, tingling, breathlessness, heart palpitations, sweating, and feelings of unreality. You can think of a panic attack as part of the natural fight-or-flight alarm that is designed to fire when we perceive danger. The symptoms of panic can be direct (e.g., rapid breathing) or indirect (light-headedness or chest pressure or pain resulting from rapid breathing) effects of this alarm reaction. At times of actual danger, attention is riveted to the source of danger. However, if the alarm reaction fires in the absence of danger, the alarm reaction symptoms become a focus of concern in their own right.
2. Panic disorder is characterized by recurring false alarms
When anxiety and panic symptoms themselves become a focus of fear, recurrent panic attacks may emerge due to a fear of this escalation of anxiety. The alarm fires in response to the perceived danger of the symptoms or their feared consequences. Common fears among patients with panic disorder include the (p. 57) misinterpretation of anxiety and panic symptoms as signaling impending death (“Am I having a heart attack?” “Am I having a stroke?” “I am going to die”), impending loss of control (“I will faint” “I am going to have to run out of the room” “I can’t find my way out or take care of the kids”) or impending humiliation (“they are going to notice my symptoms and I will be humiliated” “they will think I’m crazy” “they will think I’m a fool”). These catastrophically negative interpretations of symptoms help cue the next panic attack by providing a false alarm for danger.
3. Fear-of-fear cycle
Share with the patient the model (Figure 5.1) to illustrate that after initial panic attacks, a self-perpetuating pattern can develop to maintain and worsen the panic attacks. Here, it is important to explain why patients fear bodily sensations, even when they are not part of an anxiety reaction. You may say:
After having learned to fear the alarm reaction, many patients start responding with fear to the bodily sensations that come along with panic, even if they occur outside the context of panic. That’s (p. 58) why it is common for patients with panic disorder to fear activities such as exercise or drinking coffee.
4. Exercise can provide interoceptive exposure to help extinguish fears of bodily sensations
Review with the patient the rationale for using exercise as a method to overcome the fears of somatic arousal, and thereby panic disorder.
Exercise induces many of the feared bodily sensations that you have been avoiding and thus gives you the opportunity to get used to them again. It is that simple—repeated exposure results in habituation. For example, consider a person who has developed sleep problems after moving to a city that has 24-hr traffic. With time, she will get used to the noises that first kept her up, allowing her to return to her healthy sleep habit. Much like this example, it is important that you use exercise to allow yourself to become comfortable and embrace intense bodily sensations as natural and expected. Once you learn this in the context of exercise, you have built a memory that you can access when you are faced with similar sensations that may arise due to anxiety and panic.
Present the patient with Figure 5.2 and discuss how exercise can help undo the fear-of-fear cycle and emphasize the importance of relaxing with sensations.
(p. 59) Fine-Tuning the Exercise Prescription for Panic Disorder
Having prepared the patient for targeting anxiety sensitivity, it should come as no surprise to the patient that the exercise prescriptions should be such that they can induce sufficient somatic arousal. Accordingly, an appropriate exercise prescription in this treatment plan should involve vigorous-intensity exercise (>76% of HRmax). In addition, we recommend that you encourage the patient to engage in active learning during the exercise session by completing the following steps:
1. Prior to exercise, instruct the patient to anticipate what sensations she is going to feel so that there are no surprises.
2. During exercise, instruct the patient to fully expect to experience these sensations. Instead of engaging in distraction strategies, remind the patient to focus on the sensations and see how comfortable she can get exercising while having the sensations.
3. After exercise, encourage the patient to draw her attention to the sensations she experienced during exercise and help her become confident that they are indeed safe. Using the Exercise Practice Log for Panic-Related Concerns in Chapter 10 of the workbook, have the patient record the sensations, rate their intensity on a 0–100 scale, and rate whether the experience of anxiety was associated with anxiety on the same scale. Then, ask the patient to examine whether the symptoms had any true adverse consequences relative to the fears of these sensations based on her experiences with panic.
Review these practice log sheets with the patient during subsequent sessions. Your role is to provide ongoing support while the patient uses exercise as a tool to become comfortable with once-frightening sensations of arousal. The goal is to then use this newfound comfort with sensations to end the fear-of-fear cycle. For example, therapists can direct patients to respond to anxiety and panic sensations just as they have learned to respond to similar sensations during exercise: Notice the sensations but do nothing to control them, and learn to relax with the sensations while continuing goal-directed activities.
(p. 60) Monitoring Exercise Avoidance and Anxiety Sensitivity
In addition to helping patients address common barriers of exercise such as time, cost, or weather, you should evaluate whether the patient avoids exercise because of the fear of bodily sensations and provide additional coaching if necessary, particularly in the beginning of the program. In addition, we recommend that you regularly evaluate whether worry and anxiety sensitivity are improving with exercise. The Exercise for Mood Log can help reinforce the utility of exercise to reduce worry. Consider also administering the Anxiety Sensitivity Index (ASI; Reiss et al., 1986.) to illustrate the long-term effects of exercise for reducing the core fear underlying panic disorder.