Exercise, Anxiety, and PTSD: Part II
When I originally planned to write a follow-up piece on fear, anxiety, and kinesiophobia, I had a different plan, one that would establish clear solutions and would help people struggling with anxiety thrive.
But as I dug into the research, I realized my plan was being thwarted with the reality of what people with anxiety or PTSD experience and how poorly equipped the traditional fitness industry is to help these individuals. To be clear, exercise isn’t a magic pill that immediately works on every single person with anxiety or PTSD. In fact, exercise can be the source of the anxiety, becoming compulsory and feeding into a cycle of obsession. However, what the numbers show is people with anxiety or PTSD who are not currently physically active would benefit from the physiological effects of exercise. Specific types of exercise regulate hormones, give individuals a sense of purpose, and create more emotional and physical balance in a person’s life. Traditional fitness is focused on numbers: how much, how long, and how often; much of the narrative in the fitness industry centers around which “type” of approach or modality is the best approach for gaining strength, flexibility, endurance, or mindfulness.
As you will see, it’s not about the best type of exercise, or even the most effective. To truly help individuals who have generalized anxiety, a specific form of anxiety, or PTSD requires listening and providing individualized programming. It requires not judging or having a rigid agenda, a challenge for an industry that tends to follow a specific plan or sequence of exercises based on what science says is best for strength and flexibility, rather than focusing on what resonates most with the person. The ability to be fluid and offer suggestions to create a more adaptable environment for the student or client isn’t something I have ever been taught—it’s a skill I have learned, and it’s a component to working with people in an individualized setting that I think many trainers could benefit from learning, particularly those working with clients struggling with mental health disorders.
Characteristics of Anxiety and PTSD:
Generalized anxiety disorder is defined by the National Institute of Mental Health as excessive anxiety or worry on most days, lasting six months or more (1). Symptoms associated with generalized anxiety disorder include feelings of restlessness, fatigue, difficulty concentrating, irritability, excessive muscle tension, feelings of worry, and difficulty sleeping. Other types of anxiety disorders include panic disorder, phobia-related disorders, and social anxiety disorder.
Post traumatic stress disorder (PTSD) is no longer considered an anxiety disorder by the Diagnostic and Statistical Manual of Mental Disorders, largely because PTSD is specifically related to trauma while anxiety is not. Exposure to a traumatic event, which is defined as “actual or threatened death, serious injury, or sexual violence,” is the first criterion for the diagnosis of PTSD, though exposure to trauma doesn’t guarantee PTSD will be present (2). There are four qualifying types of exposure: personal exposure to the trauma, witnessing the trauma of others, indirect exposure through a family member’s trauma, or repeated exposure to aversive details of a traumatic event, which happens in professions like forensic child abuse investigators or military mortuary workers.
Over the course of a person’s lifetime, three out of every ten people will experience an anxiety disorder; in any given year, 19.1% of adults in the US are suffering from an anxiety disorder. (The number is higher for women, with 23.4% of women and 14.3% of men experiencing a form of an anxiety disorder annually) (3). In adolescents, the numbers are higher: 31.9% of adolescents annually have an anxiety disorder; again, the percentage is higher for females, with 38% of females and 26.1% of males experiencing an anxiety disorder annually.
Post traumatic stress disorder (PTSD) affects 8-12% of adults at some point in their lives, and 13-31% of military veterans will experience PTSD. PTSD is characterized by unwanted memories or flashbacks, avoidance of trauma reminders, negative changes in mood and changes in arousal, such as hypervigilance (4). Hypervigilance is characterized by an attentional bias towards detecting and reacting to threat-related stimuli (5). In addition to PTSD, hypervigilance exists in a range of anxiety disorders and affects cognition, physiology, and behavior.
Physical Activity and Anxiety and PTSD:
Less than 75% of the US population meets the minimum weekly recommendations for aerobic and strength training activity (6). Obviously, not everyone who isn’t exercising has anxiety or PTSD, but anxiety or PTSD can prevent a person from beginning an exercise program because of the way exercise makes a person feel.
Anxiety sensitivity, which is characterized by focusing on negative outcomes and often results in the misinterpretation of bodily sensations, can make people with anxiety reluctant to begin an exercise program because the physiological effects of exercise, such as increased heart rate, increased respiration rate, and burning muscles, mimic the physiological symptoms of anxiety (7, 8). On the flip side, when people with anxiety undertake an exercise program, they experience an increase in self-efficacy as they realize that they are strong enough to cope with the physical experience of exercise. Curiously, high intensity regimens are more effective than lower intensity regimens for lowering anxiety levels, but drop out rates in high intensity exercise programs are higher than in lower intensity exercise programs among this population.
It makes sense that drop out rates are higher—people with anxiety can be hyperaware of what they are experiencing physically, and anyone who has ever done high intensity training can attest that it doesn’t exactly feel comfortable in the moment. There is also a strong co-occurrence of anxiety and chronic pain; a study from 2003 that examined the correlation of anxiety and chronic pain found the strongest associations between chronic pain and panic disorder and PTSD (9, 10). Chronic pain and heightened sensitivity can make exercise difficult—if it hurts, it’s hard to muster up the desire to want to do more of it. The conundrum lies in the research—high intensity exercise is good, but people are less likely to stick with it. Where does this leave professionals working with anxiety and/or chronic pain and anxiety?
Here is where traditionally trained fitness professionals are ill-equipped. If you are working with people in an individualized setting and you are focused on teaching a specific set of exercises or movements in a specific way, the attachment to the program probably isn’t going to work if sensitization or fear is present. A meta-analysis from 2017 concluded resistance training significantly improves symptoms associated with anxiety, so getting people strong is important, but if someone is fearful of injury or of making pain worse, it needs to be done in a way that takes into account the individual’s concerns by not progressing too quickly and starting off with fewer sets/reps/exercises than is usually prescribed (11). Once the client trusts you and sees that you are willing to work slowly, he or she will be willing to do a little more and try things that perhaps were originally off limits because of injury concerns.
I train a man in his 70s I will call James. James has had multiple shoulder surgeries and chronic back pain. He is extremely intelligent and well-read on a variety of topics, including pain science. He also has anxiety—he has been to the ER at least once for heart palpitations that were anxiety related and when he began seeing me, he was quick to tell me what would be bad for his shoulders and what wouldn’t. Things like lifting anything heavier than six pounds and performing any sort of push-up position, he told me, was bad for his shoulders.
His first few sessions were extremely gentle. I worked on having him do simple, basic movements and asked for lots of feedback. Slowly, I began incorporating things he had originally been fearful of—one set of eight pound biceps curls, four times. One round of walking ten feet with a fifteen kettlebell in his right arm. One ten second plank hold at the wall.
Gradually, the volume increased to two sets, and as he gained confidence, the wall plank turned into a wall push-up and he was walking across the room with twenty pounds in each hand instead of fifteen pounds in one. He still has low back pain, but he feels stronger and more capable than he has in a long time. (Added bonus: his wife tells me he’s in a better mood, which I hope means he feels more positive about life.) Will he ever deadlift a hundred pounds or do three sets of twelve push-ups on the floor? Probably not, and that’s okay. That’s not what he wants, but I will continue to do my best to incrementally make him feel stronger and more confident. His workouts aren’t about my ideas of fitness, they are about his goals and concerns, requiring open communication and not being attached to specific movements or skills, something which is difficult when we are taught everyone needs to do three sets of eight to ten repetitions of every exercise to maximize strength benefits. What if instead of this idea that everyone needs to accomplish a specific amount of strength, we were all okay with trying to be a little bit stronger next week than we are today? Does the speed at which we attain strength and mobility really matter if exercise is something that creates fear surrounding pain and injury?
What about mind body modalities?
Individuals with PTSD seem particularly responsive to low/moderate exercise as a way to elevate mood and decrease anxiety, specifically mind/body interventions such as Qigong, yoga, and Tai Chi. (4). In fact, a growing body of evidence suggests mind-body interventions have a positive impact on quality of life, stress reduction, and improvement of health outcomes in individuals with PTSD.
Mind-body interventions can be defined as interventions with components of interaction among mind, body, and behavior; the intention of mind-body interventions is to integrate these three components to improve physical function, as well as mental and physical health (12). Modalities that require paying attention to the task and/or observing how a specific task happens without judging the outcome integrate the mind and body.
Though modalities such as yoga, and Tai Chi are traditionally associated as mind-body interventions, it could be argued anything related to movement that requires focus and attention is a mind-body discipline. The act of slowing down and learning a skill, or figuring out how to interact with the environment or another person in a way that requires focus and problem solving blurs the line between traditional fitness and mind-body disciplines.
Research on alternative modes of mind-body disciplines and their impact on mental health is lacking, but that doesn’t mean it should be discounted. Rock climbing, a hobby the requires focusing on how to navigate the body up a rock require being in the moment and could be argued that it fits the definition of integrating mind, body, and behavior. Nick Carpenter, a US Navy veteran who has struggled with PTSD, writes about rock climbing, “Climbing has saved me from a downward spiral that would have resulted in me taking my own life or drinking myself to death,” (13).
Dance and movement therapies are consistently used during the treatment of PTSD, but the evidence for its effectiveness comes from case studies rather than empirical studies with large sample sizes (14). Other modalities, such as MovNat and Parkour, require high degrees of attention and observation, both of the self and the environment, but aren’t mainstream enough for the potential therapeutic benefits to be studied. One journalist who has generalized anxiety disorder and uses circus art training as one aspect of her treatment writes, “But for 90 minutes I could focus only on my body. I had to, or I could get hurt. Though I got frustrated—a lot—I never cried…These activities have helped boost my confidence and quiet my fears and anxiety towards the unknown, or of being “bad” at something before I’ve given it a chance,” (15).
Anxiety and Balance:
Anxiety disorders can be associated with symptoms related to vestibular symptoms, such as vertigo, dizziness, and unsteadiness. When children with anxiety underwent a balance training intervention, their anxiety symptoms improved as their balance improved (16). Mice who are born with a balance deficit exhibit anxious behavior; when they are raised in acrobatic cages, their balance improves and their anxiety decreases, suggesting balance training can decrease symptoms related to anxiety (17).
Balance training requires paying attention to what you are doing, which makes it mentally engaging. It also requires figuring out how to use the entire body to prevent falling in a contextual way—if you are walking across an elevated surface, or you need to get over an obstacle without hitting it, you are problem solving with your body. Balance training also demands that you, so you can figure out how to perform the task in a way that is safe and minimizes risk of injury. The modalities I mentioned above all require high degrees of dynamic balance, creating mind-body connections by posing challenges that go beyond simply following directions and trying to re-create a movement or skill. Researchers Fetzner and Asmundson point out attentional focus can be directed inwards using body awareness and mindfulness, or outwards, away from bodily sensations. Both, they conclude are possible in treatment, but they encourage investigating the role physical activity can play in creating “a sense of accomplishment” and providing a reprieve from daily anxiety (18).
One of the first things I noticed about James, the client I discussed earlier. was he wasn’t steady on his feet. I regularly implemented exercises that involved tossing a ball while moving, walking backwards over obstacles, and finding footing on slightly elevated, narrow surfaces. He finds these tasks interesting. They challenge him, and while he isn’t always successful, he will try, repeatedly, until the balance and coordination begins to click in a relatively consistent way.
Using activities that are interesting, challenging, and physically and mentally engaging can be beneficial for the participant. When someone is asked to move or interact with the environment (or a person) in a way that is new or viewed as novel, the brain is activated to seek a reward by figuring out the task (19). Several areas of the brain are activated during the process of learning, keeping the individual stimulated (20). What one person finds interesting enough to figure out, another may not, requiring the fitness professional to pay attention to how the client is responding and re-routing if necessary.
Exercise Recommendations:
Aerobic activity: Though I didn’t discuss it, research does show moderate aerobic activity, such as going for a walk outside, is effective at decreasing symptoms for individuals with PTSD. Since people with PTSD and anxiety sensitivity may be less likely to exercise or fearful of the effects of exercise, a gentle walking program may be a good place to start (21).
Strength: Resistance training builds resilience, improves self confidence, and improves self efficacy. Start small, build slowly, and be willing to take a less is more approach so people have a chance to adapt and build trust in their bodies—and you.
Mindful movement: Mindful movement focuses attention and can create internal and external awareness. If someone isn’t receptive to traditional mind-body modalities, don’t be afraid to think outside of the box and suggest alternative modalities such as rock climbing, dance, or Parkour. Any movement task can be mindful depending on how it’s taught, and activities such as martial arts or MovNat classes have the added benefit of having a social component, something which can be extremely beneficial for individuals struggling with anxiety or PTSD.
Play: Incorporating activities that are challenging and interesting can make an individual feel present and elicit a learning response. Pay attention to how the person responds to the task, and don’t be afraid to try something different if your original plan isn’t working.
Helping people with anxiety and PTSD feel stronger and more physically capable may require an individualized approach. The physical sensations that arise during exercise or physical movement can be scary; having empathy, building a strong foundation, and understanding how to use focal points to create balance and security can be instrumental in the client’s success.
Exercise is only one piece to treatment for mental illness; making it rewarding and enjoyable can improve adherence and make a huge impact in a person’s life.
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References:
The National Institute of Mental Health, (2018). Anxiety Disorders. https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml.
Pai, A., Suris, A.M., & North, C.S., (2017). Posttraumatic stress disorder in the DSM-5: Controversy, change, and conceptual considerations. Behavioral Sciences, 7(1), 7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5371751/
The National institute of Mental Health, (2017). Any Anxiety Disorder. https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder.shtml
Hwan Kim, L.S., Kravitz, L., & Schneider, S. PTSD & Exercise: What every exercise professional should know. https://www.unm.edu/~lkravitz/Article%20folder/PTSD.html
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Hwan Kim, S., Schneider, S.M., Kravitz, L., Mermier, C., & Burge, M.R., (2013). Mind-body practices for post traumatic stress disorder. Journal of Investigative Medicine, 61(5), 827-834. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3668544/.
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Steinberg-Oren, S.L., Krasnova, M., Krasnov, I.S., Baker, M.R., & Ames, D., (2016). Let’s dance: a holistic approach to treating veterans with posttraumatic stress disorder. Federal Practice, 33(7), 44-49, https://www.mdedge.com/fedprac/article/110095/mental-health/lets-dance-holistic-approach-treating-veterans-posttraumatic.
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