- Email: [email protected]
Physical exercise: an adjunctive treatment for panic disorder?
Eur Psychiatry 2001 ; 16 : 372-4 © 2001 Éditions scientifiques et médicales Elsevier SAS. All rights reserved S0924933801005934/COR
CASE REPORT
Physical exercise: an adjunctive treatment for panic disorder? L. Dratcu* Division of Psychiatry, Guy’s Hospital, Guy’s, King’s and St Thomas’ School of Medical Sciences, London, United Kingdom (Received 11 November 2000; revised 27 March 2001; accepted 15 June 2001)
INTRODUCTION A range of pharmacological and psychological treatments are available for panic disorder (PD) [7]. However, many patients remain impaired by residual anxiety after receiving anti-panic treatment [9]. Although this may be partly explained by the co-morbidity of PD with generalised anxiety disorder, enduring anxiety symptoms in panic patients may be related to the pathophysiology of PD itself. Panic patients are known to chronically hyperventilate. Hyperventilation was thought to induce panic by lowering pCO2, but Klein [4] suggested that panic patients hyperventilate in the attempt to keep pCO2 low, thereby preventing activation of the brain’s suffocation alarm. Yet, chronic hyperventilation itself may generate symptoms of anxiety [1]. Panic patients would probably benefit from adopting more normal patterns of breathing. We describe three female patients who met DSM-IV criteria for PD and who reported a significant improvement in their clinical status after they engaged in aerobic exercise. All were physically fit, with normal electrocardiogram, full blood count and thyroid function. CASE HISTORIES Case 1 A.D., 47 years old, had her first panic in her late 20s, which was described as an acute episode of anxiety, with
breathlessness, palpitations and cold sweats. Thereafter similar attacks would occur several times a day, usually accompanied by sensations of choking, gastrointestinal discomfort and an urge to run away. She received different psychological treatments, but only obtained relief after using relaxation techniques. Over the years her attacks subsided spontaneously. However, she continued to experience episodes of breathlessness, in addition to a constant feeling that she was sighing instead of breathing, all of which represented a constant reminder of her attacks. She was advised to start a graded programme of jogging consisting of three sessions a week, 30 minutes each, in which she alternated running with brisk walking. Her residual symptoms resolved completely 2 months after commencing the programme. Case 2 H.M., 38 years old, had her first attack at the age of 21, when she experienced palpitations, breathlessness and the fear that she might die. Her attacks became more frequent with time and were later followed by the onset of anticipatory anxiety, which gradually turned into an unrelenting background anxiety. She started to associate her attacks with places from where she felt there was no escape. A range of avoidance behaviours developed that culminated in severe agoraphobia, to the point that she became virtually housebound. She was referred for assessment after failing to respond to a graded exposure programme. The therapist mentioned that, in addition
*Correspondence and reprints: York Clinic, Guy’s Hospital, 47 Weston Street, London SE1 3RR, UK. E-mail address: [email protected] (L. Dratcu).
Physical exercise: an adjunctive treatment for panic disorder?
to panics involving autonomic symptoms and catastrophic cognitions (e.g., the fear that she might have a heart attack), the patient suffered from depression. In the past she had only improved following treatment with moclobemide, but this had been discontinued. On this occasion she was prescribed fluvoxamine 100 mg/d. Her attacks abated after 3 weeks, but her generalised anxiety persisted for the following months, associated with panic symptoms. She used to swim in adolescence and was advised to restart swimming. She gradually adopted a routine of swimming three times a week, 45–60 minutes each session, whilst maintained on fluvoxamine. Her anxiety and panic symptoms resolved over a period of 3 months after she joined swimming classes. Case 3 G.R., 45 years old, had a 30-year-long history of mood swings, agoraphobia and anxiety. She was twice admitted to hospital in her twenties and treated with electroconvulsivetherapy for her depression. Subsequently she received various psychotropic drugs, including benzodiazepines and antidepressants, and different psychological treatments, which proved unhelpful. She was referred at the end of a course of cognitive-behavioural therapy because of her unremitting anxiety and depression. The interview revealed a history of panic attacks with onset in adolescence, involving episodes of dizziness, palpitations and sweats, accompanied by the fear that she might collapse. She would previously experience four to six attacks a week but more recently was having one attack every 1–2 weeks. She had been off any medication over the previous year. A diagnosis was made of PD, with secondary anxiety and depression, and she was begun on fluoxetine 20 mg/d. A therapeutic response was detected after 3 weeks, but 2 months later she was still reporting low mood, lack of energy and anxiety. She also used to swim in her youth and was encouraged to join swimming classes. She started to swim 30 minutes once a week, increasing it to two to three sessions a week over the following 3 months, at which stage her symptoms subsided. DISCUSSION Exercise has long been recognised as beneficial in emotional disorders. Aerobic and nonaerobic exercise performed regularly were both shown to reduce ratings of depression [5]. Fulcher and White [2] demonstrated Eur Psychiatry 2001 ; 16 : 372–4
373
that graded aerobic exercise was therapeutic in chronic fatigue syndrome and that patients showed sustained benefit 1 year after exercise treatment. Moreover, in a study of the benefits of exercise in menopausal and perimenopausal women, exercising women were found to have a significantly more positive mood than sedentary women, regardless of menopausal state [10]. Exercising women also had fewer somatic symptoms and memory-concentration difficulties. This report described patients with PD who, after receiving various treatments for their panics, were still impaired by anxiety symptoms. All had suffered from panics for years and may have become chronic hyperventilators in the attempt to keep their pCO2 low [4]. Tests to confirm this (e.g., ventilatory function, blood gasometry) were not done. However, the improvement that the patients experienced after they had engaged in aerobic exercise suggests that ventilatory abnormalities were probably involved in the perpetuation of their symptoms. Hyperventilation can induce psychological symptoms that are common in anxiety. It also leads to systemic alkalosis, cerebral vasoconstriction and cerebral hypoxia, the likeliest reason for the increased slow wave activity found in the electroencephalogram of panic patients in the non-panic state [1]. In phobic patients, positron emission tomography (PET) of the brain has shown that cerebral blood flow (CBF) was reduced following anxiety-induced hyperventilation and hypocapnia [6]. By chronically hyperventilating, panic patients may thus risk prolonged exposure to cerebral hypoxia. Indeed, brain PET scanning has identified abnormal CBF and oxygen metabolism in panic patients in the non-panic state [8]. This, in turn, may further contribute to the chronicity of their anxiety symptoms. Aerobic exercise may help patients to restore normal ventilatory patterns and mitigate adverse effects on the brain of chronic hyperventilation. This, however, can only be confirmed by further research. The need for research on the benefits of aerobic exercise in PD seems compelling, as the advantages of exercise therapy are likely to extend beyond PD alone. As panic attacks are paroxysmal episodes of anxiety, knowledge gained from studies of PD can be extrapolated to anxiety in general [7]. Also, exercise may prove an adjunct treatment for anxiety that is nonpharmacological, non-addictive, and one that has few adverse effects and contraindications. In addition to reducing the risk of coronary heart disease and stroke, exercise has psychological effects that are surely under
374
L. Dratcu
exploited [3]. Yet, physicians usually do poorly when it comes to advising patients to practice exercise. It may be up to psychiatrists to confirm that the age-old adage mens sana in corporis sano still holds true.
6
REFERENCES
7
1 Dratcu L. Panic, hyperventilation and perpetuation of anxiety. Prog Neuro Psychopharmacol Biol Psychiatry 2000 ; 24 : 1069-89. 2 Fulcher KY, White PD. Randomised controlled trial of graded exercise in patients with chronic fatigue syndrome. Br Med J 1997 ; 314 : 1647-52. 3 Gloag D. Exercise, fitness, and health. Br Med J 1992 ; 305 : 377-8. 4 Klein DF. False suffocation alarms, spontaneous panics, and related conditions. Arch Gen Psychiatry 1993 ; 50 : 306-17. 5 Matinsen EW, Hoffart A, Solberg O. Comparing aerobic with
8
9
nonaerobic forms of exercise in the treatment of clinical depression: a randomised trial. Compr Psychiatry 1989 ; 30 : 324-31. Mountz JM, Modell JG, Wilson MW, Curtis GC, Lee MA, Schmaltz S, et al. Positron emission tomographic evaluation of cerebral blood flow during state anxiety in simple phobia. Arch Gen Psychiatry 1989 ; 46 : 1-4. Nutt DJ, Lawson C. Panic attacks: a neurochemical overview of models and mechanisms. Br J Psychiatry 1992 ; 160 : 165-78. Reiman EM, Raichle ME, Robins E, Butler FK, Herscovitch P, Fox P, et al. The application of positron emission tomography to the study of panic disorder. Am J Psychiatry 1986 ; 143 : 469-77. Roy-Byrne PP, Cowley DS. Course and outcome in panic disorder: a review of recent follow-up studies. Anxiety 1995 ; 1 : 151-60.
10 Slaven L, Lee C. Mood and symptom reporting among middleaged women: the relationship between menopausal status, hormone replacement therapy, and exercise participation. Health Psychol 1997 ; 16 : 203-8.
Eur Psychiatry 2001 ; 16 : 372–4
CASE REPORT
Physical exercise: an adjunctive treatment for panic disorder? L. Dratcu* Division of Psychiatry, Guy’s Hospital, Guy’s, King’s and St Thomas’ School of Medical Sciences, London, United Kingdom (Received 11 November 2000; revised 27 March 2001; accepted 15 June 2001)
INTRODUCTION A range of pharmacological and psychological treatments are available for panic disorder (PD) [7]. However, many patients remain impaired by residual anxiety after receiving anti-panic treatment [9]. Although this may be partly explained by the co-morbidity of PD with generalised anxiety disorder, enduring anxiety symptoms in panic patients may be related to the pathophysiology of PD itself. Panic patients are known to chronically hyperventilate. Hyperventilation was thought to induce panic by lowering pCO2, but Klein [4] suggested that panic patients hyperventilate in the attempt to keep pCO2 low, thereby preventing activation of the brain’s suffocation alarm. Yet, chronic hyperventilation itself may generate symptoms of anxiety [1]. Panic patients would probably benefit from adopting more normal patterns of breathing. We describe three female patients who met DSM-IV criteria for PD and who reported a significant improvement in their clinical status after they engaged in aerobic exercise. All were physically fit, with normal electrocardiogram, full blood count and thyroid function. CASE HISTORIES Case 1 A.D., 47 years old, had her first panic in her late 20s, which was described as an acute episode of anxiety, with
breathlessness, palpitations and cold sweats. Thereafter similar attacks would occur several times a day, usually accompanied by sensations of choking, gastrointestinal discomfort and an urge to run away. She received different psychological treatments, but only obtained relief after using relaxation techniques. Over the years her attacks subsided spontaneously. However, she continued to experience episodes of breathlessness, in addition to a constant feeling that she was sighing instead of breathing, all of which represented a constant reminder of her attacks. She was advised to start a graded programme of jogging consisting of three sessions a week, 30 minutes each, in which she alternated running with brisk walking. Her residual symptoms resolved completely 2 months after commencing the programme. Case 2 H.M., 38 years old, had her first attack at the age of 21, when she experienced palpitations, breathlessness and the fear that she might die. Her attacks became more frequent with time and were later followed by the onset of anticipatory anxiety, which gradually turned into an unrelenting background anxiety. She started to associate her attacks with places from where she felt there was no escape. A range of avoidance behaviours developed that culminated in severe agoraphobia, to the point that she became virtually housebound. She was referred for assessment after failing to respond to a graded exposure programme. The therapist mentioned that, in addition
*Correspondence and reprints: York Clinic, Guy’s Hospital, 47 Weston Street, London SE1 3RR, UK. E-mail address: [email protected] (L. Dratcu).
Physical exercise: an adjunctive treatment for panic disorder?
to panics involving autonomic symptoms and catastrophic cognitions (e.g., the fear that she might have a heart attack), the patient suffered from depression. In the past she had only improved following treatment with moclobemide, but this had been discontinued. On this occasion she was prescribed fluvoxamine 100 mg/d. Her attacks abated after 3 weeks, but her generalised anxiety persisted for the following months, associated with panic symptoms. She used to swim in adolescence and was advised to restart swimming. She gradually adopted a routine of swimming three times a week, 45–60 minutes each session, whilst maintained on fluvoxamine. Her anxiety and panic symptoms resolved over a period of 3 months after she joined swimming classes. Case 3 G.R., 45 years old, had a 30-year-long history of mood swings, agoraphobia and anxiety. She was twice admitted to hospital in her twenties and treated with electroconvulsivetherapy for her depression. Subsequently she received various psychotropic drugs, including benzodiazepines and antidepressants, and different psychological treatments, which proved unhelpful. She was referred at the end of a course of cognitive-behavioural therapy because of her unremitting anxiety and depression. The interview revealed a history of panic attacks with onset in adolescence, involving episodes of dizziness, palpitations and sweats, accompanied by the fear that she might collapse. She would previously experience four to six attacks a week but more recently was having one attack every 1–2 weeks. She had been off any medication over the previous year. A diagnosis was made of PD, with secondary anxiety and depression, and she was begun on fluoxetine 20 mg/d. A therapeutic response was detected after 3 weeks, but 2 months later she was still reporting low mood, lack of energy and anxiety. She also used to swim in her youth and was encouraged to join swimming classes. She started to swim 30 minutes once a week, increasing it to two to three sessions a week over the following 3 months, at which stage her symptoms subsided. DISCUSSION Exercise has long been recognised as beneficial in emotional disorders. Aerobic and nonaerobic exercise performed regularly were both shown to reduce ratings of depression [5]. Fulcher and White [2] demonstrated Eur Psychiatry 2001 ; 16 : 372–4
373
that graded aerobic exercise was therapeutic in chronic fatigue syndrome and that patients showed sustained benefit 1 year after exercise treatment. Moreover, in a study of the benefits of exercise in menopausal and perimenopausal women, exercising women were found to have a significantly more positive mood than sedentary women, regardless of menopausal state [10]. Exercising women also had fewer somatic symptoms and memory-concentration difficulties. This report described patients with PD who, after receiving various treatments for their panics, were still impaired by anxiety symptoms. All had suffered from panics for years and may have become chronic hyperventilators in the attempt to keep their pCO2 low [4]. Tests to confirm this (e.g., ventilatory function, blood gasometry) were not done. However, the improvement that the patients experienced after they had engaged in aerobic exercise suggests that ventilatory abnormalities were probably involved in the perpetuation of their symptoms. Hyperventilation can induce psychological symptoms that are common in anxiety. It also leads to systemic alkalosis, cerebral vasoconstriction and cerebral hypoxia, the likeliest reason for the increased slow wave activity found in the electroencephalogram of panic patients in the non-panic state [1]. In phobic patients, positron emission tomography (PET) of the brain has shown that cerebral blood flow (CBF) was reduced following anxiety-induced hyperventilation and hypocapnia [6]. By chronically hyperventilating, panic patients may thus risk prolonged exposure to cerebral hypoxia. Indeed, brain PET scanning has identified abnormal CBF and oxygen metabolism in panic patients in the non-panic state [8]. This, in turn, may further contribute to the chronicity of their anxiety symptoms. Aerobic exercise may help patients to restore normal ventilatory patterns and mitigate adverse effects on the brain of chronic hyperventilation. This, however, can only be confirmed by further research. The need for research on the benefits of aerobic exercise in PD seems compelling, as the advantages of exercise therapy are likely to extend beyond PD alone. As panic attacks are paroxysmal episodes of anxiety, knowledge gained from studies of PD can be extrapolated to anxiety in general [7]. Also, exercise may prove an adjunct treatment for anxiety that is nonpharmacological, non-addictive, and one that has few adverse effects and contraindications. In addition to reducing the risk of coronary heart disease and stroke, exercise has psychological effects that are surely under
374
L. Dratcu
exploited [3]. Yet, physicians usually do poorly when it comes to advising patients to practice exercise. It may be up to psychiatrists to confirm that the age-old adage mens sana in corporis sano still holds true.
6
REFERENCES
7
1 Dratcu L. Panic, hyperventilation and perpetuation of anxiety. Prog Neuro Psychopharmacol Biol Psychiatry 2000 ; 24 : 1069-89. 2 Fulcher KY, White PD. Randomised controlled trial of graded exercise in patients with chronic fatigue syndrome. Br Med J 1997 ; 314 : 1647-52. 3 Gloag D. Exercise, fitness, and health. Br Med J 1992 ; 305 : 377-8. 4 Klein DF. False suffocation alarms, spontaneous panics, and related conditions. Arch Gen Psychiatry 1993 ; 50 : 306-17. 5 Matinsen EW, Hoffart A, Solberg O. Comparing aerobic with
8
9
nonaerobic forms of exercise in the treatment of clinical depression: a randomised trial. Compr Psychiatry 1989 ; 30 : 324-31. Mountz JM, Modell JG, Wilson MW, Curtis GC, Lee MA, Schmaltz S, et al. Positron emission tomographic evaluation of cerebral blood flow during state anxiety in simple phobia. Arch Gen Psychiatry 1989 ; 46 : 1-4. Nutt DJ, Lawson C. Panic attacks: a neurochemical overview of models and mechanisms. Br J Psychiatry 1992 ; 160 : 165-78. Reiman EM, Raichle ME, Robins E, Butler FK, Herscovitch P, Fox P, et al. The application of positron emission tomography to the study of panic disorder. Am J Psychiatry 1986 ; 143 : 469-77. Roy-Byrne PP, Cowley DS. Course and outcome in panic disorder: a review of recent follow-up studies. Anxiety 1995 ; 1 : 151-60.
10 Slaven L, Lee C. Mood and symptom reporting among middleaged women: the relationship between menopausal status, hormone replacement therapy, and exercise participation. Health Psychol 1997 ; 16 : 203-8.
Eur Psychiatry 2001 ; 16 : 372–4