# Exercise as it relates to Disease/Physical exercise vs cognitive behavior therapy for the treatment of panic disorder sufferers
## What is the background to this research?

Panic Disorder, commonly referred to as PD, is a mental disorder affecting up to 5% of the world’s population at some stage in life. PD, often complicated by agoraphobia, is a disabling disorder that is associated with a reduced quality of life. PD not only affects quality of life but has also displayed an increased use of health care utilities, low workplace productivity, and absenteeism. Although an increased yet imprecise understanding of the cause of PD has arisen, there has been evidence of the use of effective treatments for this condition, such as cognitive-behavioural therapy (CBT), pharmacological intervention, and physical exercise (PE).
Martinsen, Sandvik and Kolbjornsrud conducted a naturalistic study in 1989 with a mixed inpatient sample. Within this sample, groups of eight participated. Exercise sessions were performed each day for a minimum of one hour. These exercise regimes displayed an immediate and significant reduction of symptoms among patients with PD who were participating in the exercise treatment. In saying this, the effect of the exercise treatment did not have a long-lasting effect, with patients displaying less success at the 12-month follow-up assessment. Cognitive-behavioural therapy (CBT) is currently regarded as the most effective and successful treatment of choice for patients suffering with PD, making it an appropriate intervention, also noting that research shows the effectiveness of CBT being delivered in a group setting.

## Where is the research from?

The National Program for Integrated Clinical Specialist and PhD-training for Psychologists in Norway supported the production and conduction of this study. This study was a joint cooperation between the Universities of Oslo, Bergen, Tromso, the Regional Health Authorities, the Norwegian University of Science and Technology, and the Norwegian Psychological Association. The funding of this program was jointly contributed by the Ministry of Health and Care Services and The Ministry of Education and Research.

## What kind of research was this?

This was a randomised controlled trial which administered treatments in groups, running for 12 weeks. Physical exercise was conducted three times each week, whereas cognitive-behaviour therapy was conducted once a week. For PE and CBT intervention, a booster session was offered to each participant as a 3-month follow-up, as well as a 6- and -12-month follow up.
Follow up assessments were not a compulsory part of the study, suggesting that the overall results and effectiveness of the treatments could have been different if each participant was required to be assessed in the follow up. This research task also did not identify whether or not the participants would be medicated over the duration of the trial, which also hinders symptoms. Psychiatrist Jonathan R. T Davidson describes the long-term drug treatment as necessary and safe in the treatment of PD. Without an accurate and succinct diagnostic and pre-assessment of each participant, the assessment and result cannot be accurate.

## What did the research involve?

Primary contact was initiated by telephone, where 141 subjects were supplied with information about the nature of the study and purpose. Out of the 141 subjects, 66 were invited for a detailed diagnostic interview and were scheduled for an on-site evaluation. Subjects, prior to treatment initiation, were informed that each intervention is shown to be effective treatment options for PD, however CBT has shown a higher level of documented effectiveness.
As participants were informed of the success rates regarding each treatment option, and CBT being the most successful, the participants entered treatment with higher expectations of CBT than PE. Following these two assessments, the 36 eligible participants were immediately and randomly allocated to one of the two interventions being offered. The demographic of participants sat at 80.6% female, and 19/4% male with a mean age of 37.9. Within the 36 patients, 57% lived alone. Studies show that anxiety is an increasingly common health problem among individuals who live alone. As not all of the participants lived alone, the results do not represent a fair test of treatments working to treat PD.

## What were the basic results?

Over the course of the treatment, only one participant withdrew themselves from the CBT treatment, in the second session. Therefore, a total of 35 participants received treatment as planned. Several participants did not complete the follow-up assessments. With a mean age of 37.9 years, and a randomised allocation to each treatment programme, patients’ enthusiasm and self-efficacy towards their treatment options may have been low. The treatment of these sessions was administered by two members of the team, as well as attendance being monitored. If participants were unable to participate, they were instructed to perform an equivalent exercise on their own and record the details, however this was not recorded as attendance.
Sufferers of PD may avoid situations they have little to no control over and can fear oncoming situations, thus making the above compulsory participation/attendance ruling intimidating, unpleasant and uncomfortable. For sufferers of PD, unpleasant experiences of treatment could discourage participation in future.
The aim of this study was to identify the long-term benefits of PE and CBT as treatment for PD, however similar long-term studies for the treatment of PD progressed over the course, and consistent follow-ups were administered between 2 and 4 years after treatment began. To consider a 12-month treatment as evidence of ‘long-term’ results is not reliable, accurate, or succinctly measured. Studies show that consistent follow-ups and check-ins are proven to improve symptoms of PD, which this treatment did not offer.

## What conclusions can we take from this research?

When the effects of PE and CBT were assessed in a combined analysis, CBT was found to have performed significantly better. Overall, physical exercise has proven to be associated with improvement to panic disorders, for more consistent and larger results we recommend the use of cognitive behaviour therapy.
The limitations of this study lies within the therapists’ ratings which were not blinded from participants, meaning an idea of superiority and academia was instilled before treatments had begun. High expectations and furthermore trust was already established before treatment commenced, meaning the conduction of the treatment may not have been equitable or a fair test.
A 6-minute walk test was administered initially, however the exercise conducted throughout the treatment got progressively harder. For patients with little to no confidence in this area or field of treatment, undergoing this form of therapy would have been stressful and fearful, while potentially lowering their expectations and success of this form of treatment for the remainder of the 12 weeks. Following on from this, agoraphobia and PD are syndromes where patients avoid places or situations they feel uncomfortable with. Being monitored during PE for 3 days a week over 12 weeks is a scenario in itself that promotes fear of the unknown, embarrassment, and social anxiety .
Although this is not the purpose of the study, the grouping and monitoring component and the randomised allocation of treatments does not support the wellbeing needs of participants involved.

## Practical advice

Symptoms of panic disorder
* Feelings of fear of death, out of control and impending doom
* Intense worry about oncoming situations
* Fear or avoidance of specific places
Physical symptoms include:
* Chills
* Trembling
* Difficulty breathing
* Chest Pain
* Dizziness/Weakness
* Nausea
The first step in curing a panic disorder is to first get a diagnosis from a health care professional.

## Further information/resources

Article: https://pubmed.ncbi.nlm.nih.gov/22874661/

## References

* 1 2 Roy-Byrne PP, Craske MG, Stein MB. Panic disorder. The Lancet. 2006 Sep 16;368(9540):1023-32.
* ↑ Hovland A, Nordhus IH, Sjøbø T, Gjestad BA, Birknes B, Martinsen EW, Torsheim T, Pallesen S. 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. 2013 Jul;41(4):408-32.
* ↑ Martinsen EW, Sandvik L, Kolbjørnsrud OB. Aerobic exercise in the treatment of nonpsychotic mental disorders: An exploratory study. Nordisk Psykiatrisk Tidsskrift. 1989 Jan 1;43(6):521-9.
* ↑ McHugh RK, Otto MW, Barlow DH, Gorman JM, Shear MK, Woods SW. Cost-efficacy of individual and combined treatments for panic disorder. Journal of Clinical Psychiatry. 2007 Jul 1;68(7):1038.
* ↑ Telch, M. J., Lucas, J. A., Schmidt, N. B., Hanna, H. H., Jaimez, T. L., & Lucas, R. A. (1993). Group cognitive–behavioral treatment of panic disorder. Behaviour Research and Therapy, 31, 279–287.
* 1 2 Davidson JR. The long-term treatment of panic disorder. Journal of Clinical Psychiatry. 1998 Jan 1;59:17-23.
* 1 2 Lee YY, Lin JL. How much does trust really matter? A study of the longitudinal effects of trust and decision-making preferences on diabetic patient outcomes. Patient education and counseling. 2011 Dec 1;85(3):406-12.
* 1 2 Yu J, Choe K, Kang Y. Anxiety of older persons living alone in the community. InHealthcare 2020 Aug 22 (Vol. 8, No. 3, p. 287). MDPI.
* ↑ Pocock SJ. Allocation of patients to treatment in clinical trials. Biometrics. 1979 Mar 1:183-97.
* 1 2 Nagy LM, Krystal JH, Woods SW, Charney DS. Clinical and medication outcome after short-term alprazolam and behavorial group treatment in panic disorder: 2.5-year naturalistic follow-up study. Archives of General Psychiatry. 1989 Nov 1;46(11):993-9.
* ↑ Perugi G, Frare F, Toni C. Diagnosis and treatment of agoraphobia with panic disorder. Cns Drugs. 2007 Sep;21(9):741-64.
* ↑ Noyes Jr R, Garvey MJ, Cook BL. Follow-up study of patients with panic disorder and agoraphobia with panic attacks treated with tricyclic antidepressants. Journal of affective disorders. 1989 Mar 1;16(2-3):249-57.
* ↑ Panagopoulos C, van der Linden S. The feeling of being watched: Do eye cues elicit negative affect?. North American Journal of Psychology. 2017 Mar 1;19(1).
* 1 2 Ball S, Robinson A, Shekhar A, Walsh K. Dissociative symptoms in panic disorder. The Journal of nervous and mental disease. 1997 Dec 1;185(12):755-60.