Exercising With Anxiety: Can Cognitive Behavioural Techniques Help People With Anxiety-related Disorders Exercise More?
Condition: Anxiety Disorders; Posttraumatic Stress Disorder; Obsessive-Compulsive Disorder
MeSH terms: Anxiety Disorders; Obsessive-Compulsive Disorder; Stress Disorders, Post-Traumatic
Study type: Interventional

Summary: 
      Anxiety-related disorders such as panic disorder, social anxiety disorder, generalized
      anxiety disorder, and posttraumatic stress disorder are among the most prevalent mental
      health disorders affecting Canadian adults. Lack of access to evidence-based treatments
      prevents many people with high levels of anxiety from receiving appropriate care. Evidence
      shows that exercise is an alternative option for alleviating anxiety that could be appealing
      to individuals with high levels of anxiety who are unable, or unwilling, to access other
      evidence-based treatments. Unfortunately, people with high levels of anxiety tend to have a
      hard time using exercise independently as a strategy to manage their anxiety, in part,
      because many aspects of exercising can be anxiety-provoking (e.g., physical sensations
      produced by exercise, opportunities for evaluation by others, crowded exercise environments).
      Cognitive-behavioral techniques are therapeutic tools that could help these people overcome
      their anxiety about exercising and support them as they make positive health behavioural
      changes; however, however, no study to date has explored this possibility. The proposed study
      will use rigorous experimental techniques to determine whether an exercise-focused cognitive
      behavioural psychological intervention can support people with anxiety-related disorders to
      become more physically active and experience the reductions in anxiety that comes from making
      this lifestyle change.
    

Detailed description: 
      Exercise is a time- and cost-efficient alternative to other evidence-based treatments for
      anxiety (e.g., psychotherapy, pharmaceutical) that also is associated with physical health
      benefits. Exercise protocols such as resistance training (RT) are efficacious at reducing
      symptoms of anxiety-related disorders (ARDs); however, there are challenges associated with
      effectively implementing such protocols, most notably, that people with ARDs may avoid
      physical activity, including exercise. Emerging research suggests that people with ARDs
      experience exercise-specific anxiety (e.g., exercise-related worries, fear of physical
      sensations associated with exercise) and identify this exercise anxiety as a major
      contributor to their exercise avoidance. Consequently, exercise interventions for people with
      ARDs may need to target exercise anxiety to support long-term exercise engagement.
      Evidence-based cognitive-behavioural techniques (CBT), such as cognitive restructuring, and
      exposure, can alter maladaptive thinking and behavioural patterns associated with anxiety.
      Teaching people with ARDs how to apply CBT techniques to exercise anxiety could help increase
      and support their exercise behaviour; however, research has not been conducted to test this
      hypothesis. The primary purpose of this proposed randomized controlled trial (RCT) is to
      examine whether adding a form of CBT (i.e., the Unified Protocol) to a program for people
      with ARDs is associated with superior exercise engagement as compared to groups that do not
      receive this intervention. This proposed RCT will also evaluate potential predictors of
      exercise frequency for people with ARDs, such as exercise knowledge, exercise self-efficacy,
      and exercise motivation. A total of 90 physically inactive participants with ARDs will be
      randomized into a month of one of the following conditions: Unified Protocol + RT, RT, or
      waitlist (WL). All participants (except WL) will receive and follow a comprehensive
      instructional exercise program, consisting of three weekly full body RT workouts.
      Participants in both RT groups will also receive the guidance of a personal trainer during
      their first month of following this program. Participants in both RT groups will complete
      three exercise sessions each week for 4 weeks and these sessions will be composed of personal
      trainer and independent exercise. Participants in the Unified Protocol +RT condition will
      also receive four weekly individual CBT sessions designed to support adherence to the
      exercise sessions. Exercise frequency will be measured using the number of recorded exercise
      sessions (at least 30 minutes in length) and physical activity will be measured using the
      International Physical Activity Questionnaire-Short Form. Presence and severity of ARDs will
      be assessed using the Structured Clinical Administered Interview for the Diagnostic
      Statistical Manual of Mental Disorders-5 (SCID-5) as well as disorder-specific self-report
      measures. Exercise anxiety will also be measured using a questionnaire designed for this
      study. Exercise frequency, anxiety disorder-specific severity, and exercise anxiety will be
      measured at baseline, weekly during the first month of exercise, and at follow-up at 1-week,
      1-month, and 3-months. Diagnostic status will be evaluated at baseline and at 1-week
      follow-up. Exercise knowledge, exercise self-efficacy, exercise motivation, and physical
      activity, will be measured at baseline, 1-week-, 1-month-, and 3-month follow-ups. Multilevel
      modelling will compare exercise frequency and anxiety symptoms, across groups, at each time
      point. This RCT will be the first to evaluate whether the Unified Protocol can support people
      with ARDs to increase their exercise engagement. If the Unified Protocol does increase
      engagement, the Unified Protocol could be used by researchers and clinicians alike to support
      individuals with ARDs interested in using exercise to manage their anxiety, but who are
      experiencing difficulty maintaining an exercise regime.
    

Intervention name(s): Resistance training; Unified Protocol
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Following randomization, all participants assigned to receive the resistance training intervention will receive a comprehensive exercise program. The exercise program participants will be using is similar to past research using resistance training programs with people with anxiety-related disorders and has been developed and reviewed by a team of certified personal trainers, including the primary investigator. All participants assigned receive this resistance training intervention will complete a total of six sessions with a personal trainer and six session independently over four weeks to allow for a gradual, rather than abrupt, transition to fully independently completed exercise by the 4th week. After this time participants will be encouraged to exercise independently.; This intervention consists four weekly sessions adapted from the Unified Protocol. The first module is Psychoeducation and Motivational Interviewing. During this module, participants will develop an understanding of their own pattern of emotional responding to exercise as well as increasing participants' readiness and motivation for behaviour change.The second module is Cognitive Flexibility, during which participants will learn about how automatic negative interpretations can influence their emotional reactions and prevent them from considering alternative explanations. The third module is Countering Emotion-Driven Behaviours during which participants will identify and counter behaviours used to dampen strong emotions, particularly those associated with exercise. Lastly, module four will use Exposure to external and internal emotional triggers to increase participants' tolerance to the emotions that arise in exercise environments.
Other intervention name(s): Exercise; Cognitive-behavioural therapy
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Participants will be randomly assigned to one of three conditions: resistance training plus Unified Protocol, resistance training, or waitlist. Participants will then complete their assigned condition. Participants who receive the waitlist condition will have the option to be re-randomized into one of the resistance training conditions after they have completed their last waitlist measure.
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Anxiety-Related Disorder; Exercise; Resistance Training; Unified Protocol; Adherence; Randomized Controlled Trial; Physical Activity