A new randomized trial shows that short bursts of supervised high-intensity exercise can retrain the brain’s fear response to bodily sensations, offering a scalable and attractive new treatment avenue for people with panic disorder.
Study: Brief intermittent vigorous exercise as an introspective exposure for panic disorder: a randomized controlled clinical trial. Image credit: Pixel-Shot/Shutterstock.com
Sequential exposure (I.E) is a key component of cognitive-behavioral therapy (CBT) for panic disorder (P.D). However, his current ways I.E tend to be monotonous and unappealing to patients. A recent study published in the journal Frontiers in Psychiatry directly compared vigorous physical exercise as autonomous I.E intervention with relaxation training (RT) in patients with P.Dtrial exercise as targeted I.E strategy.
Because symptom activation can reduce panic responses
panic attacks (PA) are sudden episodes of intense fear that occur in conjunction with physiological changes such as increased heart rate or dizziness, resulting from autonomic arousal. With repeated PAas in panic disorder (P.D), patients tend to interpret these physical cues as threatening. First they become wary of them and then they become anxious and afraid.
This results in P.D Patients become unnaturally sensitive to their internal sensations and tend to overestimate their severity and consequences. For example, false feedback about heart rate can do P.D patients think they have tachycardia. Despite the absence of symptoms, they become anxious and panicky. Similarly, P.D often impairs the ability to accurately judge physical cues, such as assessing the degree of anaerobic threshold exercise during ergospirometry tests.
Such people often try to avoid PA by avoiding physical activity and a sedentary life. One hypothesis is that at P.D patients, the hyperactive sensations of the autonomic system become learning stimuli for feelings of threat and anxiety, a conditioned stimulus.
CBT is an effective treatment for P.Dand includes I.E as a central component. I.E is improving PA frequency and severity and reduces functional impairment due to P.D. I.E it involves deliberately inducing unpleasant physical sensations such as shortness of breath, palpitations and dizziness. Being similar to PA activate, help retrain the brain to tolerate them without anxiety.
However, standard office based I.E practices such as turning in the chair to induce sensation are often unacceptable to patients or relatively ineffective.
Conversely, short intermittent intense exercise (BIE) is perceived as a type of natural and healthy behavior. As such, it is a more pleasant way to produce interoceptive cues, including faster heart rate and breathing rate. Since exercise is often perceived as non-threatening, it can provide a faster route to retraining.
Only one previous study has examined the role of exercise in P.D as part of a standard CBT intervention. During this study, another primary I.E strategy was used, with exercise being an adjunct. However, the researchers did not assess P.D– specific results.
The current study sought to fill this gap by using a standardized, self-administered exercise-based I.E intervention and not complete CBT packaging and comparing it to RT. RT was selected as a psychological placebo that is accepted as a reliable treatment by patients, although it is not considered a first-line treatment for P.Densuring a valuable comparison.
Randomized trials of exercise versus relaxation therapy
The researchers conducted a parallel randomized trial of two arms and two brief bouts of intense exercise (BIE) and Jacobson RT. The latter involves deep breathing, followed by alternating tension and relaxation of different muscle groups throughout the body.
The study involved 102 randomized participants with panic disorder, of whom 72 completed the intervention and follow-up assessments. The mean age was 33 years, and both groups had comparable frequency and severity of panic attacks at baseline. All participants were free of psychotropic medications for at least 12 weeks prior to the program, did not meet moderate physical activity guidelines, had no history or current substance abuse or dependence, and had no cardiovascular risk factors.
The focus on sedentary participants was intended to recruit individuals who may have stronger fear responses to exercise-induced bodily sensations, potentially increasing the sensitivity of the study to detect the effects of perceptual learning.
Participants were randomized to BIE or RT. For BIEalternated walking with short 30-second jogging or sprinting intervals, performed in structured 30-minute sessions that included warm-ups, walking intervals, and progressive increases in sprint repetitions during the 12-week, supervised program. RT Participants followed a standardized progressive muscle relaxation protocol conducted three times per week in 45-minute sessions for 12 weeks.
All patients received the same placebo pills. All were assessed using the Agoraphobia Panic Scale (STEP) score at baseline and at 6, 12, and 24 weeks, with an additional assessment performed shortly before treatment initiation. Participants were also assessed for the frequency and severity of panic attacks. In addition, they were assessed for depression and anxiety using the Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Depression Rating Scale (HAM-D) ratings.
The exercise program offers stronger, longer-lasting improvements in symptoms
Of the 102 randomized participants, 72 completed the full intervention and follow-up period, with only three participants discontinuing after entering the final analysis cohort. The low dropout rate may reflect the perceived health benefits of the intervention, its intrinsically rewarding nature, and possibly the motivating experience of receiving treatment in a high-performing clinical setting such as the Orthopedic Institute’s Movement Laboratory, the study authors suggest.
Changes to PAS
THE STEP The score improved in both groups over time. However, when group × time interactions were analyzed, the groups showed distinctly different trajectories.
At first, the BIE and RT groups had STEP scores of 32.1 and 30.4, respectively. The average score decreased in both groups. However, the decline was steeper, with scores of 14.9 and 23.1 at week 12, representing a clinically significant reduction in panic severity in the exercise group.
At week 24, the improvement was maintained at BIE team, with the STEP is 14.2. Instead, the score rose slightly to RT group, until 24.7.
Frequency and severity of PA
Both groups also showed sharp declines in PA frequency and severity at 12 weeks, with partial recovery at 24 weeks. The rebound was quieter with BIEmost of the improvement was maintained at the 24-week follow-up. This did not happen with RTconfirming previous studies suggesting short-term benefits with only RT.
Depression and anxiety
Both groups also showed lower values HAM-D and HAM-A score over time. The most significant difference between groups was in depressive symptoms at week 24. BIE was associated with sustained and more marked improvement. In contrast, symptoms showed relative worsening beyond 12 weeks with RT.
The long term profits with BIE suggest that new learning occurs, allowing patients to reinterpret physical cues as nonthreatening. This can extend into daily life, reducing overall arousal. Previous research by the same group supports this, indicating lasting benefits from the desk I.E.
These sedentary patients were reported by the authors to not experience panic attacks during vigorous exercise, which is often associated with hyperventilation and dyspnea. A plausible explanation is that exercise-induced metabolic acidosis counteracts the respiratory alkalosis associated with hyperventilation, which is known to induce panic. The environment may also have contributed to the feeling of safety.
The study suggests that BIE it is a low cost, scalable and more attractive I.E strategy with greater effectiveness and long-term benefits than RT in this group. It offers health benefits and is inherently rewarding. The results of use BIE as I.E in this study agree with the observation that “more intensive I.E may maximize clinical benefits, particularly in reducing respiratory and general stress indices.”
The findings also directly support the effectiveness of exercise I.E compared to RT in P.D specifically, extending previous research in this area, although the results should not be interpreted as proving equivalence to comprehensive CBT programs.
However, the study has some limitations, notably the small, sedentary sample of young adults at low cardiovascular risk, which may limit generalizability to physically active or wider P.D populations. The use of placebo pills in both arms may have confounded the analysis. Also, only one trained rater was used for the assessment P.D throughout the study and diagnoses were not independently verified by multiple raters. Future trials could use multiple assessments to ensure a more accurate diagnosis and comparison BIE–CBT with standard I.E–CBT protocols for P.D.
Exercise-based exposure offers scalable treatment for panic disorder
The study suggests that while both RT and BIE were beneficial to P.Dthe BIE program provided intensive I.E is associated with more effective and sustained reductions in the severity and frequency of P.D symptoms. This can provide a feasible and low-cost alternative to the current desk I.E procedures, in particular as ancillary or targeted I.E strategy in broader therapeutic contexts.
“These findings support the incorporation of structured exercise I.E in P.D treatment programs as a low-cost and attractive option’.
Further research is needed to identify the target population for maximum benefit and to investigate the use of exercise-based I.E in various therapeutic models for P.D.
