Anxiety Sensitivity and Exercise Avoidance: Implications for Treatment SHERRY H

Anxiety sensitivity and exercise avoidance: Implications for treatment SHERRY H. STEWART, PHD PROFESSOR OF PSYCHIATRY, PSYCHOLOGY & NEUROSCIENCE, & COMMUNITY HEALTH & EPIDEMIOLOGY TIER 1 CANADA RESEARCH CHAIR IN ADDICTIONS AND MENTAL HEALTH DALHOUSIE UNIVERSITY, HALIFAX, NOVA SCOTIA, CANADA E-MAIL: [email protected] Anxiety Sensitivity

 Enduring fear of anxiety-related physiological sensations (e.g., fear of breathlessness) arising from the belief that these sensations will have catastrophic consequences (Reiss, 1991; Reiss & McNally, 1985) Links to Mental Health Problems

Panic Disorder

PTSD Health Anxiety

Anxiety Substance Abuse Sensitivity

Social Anxiety Disorder

Depression Generalized Anxiety Disorder Links to Physical Health Problems

Respiratory Disorder

Menstrual Reactivity Poor Perceived Fitness

Anxiety Post-Concussion Syndrome Sexual Functioning Sensitivity

Chronic Pain Obesity

Tinnitus Poor Perceived Health Dimensions of AS

Anxiety Sensitivity

Physical Concerns Social Concerns Fear that anxiety-related Fear that publicly- somatic sensations have Cognitive Concerns observable sensations health consequences Fear that anxiety-related (e.g., blushing, sweating, (e.g., heart attack, death) cognitive sensations are fainting) will elicit social “It scares me when my heart sign of mental illness sanction ” beats rapidly “When my thoughts race, I “I worry others will notice my worry I might be going anxiety” crazy” Dimensions of AS

Anxiety Sensitivity

Panic Disorder Social Phobia Depression Dimensions of AS

Anxiety Sensitivity

Respiratory Disorder Anxiety Sensitivity & Respiratory Disorder

Anxiety Sensitivity Index Scores In Asthma 20 18 16 14 12 10 8 6 4 2 0 No Exclusions Excluding PDA Asthmatics Controls Caccappolo-van Vliet et al. 2002 J Occup Environ Med Anxiety Sensitivity & Asthma Morbidity

AS Predicts* PD Predicts*  Overall poorer asthma control  Overall poorer asthma control  Activity Limitations  Activity Limitations  Nocturnal Waking  Waking Symptoms  Bronchodilator Use

 QoL Impairments in these domains:

 Symptoms

 Emotional Distress

*controlling baseline, age, sex, years education, medication dose, smoking history, depression, Favreau et al. 2014 Psychosom Med and FU time

AS Components & Asthma Control

McLeish et al. 2010 J Health Psychology AS and Reactivity to Asthma Sensations

McLeish et al. 2015 Behav Mod AS and Dyspnea Avoidance

Simon et al. 2006 J Nerv Ment Dis AS & Exercise Avoidance

Sabourin et al. 2011 CBT Exercise Avoidance

Sabourin et al. 2011 CBT Why do they exercise less?

Perceived Barriers to Exercise

Exercise AS Group & Fitness

Sabourin et al. 2011 CBT How do we reduce high AS?

Brief CBT

1. Psychoeducation

2. Cognitive Restructuring

3. Interoceptive Exposure Brief CBT for High AS

1. PSYCHOEDUCATION Anxiety/Panic Cycle

PHYSICAL SENSATIONS (e.g., shortness of breath)

ACTIONS THOUGHTS (e.g., exercise avoidance) (e.g., I’m going to die, I can’t handle this)

FEELINGS (e.g., fear, dread, panic) Psychoeducation Exercises

Physical Situation Sensations Thoughts Feelings Actions Brief CBT for High AS

2. COGNITIVE RESTRUCTURING

FEAR IS ONLY AS DEEP AS THE MIND ALLOWS.

-- JAPANESE PROVERB. High AS ~ Cognitive Distortions

The sky is going to fall! 1. Catastrophizing

2. Overestimation of Probability Examining the evidence for our thoughts …

Brief CBT for High AS

3. FACING THE FEAR: INTEROCEPTIVE EXPOSURE Interoceptive Exposure (IE)

 What is IE?

 Why is it important?

 Types of IE

 Running as IE Does brief CBT work?

• Three RCTs with positive results:

• (1) Watt et al. (2006a,b; CBT, JMH)

• High vs. low AS university women

• CBT vs. inactive therapist contact control

• (2) Olthuis et al. (2014, 2015a,b; JCCP, Addict Behav, CBT)

• High AS, community-recruited; distance treatment

• CBT vs. wait list control (WLC)

• (3) Sabourin et al. (in press; J Cog Psychotherapy)

• High vs. low AS university women

• CBT vs. more stringent health education control (HEC)

Effects on Anxiety Sensitivity

Intervention

3 3 Score -

20 Control ASI

0 Baseline 8 weeks 12 weeks Olthuis et al., 2014, JCCP Effects on Panic Symptoms

Intervention 10 Control

5 Olthuis et al., 2014, JCCP 0 Change at 8 Weeks Change at 12 weeks Effects on Disability

10 Intervention Control

SDS SDS Score 8

0 Baseline 8 weeks 12 weeks CRFH Bio Janine Expand next previous

AS Mediation of Intervention Effects

Anxiety Sensitivity

Intervention: Panic CBT vs WLC Symptoms How does running reduce AS?

Sabourin et al. (2008) J Cog Psychotherapy How does running reduce AS?

Sabourin et al. (2015) CBT Take Away Messages

 AS, particularly physical concerns, important factor in respiratory disorders  AS is elevated in asthma and predicts  Poorer asthma control and lower asthma-related QoL  Aversive reaction to asthma-like sensations  Greater avoidance of dyspnea  AS can be effectively targeted in brief CBT intervention  Interoceptive exposure (IE) important component  IE can be achieved through physical exercise (running)

 Running tackles exercise avoidance which may maintain AS  More research needed on how to adapt the Brief AS intervention for those with respiratory disorders (e.g., exercise as ability permits)

 Anecdotally, such modifications possible

 Needs patient- and clinician-informed modifications  Modifications should be tested; outcomes? Acknowledgements

Margo Watt

Questions? E-MAIL: [email protected]

Janine Olthuis & Brigitte Sabourin