For folks with certain types of anxiety, namely panic disorder, exercise can be a catch 22 scenario. We know that exercise will make us feel better overall, but at the same time, exercise can sometimes lead to increases in anxiety and even trigger panic attacks. This article will explore why and when this tends to happen for people. Part 2 in this series will provide practical tips to help with the management of exercise-induced anxiety. 

What is Panic Disorder?

Before describing what panic disorder (PD) is, I first have to describe a panic attack. A panic attack is a bout of extreme anxiety that most commonly emerges via physical symptoms including, but not limited to, sweating, shaking, shortness of breath, heart palpitations, hot or cold flashes, sense of dread or intense fear, and much more. It is a good idea to first rule out physical causes — such as cardiac problems — if you are experiencing these symptoms. Panic attacks look different in different people, but regardless of the type of symptoms, people often describe wondering if they are having a heart attack or if they are dying while in the throes of a panic attack. This only increases their levels of panic and anxiety at the moment. 

Panic disorder is a specific type of anxiety disorder that is characterized by recurrent and unexpected panic attacks followed by one month or more of fear of having more panic attacks. Panic disorder will impact about 4.7% of US adults at some point in their lives, with women being more likely to experience it than men (Harvard Medical School, 2017). 

Panic disorder may or may not be accompanied by agoraphobia, or the fear of being in situations where escape might be difficult. With agoraphobia, the fear is that a panic attack might happen at any moment and getting to a place of perceived safety would be difficult or impossible. Often, this results in people avoiding situations they anticipate will cause anxiety, like public transportation, open or enclosed spaces, standing in lines, or crowds. In its most severe forms, people have a difficult time leaving their home at all. 

Exercise-induced panic attacks

For folks with panic disorder, exercise can sometimes be a trigger for increased anxiety or for panic attacks. There are many theories as to why this is, and here are a few:

• Autonomic dysregulation: If you think back to the fight-or-flight series, the autonomic nervous system (ANS) regulates breathing, blood pressure, heart rate, and circulation. Within the ANS we have the sympathetic (fight-or-flight) and parasympathetic (rest) nervous systems. Folks with panic disorder experience autonomic dysfunction — in which their sympathetic nervous system is hypersensitive and overactive — and have less activation in their parasympathetic nervous system. This results in increased sensitivity to stressors and difficulties using techniques to calm the body down when they do experience those stressors. Exercise is one such stressor that, even though desirable, the body cannot distinguish between and leads to increased anxiety (Muotri & Bernik, 2014).
   
• Conditioning: The physiological symptoms of a panic attack (described above) overlap significantly with some of the symptoms of exercise, namely, shortness of breath, sweating, dizziness, etc. These feelings have been conditioned or associated over time with panic. Therefore, when people start to exercise and experience these feelings, they associate them with a panic attack. This cognitive association then perpetuates the presence of the panic attack.
   
• Increased lactic acid buildup: Lactic acid is a compound created by the body during intense workouts. We are well aware that this lactic acid buildup leads to sore muscles, but it also impacts the brain. Some folks have difficulties clearing the lactic acid from their brain and this leads to a hypersensitive amygdala (emotion center of the brain). Therefore, when people engage in vigorous physical activity, their body increases lactate and can lead to panic attacks (Martinsen et al., 1998).

Technically, anyone could experience anxiety or panic during exercise, but folks with panic disorder or family histories of anxiety disorders are more likely to experience them. 

Research shows that, for folks with panic disorder, moderate intensity exercise does increase one’s levels of anxiety immediately following the workout, but even 10 minutes later actually lowers the individual’s level of anxiety compared to their baseline (Ströhle et al., 2009; Lattari et al., 2018). Therefore, this subjective experience where people report increases in anxiety during exercise, but then long-term reductions in their anxiety, is supported by empirical literature. 

Impact of the type of workout

It is not exactly clear from the research which types of workouts are most likely to lead to panic symptoms; however, we know anecdotally that people tend to experience them during higher intensity cardiovascular workouts. Harkening back to the conditioning explanation above, within high intensity cardio workouts (like HIIT), our bodies quickly reach the physiological state that reminds us of a panic attack. When we are unable to then either cognitively distinguish that an increased heart rate from exercise is actually a good thing and/or stop our bodies from automatically spiraling into a panic attack, we feel little control over our levels of anxiety. 

However, research shows that mild to moderately intense exercise does lead to a reduction in anxiety in the long-term (Ströhle et al., 2009; Lattari et al., 2018) and there is even burgeoning research that shows high-intensity exercise can be tolerated by folks with panic disorder under the right conditions (Plag et al., 2019). In particular, gradually increasing your heart rate with a longer warm-up and easing into the high intensity portions can help signal to the mind and body that this is a good and intended physiological response. 

In the next part of this series, we will provide tips for managing anxiety that emerges due to exercise, as well as a workout to try if this is a common experience for you! In the meantime, check out this article about mindfulness for anxiety. What helps you to manage anxiety during workouts?

References

Harvard Medical School (2017, August 21). National Comorbidity Survey (NCS). Retrieved from Harvard. Data Table 1: Lifetime prevalence DSM-IV/WMH-CIDI disorders by sex and cohort.

Martinsen, E. W., Raglin, J. S., Hoffart, A., & Friis, S. (1998). Tolerance to intensive exercise and high levels of lactate in panic disorder. Journal of Anxiety Disorders, 12(4), 333-342.

Muotri, R. W., & Bernik, M. A. (2014). Panic disorder and exercise avoidance. Revista Brasileira de Psiquiatria, 36, 68-75. 

Lattari, E., Budde, H., Paes, F., Albuquerque Maranhão Neto, G., Carlos Appolinario, J., Egídio Nardi, A., Murillo-Rodriguez, E., & Machado, S. (2018). Effects of aerobic exercise on anxiety symptoms and cortical activity in patients with panic disorder: A pilot study. Clinical Practice & Epidemiology in Mental Health, 14, 11-25. 

O'connor, P. J. (2005). State anxiety is reduced after maximal and submaximal exercise among people with panic disorder. International Journal of Sport and Exercise Psychology, 3(4), 501-508.

Plag, J., Ergec, D. L., Fydrich, T., & Ströhle, A. (2019). High-intensity interval training in panic disorder patients: a pilot study. The Journal of Nervous and Mental Disease, 207(3), 184-187.

Ströhle, A., Graetz, B., Scheel, M. Wittmann, A., Feller, C., Heinz, A., & Dimeo, F. (2009). The acute antipanic and anxiolytic activity of aerobic exercise in patients with panic disorder and healthy control subjects. Journal of Psychiatric Research, 43, 1013-1017.