Workout Your Worries: Anxiety and Exercise in MS
What is Anxiety?
Anxiety is an umbrella term that describes an emotional state of apprehension, worry, fear, or terror. Typically one’s body also responds resulting in: sweating, increased heart rate, muscle tension, shaking, dry mouth, or a flushed face. It is normal to occasionally feel worried or anxious. However, anxiety is considered problematic when it starts to interfere with your daily life. In such cases, you might notice that anxiety (1) impacts your ability to fall asleep or stay asleep, (2) causes you to avoid certain people, places or things, (3) causes arguments with friends or loved ones, or (4) compels you to perform certain actions or complete tasks in a particular way. There are many kinds of anxiety:
- Generalized anxiety. One of the most common forms of anxiety. People with generalized anxiety are daily worriers. They feel worried nearly every day, for most of the day. They may worry about all kind of things including: finances, loved ones, health, etc.
- Panic attacks. Brief episodes of intense anxiety, fear or terror that seems to come “out of the blue.” Panic attacks may or may not be accompanied by agoraphobia. Agoraphobia is avoiding places or activities that might cause a panic attack. Typically, these are public or open spaces like a shopping mall or public transportation.
- Phobia. An intense, unrealistic, fear of objects or situations; often accompanied by avoidance of the feared thing. Common phobias might be fear of needles, flying, dogs, spiders, or public speaking.
- Obsessive-Compulsive Disorder (OCD). There are two aspects of OCD, obsessions and compulsions. Obsessions involve recurrent thoughts or images that trigger anxiety. The compulsion is how an individual behaviorally deals with the obsessive thought or images to reduce anxiety.
- Post-Traumatic Stress Disorder (PTSD). PTSD may develop after an individual is exposed to an event that is shocking or perceived as dangerous. It is normal to feel scared or anxious after such life events. However, in individuals that develop PTSD, symptoms persist for at least one month and interfere with their daily lives. Symptoms might include flashbacks, nightmares, avoidance of feared places or thoughts, feeling on edge, difficulty sleeping, being easily startled, or having cognitive troubles.
Anxiety and Multiple Sclerosis
Worry or anxiety is more common in people with multiple sclerosis. In fact, at any one point in time, approximately 20% of people with MS could meet criteria for a clinical anxiety disorder, specifically generalized anxiety disorder. Compare that to 6% in the typical person, or 8% of people visiting their primary care doctor. Phobias (e.g., needle phobia), panic attacks, OCD, and PTSD are all more common in MS.
Not unexpectedly, anxiety impacts the lives of people with MS. Generalized anxiety is associated with an increase in confirmed exacerbations, increase in pseudo-exacerbations, poor adherence to medication, an increased number of doctor visits, and even thoughts of suicide. Therefore, it’s important to address these symptoms.
Getting Anxiety Under Control
There are many ways to address anxiety:
Cognitive-Behavioral Therapy (CBT) is extremely effective in treating anxiety disorders. This type of therapy helps you identify and alter unhelpful thinking patterns that reinforce worry and anxiety (e.g., “If I have another exacerbation, I’ll lose my job!”). CBT also helps you identify then modify behaviors that trigger or reinforce worry and anxiety.
- Avoiding feared situations or objects like injections, doctor appointments, or MRIs.
- Avoiding the use of assistive devices, such as a cane, because of what others might think of you.
- Flinching or tensing up before using an injectable disease modifying medication
Acceptance and Commitment Therapy (ACT) is another effective treatment, especially for generalized anxiety. The primary goal of ACT is to find ways to pursue your chosen values, despite difficult and changing life circumstances (e.g., a diagnosis of MS).
Medication is not necessarily a cure for anxiety, but can keep symptoms under control while you learn coping strategies, or until life stressors decrease.
Medications most commonly used for anxiety include:
- Antidepressants: SSRIs, Tricyclics, or MAOIs
- Anti-Anxiety Medications: benzodiazepines, buspirone
- Beta-Blockers (prevent the physical symptoms that accompany certain anxiety disorders such as increased heart rate)
Have an open and honest conversation with your doctor about anxiety symptoms. This will help them determine what medication might be most helpful for you.
Relaxation exercises can help with the physiologic symptoms of anxiety; increased heart rate, shallow breathing, etc. There are many free resources on the web that will walk you through such strategies.
- Mindfulness-based stress reduction (MBSR)
- Diaphragmatic breathing
- Progressive muscle relaxation
- Autogenic training
Exercise and Physical Symptoms
Anxiety can also exacerbate physical symptoms of MS. For example, anxiety and fear associated with falling can exacerbate spasticity, or stiffness/tightness in the legs, and, in turn, make walking even more challenging. Similarly, physical symptoms of MS can also contribute to anxiety. An example may involve bladder urgency. When a person with MS has to use the bathroom more frequently, the bladder urgency can create a situation of increased anxiety because then the person with MS is quite concerned and anxious to travel to unfamiliar places for fear of not knowing if they can access a bathroom in time. In either situation, anxiety can be quite limiting.
Fortunately, in these two highlighted situations, once the physical symptoms are better managed with the help of urology, nursing, physicians, and rehabilitation professionals, then generally, the anxiety associated with the physical limitation will also lessen. However, when anxiety exists without a specific activity association, one may wonder will physical interventions, such as exercise, still help? Yes, exercise CAN!
Research in the field of MS, as well as many other diseases, suggests that exercise CAN help people better manage their anxiety. Some studies suggest that exercise can be as beneficial as medication for the management of anxiety (www.adaa.org). Exercise releases endorphins in the brain that may help to regulate mood. Exercise can also help to minimize cortisol in the body. Cortisol is known as the “stress” hormone and can elevate as a result of stress and anxiety (www.calmclinic.com). Aerobic exercises and stretching exercises (i.e. yoga) are particularly beneficial.
Aerobic exercise, by definition, is exercise that requires oxygen. To reach the level of aerobic exercise, a person needs to achieve 50-70% of maximal heart rate. Aerobic exercises can include walking, biking, swimming, or dancing, just to name a few. A physical therapist or exercise physiologist can help to define your aerobic heart rate zone, as well as provide other alternatives to measuring your exercise intensity, such as the Rating of Perceived Exertion Scale (RPE). Recent research has demonstrated that as little as 20 minutes of moderate exercise helped to improve mood for up to 45 minutes afterwards without aggravating MS related fatigue.
Fortunately, a similar effect has been demonstrated in yoga. Yoga for people with MS, whether seated or traditional poses, may help to improve mood and cognition. Even an activity as simple as deep breathing or meditation has proven to be effective at anxiety reduction. Respiratory or breathing muscles weakness has been shown to be present in nearly all people with MS, regardless of their ambulation. Respiratory breathing exercises can not only strengthen these muscles, but also have a positive, relaxing effect on mood. Not to mention, deep breathing can be done without equipment and even on days when MS fatigue is overwhelming.
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