Michelle

Exercise Therapy and Health Education with a Client Suffering from Mental Health Illness

Executive Summary

The positive effects of exercise therapy and health education on mental wellbeing are proven to be beneficial in many studies that have been completed.  In an article written by The Heart Foundation (2007), it details benefits such as decreased feelings of depression, stress and anxiety over the long and short term from regular physical activity. For many who are suffering from a mental illness, the symptoms associated i.e. negative self-talk, social anxiety and low self-esteem may be inhibiting them from undertaking an exercise program in the first instance and therefore are solely relying on traditional treatment methods such as prescribed medication to manage their disease/s.

With a lack of physical activity, additional improvements in mental health is not achieved outside the usual scope and the increased risk of other major health concerns such as obesity and type 2 diabetes become apparent. In a journal completed by Zschucke E et.al (2013), it discusses the increased incidence of the comorbidity of various physical health conditions such as respiratory or cardiovascular disease in mental health patients due to an unhealthy / inactive lifestyle.

Mental illness, in its many forms comes with startling statistics within Australia alone particularly in the form of anxiety / depression where:

  • 1 in 4 will experience anxiety in their life
  • Over a 12-month period over two million people will have some form of anxiety
  • For those suffering both anxiety and depression, only 35% access any form of treatment
  • Depression is the stand alone cause of disability across the world.

Australian Bureau of Statistics, (2008)

This case study will examine the benefits of exercise therapy and health education in conjunction with prescribed medication and Cognitive Behavioral Therapy (CBT) in a female who was diagnosed with three forms of mental health disease 19 years ago.  The exercise therapy methods and outcomes will be detailed with relevance to completed clinical studies and current research.

Michelle is a 34-year-old female who was diagnosed with Obsessive Compulsive Disorder (OCD), generalised anxiety and depression in 1998 (age 15).  Undertaking CBT and prescribed medication to assist in the treatment of the conditions, she still struggled daily with an overactive mind, suspected body dysmorphia and excess weight which reduced her quality of life.  Initially encouraged by a family member to try exercise therapy in the form of personal training, he sought the services of Fitness Forever due to their focus on chronic health – disease prevention / management.  Seeking weight loss for her upcoming wedding, she did not come with the purpose of having exercise therapy and health education aiding her mental health.  Additionally she did not understand how her obsession with weight, eating and negative body image had caused a vicious lifelong cycle of struggling with weight loss – increasing her mental health symptoms. It was not until Michelle commenced a regular exercise training program and received basic health education with Fitness Forever that the benefits to her mental health started to show.

Some of the key issues on the commencement of Michelle’s exercise program were:

  1. OCD – Obsession with weight
  2. Negative body image and body comparisons
  3. History of binge / emotional eating
  4. Anxiety in relation to fitness testing & measurements
  5. Anxiety in relation to exercise technique and repetitions
  6. Social anxiety

In order for Michelle to achieve her key goals / objectives of;

  1. Weight loss
  2. Maintaining a regular exercise routine
  3. Understanding the basics of nutrition / exercise
  4. Disassociation of weight with compulsive behaviour
  5. Achieving and maintaining a healthy weight
  6. Reduced OCD, anxiety and depression symptoms

It was essential to work with Michelle on the theory that exercise therapy and basic health education are beneficial in their relationship to mental health – potentially reducing the symptoms associated with OCD, anxiety and depression. Using this theory, the key goals and objectives should be achieved or at a minimum, noticeable improvements made.  It is assumed that Michelle may need extra education in relation to nutrition in order to understand how her diet &/or eating habits have affected her lifelong weight battles in addition to general teachings of exercise, techniques and how to use her body effectively to achieve her own goal.

Findings

  1. OCD – Obsession with weight
    1. On the commencement of exercise therapy, Michelle presented with 2 foolscap folders containing daily weigh-in records over many years which highlighted her unhealthy obsession with weight and weight loss. Daily, she weighed in post-bowel movements and prior to breakfast to ensure it would be at her lightest weight.  This obsession highlighted many issues;
      1. OCD had caused Michelle to have a dysfunctional relationship with weight which increased anxiety and depression symptoms
      2. She displayed a lack of education in basic nutrition
      3. Her fluctuating monthly weight didn’t consider women’s cycles, daily calorie intake etc.
      4. A weight gain on the scales triggered anxiety symptoms and feelings of failure and depression
      5. There had previously been a lack of regular exercise which had also potentially hindered weight loss
      6. Her focus was solely on weight alone, not overall health
    2. Prior to commencing with Fitness Forever, Michelle had little to no previous nutrition education which enabled her OCD to fixate on her weight. Additionally, she had not undertaken a specialised exercise program to seek the benefits of exercise on her mental health.
  1. Body image and comparing her body to others has proved to be another major issue throughout Michelle’s life. Throughout the early-mid stages of exercise therapy, Michelle constantly struggled with her body image and compared herself to others on a constant basis.  Issues arising from this negative mentality included;
    1. Her focus was to look “skinny” rather than fit and strong
    2. Regardless of exercise intensity or frequency, she could not ultimately change the “shape” of her body
    3. She disliked her body and did not see it’s remarkable physical potential
    4. She was driven by social media, magazines and friends and family to look a certain way
  1. Before understanding the full extent of Michelle’s anxiety disorder, she was requested to perform a standard fitness test, this posed individual problems such as;
    1. The pressure of a fitness test caused anxiety symptoms
    2. She feared not measuring up to other client’s results (note: results were never compared between clients)
    3. Her apprehension during the test skewed results due to her anxiety
    4. The feelings of worry that she hadn’t performed well enough overshadowed the achievement of completing the test
  1. Exercise therapy at its early stages indicated strong symptoms of anxiety and obsessive-compulsive behaviour, whereby;
    1. Exercises were performed potentially not to their fullest due to an obsessive thought process that she was not preforming the exercise correctly despite using correct technique
    2. She displayed constant concern that everything that had been planned for the session had not been achieved despite that not being the case
    3. Her muscle tension inhibited some movements which restricted a full range of motion on some exercises
    4. Lack of sleep due to her overactive mind left her lacking energy on occasion
    5. Michelle’s exercise therapy program needed to contain specific and proven methods in the form of style and type of exercise based on previous research with demonstrated improvements in the symptoms of OCD and anxiety.

Discussion

For 19 years, Michelle, through her mental illnesses has struggled with weight and formed an unhealthy relationship to eating, her body image, nutrition and her perception of what it means to be “healthy”.  From initiation, changing 19 years of progressively worsening habits due to her OCD, anxiety and depression was a slow and steady road.  A lack of health education and regular exercise had caused many issues including suspected body dysmorphia, excess weight, binge eating, emotional eating and apprehension to try a fitness program due social anxiety.

The benefits of exercise therapy and generalised anxiety have been well documented over the years, particularly in articles like that of Ströhle, A. (2008) which discusses numerous benefits on generalised anxiety with exercise therapy consisting of 3-4 sessions per week for a minimum of 20-30min with moderate intensity.  However minimal research has been conducted focussing specifically on OCD and exercise therapy and therefore advancements in treatment of this condition remains limited.

One specific Randomized Controlled Trial by (Abrantes AM, McLaughlin N, Greenberg BD, et al., 2012) studies 102 participants who have significant OCD symptoms and exposes them to aerobic intervention and health education (12 health topics) over a 12-week period with results recorded for 12 months post-program. In addition, participants were rewarded for achievements made each week throughout the course of the study. It was found that there is clear evidence that OCD severity was reduced and participants had improvements in their quality of life, overall mood and cardiorespiratory fitness with results lasting at least 6 months post-study.

For Michelle to achieve success, she requires a strong structure around her exercise program where she will have a clear understanding what is expected of her, when and what she will be undertaking.  Verbal and written communication is imperative including pre-session confirmation, positive post-workout reinforcement and providing feedback where required.  It is essential for Michelle to work within her means and not be put under pressure or forced to feel inadequate or sub-class during any session.  She would strongly benefit from health education in the form of a nutrition course which will lay a solid foundation for her understanding of “basic” nutrition and have her provided with an understanding of body types, shapes and fat distribution particularly on a female body.  A variety in Michelle’s training will also provide her with an increased chance of improvements which should be seen in both her physical and mental health.

Conclusion & Recommendations

In order for Michelle to achieve her personal goal of weight loss success, to commence, a 6-week nutrition course – facilitated by Fitness Forever would be recommended to shift the mental focus off “weight” and instead have her understand the caloric value of food, food labels, product claims etc.  This education is designed to undo her unhealthy relationship with weight and food and instead focus on being healthy and strong.  With this new mindset, it was hoped that weight loss (in conjunction with exercise therapy) would occur naturally.  Positive, regular reinforcement is to be given relating to food choices and a food diary focussing on calorie counting was to be recommended for a period of 3-4 months or until her understanding of energy in vs. energy out became apparent and she felt confident making informed food choices.

To measure successful weight loss, tape measurements were chosen as an indicator for weight loss rather than scales.  With a negative lifelong relationship with the scales, it was imperative that she was shown an alternate method to see weight loss that wasn’t hindered by menstrual cycles, time of day, bowel movements etc.

For exercise, to benefit the symptoms of anxiety, depression and OCD, Michelle’s exercise program was structured to contain as per above recommendations Ströhle, A. (2008);

  1. 3 x 45min exercise sessions per week
  2. Varied exercises at each session
  3. Non-repetition focussed sets
  4. Interval training to focus on time rather than repetitions
  5. A flexibility / stretching session to reduce symptoms of anxiety, muscle tension and to increase mental awareness and provide a calming affect
  6. Boxing to help relieve nervous energy
  7. Regular commendation of results achieved
  8. Gentle, yet steady increase in exercise intensity to improve overall fitness
  9. Fitness tests were to be completed on a regular basis, the length of time between was to be lengthened to enable a sufficient increase in strength and cardiovascular fitness and to reduce her anxiety level.

In order to seek the required benefits, it was believed that Michelle required structure around her exercise program and by designating 3 specific days / times each week to exercise with particular workouts planned for each day i.e. Tuesday – Cardiovascular/strength, Wednesday – Boxing, Friday – Flexibility / Stretching session it was hoped that she could focus on each day with a different mindset, allowing her to benefit from the different training methods.  The risk of designing such a program was that she may expect results quickly rather than over time due to the training load which may increase symptoms of depression if the results were not what she had anticipated.  Additionally, she was also at risk of not attending sessions due to the social anxiety that she felt, however this was considered and she was to be trained in a studio environment where it would only be herself and her personal trainer in the training space.

This exercise therapy program is designed to work in conjunction with the participants Psychologist or General Practitioner, particularly if the client is on prescribed medication or is undertaking CBT as it would be encouraged that they discuss the training sessions and outcomes during their sessions.  At commencement of the program, the personal trainer is to detail the structure of the program to the client detailing what the sessions will involve i.e. cardiovascular / strength or flexibility training, when fitness testing and measurements will be undertaken (scheduled each 8 weeks) and what additional education / training is required – in this case, a nutrition course detailing when, where, timings and cost of the course.  A confirmation message would be sent prior to every session, and positive reinforcement given at the end of each training session.  Results from testing would be provided within 24hrs of being undertaken with constructive feedback provided.  The success of the Exercise Therapy program would be reviewed every two months and modifications to exercise prescription, session length etc. would be revised at this time.

References

Abrantes AM, McLaughlin N, Greenberg BD, et al. Design and Rationale for a Randomized Controlled Trial Testing the Efficacy of Aerobic Exercise for Patients with Obsessive-Compulsive Disorder. Mental health and physical activity. 2012;5(2):155-165. doi:10.1016/j.mhpa.2012.06.002.

Australian Bureau of Statistics. (2008). National Survey of Mental Health and Wellbeing: Summary of Results, 2007. Cat. no. (4326.0). Canberra: ABS.

Ströhle, A. (2008). Physical activity, exercise, depression and anxiety disorders. J Neural Transm (2009) 116:777-784. DOI 10.1007/s00702-008-0092-x

The Heart Foundation. (2007).  Physical Activity and Depression. https://www.heartfoundation.org.au/images/uploads/publications/Physical-activity-and-depression.pdf

Zschucke E, Gaudlitz K, Ströhle A. Exercise and Physical Activity in Mental Disorders: Clinical and Experimental Evidence. Journal of Preventive Medicine and Public Health. 2013;46(Suppl 1):S12-S21. doi:10.3961/jpmph.2013.46.S.S12.

 

 

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