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Cognitive and Behavioral Practice 14 (2007) 364–374

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Translating Empirically Supported Strategies Into Accessible Interventions:

The Potential Utility of Exercise for the Treatment of Panic Disorder
Jasper A. J. Smits, Southern Methodist University
Mark B. Powers, Universiteit van Amsterdam
Angela C. Berry, Southern Methodist University
Michael W. Otto, Boston University

Many patients suffering from panic disorder do not receive adequate care. Advances in the conceptualization and treatment of panic
disorder encourage innovative strategies for targeting core fears (fears of anxiety sensations) that underlie this disorder. In this article, we
discuss the use of exercise as a potential strategy for therapeutic exposure to these feared sensations, and the role that exercise may play as
an acceptable intervention to aid the dissemination of exposure-based approaches to the treatment of panic disorder. Evidence for the
efficacy of exercise for the treatment of anxiety and panic is presented; along with strategies to enhance the role exercise can play as an
interoceptive (internal sensation) exposure procedure. Finally, issues of comorbidity and exercise acceptability are discussed. Our
conclusion is that exercise-based interventions are promising strategies for improving the utilization of exposure-based interventions for
panic disorder. Clinical guidelines and future research directions are discussed.

T HE QUEST TO DEVELOP effective interventions for adult

psychopathology has been particularly successful for
panic disorder. Randomized controlled trials and meta-
analytic reviews have consistently shown that cognitive
behavior therapy (CBT) and pharmacotherapy for panic
disorder each offer greater benefits than control condi-
tions (e.g., wait list, supportive treatment, or placebo;
Clum, Clum, & Surls, 1993; Gould, Otto, & Pollack, 1995).
CBT commonly emphasizes psychoeducation, cognitive
restructuring, and exposure interventions, combined at
times with relaxation or breathing retraining (e.g.,
Barlow, Gorman, Shear, & Woods, 2000; Telch et al.,
1993). Pharmacologic agents that have established
efficacy for panic disorder include tricyclic antidepres-
sants, benzodiazepines, and selective serotonin reuptake
inhibitors (SSRIs) (Lydiard, Brawman-Mintzer, & Ballen-
ger, 1996).
In the short-term, the treatment modalities yield
comparable results (e.g., Barlow et al., 2000; Clum et al.,
1993; Gould et al., 1995). However, as evidenced by lower
relapse rates, CBT produces more durable effects
compared to pharmacotherapy or combination treat-
ments (Barlow et al., 2000; Gould et al., 1995). The
benefits of CBT and pharmacotherapy are not limited to
improvements in panic-related symptoms but extend to
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© 2007 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
improvements in quality of life (Jacobs, Davidson, Gupta,
& Meyerhoff, 1997; Rapaport, Pollack, Wolkow, Marde-
kian, & Clary, 2000; Telch, Schmidt, Jaimez, Jacquin, &
Harrington, 1995). Lastly, the modest dropout rates
observed in clinical trials suggest that these treatments
are relatively well tolerated, with evidence for advantages
of CBT over pharmacotherapy (Gould et al., 1995;
Hofmann et al., 1998).
The question whether results observed in controlled
settings generalize to real-world practice has received only
limited empirical attention. Preliminary results indicate
that the empirically supported interventions for panic
disorder can be effectively transported to community
health care settings (Addis et al., 2004; Roy-Byrne, Katon,
Cowley, & Russo, 2001; Stuart, Treat, & Wade, 2000; Wade,
Treat, & Stuart, 1998). For example, Addis et al. (2004)
examined the effectiveness of CBT for panic disorder in
80 patients enrolled in a managed care plan. Patients who
received manualized CBT reported significantly greater
panic disorder symptom reduction compared to those
who received treatment as usual. These findings comple-
ment earlier reports indicating that the clinical benefits of
CBT as applied in effectiveness studies in community
health centers are comparable to those observed in
controlled clinical trials (Stuart et al., 2000; Wade et al.,
1998).
Despite these encouraging data regarding the efficacy
and effectiveness of CBT and pharmacotherapy, their
dissemination to clinical practice has been slow. Examina-
 Exercise for Panic Disorder
tion of the quality of care that anxiety disorder patients
receive suggests that only 20% receive appropriate
pharmacotherapy or psychotherapy (Young, Klap, Sher-
bourne, & Wells, 2001). Similarly, Goisman, Warshaw, and
Keller (1999) found that only one-third of patients
reported having ever received CBT, and that CBT
prescriptions remained low between 1991 and 1996
(28% vs. 22%). These findings were corroborated in a
recent study examining the quality of care for primary
care outpatients in West Coast cities in the United States
(Stein et al., 2004). More specifically, only 17% of panic
disorder patients received treatment with at least one
cognitive-behavioral component, and only 9% of patients
received treatment with at least three empirically sup-
ported components. Appropriate pharmacotherapy was
observed in only 30% of panic disorder patients. More-
over, another large proportion of patients fail to seek care
for panic disorder. For example, the National Comorbid-
ity Study (NCS) found that only 35% of panic disorder
patients reported receiving outpatient mental health
services (Kessler et al., 1999). Likewise, Katerndahl and
colleagues have reported that about 40% of people with
panic attacks never seek care (Katerndahl, 1990; Katern-
dahl & Realini, 1995).
When panic disorder patients do seek care, they are
more likely to present to medical settings than to mental
health settings (49% and 26%, respectively), specifically
the general practitioner’s office (35%) and the hospital
emergency room (32%) (Katerndahl & Realini, 1995).
Indeed, the prevalence of panic disorder in primary care
clinics ranges from 2% to 13% (Leon, Portera, &
Weissman, 1995; Shear & Schulberg, 1995; Tiemens,
Ormel, & Simon, 1996), and as high as 25% in emergency
rooms where panic disorder patients present with severe
chest pain (Huffman & Pollack, 2003). An analysis of
predictors of the type of care that panic disorder patients
seek revealed that chest pain during panic attacks was
associated with seeking care from the general practi-
tioner, whereas the presence of heart palpitations during
panic attacks negatively predicted seeking help from a
psychologist (Katerndahl & Realini, 1995). Findings from
Hazlett-Stevens et al. (2002) provide further insight
regarding the likelihood that panic disorder patients
will receive evidence-based interventions when they
present at primary care clinics. When asked whether
they would consider mental health care, 64% of panic
disorder patients were willing to consider pharmacother-
apy and 67% were willing to consider a psychological
intervention.
These disconcerting findings with respect to the
utilization of CBT have encouraged strategies to facilitate
the dissemination of CBT (Addis, 2002; Collins, Westra,
Dozois, & Burns, 2004; Gotham, 2004; Kettlewell, 2004;
Stirman, Crits-Christoph, & DeRubeis, 2004). Specific
365
recommended strategies include the development of
therapist-friendly manuals (Carroll & Nuro, 2002), the
development of more broad-based treatments that are not
particular to one disorder (Addis, 2002), and the
establishment of partnerships between researchers and
practitioners (Kettlewell, 2004). Other promising efforts
include state-initiated large-scale efforts to support the
dissemination and implementation of evidence-based
interventions (Chorpita et al., 2002). Enforcing the
adoption of empirically supported treatments among
mental health providers will likely increase access to
evidence-based care once individuals present for treat-
ment. However, these efforts do not address the limited
numbers of individuals who present for mental health
treatment.
In addition to the efforts aimed at enhancing adoption
rates of CBT in mental health care, individuals with panic
disorder may also be served by making effective interven-
tions available that can be implemented outside the
mental health arena. Support for the development of
such interventions comes from the National Institute of
Mental Health (NIMH) Psychosocial Intervention Devel-
opment Workgroup (Hollon et al., 2002). In their
discussion on dissemination of effective psychosocial
interventions, they emphasized the need for novel
interventions that can be implemented by multiple
disciplines (Hollon et al., 2002). Other specific features
that can increase the accessibility of interventions include
a straightforward and easy-to-teach method that is
acceptable to both patients and clinicians and does not
require a specialized setting (Hollon et al., 2002).
Advances in the understanding of the pathogenesis of
and maintaining factors for panic disorder aid the
development of such novel interventions. In short,
clarification of the mechanisms of action of CBT in
relation to the core fears of panic disorder provides a
framework for considering novel treatment strategies.
Indeed, as we argue below, specialized exercise programs
emerge as interesting candidates. In the next sections, we
will focus on the potential utility of exercise programs for
the treatment of panic disorder. First, we will discuss the
potential of exercise1 to target maintaining factors of
panic disorder. Second, we review the empirical data
1
We have limited our review to the potential effects of aerobic
exercise for panic disorder because of a lack of empirical data on the
effects of anaerobic exercise. The American College of Sports Medicine
(2005) defines aerobic exercise as a physical activity that lasts longer
than 3 minutes during which glycogen is burned with oxygen (e.g.,
walking, swimming, running). Anaerobic exercise is defined as a
physical activity that lasts less than 3 minutes, during which glycogen is
burned without oxygen (e.g., weight lifting, sprinting). It should be
noted that physical activity is a broad term that encompasses all
muscle movements ranging from sports to lifestyle activities (The
American College of Sports Medicine (2005)).
366 Smits et al.
relevant to the efficacy of exercise interventions for panic
disorder and related symptoms. Third, we will consider
issues of acceptability of exercise-based interventions.
Finally, we will conclude this review with some practical
guidelines derived from preliminary work completed to
date and a discussion on suggested avenues for further
research in this area.
Change Mechanisms and Novel Interventions
There is considerable evidence implicating anxiety
sensitivity in the pathogenesis of panic. Anxiety sensitivity
refers to the tendency to respond fearfully to anxiety-
related sensations, such as racing heart, rapid breathing,
gastrointestinal distress, and dizziness (Reiss, Peterson,
Gursky, & McNally, 1986). Anxiety sensitivity differs from
trait anxiety, which denotes a tendency to respond
anxiously to stressors in general (McNally, 2002). Descrip-
tive studies have shown that, compared to psychiatric and
nonpsychiatric controls, panic disorder patients report
elevated scores on measures that tap anxiety sensitivity
(Taylor, Koch, & McNally, 1992; Telch, Jacquin, Smits, &
Powers, 2003), and respond with significantly greater
panic and anxiety to laboratory challenges that induce
anxiety-related symptoms (e.g., voluntary hyperventila-
tion or inhalation of CO2-enriched air; Gorman et al.,
1994; Griez, Lousberg, van den Hout, & van der Molen,
1987; Papp et al., 1997; Telch et al., 2003). Moreover,
anxiety sensitivity predicts the level of emotional respond-
ing to these challenges (Brown, Smits, Powers, & Telch,
2003; Rapee, Brown, Antony, & Barlow, 1992). Several
prospective studies have demonstrated that people with
elevated anxiety sensitivity are at a greater risk for
developing naturally occurring panic attacks (Hayward,
Killen, Kraemer, & Taylor, 2000; Schmidt, Lerew, &
Jackson, 1997a; Schmidt, Lerew, & Jackson, 1999).
Similarly, preliminary evidence suggests that modifying
anxiety sensitivity in people with no panic history is
associated with a decreased risk of panic onset (Garden-
swartz & Craske, 2001).
Evidence for the notion that anxiety sensitivity serves
as a maintaining factor for panic disorder (Bouton,
Mineka, & Barlow, 2001; Clark, 1986; Goldstein &
Chambless, 1978) comes from treatment outcome
studies. For example, successful treatment of panic
disorder is associated with a decrease in scores on the
measures tapping anxiety sensitivity (Penava, Otto, Maki,
& Pollack, 1998; Simon et al., 2004; Smits, Powers, Cho,
& Telch, 2004), and improvement in emotional respond-
ing to laboratory challenges (Schmidt, Trakowski, &
Staab, 1997b). Moreover, Clark and colleagues have
reported that measures of fear of anxiety-related
sensations taken at posttreatment predict clinical status
at follow-up (Clark et al., 1994; Clark et al., 1999).
Similarly, Smits et al. (2004) found that a decrease in
fear of anxiety-related sensations observed during treat-
ment mediated the short-term improvements in panic
disorder symptoms achieved with CBT. Taken together,
clinical evidence suggests that targeting anxiety sensitiv-
ity may be critical to helping patients overcome panic
disorder.
Exercise as a Means to Provide
Interoceptive Exposure
Contemporary CBT packages stress the importance of
systematic exposure to feared internal sensations (inter-
oceptive exposure: IE). These IE exercises (e.g., running
in place to induce sensations such as heart racing, rapid
breathing, and sweating) are used to provide an
opportunity for a corrective learning experience, thereby
helping diminish fears of bodily sensations (Hofmann,
Bufka, & Barlow, 1999). Several reports have suggested
that IE is indeed essential to the efficacy of CBT (e.g.,
Barlow, Craske, Cerny, & Klosko, 1989; Gould et al., 1995).
The efficacy of IE for the treatment of panic underscores
the relevance of providing panic patients with direct
exposure to bodily sensations. As suggested by Hofmann
and colleagues (1999), physical exercise may be used to
provide this relevant learning experience. Characteristi-
cally, aerobic exercise induces many of the bodily
sensations (e.g., heart racing, rapid breathing, and
sweating) that have shown to elicit increased anxiety
reactions in panic disorder patients (Rief & Hermanutz,
1996). Indeed, in a cross-sectional study with under-
graduate students, McWilliams and Asmundson (2001)
found an inverse relationship between anxiety sensitivity
and exercise frequency, suggesting that the fear of bodily
sensations may be maintained by low exercise frequency,
or that anxiety sensitivity may lead people to avoid
exercise. This relationship was also observed among a
sample of 39 individuals suffering from panic disorder,
with physically inactive individuals reporting significantly
higher anxiety sensitivity compared to those who did
report engaging in exercise during leisure time (Smits &
Zvolensky, 2006).
Perhaps a more important question in the evaluation
of the utility of exercise for treating panic is whether
exercise can reduce anxiety sensitivity. This question was
recently examined by Broman-Fulks, Berman, Rabian,
and Webster (2004). They randomized 54 participants
with elevated anxiety sensitivity to either a high-intensity
or low-intensity level aerobic exercise program. High
intensity was defined as briskly walking or jogging on a
treadmill that produced heart rates between 60% and
90% of the individual’s age-adjusted predicted maximal
heart rate. Low intensity was defined as a walking
comparison condition that produced heart rates below
60% of the individual’s age-adjusted predicted maximal
heart rate. All participants received six 20-minute sessions
 Exercise for Panic Disorder
of aerobic exercise, and completed measures of anxiety
sensitivity at pretreatment, posttreatment, and 1-week
follow-up. Participants in both the high and low intensity
exercise groups showed significant reductions in anxiety
sensitivity (pretreatment to follow-up raw-score mean
reductions of 10.69 and 6.12 points, respectively).
However, high-intensity exercise was associated with a
more rapid decline in anxiety sensitivity (pre- to
posttreatment raw score mean reduction of 9.14 versus
2.88 for the low-intensity group), and greater response
rates compared to low-intensity exercise. Preliminary
findings from our laboratories are consistent with the
notion that six repeated brief sessions comprised of high-
intensity aerobic exercise can produce marked changes
in anxiety sensitivity (pre-to posttreatment raw score
mean reduction of 21.10 for exercise versus 1.00 for the
no-treatment control group; controlled d = 0.94; Smits,
Powers, Utschig, & Otto, 2005).
Association Between Exercise and Clinical and
Subclinical Anxiety
In addition to studies examining the efficacy of
exercise for the treatment of a core component of panic
disorder—the fear of anxiety sensations—there are also
some trial-outcome data for panic disorder. Broocks et al.
(1998) randomized 46 patients with panic disorder to one
of three conditions: (a) aerobic exercise, (b) clomipra-
mine, or (c) pill placebo. Clomipramine was prescribed
following evidence-based guidelines. Aerobic exercise
consisted of endurance training, following general
recommendations for effective aerobic exercise. More
specifically, patients were asked to find a 4-mile route
(forest or park) that was easily accessible from their home,
and complete this entire route at least three times a week,
where walking was allowed during the first 6 weeks, and
running was expected during the last 4 weeks. Patients
also met with a trainer once each week to run together.
Analyses of panic disorder symptom change over the
course of 10 weeks revealed that the advantage of exercise
over placebo appeared after 8 weeks of treatment, and
clomipramine yielded significantly greater effects com-
pared to placebo after 4 weeks. At posttreatment, both
active treatments outperformed the placebo condition
and were equally effective in reducing anxiety. Compared
to exercise, clomipramine yielded greater changes in
global improvement ratings. In discussing the magnitude
of the effects observed for exercise in their study, Broocks
et al. (1998) hypothesized that additional coaching early
in treatment would have enhanced the benefits among
participants in the exercise condition. Specifically, thera-
pists could have assisted patients in preparing to
reappraise some of the feared consequences of exercise-
induced sensations. This type of preparation could have
potentially prevented avoidance of intense exercise that
367
was evident in a subset of the patients (Broocks et al.,
1998).
Clinical evidence indicates that aerobic exercise is also
efficacious in reducing state anxiety (Long & van Stavel,
1995), even when a low-intensity dose is prescribed
(Broman-Fulks et al., 2004; Sexton, Maere, & Dahl,
1989). Two independent controlled studies showed that
a jogging program yielded reductions in anxiety similar to
a stress-inoculation program (Long, 1984) or relaxation
(Long & Haney, 1988). Steptoe, Edwards, Moses, and
Mathews (1989) compared a moderate aerobic training
program to an attention-placebo condition in inactive
anxious adults. The moderate exercise program out-
performed placebo on reductions in anxiety and depres-
sion, as well as the perceived ability to cope with stress,
with maintenance of gains at 3-month follow up. These
data comport well with a large number of studies of
nonclinical populations documenting the general anxi-
ety-ameliorating effects of exercise (Long & Van Stavel,
1995), as well as epidemiological and cross-sectional
studies. Specifically, using data from the National
Comorbidity Study, Goodwin (2003) found that regular
physical activity was associated with a significantly
decreased likelihood of major depression, agoraphobia,
panic attacks, GAD, specific phobia, and social phobia.
Likewise, Stephens (1988) collapsed data from four
studies to total a sample size of approximately 55,000
and found that self-reported level of recreational physical
activity was associated with fewer symptoms of both
anxiety and depression, even after controlling for demo-
graphic variables and physical illness.
Breadth of Exercise Effects: Issues of Comorbidity
Panic disorder is associated with a number of
comorbid psychiatric and medical conditions (Rogers
et al., 1994; Weissman, Markowitz, Ouellette, Greenwald,
& Kahn, 1990). For example, Kessler et al. (1998)
reported that about half (55.6%) of the respondents in
the National Comorbidity Study suffering from panic
disorder also met lifetime criteria for depression.
Similarly, comorbidity rates for respiratory disorders,
hypertension, and migraines among patients with panic
disorder are three-(e.g., hypertension and respiratory
disorders) to sevenfold (e.g., migraine) of the rate
observed among individuals without panic disorder
(Katon, Vitaliano, Russo, Cormier, Anderson, & Jones,
1986; Spinhoven, Ros, Westgeest, & Van der Does, 1994;
Stewart, Linet, & Celentano, 1989; Stewart, Shechter, &
Liberman, 1992). Moreover, a recent study revealed that
panic disorder sufferers are at a significantly increased
risk to develop coronary heart disease, particularly when
comorbid depression is present (Gomez-Caminero et
al., 2005). Accordingly, the degree to which exercise can
benefit these comorbid conditions is of direct relevance
368 Smits et al.
to treatment outcome, and potentially to treatment
retention.
Although group data is never an alternative to
evaluating the medical capacity of any one patient for
exercise, the literature does suggest that exercise offers
benefit for a range of these comorbid conditions. For
example, a recent meta-analysis of 11 treatment outcome
studies of individuals with depression (Stathopoulou,
Powers, Berry, Smits, & Otto, 2006) yielded a large
combined effect size for the advantage of exercise over
control conditions, d = 1.42. Similarly, exercise has shown
to lower blood pressure (Whelton, Chin, Xin, & He,
2002) and improve other cardiovascular risk factors such
as plasma lipoprotein-lipid levels, and left ventricular
hyperthrophy (Kokkinos et al., 1995; Sasaki et al.,
1989). The clinical benefits of exercise are also
observed among patients with chronic obstructive
pulmonary disease (Cambach, Wagenaar, Koelman,
van Keimpema, & Kemper, 1999; Lacasse et al., 1996).
Further, in a meta-analysis examining the effects of
physical training in asthma, Ram, Robinson, and Black
(2000) found that aerobic exercise resulted in a
significant increase in cardiorespiratory strength, as
evidenced by significant increases in maximum oxygen
uptake. In addition to attaining better overall fitness,
Emtner and colleagues (1996) reported that patients
with asthma who undergo exercise training show a
considerable reduction in fear of training-induced
breathlessness. This reduction in fear may only facilitate
the desired reduction in anxiety sensitivity that is often
present in panic disorder. Research also suggests that
people with asthma show adequate tolerance to aerobic
exercise, as they react similarly to healthy controls
(Ram et al., 2000). Even for patients who are at risk for
exercise-induced asthma attacks, intense exercise can be
tolerated if it is coupled with the medically supervised
administration of beta2-agonists before training and, if
necessary, during training (Emtner et al., 1996; Hall-
strand et al., 2000). Collectively, these findings indicate
that patients with comorbid problems show clinical
benefits following high intensity exercise programs. As
such, the potential to treat multiple health and mental
health outcomes simultaneously makes exercise an
attractive and cost-effective intervention (see also M. B.
Stein, 2005).
Exercise as Treatment for Panic Disorder:
Will it Sell?
Currently, systematic research on critical issues such as
acceptability and cost-effectiveness of exercise-based
interventions for panic disorder is lacking. Therefore, it
is too early to provide a definitive answer to the question
of whether exercise-based interventions can help fill the
existing gaps in accessing treatment for panic disorder.
However, as documented below, there are a number of
reasons to be optimistic.
As mentioned earlier, a considerable percentage of
patients who seek treatment do not receive adequate
care. Clinical evidence suggests that this gap can in part
be accounted for by the social stigma associated with
mental health treatment (Sirey et al., 2001). Exercise
may appeal to a broader population of individuals than
traditional treatment for a number of reasons. As has
been argued by others (i.e., Dunn et al., 2005),
alternative therapies may be particularly viable treatment
strategies because they do not carry a negative social
stigma. Indeed, using a nationally representative sample
of 2,055 respondents, Kessler et al. (2001) found that the
majority of people in the United States suffering from
panic attacks or depression do seek complementary or
alternative therapy for their symptoms. The authors
concluded that “people with these conditions are
considerably more likely to use complementary and
alternative therapies than conventional medical or
mental health treatments” (p. 291).
Are exercise-based interventions tolerable for patients
suffering from panic disorder? Several studies have
demonstrated that intense exercise is well-tolerated by
patients with panic disorder (Martinsen, Raglin, Hoffart, &
Friis, 1998; Rief & Hermanutz, 1996; Stein et al., 1992),
despite the fact that they frequently display reduced
cardiopulmonary fitness (Broocks et al., 1997; Martinsen
et al., 1998; Taylor et al., 1987; Schmidt et al., 2000; Stein et
al., 1992). In addition, Broocks et al. (1998) reported that
attrition in their efficacy trial of exercise for panic disorder
was a consequence of nontolerance-related issues such low
expectancy, lack of improvement, and intermittent disease
that was not related to exercise.
Certainly, the statistic that nearly 40% of U.S. adults do
not engage in any physical activity (Schoenborn, Adams,
Barnes, Vickerie, & Schiller, 2004) appears daunting for a
novel intervention utilizing exercise. However, the use of
exercise for panic disorder has one clear advantage over
exercise for general health promotion. The literature
suggests that adherence to recommended interventions
may be particularly low when there is no direct symptom
reduction that is linked with the health behavior (i.e., the
intervention is preventive in nature; Christensen-Sza-
lanski & Northcraft, 1985). For example, the taking of
an antihypertensive medication may present more adher-
ence challenges than taking an analgesic in response to a
headache; there is both a cue (the headache) and a
contingent response (pain reduction) for the desired
health behavior (taking the pill) that is absent for
antihypertensive treatment. Accordingly, exercise inter-
ventions for panic disorder have the advantage of being
linked with reductions in core fears that are contingent
on exercise (exposure) success. Indeed, investigations of
 Exercise for Panic Disorder
the week-by-week progress of patients in CBT suggest that
benefit starts as early as Session 1 and proceeds, on a
group basis, linearly from that point (Penava et al., 1998).
Accordingly, exercise interventions delivered with a clear
rationale for acute benefit offers the potential for greater
adherence. The literature further suggests that adher-
ence and success of activity counseling may require the
provision of written materials indicating treatment dose
and suggestions for potentially anticipated barriers
(Eakin, Glasgow, & Riley, 2000; Gorin et al., 2005; Jakicic,
Winters, Lang, & Wing, 1999), as well as the involvement
of a provider (Reed, Jensen, & Gorenflo, 1991; Williford,
Barfield, Lazenby, & Olson, 1992).
Evidence suggests that many physicians already
endorse the value of exercise for their patients (Reed
et al., 1991), as it has been formally recommended by
the American College of Sports Medicine and the
Centers for Disease Control and Prevention (Pate et
al., 1995). Although physicians typically consider pre-
scribing aerobic exercise for patients who are at risk for
cardiovascular disease (Rosen, Logsdon, & Demak,
1984), a survey of 1,750 physicians revealed that most
physicians already consider physical activity as an
intervention for depression and anxiety (85% and
60%, respectively; Dishman, 1986), suggesting that it
seems plausible that physicians will endorse an effica-
cious exercise-based intervention for panic disorder. The
fact that exercise has the potential to target several
physical and mental health outcomes simultaneously
may increase the willingness of health care providers to
prescribe exercise for the treatment of panic disorder. A
number of guidelines and possible strategies for the
prescription of exercise treatment are outlined in the
next section.
Intervention Procedures
When selecting exercise as a treatment strategy for
psychiatric disorders, clinicians should take a number of
factors into account. Concerning the suitability of
exercise, an initial screening should be conducted to
ensure that patients are free from cardiovascular and
acute infectious diseases. In terms of intensity and
frequency, workout sessions of moderate to high intensity
should last up to 30 minutes and such sessions should be
completed two to four times a week if improvement of
endurance capacity is one of the program aims (see
American College of Sports Medicine, 2005a,b). Pro-
grams should be at least 4 weeks in length in order for
patients to adopt an exercise training habit. Meyer and
Broocks (2000) also suggest that patients use portable
heart-rate devices to monitor exercise intensity during
these sessions.
In our ongoing work examining the efficacy of exercise
as a treatment for panic disorder, we have adopted these
369
guidelines along with strategies designed to improve the
degree to which exercise functions as an interoceptive
exposure procedure (see Fig. 1). Specifically, we empha-
size guided threat reappraisal (Kamphuis & Telch, 2000)
where, prior to exposure, patients are asked to identify
their core fears and seek to invalidate these fears using
information from the exercise exposure. Before the
intervention, potential participants are thoroughly screen-
ed to make sure that the treatment protocol is appropriate
for them. The intervention starts with a 7-minute
videotape presentation of information about the role of
fear of anxiety sensations (anxiety sensitivity) in panic
attacks, and the importance of exposure to feared
sensations and situations, along with reevaluation of the
cognitions surrounding these fears, using experiences
with exercise as a guide. For example, for fear of a racing
heart, a patient would be asked to pay specific attention to
heart rate during exercise and ask the question, “What are
the consequences of this feeling?” Following the presenta-
tion of the videotape, the therapist asks the patient to
summarize the rationale and procedures for the interven-
tion and provides any clarification if necessary. Patients
only proceed if they understand the specific objectives of
the exercise program. During the actual exercise, the
therapist repeatedly prompts the patient to notice the
rapid heart rate and evaluate its dangerousness (“Do you
notice anything right now that tells you that it is
dangerous?”). With this sort of prompting patients are
able to identify the difference between the feelings
induced by exercise and the catastrophic consequences
that are not occurring. The guided threat reappraisal is
individually tailored to each participant based on the items
endorsed as particularly concerning on the Anxiety
Sensitivity Index (ASI; Peterson & Reiss, 1992).
While participants undergo exercise exposure, partici-
pants are monitored by a portable heart rate monitor in
order to target a pulse rate at 75% of their maximal heart
rate. This allows participants to experience intense
physical sensations for treatment purposes, while at the
same time maintaining a heart rate within a safe range.
Immediately following the exercise session, the therapist
asks patients to describe in their own words what they
learned from the session in order to aid the consolidation
of new memory. We also ask participants to engage in
scheduled exercise outside of the treatment sessions in
order to increase exposure to physiological sensations in
different settings.
Conclusions and Future Research Directions
Although CBT and pharmacotherapy have shown to be
effective in treating panic disorder, many patients do not
receive these types of treatments. The inadequate access
to conventional treatments calls not only for a continued
effort to diffuse these existing treatment modalities, but
370 Smits et al.

Figure 1. Exercise prescription guidelines for the treatment of panic disorder.

 Exercise for Panic Disorder
also the development of new treatments that accommo-
date the diverse preferences of sufferers from panic
disorder and that are likely to be adopted in settings
where patients seek care. In this article, we discussed the
use of aerobic exercise as a strategy for therapeutic
exposure to feared sensations, and the role that exercise
may play as an acceptable intervention to aid the
dissemination of exposure-based approaches to the
treatment of panic disorder. More specifically, initial
evidence indicates that interoceptive exposure, a CBT
component that has shown to reduce the core fear in
panic disorder, may be effectively delivered in the form of
an aerobic exercise program. Not only can aerobic
exercise yield the learning essential for diminishing
panic disorder symptoms, it also has positive effects on
conditions commonly comorbid with panic disorder,
including depression (Stathopoulou et al., 2006), hyper-
tension (Whelton et al., 2002), migraine headaches
(Lemstra, Stewart, & Olszynski, 2002), and respiratory
illness (Ram et al., 2000).
Consumer data, albeit limited, seem to further
underscore that exercise may appeal to a broader
population of individuals with panic attacks who indicate
a preference for nontraditional treatments, perhaps
because they do not carry a social stigma. Finally, given
that the medical community already endorses the
prescription of aerobic exercise programs in the treat-
ment of (mental) health problems, an aerobic exercise
program developed for the treatment of panic may be
met with little resistance.
Our conclusions are based on preliminary evidence,
and accordingly, it is time for more in-depth study of the
feasibility of exercise protocols applied in settings where
patients with panic disorder present for treatment (e.g.,
primary care, emergency rooms). Specific attention
should be given to issues surrounding implementation
(e.g., level of training required for behavioral health
specialists—primary care physicians, nurse practitioners,
social workers), and issues of acceptability (i.e., Are
behavioral health providers willing to employ this treat-
ment? Are there differences in acceptability rates among
females or males or across various ethnic groups of social
class?). In this context, it is also important to determine
necessary exercise program parameters (e.g., aerobic vs.
anaerobic, self-guided vs. therapist-assisted, psychoeduca-
tion vs. no psychoeducation). Nonetheless, available data
from 11 controlled trials of exercise interventions for
major depression indicate that exercise is both efficacious
and tolerable, with dropout rates below the range
generally reported for antidepressant treatment (Statho-
poulou et al. 2006). As bolstered by these promising
findings, additional data from randomized trials are
needed for the application of exercise interventions to
panic disorder, with particular attention to cost-effective-
371
ness issues to evaluate whether this approach offers
savings relative to existing methods.
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Address correspondence to Jasper A. J. Smits, Ph.D., Department of
Psychology, Southern Methodist University, Dedman College, P.O. Box
750442, Dallas, TX 75275, USA; e-mail: jsmits@smu.edu.
Received: February 7, 2006
Accepted: July 21, 2006
Available online 5 September 2007