Body Work and Exercise for Anxiety Panic Attacks Depression and OCD


Body Work and Exercise for Anxiety, Panic Attacks, Depression and OCD

Christian Jonathan Haverkampf, M.D.

Working with the body is often neglected in major schools of psychotherapy, such as psychodynamic psychotherapy and CBT. Depression and anxiety disorders are some of the most prevalent psychiatric disorders with close to one in five of adults exhibiting symptoms. Exercise has been shown to reduce symptoms associated with these disorders, has the potential to increase the effectiveness of psychopharmacology and to reduce depenndance on it in specific cases. The balance seems to be important between too little and excessive exercise.

Keywords: body work, exercise, treatment, anxiety, panic attacks, depression, OCD, obsessive-compulsive disorder, Communication-Focused Therapy, CFT, psychotherapy, psychiatry


Introduction. 4

Reconnection. 4

Communication. 4

Information Processing. 4

Integrative Therapy. 5

Exercise and Mental Health. 5

Depression and Anxiety. 5

Age. 6

Neurophysiology. 6

Hippocampal Volume. 6

Endocannabinoids. 6

Adrenocorticotropic Hormone (ACTH) 6

Serotonin. 7

Depression. 7

Body Image. 7

Body Image as a Problem.. 7

Obesity. 9

Breast Cancer. 9

Exercise as an Adjunct to Medication. 10

Techniques. 10

Basic Body Awareness Therapy (BBAT) 10

Pilates. 11

Body Psychotherapy (BPT) 11

Tai Chi 11

Yoga. 11

Exercise Dose. 12

Exercise and Anxiety. 12

Anxiety Sensitivity. 13

Body Dysmorphic Disorder: OCD.. 13

Hypochondriasis. 14

Risks. 15

Prevention. 15

Conclusion. 15

References. 17


Much of the information the brain processes is received from and through the body. Since anxiety, depression and OCD are disturbances in the communication and processing of information, it makes theoretical and practical sense to involve the body in the therapeutic process.

While studies support the use of exercise as a treatment for depression, healthcare professionals irregularly suggest and rarely prescribe it. In their depression treatment guidelines, the American Psychiatric Association (APA) states that exercise may be of value but does not consider it as a first-line treatment. The National Guideline Clearinghouse states in a consensus-based recommendation that exercise is recommended as an adjunctive treatment to antidepressants or psychotherapy.

Chronic major depressive disorder and dysthymia are associated with a high burden and substantial care costs. New and more effective treatments are required. Besides case series and small uncontrolled studies, recent well-controlled studies suggest that exercise training may be clinically effective, at least in major depression and panic disorder. (Ströhle, 2009)


Information comes in through the body. Types of body work and exercise which increase the sense of the body appear to be helpful in various psychiatric conditions. It helps to lessen the focus on a particular bodily function or organ and opens the inflow of information from more points in the body. This can help lower the partial disconnect which is usually present in conditions, such as anxiety, depression, panic attacks, OCD and more.


The body is a communication device, receiving information from the environment and allowing one to send messages, whether verbal or non-verbal. (Haverkampf, 2018) Communication is also the process which brings about change (Haverkampf, 2010a) and takes a preeminent place in communication-focused therapy (CFT) (Haverkampf, 2017a), which has been developed by the author, and plays a role in all psychotherapies.

Information Processing

The body also uses information that is communicated to it. As the nervous system innervates most parts of the body, there is a fast and ubiquitous connectedness throughout the body. While much information is relayed in the central nervous system (CNS) and then send out again, there are relatively autonomous neural networks distributed throughout the body. From a communication viewpoint one needs to look at them as doing something similar to the brain, though on a simpler level. Information is received, processed and new information is sent out again.

Integrative Therapy

The work with the mind and the work with the body in various shapes and form should be seen as two ways to work on communication systems inside the person. The objective is to make communication work better for the patient. This may require a new perspective on how the mind and the body interact, but communication is how things get done inside the body and with the rest of the world.

Exercise and Mental Health

Early large population studies examined the relationship between exercise behavior and mental health . The relation between self-reported physical activity and depressive symptom was analyzed for 1,900 healthy subjects aged 25–77 years in the Epidemiologic Follow-up Study (1982–1984) to the first National Health and Nutrition Examination Survey (NHANES I) and found that physical inactivity may be a risk factor for depressive symptoms.

Weyer found the odds ratio for depression to be significantly higher (OR 3.15) for the physically inactive compared to regular exercisers in a sample of 1,536 individual 15 years of age and older.

Subsequently, physical activity has been shown to be associated with decreased symptoms of depression and anxiety in numerous studies. For example, in a nationally representative sample of adults ages 15–54 in the United States (n = 8,098), regular physical activity was associated with a significantly decreased prevalence of current major depression and anxiety disorders.

Depression and Anxiety

There is a general belief that physical activity and exercise have positive effects on mood and anxiety and a great number of studies describe an association of physical activity and general well-being, mood and anxiety. (Ströhle, 2009) In a study of 19,288 individuals, De Moor found that regular exercise was associated with lower levels of depression, anxiety, and neuroticism.

Cooney and colleagues conducted a search of the Cochrane Depression, Anxiety and Neurosis Review Group’s Controlled Trials Register up to 2013, www.controlled‐, and the WHO International Clinical Trials Registry Platform and any potentially eligible trials not already included are listed as ‘awaiting classification.’ Exercise appeared moderately more effective than a control intervention for reducing symptoms of depression, but analysis of methodologically robust trials only showed a smaller effect in favor of exercise. When compared to psychological or pharmacological therapies, exercise appeared to be no more effective, though this conclusion was based on a few small trials. (Cooney et al., 2013)

Habitual exercise correlates to a heightened level of mental health and wellbeing and reduced feelings of anxiety regardless of the gender of the individual. Relative increases in maximal cardiorespiratory fitness and habitual physical activity appear to be associated with lower depressive symptoms and greater emotional well-being. Ohta noted that 30 minutes or more of walking or cycling while commuting to work might be associated with an increased perception of mental health in men.


The age of the individual may affect the relationship between physical activity and mental health. Exercise has a very small but statistically insignificant effect on reducing anxiety in adolescents. In contrast, Fox found that a population of European adults over the age of 70 had perceived levels of health and quality of life that were positively correlated to higher levels of physical activity.

While regular physical activity appears to be related to mental well-being, physical inactivity appears to be associated with the development of psychological disorders. Some cross-sectional and prospective-longitudinal clinical and epidemiological studies have shown a direct relationship between physical inactivity and symptoms of depression and anxiety.


Physical activity and exercise have been shown to induce widespread neurobiological adaptations. Imaging studies have demonstrated structural changes associated with early-onset depression in the hippocampus, amygdala, striatum, and frontal cortex; areas that are all extensively interconnected. Most consistently associated with depression are the findings of volume loss in the hippocampal formation. Increased levels of hippocampal brain-derived neurotrophic factor (BDNF) levels are associated with decreased anxiety. Exercise is associated with the increased synthesis and release of both neurotransmitters and neurotrophic factors, and these increases may be associated with neurogenesis, angiogenesis and neuroplasticity (Portugal et al., 2013).

Hippocampal Volume

As noted above, imaging studies have shown that depressed patients have decreased hippocampal volume. Brain neurogenesis is increased by antidepressant medications. Ernst and colleagues hypothesize that exercise similarly decreases depressive symptoms by increasing brain neurogenesis. They outline four possible molecular mechanisms for this increased neurogenesis, all of which both promote hippocampal neurogenesis and increase with exercise: B-endorphins, vascular endothelial growth factor, brain-derived neurotrophic factor, and serotonin.


Other possible mechanisms for exercise’s ability to improve mood include the association with exercise and increased levels of endocannabinoids, which are associated with analgesia, anxiolysis, and a sense of well-being.

Adrenocorticotropic Hormone (ACTH)

Changes in the hypothalamo-pituitary adrenal axis, including increased adrenocorticotropic hormone (ACTH) and decreased cortisol production, are associated with exercise and thought to be part of the mechanism of its positive effects on mood.


A randmoised prospective study by Wipfli and colleagues showed that the exercise group had lower levels of depression than the stretching‐control group after the intervention. The exercise group also showed a larger percentage decrease in serotonin than the stretching‐control group. This reduction in blood serotonin after exercise is similar to the effects of selective serotonin reuptake inhibitors. Additionally, percent change in serotonin was found to partially mediate the relationship between exercise and depression. (Wipfli, Landers, Nagoshi, & Ringenbach, 2011)


Multiple studies exist that suggest that exercise is an effective treatment for depression. A Cochrane meta-analysis of 25 randomized controlled trials comparing exercise and placebo or a control intervention found that the exercise groups had a significant improvement in depressive symptoms when compared to the placebo or control group. Only three trials with sufficient allocation concealment, intention to treat analysis, and blinded outcome assessment were found. When these three trials were analyzed together, the effect size was not significant.

There is empirical evidence that exercise compares favourably to antidepressant medications as a first-line treatment for mild to moderate depression. Blumenthal and colleagues conducted a randomized controlled trial in which they assigned 156 adults over age 50 to either aerobic exercise, sertraline, or both. After four months, all three groups had a statistically significant improvement in their depressive symptoms with no statistically significant difference between the groups. The medication group did have a faster response to treatment in the first four weeks, however. However, in a more recent study, the remission rates were also very similar (45-47%), while the rate in the placebo group was moderately, yet not statistically significantly, lower (31%).

Body Image

Exercise improves self-concept in depressed patients, possibly leading to decreased depressive symptoms. Bodywork is related to body image. Bodywork allows us to become more aware of our bodies. It is not necessarily the aim that one builds muscles or achieves a body ideal, which changes as soon as the new magazine ad replaces the old one. But working on and with anything increases our awareness for it. This also applies to the body. By working with the body, we learn about the body. Out of the interaction with the body we get new meaningful information and vice versa. Our bodies are powerful information processing entities, and the information we put into it can bring about significant changes. Exercising is a form of interacting with the body and having the body interact with the world, which leads to a range of changes.

Body Image as a Problem

With a healthy sense of self and a positive body image to go with it, the psyche and the body can work together well and lead to an experience of happiness and contentment. Unfortunately, body image disturbance is an increasing problem in Western societies and is associated with several adverse mental health outcomes, including anorexia, bulimia, body dysmorphia, and depression. (Pimenta, Sánchez-Villegas, Bes-Rastrollo, Lpez, & Martínez-González, 2009)

Body image is, of course, a subjective perception, something that is built from information from the outside (such as a visual image from a mirror) and the inside (perceived needs, values, aspirations, expectations). Body image thus also depends on what we believe is essential and what we think we need, value and should aspire to. It depends on how we communicate and interact with ourselves and other people. (Haverkampf, 2010a, 2017a)

How one sees one’s body affects how one shapes one’s body in the future. It also influences how one feels about the body and, as a consequence, about oneself. Pimenta and colleagues studied the association between body image disturbance and the incidence of depression in 10,286 participants from a dynamic prospective cohort of Spanish university graduates, who were followed-up for four years on average (the SUN study). The difference between BMI and body size perception was considered as a proxy of body image disturbance. Men who underestimated their body size were much more likely to be overweight and obese, whereas women who overestimated their body size were much more likely to be underweight. (Pimenta et al., 2009) However, the authors found no association between body image disturbance and subsequent depression.

Different population may place different emphases on different body attributes. Body fat may, for example, play a greater role in one population than in another, which is probably influenced to a large extent by socialization and communication with others. A study that looked at muscle dissatisfaction, body fat, and height dissatisfaction as predictors of signs of psychological distress, such as depression, eating restraint, eating concerns, and social sensitivity) in a community sample of 228 gay men found that body fat dissatisfaction was predictive of all four distress signs (controlling for muscle dissatisfaction). Conversely, muscle dissatisfaction was only associated with social sensitivity, while height dissatisfaction failed to significantly predict any of the criterion variables for distress. (Blashill, 2010) Another study found that women were more likely to engage in indoor tanning and perceived greater susceptibility to photoaging than men. Body image and depression were found to be associated with tanning behaviors and attitudes. (Gillen & Markey, 2012) Since preferred skin tone, and the behaviors to achieve it, has changed significantly throughout the ages, from very light in past centuries to suntanned in the 1970s and 1980s, social trends must play a significant role. Identifying how one takes in outside preferences and makes them one’s own is an important step in identifying more closely the own needs, values and aspirations, which has a direct effect on quality of life and mental health (Haverkampf, 2010b, 2017a).

Mood plays a large role in how one perceives one’s body. If one sees things more negatively overall, this can also affect one’s view of the own body. Joiner and colleagues examined the relationship between body dissatisfaction, depression, and bulimia in 119 female participants and found that depressed symptoms, but not whether the individual was bulimic, were associated with body dissatisfaction. (Joiner, Wonderlich, Metalsky, & Schmidt, 1995) It is thus important to keep in mind that aside from the effect of variations of the body on mood, the latter does have a significant effect on how we perceive the former. A significant aspect of how depression reduces the activity radius and the quality of life is through a distorted perception of the body.


There is a relatively close link between obesity and depression, although it is unclear what is the cause and what the effect. Depression may cause obesity, for example through changing eating patterns or reduced physical activity. But it is also possible that obesity may cause depression through an even more negatively perceived body image, which is a result from an interaction between the obesity and experienced social norms and interactions. The author has discussed possible etiologic factors from a communication perspective elsewhere (Haverkampf, 2017b). In any case, it is easy to see how a vicious cycle can form at the intersection between the psychological and the physical. Breaking that cycle requires awareness for an individual’s internal and external communication.

That internal or external communication dynamics may play a significant role could explain why being ‘overweight’, but not the extremes of being underweight or severely overweight, is most highly correlated with depression. De Wit and colleagues showed in their study a significant U-shaped trend in the association between BMI and depression. (De Wit, Van Straten, Van Herten, Penninx, & Cuijpers, 2009) Externally, the social context seems to play a role. Xie and colleagues investigated in a prospective study the associations between overweight and depressive symptoms in Asian and Hispanic adolescents. Significant mediation effect was found only in Asian girls and girls with high acculturation. Overweight significantly predicted higher body image dissatisfaction, which in turn was significantly related to depressive symptoms. (Xie et al., 2010)

On the other hand, there is data which shows an independence from social factors and current comorbidities. Zhao and colleagues examined the associations of depression and anxiety with BMI after taking into consideration obesity-related comorbidities and other psychosocial or lifestyle factors. They analyzed the data collected from 177 047 adults in the US. Within each gender, the prevalence of the three psychiatric disorders was significantly higher in both men and women who were underweight (BMI<18.5), in women who were overweight (BMI:25–<30) or obese (BMI⩾30), and in men who were severely obese (BMI⩾40) than in those with a normal BMI. Compared with men with a normal BMI, severely obese men were significantly more likely to have current depression or lifetime diagnosed depression and anxiety. Underweight men were also significantly more likely to have lifetime diagnosed depression. Overweight or obese women were significantly more likely than women with a normal BMI to have all three psychiatric disorders. (Zhao et al., 2009)

Breast Cancer

A condition that threatens the body’s integrity also tends to have a psychological effect. If the condition represents a serious threat, fear and anxiety are normal reactions to it. In one study with female survivors of breast cancer of all ages, 56% of the participants had scores that would correlate with potential depression (Begovic-Juhant, Chmielewski, Iwuagwu, & Chapman, 2012). The majority of women felt less attractive and less feminine. Low body image, attractiveness, and femininity positively correlated with depression and negatively with overall quality of life. (Begovic-Juhant et al., 2012) However, this may also provide an approach for ameliorating the depression through work on body image and the self-perception of attractiveness and femininity. Much of this could involve work with communication (Haverkampf, 2017a).

The body and the mind are inseparable. If the integrity of one is in danger, that will reflect of the sense of wholeness of the other. Lasry and colleagues investigated the psychological and social adjustment following total and partial mastectomy. Total mastectomy patients showed higher levels of depression and less satisfaction with body image. Partial mastectomy patients did not display any measurable increase in fear of recurrence. Patients undergoing radiation therapy showed a surprising rise in depressive symptoms, which could be related to an underestimated anxiety they experience. (Lasry et al., 1987)

Exercise as an Adjunct to Medication

Exercise has also been shown to improve depressive symptoms when added to medication. There seems to be an added benefit beyond the direct effect of the antidepressant. In one study, exercise significantly improved symptoms when added to an antidepressant in a group of older patients with depression that had not responded to 6 weeks of antidepressant medication alone. Unlike its benefit as an adjunct to antidepressant medications, exercise in addition to cognitive therapy was found not to be more beneficial than either one by itself. (Ströhle, 2009)


Many types of bodywork exist, and several are generally assumed to maintain and improve overall health and raise the quality of life. Important is as already mentioned above, aside from the physical exercise, the greater awareness and the better more meaningful information about the body and how it interacts with the psyche and the outside world. However, there is still far less knowledge of movement-based treatments focusing on body awareness than medication or psychotherapeutic approaches.

While more research is needed on the type of exercise needed for depression treatment, available research indicates that the type of exercise may not be as important as having the physical activity reach a sufficient intensity. For example, both running and weightlifting were found to significantly decrease depressive symptoms with no significant difference found between these two forms of physical activity and the decrease in symptoms.

Basic Body Awareness Therapy (BBAT)

Danielsson and Rosberg explored the experiences of basic body awareness therapy (BBAT) in 15 persons diagnosed with major depression who participated in the treatment in a randomized clinical trial. The participants’ experiences were essentially grasped as a process of

  • (Danielsson & Rosberg, 2015)

Five constituents of this meaning were described (Danielsson & Rosberg, 2015):

The authors conclude that the process of enhanced perceptual openness challenges the numbness experienced in depression, which can provide hope for change, but it is connected to hard work and can be emotionally difficult to bear. (Danielsson & Rosberg, 2015)


Mokhtari and colleagues investigated the efficiency of 12-week Pilates exercises on depression and balance associated with falling in thirty elderly participants. The Pilates exercises decreased depression and improved the balance related to falling in participants. (Mokhtari, Nezakatalhossaini, & Esfarjani, 2013)

Body Psychotherapy (BPT)

Body Psychotherapy (BPT) may be an effective treatment option for patients with chronic depression. Rohricht and colleagues studied the effectiveness of BPT in patients with chronic depression. Patients with chronic depressive syndromes and a total score of ≥20 on the Hamilton Rating Scale for Depression (HAMD) were randomly allocated to either immediate BPT or a waiting group which received BPT 12 weeks later. Thirty-one patients were included and twenty-one received the intervention. At the end of treatment patients in the immediate BPT group had significantly lower depressive symptom scores than the waiting group (mean difference 8.7). (Rohricht, Papadopoulos, & Priebe, 2013)

Mindfulness-Based Cognitive Therapy (MBCT) pursues the development of a heightened awareness of one’s body, and its effectiveness has been shown in several empirical studies. Research has focused on the interactions between bodily, cognitive, and emotional processes. Michalak and colleagues argue that considering embodied processes might be a useful perspective for research on the etiology of depression and for mechanisms of action in MBCT. (Michalak, Burg, & Heidenreich, 2012)

Tai Chi

Tai Chi has also been explored in its effectiveness against mental health conditions. It has soft movements, slower speeds, and is relatively easy to learn. The posture of high or low and the amount of exercise can be different according to individual physical fitness. It can meet the needs of different ages and physical fitness. Data from a small study with a single-case design suggests that the intervention had the strongest effect on the participant who presented with hyperactivity and heightened anxiety. (Baron & Faubert, 2005)


Field and colleagues compared the effects of yoga (physical activity) versus social support (verbal activity) on prenatal and postpartum depression. Ninety-two prenatally depressed women were randomly assigned to a yoga or a social support control group at 22 weeks gestation. The yoga group participated in a 20-min group session (only physical poses) once per week for 12 weeks. The social support group (a leaderless discussion group) met on the same schedule. At the end of the first and last sessions the yoga group reported less depression, anxiety, anger, back and leg pain as compared to the social support group. At the end of the last session the yoga group and the support group did not differ. They both had lower depression, anxiety, and anger scores and improved relationship scores. In addition, cortisol levels decreased for both groups following each session. Estriol and progesterone levels decreased after the last session. At the postpartum follow-up assessment depression and anxiety levels were lower for both groups. (Field, Diego, Delgado, & Medina, 2013)

Exercise Dose

A dose-response effect with exercise in the treatment for depression has been noted. In one study, high-intensity weight training was more effective than low-intensity weight training in treating depression. Low-intensity weight training and general practitioner care were found to have nearly the same improvement in depression that is consistent with the widely accepted number of the 30% placebo effect in depression treatment. With aerobic exercise, intensity equaling the energy expenditure in public health recommendations was more effective than a program of guided movements of low intensity that had a reduction in depressive symptoms equal to the placebo group.

Aerobic exercise at a dose consistent with public health recommendations is an effective treatment for MDD of mild to moderate severity. Dunn and colleagues studied whether exercise is an efficient treatment for mild to moderate major depressive disorder (MDD), and the dose-response relation of exercise and reduction in depressive symptoms. Participants were randomized to one of four aerobic exercise treatment groups that varied total energy expenditure and frequency or to exercise placebo control. A 17.5-kcal/kg/week dose is consistent with public health recommendations for physical activity. The main effect of energy expenditure in reducing Hamilton Rating Scale for Depression (HRSD17) scores at 12 weeks was significant. Adjusted mean HRSD17 scores at 12 weeks were reduced 47% from baseline for the 17.5-kcal/kg/week dose, compared with 30% for a lower dose and 29% for control. There was no main effect of exercise frequency at 12 weeks. (Dunn, Trivedi, Kampert, Clark, & Chambliss, 2005)

Exercise and Anxiety

Compared to the wide range of research on the positive effects of exercise on depression, anxiety disorders have been less frequently studied. In general, aerobic exercise has been shown to be an effective and cost-efficient treatment alternative for a variety of anxiety disorders. Several studies have indicated that aerobic exercise may be as effective in reducing generalized anxiety as cognitive behavioral therapy.

In general, exercise does appear to be effective in reducing symptoms associated with anxiety. Furthermore, symptoms improve following both an acute episode of physical activity as well as following a program of routine exercise.

In treating anxiety, exercise has been shown to alleviate anxious feelings. While useful in treatment, exercise does not seem to reduce anxiety to the level achieved by psychopharmaceuticals. In a study of patients suffering from moderate to severe panic disorder, both a 10-week protocol of regular aerobic exercise and clomipramine were associated with significant improvement of symptoms compared to placebo. In comparison with exercise, clomipramine improved anxiety symptoms more effectively and significantly earlier.

In another study, the effects of a Feldenkrais® Awareness Through Movement program and relaxation procedures were assessed on a volunteer sample of 54 undergraduate physiotherapy students over a 2-week period. Analysis of variance showed that anxiety scores for all groups varied significantly over time and, specifically, that participants reported lower scores at the completion of the fourth intervention. Further, compared to the control group, females in the Feldenkrais® and relaxation groups reported significantly lower anxiety scores on completion as compared to the beginning of the fourth session, and this reduction was maintained one day later. (Kolt & McConville, 2000)

Anxiety Sensitivity

Exercising at 70%–90% of maximum heart rate for 20 minutes three times a week seems to reduce anxiety sensitivity significantly (Carek, Laibstain, & Carek, 2011). Self-reported fears of anxiety sensations, fears of respiratory and cardiovascular symptoms, publicly observable anxiety symptoms, and cognitive dyscontrol decrease following a prescribed exercise program (Carek et al., 2011). In a study by Cox and colleagues, the most substantial reduction in state anxiety occurred 90 minutes following 20 minutes of aerobic exercise at 80% of maximal oxygen uptake (Cox, Thomas, Hinton, & Donahue, 2004).

Body Dysmorphic Disorder: OCD

The relationship between obsessive–compulsive disorder (OCD) and body dysmorphic disorder (BDD) is unclear. BDD has been proposed to be an OCD‐spectrum disorder or even a type of OCD. There is a growing literature on the concept of an obsessive–compulsive spectrum of disorders. (Lochner & Stein, 2006)

Body dysmorphic disorder (BDD) is a distressing and impairing preoccupation with an imagined or slight defect in appearance, with depression as its most frequent comorbid condition. (Nierenberg et al., 2002)

BDD is frequently comorbid with major depression, is associated with an earlier age of onset of depression and longer duration of depressive episodes, and is found more frequently with atypical than non-atypical depression. Nierenberg and colleagues evaluated the rate of BDD in a cohort of consecutive outpatients with typical and atypical major depressive disorder in 350 outpatient participants. Twenty-eight (8.0%) subjects had a lifetime history of BDD and 23 (6.6%) had current BDD. Those with comorbid lifetime BDD had an earlier age of onset of depression and longer duration of the current episode, but not a greater number of depressive episodes or greater severity of depression. Subjects with and without BDD were similar with respect to age, gender, and marital status. There was a higher rate of lifetime and current BDD in subjects with atypical depression than in those with non-atypical depression. Subjects with BDD also had higher rates of social phobia, any eating disorder, and any somatoform disorder but not OCD. They also had higher rates of avoidant, histrionic, and dependent personality disorders. (Nierenberg et al., 2002)

OCD and BDD do not significantly differ on many variables but did have some clinically important differences. In one study, the comorbid BDD/OCD group evidenced greater morbidity than subjects with OCD or BDD in a number of domains, but differences between the comorbid BDD/OCD group and the BDD group were no longer significant after controlling for BDD severity. However, differences between the comorbid BDD/OCD group and the OCD group remained significant after controlling for OCD severity.

Lochner and Stein conducted a computerized literature search (MEDLINE: 1964–2005) to collect studies addressing different dimensions on which the OCSDs lie. Their cluster analysis found that in OCD there were 3 clusters of OCD spectrum symptoms:

  • “Reward deficiency” (including trichotillomania, pathological gambling, hypersexual disorder and Tourette’s disorder),
  • “Impulsivity” (including compulsive shopping, kleptomania, eating disorders, self-injury and intermittent explosive disorder), and
  • “Somatic” (including body dysmorphic disorder and hypochondriasis).

It is unlikely that OC symptoms and disorders fall on any single phenomenological dimension; instead, multiple different constructs may be required to map this nosological space. Although there is evidence for the validity of some of the relevant dimensions, additional work is required to delineate more fully the endophenotypes that underlie OC symptoms and disorders. (Lochner & Stein, 2006)

It has been argued that body-focused repetitive behavior disorders (e.g., trichotillomania and skin-picking disorder) should be included within the obsessive-compulsive and related disorders category, as this is how most clinicians see these behaviors, and as this may optimize clinical utility. The descriptions of these disorders should largely mirror those in DSM-5, given the evidence from recent field surveys. (Stein & Bouwer, 1997)


The symptoms of HC overlap to an extent with certain anxiety disorders, such as panic disorder and OCD. The results of a study using discriminant function analysis indicated that whereas individuals with hypochondriasis experience panic attacks, obsessions, and compulsions, these symptoms are markedly less pronounced than among those with panic disorder and OCD. Conversely, overlaps were found in terms of cognitive biases, with hypochondriasis patients demonstrating elevated levels of intolerance of uncertainty, body vigilance, and fear of cardiovascular symptoms. (Deacon & Abramowitz, 2008)


While the Center for Disease Control and Prevention and the American College of Sports Medicine recommend that individuals should engage in 30 minutes or more of moderate-intensity physical activity on most (preferably) all days of the week, physical activity and exercise have risks that need to be considered. The most common risk of physical activity in adults is musculoskeletal injury. The risk of injury increases with obesity, volume of exercise, and participation in vigorous exercise such as competitive sports.

Furthermore, vigorous physical activity acutely increases the risk of sudden cardiac death and myocardial infarction among individuals with both diagnosed and occult heart disease.


Reduced incidence rates of depression and (some) anxiety disorders in exercising subjects raise the question whether exercise may be used in the prevention of some mental disorders. A review of studies showed a bidirectional relationship between physical activity, exercise and adolescent mental health (Pascoe & Parker, 2019). The results suggested that physical activity and exercise programs designed to increase the level of activity in young people should be implemented to be attractive and achievable to young people that may have poor psychological health (Pascoe & Parker, 2019). Another study found that participating in diverse leisure activities and longer exercise time decreases older adults’ risk of having depression. Additionally, the results confirmed that depression is positively correlated with chronic diseases (Lee, Yu, Wu, & Pan, 2018). On the other hand, data from the Netherlands Mental Health Survey and Incidence Study did not find evidence for a dose–response relationship between exercise levels and mental health. Among those with mental disorder at baseline, exercise participants were more likely to recover from their illness compared to their counterparts who did not take exercise, but the authors pointed out that it remains uncertain whether this association truly reflects a causal effect of exercise (Ten Have, de Graaf, & Monshouwer, 2011). In a 2010 meta-review, an ssociation between physical activity and mental health in young people was evident, but research designs were described as often weak and effects small to moderate. Evidence showed small but consistent associations between sedentary screen time and poorer mental health (Biddle & Asare, 2011). In another study involving 42 undergraduates, vigorous exercise had mental health benefits beyond moderate physical activity, was associated with less stress, pain, insomnia and depression, more favorable objective sleep patterns, and fewer mental health problems if the individual was exposed to high stress (Gerber et al., 2014).


Depression and anxiety disorders are some of the most prevalent neurological disorders with close to one in five of adults demonstrating symptoms. Exercise has been shown to reduce symptoms associated with these disorders and has the potential to lessen the dependability on psychopharmacology. Physicians should recommend that adults participate in at least 30 minutes of accumulated moderate-intensity physical activity (for example, walking fast) on most days of the week. (Phillips et al., 2007) The balance seems to be important. The term ‘exercise addition’ has been coined for another extreme, in which an individual experiences a need to engage in excessive exercise, has the potential to have adverse effects on both physical and mental health (Berczik et al., 2012).

Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at or on the websites and


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California Rocket Fuel – Combining Medication against Depression (1)


Depression and Psychotherapy (6)

Abstract – Depression has become highly treatable and this article explores some ways of treating it with the use of psychotherapy. The approach presented is a communication focused psychotherapy which has been developed and described by the author before. Psychotherapy alone may not be sufficient in more severe cases, where medication is usually added to bring faster relief to the symptoms of depression, which also facilitates the psychotherapeutic treatment.

Keywords: depression, psychotherapy

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Depression and Psychotherapy (6) Christian Jonathan Haverkampf

Depression and Medication

Depression and Medication (2) 


Depression comes in a multitude of flavors. Traditionally a distinction has been made between the reactive or neurotic depression on one end, which has been seen as largely environmentally induced, and the endogenic depression, which was largely seen as driven by biology. We now know that all three factors of biology, psychology and environment interact together in leading to the symptoms of depression.


The Circularity of Depression

Due to the plasticity of the brain, which regulates its morphological and chemical balance all the time, environmental influences can affect the circuitry and the functioning of the brain. Since the biology of the brain determines our thoughts and actions, it influences our environment, which again has a feedback on the brain. Thus, all effect depends on communication inside the brain and between the brain and the environment, and vice versa. This plays an immense role in the etiology and the symptoms of depression. It also explains why a combination of medication and psychotherapy in the majority of cases has the best outcome. Medication should be thought of in many cases of depression, except for the lighter reactive versions, while psychotherapy is always indicated if an individual suffers from depression. A condition that relies largely on communication deficits to be maintained, can also be cured through the ‘talking cure’, psychotherapy.


The Combination of Psychotherapy and Medication

Depression should in any case be treated with a combination of psychotherapy and medication if it is serious enough. Psychotherapy in most cases takes a few months to work, and medication, while also requiring a few weeks to work, will in many cases get results quicker than psychotherapy alone. In less severe cases, especially when it is a reaction to obvious external factors, psychotherapy alone may do. Medication can especially provide relief before the effect of psychotherapy, which is more geared towards the long-run, takes hold. While medication cannot make life more meaningful per se, it can improve an individual’s mood, which usually leads to more positive thoughts, a more positive outlook on the world, a decrease in ruminations, less anxiety and improved sleep – and appetite if that is desired.


Suicidal Ideation

Suicidality needs to be kept in mind in any form of depression and the mainstream opinion has shifted towards addressing these thoughts rather than avoiding talking about them out of fear that it might trigger them. Since the stability of the therapeutic relationship and communication itself are important tools in relieving depression, one should not be too anxious about naming issues that seem relevant.

A concern was that since the activating effect in several antidepressants can occur before the antidepressant affect, the risk for suicide might increase because a patient who still feels depressed becomes more active. However, the clinical experience is that the opportunity to talk about feelings and thoughts openly in a secure relationship reduces the urge towards self-harm.


Interests and Values

As I have outlined in another article on depression, facilitating the idea of a future the patient has some control over is often an important step in treating depression. This often means identifying values, interests and aspirations, which can provide greater motivation and a good feeling about the future, should be allowed enough space. There can be sadness about lost opportunities, but this usually subsides in the face of having a clearer direction in life and a greater promise of happiness, if one pursues the things one truly values and aspires to.



Unfortunately, the perfect medication does not exist. But this is also not to be expected since each antidepressant has a unique profile of effects, positive and negative, which can still be influenced largely by the unique biology of the patient. The following antidepressants are the most common ones. Using a single antidepressant (monotherapy) is usually to be preferred over polypharmacy. However, especially in more severe and treatment-resistant cases of depression, combinations may have to be explored, such as combining venlafaxine and mirtazapine (“California rocket fuel”) to yield an especially potent antidepressant and activating combination, which can even improve sleep (at lower to medium doses of mirtazapine).

Selective serotonin reuptake inhibitors (SSRIs)

The selective serotonin reuptake inhibitors (SSRIs) are the most common used antidepressants because of their relative safety and low side-effect profile. Unfortunately, in the beginning the indiscriminate use of the SSRI Prozac® against ‘everything’ from workplace problems to the stress of unhealthy living lead to a backlash in the media, which unfortunately made many patients avoid all medication out of fear to become emotionally flat or experience a change in one’s personality, which has not been shown so far in any convincing way.

There are several other substances, that work as antidepressants, and all have potential side-effects. Often a substance is used which has a ‘desirable’ side-effect and that deals more effectively with the individual constellation of symptoms:

  • Insomnia: Mirtazapine (Remeron® and many generics) is effective in inducing sleep at lower doses (around 15mg), an effect that seems to wear off once one goes up to 45mg. However, the antidepressant effect of 15mg is usually too small. Especially early on ‘hangovers’ in the morning are not uncommon. Among very common side effects are dry mouth, constipation, increased appetite, as well as somnolence, sedation, sleepiness (which may wear off).
  • Lack of activation: Venlafaxine (Effexor®, Effexor XR®, Lanvexin®, Viepax®, Trevilor®) is a noradrenaline and serotonin reuptake inhibitor (NSRI) and often affectively increases activation. However, one should be careful with patients who might harm themselves (or others) because activation often occurs before the antidepressant effect takes hold. Also, if used in cases of anxiety it may increase the anxiety before reducing it.
  • Co-morbidity with anxiety, panic attacks, OCD: the SSRIs are a good first choice. Venlafaxine seems to be helpful with anxiety, but often it increases anxiety early on, and possibly even medium-term.

Tricyclic antidepressants

Tricyclic antidepressants should not be used to treat symptoms that can be treated with the SSRIs or an NSRI, because of the letter’s better safety profile. It is difficult to imagine there still is an application for MAO inhibitors, except in the rare depression that does not respond to treatment. In the latter cases, my experience is that often medication has not been administered long enough or prescribed in the right dose. Quite frequently there has been no or only inadequate psychotherapy. It is worth remembering that psychotherapy is still and will always be the core treatment for what were a century ago referred to the ‘neurotic’ conditions, such as reactive depression, anxiety, OCD and the like. The reason is that the symptomatology can be traced to problems in interactions, communication and human relationships. Generally, there is better empirical evidence for the usefulness of antidepressants in the treatment of depression that is chronic (dysthymia) or severe.

In any case, it can take weeks for the full effect of medication to be noticed. A 2008 review of randomized controlled trials concluded that symptomatic improvement with SSRIs was greatest by the end of the first week of use, but that some improvement continued for at least 6 weeks.


Major depressive disorder

The UK National Institute for Health and Care Excellence (NICE) 2009 guidelines indicate that antidepressants should not be routinely used for the initial treatment of mild depression, because the risk-benefit ratio is poor. The guidelines recommend that antidepressant treatment should be considered for:

  • People with a history of moderate or severe depression,
  • Those with mild depression that has been present for a long period,
  • As a second-line treatment for mild depression that persists after other interventions,
  • As a first-line treatment for moderate or severe depression.

The guidelines further note that antidepressant treatment should be used in combination with psychosocial interventions in most cases, should be continued for at least 6 months to reduce the risk of relapse, and that SSRIs are typically better tolerated than other antidepressants.



Between 30% and 50% of individuals treated with a given antidepressant do not show a response. In clinical studies, approximately one-third of patients achieve a full remission, one-third experience a response and one-third are non-responders. Partial remission is characterized by the presence of poorly defined residual symptoms. These symptoms typically include depressed mood, psychic anxiety, sleep disturbance, fatigue and diminished interest or pleasure. It is currently unclear which factors predict partial remission. However, residual symptoms are powerful predictors of relapse, with relapse rates 3–6 times higher in patients with residual symptoms than in those who experience full remission.


“Trial and error” switching

The American Psychiatric Association 2000 Practice Guideline advises that where no response is achieved following six to eight weeks of treatment with an antidepressant, to switch to an antidepressant in the same class, then to a different class of antidepressant. A 2006 meta-analysis review found wide variation in the findings of prior studies; for patients who had failed to respond to an SSRI antidepressant, between 12% and 86% showed a response to a new drug. However, the more antidepressants an individual had already tried, the less likely they were to benefit from a new antidepressant trial. A later meta-analysis found no difference between switching to a new drug and staying on the old medication; although 34% of treatment resistant patients responded when switched to the new drug, 40% responded without being switched.



A combination strategy involves adding another antidepressant, usually from a different class of antidepressants to have effect on other mechanisms. Although this may be used in clinical practice, there is little evidence for the relative efficacy or adverse effects of this strategy.



For a partial response, the American Psychiatric Association guidelines suggest augmentation, or adding a drug from an altogether different class of substances. These include lithium and thyroid augmentation, dopamine agonists, sex steroids, NRIs, glucocorticoid-specific agents, or the newer anticonvulsants.


Which medication to use?

The medication used needs to be tailored specifically to the individual and the set of effects that are desired and those which need to be voided. However, there seem to be clear favorites overall, which the following list of antidepressant prescriptions in the US in 2010 shows:

Drug name Commercial name Drug class Total prescriptions
Sertraline Zoloft® SSRI 33,409,838
Citalopram Celexa® SSRI 27,993,635
Fluoxetine Prozac® SSRI 24,473,994
Escitalopram Lexapro® SSRI 23,000,456
Trazodone Desyrel® SARI 18,786,495
Venlafaxine (all formulations) Effexor (IR, ER, XR) ® SNRI 16,110,606
Bupropion (all formulations) Wellbutrin (IR, ER, SR, XL) ® NDRI 15,792,653
Duloxetine Cymbalta® SNRI 14,591,949
Paroxetine Paxil® SSRI 12,979,366
Amitriptyline Elavil® TCA 12,611,254
Venlafaxine XR Effexor XR® SNRI 7,603,949
Bupropion XL Wellbutrin XL® NDRI 7,317,814
Mirtazapine Remeron® TeCA 6,308,288
Venlafaxine ER Effexor XR® SNRI 5,526,132
Bupropion SR Wellbutrin SR® NDRI 4,588,996
Desvenlafaxine Pristiq® SNRI 3,412,354
Nortriptyline Sensoval® TCA 3,210,476
Bupropion ER Wellbutrin XL® NDRI 3,132,327
Venlafaxine Effexor SNRI 2,980,525
Bupropion Wellbutrin IR NDRI 753,516


The Need for Psychotherapy

In any case, medication should always be combined with psychotherapy. In the less severe forms of depression and those that seem to have an explanation and are “reactive”, medication often shows to be less effective and psychotherapy eventually leads in many cases to a full remission of the symptoms.


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy (psychoanalytic and CBT)  and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at or on the websites and

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.

© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved.

Depression and Psychotherapy

Depression and Psychotherapy (2)

Depression usually means feeling low and lacking motivation and energy to do anything enjoyable, but sometimes it may predominantly show in disturbed sleep, a lack of appetite and other diffuse bodily symptoms. The latter condition we call an atypical depression. Often individuals remain undiagnosed or misdiagnosed for a long time before someone correctly identifies the underlying problem as a depression. Frequently, depression is associated with anxiety, and in many cases also with OCD, because they involve some of the same neurobiological pathways, and the same medication can have an effect on all three.

How Anxiety Got Rebranded As Depression

New research finds that one in six U.S. adults used a psychiatric drug in 2013, most often as a treatment for depression. Depression diagnoses have skyrocketed over the past 50 years, but, as Allan V. Horwitz wrote in a 2010 paper, that’s not necessarily a result of underlying changes in our mental health.

See the articlet on JSTOR Daily at

Using multiple social media platforms dramatically raises likelihood of depression and anxiety in young adults, study finds

Using multiple social media platforms has a dramatic link with depression and anxiety even taking into account the time users spend on social media, a study has shown.
The new study, published in Computers in Human Behaviour, found those who reported using seven to 11 social media platforms had more than three times the risk of depression and anxiety than their peers who use zero to two – and the scientists concluded it may be worth doctors asking how many platforms depressed or anxious patients use. …

See the full article in the Irish Examiner at

The difference between bipolar disorder and depression

Bipolar disorder and depression are mental health conditions that share similar features but are separate medical conditions.

Diagnosis for either bipolar disorder or severe depression is difficult and may take some time. However, effective management of both conditions is possible.

See the full article on MNT at