MODULE 1

Understanding Mental
Health

This project has been funded with support from the European Commission. This publication
[communication] reflects only the views of the author, and the Commission cannot be held
responsible for any use which may be made of the information contained herein.
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COURSE CONTENTS & TOPICS

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 UNDERSTANDING MENTAL HEALTH

CONTENTS
UNIT 1: Introduction to mental health and mental disorder.

UNIT 2: Mental health disorders and symptoms.

UNIT 3: Recovery and treatment.

UNIT 4: Medication and side effects.

UNIT 5: Professional intervention patterns.

UNIT 6: Self-care
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UNIT 1: Mental health and mental illness

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UNIT 1: Mental health and mental disorders
Learning objectives

• Knowing the current most accepted concepts of mental health and mental disorders.

• Learning about the incidence of mental health disorders in EU.

• Understanding that mental health disorders are caused by a combination of factors.

• Learning about the stages of mental health disorder.

• Understanding how mental disorder affects daily life

• Learning about the stigma suffered by people with mental health disorders

• Promote respect of people with mental health disorders

• Learning how professionals can address stigma

 UNDERSTANDING MENTAL HEALTH

1. MENTAL HEALTH & MENTAL DISORDER (I)

Mental health is currently understood as wellbeing

The World Health Organization (WHO, 2001) defines mental health as a welfare state in which
everyone realizes his/her own potential, can face with the normal stresses of life, can work
productively and fruitfully, and he/she is able to contribute and participate in his/her community.
Mental health is an integral component for health and well-being in general (WHO, 2013).

It should be treated with the same urgency and consideration than physical health is treated:
“There is no health without mental health”.
(The Comprehensive Mental Health Action Plan 2013-2020, WHO, 2013 a)

Mental health is not the absence of mental illness.

The absence of a recognized mental disorder is not necessarily an indicator of mental health. In
regards to this statement, mental health or a state of well-being protects against the development of
disorders, while mental disorders increase the risk of mental discomfort.
 UNDERSTANDING MENTAL HEALTH

1. MENTAL HEALTH & MENTAL DISORDER (II)

Mental disorders
Mental disorders comprise a broad range of problems, with different symptoms.

However, they are generally characterized by some combination of abnormal

thoughts, emotions, behavior and relationships with others.

Examples are schizophrenia, depression, intellectual disabilities and disorders due

to drug abuse.

Most of these disorders can be successfully treated. (WHO, 2001)

1. MENTAL HEALTH & MENTAL DISORDER (III): MH in Europe
UNDERSTANDING MENTAL HEALTH
1 / 4 persons in Europe suffers mental health disorders in EU and 7% of the population
Worldwide)

Mental disorders are the most significant of the chronic conditions in EU affecting near the 40% of the population

• The percentage of persons who reported having consulted a psychologist, psychotherapist, or psychiatrist
is higher among women (6,3 %) than men (4,2 %). This pattern was apparent across almost all EU Member
States (Eurostat).
• Depressive disorder: the most extended disorder in EU (30 million people in EU). It is twice as common in
women as in men.
• Anxiety and specific phobias are the second most frequent disorders in EU (WHO 2015)
• Psychotic disorders: about 1–2% of the population is diagnosed with, men and women equally.
• Substance use disorders (alcohol and drugs): 5,6% of men and 1,3% of women.
• Dementia: there is an increasing prevalence among the ageing population, typically 5% in people over 65
and 20% of those over 80.
• In all countries, mental disorders tend to be more prevalent among those who are most deprived.
1. MENTAL HEALTH & MENTAL DISORDER (IV): CAUSAL FACTORS

BIOLOGICAL FACTORS STRESSING FACTORS

• Genetical component.
• Lack of personal
• Brain biochemical alteration
coping strategies.
(dopamine). THERE IS NO ONE
• Alteration of brain structures and
functions: ventricular dilation.
UNIQUE CAUSE • Consume of alcohol
Reduction of metabolic activity in BUT A and drugs.
some areas COMBINATION OF
• Early alterations of brain VARIOUS FACTORS
development. Prenatal factors Early
biochemical changes. Embryonic
brain.
• Pregnancy infections and
complications in childbirth
1. MENTAL HEALTH & MENTAL DISORDER (V): STAGES

BEGINING STATE PHASE RESIDUAL PHASE

• Starts between 14 • Evolution in form • Advanced phases of

and 25 years old outbreaks or crises: the illness
(approximately). variable number, • Usually predominate
duration and Negative symptoms
• It can happened intensity
both in a sudden or and / or decreased
slow way. • Periodical instability- intensity of positive
stability phases symptoms
• The first episode can
happened during a • Important: the
strong stress period medication and
avoid stressful
• Acute phase or situations
outbreak
 UNDERSTANDING MENTAL HEALTH

1. MENTAL HEALTH & MENTAL DISORDER(VI): ASPECTS OF DAILY LIFE

Mental illness affects to daily life tasks
• Self care: not caring for personal hygiene, dressing…
• Autonomy: difficulties in home cleaning, money handling, mobility, job performance…
• Self control: inability to stress handling, personal competences, mood…
• Interpersonal relationships: lack of social skills, social relationships…
• Leisure: isolation, apathy, inability to enjoy, passivity…
• Cognition: difficulties for keeping attention and concentration, memory, reasoning…

Affects to their socio-economic status

• People living alone or with their parents
• Low income
• Usually do not work
 UNDERSTANDING MENTAL HEALTH

MENTAL HEALTH & MENTAL DISORDER(VII): ASPECTS OF DAILY LIFE

Affects to their general health
• They use to have worse physical health.
• Frequent use of health services
• Frequent hospital admission
Affects to their family
The burden of care falls on the parents and especially on the mother. This carry on other issues for the
families/carers:
• Parent aging problems
• Unpaid care tasks
• Reduction of the time available for work, social and leisure activities.
• Overwhelming feeling of carers cause:
o Criticism: Critical comments about the behavior of the person with MH. Negative evaluation of the
behavior, both in the content (dislike and discomfort) and intonation of what was said.
o Hostility: Generalized negative evaluation (directed more at the person than at the behavior) or a
manifest rejection towards the person
o Emotional overplay: Attempt to exert excessive control over the person's behavior. Refers to despair,
self-sacrifice, overprotection and intense emotional manifestation
 UNDERSTANDING MENTAL HEALTH

MENTAL HEALTH & MENTAL DISORDER (VIII): STIGMA

Affects also to social inclusion: People with severe mental health issues suffers social stigma
• They are one of the most historically stigmatized groups: Especially schizophrenia
• They are perceived as dangerous, aggressive, estrange, unpredictable, vague , etc. They are
seem with fear
• There is a great ignorance and lack of awareness about mental disorders.
• Media, films, literature…had also created a negative image of mental disorders
• Families use to feel embarrassment, guilt and use to hide the illness.
• They find difficulties to find a job, a house, a couple, friends…
• It is difficult for the person with MHD to reach the status of citizen with full rights.
• Stigma worsen their situation: social maladjustment, low self-esteem, depression, increased
family burden, integration into the community.
 UNDERSTANDING MENTAL HEALTH

MENTAL HEALTH & MENTAL DISORDER (IX): STIGMA

What impact stigma have? Stigma has serious and long lasting consequences.
1. It brings the experience of: 2. Emotional state: Affects sense of self-worth,
o Shame self-steem.

o Blame 3. Sypmtoms:
o Hopelessness o Contributes to shorten life expectancy
o Slows recovery
o Distress
4. Access and quality treatment: Limits access
o Reluctance to seek or accept help
and quality of health.
o Fear
5. Human rights: can lead to abuse.
o Isolation
6. Family: Disrupts relationships.
 MENTAL HEALTH & MENTAL ILLNESS (X): PROMOTING RESPECT AND DIGNITY

What can sport professionals do to address stigma?.

• Change your own perception and attitude towards people with MH disorders.

• Understand that most of the people (including us) can suffer or have suffered MH disorders like anxiety,
depression…

• Reaffirm that all persons with all types of disabilities must enjoy all human rights and fundamental
freedoms.

• Play a large part in fulfilling these rights.

• Respect and advocate for the implementation of relevant international conventions, such as the United
Nations Convention of the Rights of Persons with Disabilities (CRPD) New York, 2006*

*Check if your country has ratified the Convention here: https://www.un.org/disabilities/documents/maps/enablemap.jpg

MENTAL HEALTH & MENTAL ILLNESS (XI): PROMOTING RESPECT AND DIGNITY

CRPD in brief
PURPOSE:
To promote, protect and ensure the full and equal enjoyment of all human rights and
fundamental freedoms by all persons with disabilities, and to promote respect for their
inherent dignity
PARADIGM SHIFT:
The Convention marks a major shift in the way societies view persons with disabilities, with the person
being the key decision-maker in his or her own life. It makes persons with disabilities “rights holders”
and “subjects of law”, with full participation in formulating and implementing plans and policies
affecting them.
• The Convention marks a ‘paradigm shift’ in attitudes and approaches to persons with disabilities.
• Persons with disabilities are not viewed as "objects" of charity, medical treatment and social
protection; rather as "subjects" with rights, who are capable of claiming those rights and making
decisions for their lives based on their free and informed consent as well as being active
members of society.
• The Convention gives universal recognition to the dignity of persons with disabilities.
 MENTAL HEALTH & MENTAL ILLNESS (XI): CPRD

CRPD in brief
KEY CONCEPTS:
Persons with disabilities include those who have long-term physical, mental, intellectual or sensory
impairments which in interaction with various barriers may hinder their full and effective participation in society
on an equal basis with others (Art 1).

Disability results from an interaction between a non-inclusive society and individuals:

“Disability is an evolving concept, and that disability results from the interaction between persons with impairments
and attitudinal and environmental barriers that hinders full and effective participation in society on an equal basis
with others”.
• Person using a wheelchair might have difficulties gaining employment not because of the wheelchair, but
because there are environmental barriers such as inaccessible buses or staircases which impede access
• Person with extreme near-sightedness who does not have access to corrective lenses may not be able to
perform daily tasks. This same person with prescription eyeglasses would be able to perform all tasks
without problems.

*Check if your country has ratified the Convention here: https://www.un.org/disabilities/documents/maps/enablemap.jpg

 MENTAL HEALTH & MENTAL ILLNESS (XII): PROMOTING RESPECT AND DIGNITY
CRPD GENERAL PRINCIPLES
• Respect for inherent dignity, individual autonomy including the freedom to make one’s own choices, and
independence of persons
• Non-discrimination
• Full and effective participation and inclusion in society
• Respect for difference and acceptance of persons with disabilities as part of human diversity and humanity
• Equality of opportunity
• Accessibility
• Equality between men and women
• Respect for the evolving capacities of children with disabilities and respect for the right of children with
disabilities to preserve their identities

CRPD TERMINOLOGY
• YES: ‘persons with disabilities’ NO: ‘handicapped’ , ‘physically or mentally challenged’

• Note: Preferences for terminology among persons with disabilities and among geographic regions may vary. The individual wishes of persons
with disabilities should be respected as much as possible.

*Check if your country has ratified the Convention here: https://www.un.org/disabilities/documents/maps/enablemap.jpg

 MENTAL HEALTH & MENTAL ILLNESS (XIII): PROMOTING RESPECT AND DIGNITY
DOs and DON’Ts to promote respect and dignity *

* SOURCE: WHO Mental Health Gap Action Programme (mhGAP), mhGAP Training Manual for the mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health
settings – version 2.0
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UNIT 2: Mental health disorders and
symptoms

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UNIT 2: Mental health disorders and symptoms
Learning objectives

• Learning about the two most widely systems of classification of mental health disorders

• Identifying the characteristics of most common mental health disorders.

• Understanding how persons with mental health disorders feels.

• Learning that diagnoses are based on symptoms but are not pure

• Learning the different type of symptoms

• Promote respect and dignity for people with mental health disorders
 UNDERSTANDING MENTAL HEALTH

2. MENTAL HEALTH DISORDERS & SYMPTOMS

CLASSIFICATION OF DISORDERS
ANSIETY MOOD PERSONALITY
PSYCOSIS NEUROSIS DISORDERS DISORDERS DISORDERS
• SCHIZOPHRENIA • OBSESIVE • OBSESIVE- • DEPRESSION • BORDERLINE
• BIPOLAR NEUROSIS COMPULSIVE • DISSOCIATIVE
DISORDER • HYSTERIA DISORDER IDENTITY
• PSYCOSIS • PHOBIAS • PANIC DISORDER (DID)
• POST-TRAUMATIC
STRESS

There are several classifications of mental health issues.

The two most widely established systems of psychiatric classification are:
• DSM (Diagnostic and Statistical Manuel of Mental Disorders)
• ICD (International Classification of Diseases)

https://www.mentalhealthtoday.co.uk/innovations/an-introduction-to-the-classification-of-mental-disorders-the-dsm-and-the-icd
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION

DEPRESSION

WATCH ANGELO’S STORY: https://www.youtube.com/watch?v=PYbuB-Ateus

2. MENTAL HEALTH DISORDERS & SYMPTOMS: DEPRESSION

DEPRESSION
• Depression is the most common mental disorder (322 million people worldwide).
• It is characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth,
disturbed sleep or appetite, tiredness, and poor concentration.
• People with depression may also have multiple physical complaints with no apparent physical
cause.
• Depression can be long-lasting or recurrent, substantially impairing people’s ability to function
at work or school and to cope with daily life.
• At its most severe, depression can lead to suicide.
• Symptoms of depression are lack of interest and pleasure in daily activities, significant weight
loss or gain, insomnia or excessive sleeping, lack of energy, inability to concentrate, feelings of
worthlessness or excessive guilt and recurrent thoughts of death or suicide
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DEPRESSION

Depression results from a complex interaction of social,

psychological and biological factors.
• For example:
Biological People who have gone through adverse life events
(unemployment, bereavement, psychological trauma) are
likely to develop depression.
Their depression can, in turn, lead to the person
experiencing more stress and dysfunction (such as social
isolation, indecisiveness, fatigue, irritability, aches and
Social Psicological pains), thus worsening the person’s life situation and the
depression itself.
Biological factors may contribute to a person developing
depression, such as a person with a family history of
depression.
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DEPRESSION

LOW MOOD ≠ DEPRESSION

• Low mood is normal and transient; many people can experience low mood from time
to time.
• Depression lasts longer and has a profound impact on a person’s ability to function in
everyday life. Symptoms must be present for at least two weeks.
In many cases depression can reduce a person’s ability to carry out daily tasks such
as cooking, cleaning, washing etc. Those with depression may struggle with getting
out of bed and/or engaging in any activities of daily living.
If a person is experiencing persistent low mood but continues to function in their
everyday life then they have symptoms not amounting to depression,
• Therefore, when identifying depression, it is important to consider both:
o The duration of the symptoms.
o The effect on daily functioning
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION

SCHIZOPHRENIA, BIPOLAR DISORDER AND OTHER PSYCHOSES

• Schizophrenia is a severe mental disorder, affecting about 23 million people worldwide
• Psychoses, including schizophrenia, are characterized by distortions in thinking, perception, emotions, language, sense
of self and behavior.
• The disorder can make it difficult for people affected to work or study normally.
• Schizophrenia typically begins in late adolescence or early adulthood
• Some patients may present clear symptoms, but on other occasions, they may seem fine until they start explaining
what they are truly thinking.
• Symptoms and signs of schizophrenia will vary, depending on the individual. The symptoms are classified into four
categories (APA):
1. Psychotic symptoms. For example, delusions and hallucinations.
2. Negative symptoms - these refer to elements that are taken away from the individual. For example, absence of
facial expressions or lack of motivation.
3. Cognitive symptoms - these affect the person's thought processes. They may be positive or negative symptoms,
for example, poor concentration is a negative symptom.
4. Emotional symptoms - these are usually negative symptoms, such as blunted emotions.
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION

BIPOLAR AFFECTIVE DISORDER

• It affects about 60 million people worldwide.
• Bipolar disorders are brain disorders that cause changes in a person’s mood, energy and ability to function.
• It typically consists of both manic and depressive episodes separated by periods of normal mood.
• Manic episodes may involve these symptoms:
o Increased activity levels, elevation of mood potentially very happy and very agitated􀁀.
o Elevated or irritable mood.
o They may talk very rapidly, have lots of different ideas and increased levels of self-worth and self importance.
o A decreased need for sleep.
o They may have hallucinations and delusions, i.e. hear voices and/or believe that they are powerful, that their
ideas can change the world.
o Engage in risk taking Behaviours (gambling, spending money, promiscuity etc.).
People who have manic attacks but do not experience depressive episodes are also classified as having bipolar
disorder.
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION

BIPOLAR AFFECTIVE DISORDER

• Bipolar disorder is a category that includes three different conditions:
o Bipolar I: can cause dramatic mood swings. During a manic episode, people with bipolar I disorder may feel high
and on top of the world, or uncomfortably irritable and “revved up”. During a depressive episode they may feel
sad and hopeless. There are often periods of normal moods in between these episodes
o Bipolar II: involves a person having at least one major depressive episode and at least one hypomanic episode.
People return to usual function between episodes. People with bipolar II often first seek treatment because of
depressive symptoms, which can be severe.
o Cyclothymic disorder: is a milder form of bipolar disorder involving many mood swings, with hypomania and
depressive symptoms that occur often and fairly constantly. People with cyclothymia experience emotional ups
and downs, but with less severe symptoms than bipolar I or II.
o Bipolar disorder it is sometimes considered as a type of psycosis
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION

BIPOLAR AFFECTIVE DISORDER : CLINICAL COURSE

• First onset typically between age 15 and 25 years
• The pattern of mood swings can vary widely between people:
• Some will have a couple of bipolar episodes in their life time and stay stable in between.
• Others will have many episodes.
• Some will only experience manic episodes.
• Some will experience more depressed episodes than manic episodes.
• There are 3 possible clinical courses
o The person recovers completely or partially with some symptoms
o The person recovers but has a future episode (relapse).
o Symptoms continue for a longer period
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION

PSYCHOSES: IMPACT ON LIFE

IMPACT ON THE INDIVIDUAL
• Break up of relationships
• Negative and at times scary experience of symptoms.
• Loss of employment, studies, opportunities.
• Financial consequences.
• Stigma and rejection by community.
IMPACT ON THE FAMILY
• Medical costs.
• Time and energy looking after the person (carer burden).
• Emotional distress.
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION

PSYCHOSES: IMPACT
IMPACT ON SOCIETY
Loss of workforce.
• Costly medical interventions and (unnecessarily) lengthy hospitalizations.
HUMAN RIGHTS VIOLATION
• People with psychoses maybe chained and confined.
• They may be beaten as punishment or treatment.
• They may receive treatments that are ineffective and dangerous due to misunderstanding the causes of psychoses.
SUBSTANCE ABUSE DISORDERS
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION
SUBSTANCE ABUSE DISORDERS
• Addiction is a complex condition, a brain disease that is manifested by compulsive substance use despite harmful
consequence.
• People with addiction (severe substance use disorder) have an intense focus on using a certain substance(s), such as alcohol
or drugs, to the point that it takes over their life
• People with a substance use disorder have distorted thinking, behavior and body functions.
• Changes in the brain’s wiring are what cause people to have intense cravings for the drug and make it hard to stop using the
drug.
• Brain imaging studies show changes in the areas of the brain that relate to judgment, decision making, learning, memory and
behavior control.
• These substances can cause harmful changes in how the brain functions. These changes can last long after the immediate
effects of the drug
• Over time people with addiction build up a tolerance, meaning they need larger amounts to feel the effects
• Substance-related disorders are usually broken down into two groups (Domingo, Zhang, 2019):
o Substance-induced mental disorders: they refer to those mental changes caused by the direct effects of a substance or
withdrawal, namely, depression, psychosis, or anxiety.
o Substance use disorders: they refer to the difficulty to control the use or intake of certain substances.
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION
DEMENTIA

• Dementia is not a single disease in itself, but a general term to describe describe a large group of conditions
affecting the brain which cause a progressive decline in a person’s ability to function: symptoms of
impairment in memory, communication, and thinking.
• It is not a normal part of ageing.
• Worldwide, approximately 50 million people have dementia
• Dementia is usually of a chronic or progressive nature in which there is deterioration in cognitive function (i.e.
the ability to process thought) beyond what might be expected from normal ageing
• It affects memory, thinking, orientation, comprehension, calculation, learning capacity, language, and
judgement. The impairment in cognitive function is commonly accompanied, and occasionally preceded, by
deterioration in emotional control, social behaviour, or motivation.
• Dementia is caused by a variety of diseases and injuries that affect the brain, such as Alzheimer's disease or
stroke.
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION
DEMENTIA

• These are some types of dementia (APA):

o Alzheimer's disease is characterized by "plaques" between the dying cells in the brain and "tangles"
within the cells (both are due to protein abnormalities). The brain tissue in a person with Alzheimer's has
progressively fewer nerve cells and connections, and the total brain size shrinks.
o Dementia with Lewy bodies is a neurodegenerative condition linked to abnormal structures in the brain.
The brain changes involve a protein called alpha-synuclein.
o Mixed dementia refers to a diagnosis of two or three types occurring together. For instance, a person
may show both Alzheimer's disease and vascular dementia at the same time.
o Parkinson's disease is also marked by the presence of Lewy bodies. Although Parkinson's is often
considered a disorder of movement, it can also lead to dementia symptoms.
o Huntington's disease is characterized by specific types of uncontrolled movements but also includes
dementia.
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION
DEMENTIA: Stages
1. Early stage
Becoming forgetful, especially of things that have just happened.
Some difficulty with communication (e.g. difficulty in finding words).
Becoming lost and confused in familiar places - may lose items by putting them in unusual places and be
unable to find them.
Losing track of the time, including time of day, month, year.
Difficulty in making decisions and handling personal finances.
Having difficulty carrying out familiar tasks at home or work (trouble driving or forgetting how use
appliances in the kitchen).
Mood and behaviour:
• Less active and motivated, loses interest in activities and hobbies.
• May show mood changes, including depression or anxiety.
• May react unusually angrily or aggressively on occasion.
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION

DEMENTIA: Stages
2. Middle stage
Becoming very forgetful, especially of recent events and people names.
Having difficulty comprehending time, date, place and events.
Increasing difficulty with communication.
Need help with personal care (i.e. toileting, dressing).
Unable to prepare food, cook, clean or shop.
Unable to live alone safely without considerable support.
Behaviour changes (e.g. wandering, repeated questioning, calling out, clinging, disturbed sleeping,
hallucinations)
Inappropriate behaviour (e.g. disinhibition, aggression)
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION

DEMENTIA: Stages
3. Late stage
Unaware of time and place.
May not understand what is happening around them.
Unable to recognize relatives and friends.
Unable to eat without assistance.
Increasing need for assisted self-care.
May have bladder and bowel incontinence.
May be unable to walk or be confined to a wheelchair or bed.
Behaviour changes may escalate and include aggression towards carer (kicking, hitting, screaming or
moaning).
Unable to find their way around in the home.
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION

ANXIETY DISORDERS
• Anxiety is a very normal response to stressful life events like moving, changing jobs or having financial troubles.

• But Anxiety disorders differ from normal feelings of nervousness or anxiousness, and involve excessive fear or anxiety. When
symptoms of anxiety become larger than the events that triggered them and begin to interfere with your life, they could be
signs of an anxiety disorder

• Anxiety refers to anticipation of a future concern and is more associated with muscle tension and avoidance behavior

• Anxiety disorders are the most common of mental disorders and affect nearly 30 percent of adults at some point in their lives.

• Anxiety disorders are treatable and a number of effective treatments are available. Treatment helps most people lead normal
productive lives.

• People under the age of 65 are at the highest risk of generalized anxiety disorder, especially those who are single, have a lower
socioeconomic status and have many life stressors.

• Anxiety disorders can cause people into try to avoid situations that trigger or worsen their symptoms. Job performance, school
work and personal relationships can be affected.

• In general, for a person to be diagnosed with an anxiety disorder, the fear or anxiety must:

o Be out of proportion to the situation or age inappropriate

o Hinder the ability to function normally

2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION

ANXIETY DISORDERS
• Symptoms:

• Excessive worrying: disproportionate to the events that trigger it and typically occurs in response to normal, everyday
situations.
• Feeling agitated: When someone is feeling anxious, part of their sympathetic nervous system goes into overdrive. This
kicks off a cascade of effects throughout the body, such as a racing pulse, sweaty palms, shaky hands and dry mouth.

• Restlessness: they often describe it as feeling “on edge” or having an “uncomfortable urge to move

• Fatigue
• Difficulty concentrating

• Irritability.

• Tense Muscles: Having tense muscles on most days of the week

• Trouble Falling or Staying Asleep.

• Panic Attacks: Intense, overwhelming sensation of fear that can be debilitating

• Avoiding Social Situations: Feeling anxious or fearful about upcoming social situations

• Irrational Fears: Extreme fears about specific things, such as spiders, enclosed spaces or heights, could be a sign of a
phobia (an extreme anxiety).
2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION

DEVELOPMENTAL DISORDERS
• Developmental disorder is an umbrella term covering intellectual disability and autism spectrum disorders.

• Developmental disorders are defined by limitations in core functional domains (e.g., motor, communication,
social, academic) resulting from aberrant development of the nervous system. These limitations can manifest
during infancy or childhood as delays in reaching developmental milestones, and as qualitative abnormalities
or lack of function in one or multiple domains

• Developmental disorders usually have a childhood onset but tend to persist into adulthood, causing
impairment or delay in functions related to the central nervous system maturation.

• They generally follow a steady course rather than the periods of remissions and relapses that characterize
many other mental disorders.
• Currently 10–20% of children and adolescents worldwide live with mental and developmental disorders.
 2. MENTAL HEALTH DISORDERS & SYMPTOMS: DESCRIPTION
DEVELOPMENTAL DISORDERS
Neurodevelopmental disorders include, among others (Sulkes, 2018):
• ATTENTION-DEFICIT/HYPERACTIVITY: poor or short attention span and/or excessive activity and impulsiveness inappropriate for
the child’s age that interferes with functioning or development. Symptoms may include difficulty in concentrating, in completing
tasks (poor executive skills), restlessness, mood swings, impatience, and difficulty in maintaining relationships.

• AUTISM SPECTRUM DISORDERS (ASDs) are conditions in which people have difficulty developing normal social relationships, use
language abnormally or not at all, and behave in compulsive and ritualistic ways. Autism spectrum disorder (ASD) comprises a
group of neurodevelopmental disabilities. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5)
includes autism, Asperger’s disorder, and “pervasive personality disorder not otherwise specified” under the umbrella heading of
ASD. (APA, 2013)
Symptoms of autism spectrum disorders include impaired social behavior, communication and language, and a narrow range of
interests and activities that are both unique to the individual and are carried out repetitively (Reis). Children with autism
spectrum often repeat certain behaviors, for instance:
o Avoid eye contact
o Not be able to express what they’re thinking through language
o Have a high-pitched or flat voice
o Find it hard to keep up a conversation
o Have trouble controlling emotions
o Perform repetitive behaviors like hand-flapping, rocking, jumping, or twirling
o Developmental disorders often originate in infancy or early childhood. People with these disorders occasionally display
some degree of intellectual disability.
DEVELOPMENTAL DISORDERS
• With early identification and treatment, the prognosis for a child/ adolescent with mental and behavioral disorders can
improve drastically and change the course of a person’s entire life.

• What happens to the child in the early years is critical for the childs develoment trajectory and life course.
Healthy early development strongly influences well-being, mental health, transversal competences and civic participation
through out life. Healthy development includes:
• Physical motor skills
• Social/emotional skills
• Language/cognitive skills

• Children/adolescents with developmental disorders face major challenges with stigma, isolation and discrimination. Some
forms of discrimination may be:
o Bullying by siblings or peers at school
o Harshly treated by frustrated parents
o Excluded from school activities by peers and/or teachers
o Others….
DEVELOPMENTAL DISORDERS
IMPACT:

• Poor school performance

• Reduced community participation

• Impaired capacity to live independently

• Limited employment opportunities

• High carer burden (socially, emotionally, financially)

• Mothers or families may also be stigmatized or become isolated

 UNDERSTANDING MENTAL HEALTH
2. MENTAL HEALTH DISORDERS & SYMPTOMS

Symptoms and diagnoses

The diagnoses help to establish a series of intervention guidelines: from the cognitive, emotional and
behavioral symptoms
Diagnoses in most cases are not pure:
Symptomatology of other diseases associated with the main diagnosis (intellectual disability, toxic
consumption, anxiety, depression ...) may appear.

Symptoms used to be divided into two categories:

Possitive: thoughts, behaviors, or sensory perceptions present in a person with a mental disorder,
but not present in people in the normal population.

Negative: thoughts, feelings, or behaviors normally present in healthy persons that are absent or
diminished in a person with a mental disorder.
 UNDERSTANDING MENTAL HEALTH
2. MENTAL HEALTH DISORDERS & SYMPTOMS

Types of Symptoms
POSSITIVE SYMPTOMS NEGATIVE SYMPTOMS
• Thoughts, behaviors, or sensory perceptions • Thoughts, feelings, or behaviors normally
present in a person with a mental disorder, present in healthy persons that are absent
but not present in people in the normal or diminished in a person with a mental
population.. disorder
• They are more common in the acute phase • Most common in the stabilization phase.
• They respond better to medication • More resistant to medication
• Easy to diagnose • Difficult to diagnose

Examples: Examples:
• Hallucinations • Apathy
• Delusions • Poverty of speech
• Bizarre behaviour • Inability to experience pleasure (anhedonia)
• Formal thought disorder • Limited emotional expression
• Disorganized speech • Defects in attention control

http://www.minddisorders.com/Ob-Ps/Positive-symptoms.html
 UNDERSTANDING MENTAL HEALTH
2. MENTAL HEALTH DISORDERS & SYMPTOMS

POSSITIVE Symptoms (1)

HALLUCINATIONS
False perception occurring without any identifiable external stimulus and indicates an
abnormality in perception. The false perceptions can occur in any of the five sensory modalities.
Therefore, a hallucination essentially is seeing, hearing, tasting, feeling, or smelling something
that is not there.

Symptom of either a medical (e.g., epilepsy), neurological, or mental disorder.

Hallucinations may be present in any of the following mental disorders:

• Psychotic disorders (including schizophrenia, schizoaffective disorder, schizophreniform

disorder, shared psychotic disorder, brief psychotic disorder, substance-induced psychotic
disorder)
• Bipolar disorder
• Major depression with psychotic features
• Delirium
• Dementia
http://www.minddisorders.com/Flu-Inv/Hallucinations.html
 UNDERSTANDING MENTAL HEALTH
2. MENTAL HEALTH DISORDERS & SYMPTOMS

POSSITIVE Symptoms (2)

DELUSIONS

Believes that are clearly false and that indicate an abnormality in the affected person's content of
thought. The false belief is not accounted for by the person's cultural or religious background or his
or her level of intelligence. A person with a delusion will hold firmly to the belief regardless of
evidence to the contrary. Delusions can be difficult to distinguish from overvalued ideas, which are
unreasonable ideas that a person holds. A person with a delusion is absolutely convinced that the
delusion is real, without any doubt.
Symptom of either a medical, neurological, or mental disorder.
Delusions may be present in any of the following mental disorders:
• Psychotic disorders (including schizophrenia, schizoaffective disorder, schizophreniform
disorder, shared psychotic disorder, brief psychotic disorder, substance-induced psychotic
disorder)
• Bipolar disorder
• Major depression with psychotic features
• Delirium
• Dementia
http://www.minddisorders.com/Flu-Inv/Delusions.html
 UNDERSTANDING MENTAL HEALTH
2. MENTAL HEALTH DISORDERS & SYMPTOMS

POSSITIVE Symptoms (3)

FORMAL THOUGHTS DISORDER & DISORGANIZED SPEECH

The thoughts that the person has are translated into their language and show a disorganized
speech, the person moves from one topic to another without connection or any relationship,
emits strange words, suffers a blockage of language, looses association between
ideas, derails sentences, says incoherent ideas, illogical statements, gives excessive detail, and
rhyming of words

It may be present in any of the following mental disorders:

• Psychotic disorders (including schizophrenia, schizoaffective disorder, schizophreniform
disorder, shared psychotic disorder, brief psychotic disorder, substance-induced psychotic
disorder)
• Bipolar disorder
• Delirium
• Dementia
 UNDERSTANDING MENTAL HEALTH
2. MENTAL HEALTH DISORDERS & SYMPTOMS

POSSITIVE Symptoms (4)

BIZARRE BEHAVIOUR
Disorganized behavior, or behavior lacking in logic and common sense. I.E.: agitation, disorganized
behavior, unmotivated laughter .

It may be present in any of the following mental disorders:

• Psychotic disorders (including schizophrenia, schizoaffective disorder, schizophreniform
disorder, shared psychotic disorder, brief psychotic disorder, substance-induced psychotic disorder)
• Bipolar disorder
• Depression
• Dissociative identity disorder (DID)
• Post-traumatic stress disorder
• Obsessive-compulsive disorder
 UNDERSTANDING MENTAL HEALTH
2. MENTAL HEALTH DISORDERS & SYMPTOMS

NEGATIVE Symptoms (1)

APATHY
Disinterest for life and lose motivation to do things that you liked before. It can translate into
exhaustion, slowness, lack of hygiene

It may be present in any of the following mental disorders:

• Psychotic disorders (including schizophrenia, schizoaffective disorder, schizophreniform
disorder, shared psychotic disorder, brief psychotic disorder, substance-induced psychotic disorder)
• Depression

SOCIAL WITHDRAWAL
Diminution of social relationships, isolation, individual's reticence to engage in social interaction
It may be present in any of the following mental disorders:
• Psychotic disorders (including schizophrenia, schizoaffective disorder, schizophreniform
disorder, shared psychotic disorder, brief psychotic disorder, substance-induced psychotic disorder)
• Depression
• Autism
 UNDERSTANDING MENTAL HEALTH
2. MENTAL HEALTH DISORDERS & SYMPTOMS
NEGATIVE Symptoms (2)
EMOTIONAL FLATTENING
The person does not express any emotion with gestures or words (he/she does not laugh at funny
situations, he/she does not smile when other people smile at him/her, he/she does not cry or express pain
in the face of misfortune). Inexpressiveness in the face and lifeless gaze. He/she speaks monotonously and
without modulation
It may be present in any of the following mental disorders:
• Autism
• Psychotic disorders (including schizophrenia, schizoaffective disorder, schizophreniform disorder, shared
psychotic disorder, brief psychotic disorder, substance-induced psychotic disorder)
• Depression
ANHEDONIA
The inability to experience pleasure, the loss of interest or satisfaction in almost all activities. It is considered
a lack of reactivity to pleasant stimuli.
It may be present in any of the following mental disorders:
• Psychotic disorders (including schizophrenia)
• Depression
• Autism
 UNDERSTANDING MENTAL HEALTH
2. MENTAL HEALTH DISORDERS & SYMPTOMS

NEGATIVE Symptoms (3)

COGNITIVE DEFICIT

The person finds difficulties in understanding information, explaining things, paying attention,
remembering , reasoning, etc.

This is the main symptom of dementia but may be also present in any of the following mental disorders:
• Psychotic disorders (including schizophrenia, schizoaffective disorder, schizophreniform disorder, shared
psychotic disorder, brief psychotic disorder, substance-induced psychotic disorder)
• Depression

OTHER SYMPTOMS
Depression, loss of appetite, difficulties to get asleep or insomnia, etc.
“
UNIT 3: Recovery

”
 UNIT 3: Recovery
Learning objectives
• Learning that recovery depends on a combination of factors.

• Getting a general idea of the biopsychosocial model.

• Knowing the main principles that should be taken into

consideration to contribute to recovery.

• Understanding the role of the sport professional in the recovery.

3. RECOVERY: PERCENTAGES

Total recovery
Several crisis. 25%
Minimum
deterioration
50%
Bad evolution
25%

Evolution is unpredictable: it depends largely on the conditions sociofamiliares, medication taking,

coping capacity ...
 UNDERSTANDING MENTAL HEALTH

3. RECOVERY: FACTORS

SOCIAL
SUPPORT

HEALTHY RIGHT
LEISURE
MEDICATION
TIME
RECOVERY
FACTORS

AVOIDING
RISKY PERSONAL
SITUATIONS RECOVERY
(ALCOHOL; TRARMENTS
DRUGS, STRESS,
etc:
 UNDERSTANDING MENTAL HEALTH

3. RECOVERY: BIOPSYCOSOCIAL MODEL

BIOPSYCOSOCIAL MODEL (BPS)

The Biopsychosocial model was first conceptualised by George Engel in 1977, suggesting that to
understand a person's medical condition it is not simply the biological factors to consider, but also
the psychological and social factors.

BPS is a holistic approach that systematically considers biological, psychological, and social factors
and their complex interactions in understanding health, illness, and health care delivery.
It emphasizes the importance of understanding human health and illness in their fullest contexts.

It contradicts the prevailed biomedical model that had dominated the industrialized societies since
mid-20th century
 UNDERSTANDING MENTAL HEALTH

3. RECOVERY: BIOPSYCOSOCIAL MODEL versus TRADITIONAL MODEL

TRADITIONAL BIOMEDICAL MODEL

Focused on pathophysiology and other biological approaches to disease.

Tries to explain psychological phenomenon with pure biological explanations (i.e. neurotransmitter
dysregulation to fully explain a mental disorder)

It only treats the physiological manifestations of the disease.

The disease is seem as a biological dysfunction without considering other factors.

It is more important to cure the symptoms than to promote health.

RECOVERY : The patient establishes an obedience relationship with the doctor. Responsible professional
3. RECOVERY: BIOPSYCOSOCIAL MODEL
• Biological: anatomical, structural
and molecular substrate of the
disease. Chemical, physical factors
...

• Psycological: thougths, emotions,

experiences, expectations,
affections...

• Social : familial, cultural, economic

context.

RECOVERY: The person is considered

responsible for him/herself (not the
professional)
 UNDERSTANDING MENTAL HEALTH

3. RECOVERY: BIOPSYCOSOCIAL MODEL PRINCIPLES

• Building the own project life: defined by the person who decides his/her own goals and designs the path to reach
them, regardless of the evolution of their symptoms.
• Recovery interconnected with health, strength and general well-being.
• Based on hope: persons can recover and they also feel an increasing hope as he assumes greater control over his life.
• Personal identity: Promoting a discovery or rediscovery of a sense of personal identity.
• Coaching: Professionals play a simila role of a coach, a facilitators or a travel companion in the process.
• Respect and inclusion: It is related to social inclusion and with the development of satisfactory social relationships
within the community.
• Personal stories: Language and personal stories are very important as they reinforce a sense of hope and possibilities.
• Personal skills of professionals : empathy, hope, care, realism , creativity and resilience are skills required in mental
health professionals.
 UNDERSTANDING MENTAL HEALTH

3. RECOVERY COMPONENTS
• Self-direction by the individual: She/he defines her/his own goals and design a path to reach them..
• Comprehensive: covers every factor of the life of the person (housing, employment, education, treatment, services,
spirituality, creativity, social networks, community participation, family support ...).

• Person centered intervention, individualized treatments.

• Empowerment: they can choose from a range of options and participate in decisions that will affect their lives.
• Hope: people can and effectively overcome the barriers and obstacles they face.
• Personal responsibility for the own care.
• Based on strengths: to start new life roles, new support relationships based on trust..
• Peer support: encourage and involve others to others, give up a sense of belonging, supportive relationships ....
• Respect: in the community, protection of their rights, elimination and protection of stigma..
 UNDERSTANDING MENTAL HEALTH

3. RECOVERY: TREATMENT

MEDICATION

RESIDENCIAL PSYCOSOCIAL
CARE REHABILITATION

COMMUNITARY LABOR
INTERVENTION REHABILITATION

LEISURE
ACTIVITIES
 3. RECOVERY: BIOPSYCOSOCIAL MODEL

Treatment based of he
BPS model
 UNDERSTANDING MENTAL HEALTH

3. RECOVERY COMPONENTS
REASONS FOR INCLUDING SPORT AND P.A. INTO RECOVERY PROCESSES

1. The burden the mental health disorders is great

2. Mental and physical health problems are interwoven
3. It is proven that sport and physical activity improve mood
4. Sport and physical activity improve general health and promotes balanced life
5. In some cases medication treatments can be reduced
6. Sport and physical activity promote social interaction and friendship
7. They contribute to social inclusion and to fight against stigma
8. It is affordable and cost-effective
9. Leisure is a key factor of the BPS recovery model and they healthy leisure activities.
 UNDERSTANDING MENTAL HEALTH

3. RECOVERY COMPONENTS
SPORTS PROFFESIONALS CONTRIBUTION TO RECOVERY

Sport professionals can contribute to the recovery of people with MHD helping them to thrive inside and
outside of the sport sessions by:

• Building people’s resilience, self-esteem and confidence

• Adapting the sessions to make them more inclusive
• Enabling and supporting mental health recovery
• Tackling stigma and discrimination.
“
UNIT 4: Medication and side effects

”
 UNIT 4: Medication and side effects
Learning objectives

• Knowing some general considerations about medication and side

effects
• Learning about the consequences of quitting medication and how
to encourage the intake
• Learning about the most common side effects
• Learning how side effects can affect physical activity
 UNDERSTANDING MENTAL HEALTH

4. MEDICATION AND SIDE EFFECTS

GENERAL CONSIDERATIONS
Psychiatrist shall find the right treatment for each person.
Medication should not be modified without consulting the professional
Medication sometimes has to be taken for a long time, even when the person feels well
Abandonment of medication is an important cause of relapse.

SIDE EFFECTS
Medication may have side adverse effects.
Some side effects can be controlled by simple measures (reduction of doses, i.e.) or by taking some other
corrective medication.
Side effects cannot be the cause for leaving the treatment .
When unexpected or extrange side effects are observed, a doctor should check them.
 UNDERSTANDING MENTAL HEALTH

4. MEDICATION AND SIDE EFFECTS

CONSEQUENCES OF QUITTING MEDICATION
Higher number of relapses: 80% of those who do not take the medication relapse during the first year.
recuperate. • Worse
Increased severity of evolution of the
relapse: they disease:
enter recoverymore
involuntarily is better and more
frequently andcomplete
present aas soonserious
more as theclinical
pharmacological
picture. treatment is established and maintained.
Longer duration of hospital admissions: they need more days of admission to recuperate
Worse evolution of the disease: recovery is better and more complete as soon as the pharmacological
treatment is established and maintained.

RECOMMENDATIONS TO ENCOURAGE MEDICATION INTAKE

Listen to the reasons the patient gives for not taking the medication: they usually make a lot of sense..
Try to convince him through information and understanding instead of forcing him: Long gives better result..
Achieve a quiet and less intrusive environment as possible for the patient..
Show satisfaction every time you take the medication, relating it to how well you are.
Consult with the psychiatrist as many times as necessary. Coordination between professionals.
 UNDERSTANDING MENTAL HEALTH

4. MEDICATION AND SIDE EFFECTS

MOST COMMON SIDE EFFECTS

Extrapyramidal symptoms (EPS) also known as extrapyramidal side effects (EPSE)

are the most common side effects:

• Dystonia (continuous spasms and muscle contractions)

• Akathisia (motor restlessness)
• Parkinsonism (characteristic symptoms such as rigidity)
• Bradykinesia (slowness of movement)
• Tremor, and tardive dyskinesia (irregular, jerky movements)
• Excessive salivation
 UNDERSTANDING MENTAL HEALTH

4. MEDICATION AND SIDE EFFECTS

LESS SEVERE MORE SEVERE

• Sun sensitive eyes. • Blurry vision
• Dry mouth • Drooling or trouble swallowing
• Stomach discomfort • Diarrhea
• Constipation • Body tremors or spasms
• Dizziness • Muscle stiffness
• Fatigue
• Acne
• Dry skin
• Skin discoloration
• Muscle seizure
• Sexual difficulties or irregular
• Weight gain
menstruation
• Sun burns
• Slow or involuntary movements of body
parts
• Daytime sleepiness
• Difficulty urinating
• Nervousness and motor restlessness
4. MEDICATION AND SIDE EFFECTS
DEPRESSION MEDICATION - SIDE EFFECTS

• There are several drugs used for its treatment that are classified depending on the neurotransmitter on which they act.
The main side effects of medication for depression could be:
• Nausea
• Increased appetite, which causes increased weight
• Sexual dysfunction
• Fatigue
• Drowsiness
• Insomnia
• Dry mouth
• Blurred vision
• Constipation
• Dizziness
• Agitation,
• Anxiety
• Uneasiness
• And even genetic variations.
4. MEDICATION AND SIDE EFFECTS
ANXIETY DISORDERS MEDICATION - SIDE EFFECTS
The most commonly used medications to treat anxiety disorders are anti-anxiety medications – SNRIs (generally
prescribed only for a short period of time) and antidepressants (SSRIs)

The side effects of SSRIs and SNRs are similar

• blurry vision,
• dizziness,
• drowsiness or fatigue,
• dry mouth,
• feeling agitated or restless,
• gaining weight,
• headaches,
• nausea,
• sexual problems or erectile dysfunction,
• sleep problems, an upset stomach
4. MEDICATION AND SIDE EFFECTS
BIPOLAR AFFECTIVE DISORDERS MEDICATION - SIDE EFFECTS

Medications known as “mood stabilizers”, like lithium, are the most commonly prescribed type of medication for
bipolar I disorder. Anticonvulsant medications are also sometimes used and antipsychotics can also help manage
bipolar disorders, especially those accompanied by periods of psychosis during severe depression or mania (APA,
2013)

The side effects of Lithium : The side effects of Anticonvulsant :

• Shaking • Nausea
• Dry mouth • Shaking
• Frequent urination • Gaining weight
• Diarrhea • Dizziness
• Gaining weight • Drowsiness
• Increased thirst • Blurred vision
• Loss appetite, • Dry mouth
• Kidney trouble • Decreased white blood cell or platelet count
• Lowered thyroid activity • Skin rashes
• Fatigue
• Emotional numbness
• Dull feeling.
4. MEDICATION AND SIDE EFFECTS
SCHIZOPHRENIA AND OTHER PSYCHOSES MEDICATION - SIDE EFFECTS

The neuroleptics and antipsychotics are the most common treatments. These drugs block the receptors of dopamine
(substance responsible for transmitting information between cells of the nervous system), in which an excess can produce
symptoms such as hallucinations and delusions. They organize the thought and consequently, they also prevent relapses
acting as a “filter” which avoid the excessive transmission of information from one neuron to another in the brain.

The side effects:

• Gaining weight
• Metabolic syndrome
• Sexual dysfuction
• Extrapyramidal effects: motor restlessness, especially of legs, forcing the person to move them (akathisia), muscle
stiffness, tremor (especially in hands), spasms and the tendency of having the mouth open and with excessive
salivation.
4. MEDICATION AND SIDE EFFECTS
DEMENTIA MEDICATION - SIDE EFFECTS

Brain cell death cannot be reversed, so there is no known cure for degenerative dementia, nevertheless there are four
drugs, called cholinesterase inhibitors that are used to reduce the symptoms, especially for Alzheimer’s disease and can
also help with the behavioral elements of Parkinson's disease

The majority of the people do not have side effects when they take cholinesterase inhibitors, but some do have:
• Nausea, vomiting,
• Loss of appetite
• More frequent bowel movements
• Bruising
• Muscle cramps
• Headaches
• Fatigue
• Insomnia
4. MEDICATION AND SIDE EFFECTS
DEVELOPMENTAL DISORDERS MEDICATION - SIDE EFFECTS
Medication for developmental disorders differs for each type of disorder. These are the most common ones and their side
effects:
• Treatment of ADHD: Psychostimulant drugs are the most effective drug treatment. Methylphenidate and other
amphetamine-like drugs are the psychostimulants most often prescribed. They have similar side effects but most children
have no side effects except perhaps a decreased appetite.
o Sleep disturbances (such as insomnia),
o appetite suppression
o depression, sadness, or anxiety,
o headaches,
o stomachaches,
o elevated heart rate and blood pressure.
4. MEDICATION AND SIDE EFFECTS
DEVELOPMENTAL DISORDERS MEDICATION - SIDE EFFECTS II
• Autism spectrum disorders (ASDs): Drug therapy cannot change the underlying disorder, however some medication is
sometimes effective to treat or reduce some ritualistic behaviors:
o The selective serotonin reuptake inhibitors (SSRIs) are
often effective in reducing ritualistic behaviors of people o Mood stabilizers and psychostimulants may be helpful
with an ASD. Its main side effects are: for people who are inattentive or impulsive or who have
• blurry vision, hyperactivity.
• dizziness, • Shaking
• drowsiness or fatigue, • Dry mouth
• dry mouth, • Frequent urination
• feeling agitated or restless, • Diarrhea
• gaining weight, • Gaining weight
• headaches, • Increased thirst
• nausea, • Loss appetite,
• sexual problems or erectile dysfunction, • Kidney trouble
• sleep problems, an upset stomach • Lowered thyroid activity
• Fatigue
o Antipsychotic drugs, may be used to reduce self-injurious • Emotional numbness
behavior. Side effects: • Dull feeling
• Gaining weight and metabolic syndrome
• Sexual dysfuction
• Extrapyramidal effects
4. MEDICATION AND SIDE EFFECTS
SUBSTANCE ABUSE MEDICATION - SIDE EFFECTS
Medications are used to control drug cravings and relieve severe symptoms of withdrawal; nevertheless, treatment varies
depending on substance and circumstances. Specific treatment depends on the drug being used, but it typically involves
counseling and sometimes involves use of other drugs.
• Cocaine abuse: The principles of cocaine rehabilitation are similar to treatment of alcoholism or sedatives they use
antianxiety medication and/or antidepressant:
o Antianxiety medication. Side effects: o Antidepressant side effects
• blurry vision, • Nausea
• dizziness, • Increased appetite, which causes increased weight
• drowsiness or fatigue, • Sexual dysfunction
• dry mouth, • Fatigue
• feeling agitated or restless, • Drowsiness
• gaining weight, • Insomnia
• headaches, • Dry mouth
• nausea, • Blurred vision
• sexual problems or erectile dysfunction, • Constipation
• sleep problems, an upset stomach. • Dizziness
• Agitation,
• Anxiety
• Uneasiness
• And even genetic variations.
4. MEDICATION AND SIDE EFFECTS
SUBSTANCE ABUSE MEDICATION - SIDE EFFECTS
• Opioids abuse: The medicines used to treat opioid abuse and addictions are methadone, buprenorphine, and
naltrexone:
o Side effects of methadone can be: • back pain.
• headache,
• weight gain, o Naltrexone side effects may include:
• stomach pain, • nausea,
• dry mouth, • vomiting,
• sore tongue, • stomach pain or cramping,
• flushing, • diarrhoea,
• difficulty urinating, • constipation,
• mood changes, • loss of appetite,
• vision problems, • headache,
• difficulty falling asleep or staying asleep. • dizziness,
• anxiety,
o Side effects of buprenorphine may be: • nervousness,
• headache, • irritability,
• stomach pain, • difficulty falling or staying asleep,
• constipation, • increased or decreased energy,
• difficulty falling asleep or staying asleep, • drowsiness, muscle or joint pain,
• mouth numbness or redness, • rash
• tongue pain,
• blurred vision,
4. MEDICATION AND SIDE EFFECTS
SUBSTANCE ABUSE MEDICATION - SIDE EFFECTS
• Alcohol abuse: A number of medications are recommended to treat alcohol misuse. These include:

o Acamprosate: is used to help prevent a relapse in o Disulfiram: works by deterring from drinking by
people who have successfully achieved abstinence causing unpleasant physical reactions:
from alcohol. Some side effects of acamprosate • nausea,
can be: • chest pain,
• diarrhea, • vomiting,
• gas, • Dizziness
• upset stomach,
• loss of appetite, o Nalmefene: can be used to prevent a relapse or
• dry mouth, limit the amount of alcohol someone drinks. It
• dizziness, works by blocking opioid receptors in the body,
• itching, which reduces cravings for alcohol.
• weakness, Side effects may include:
• nausea, • nausea,
• anxiety, • vomiting,
• difficulty falling asleep or staying asleep, • tachycardia and hypertension.
• Sweating

o Naltrexone: also use for opioids abuse (side effects

already described)
“
UNIT 5: Patterns of Professional Interaction

”
UNIT 5: PATTERNS OF PROFESSIONAL INTERACTION
Learning objectives

• Identify the general principles of interaction with people with MHD

• Understand and practice using effective communication skills
• Identify the signs of crises and risk factors
• Learn patterns of intervention when crises occur and in specific situations
• Learn about the most common errors of professionals’ reactions and the best
attitude to take
5. INTERVENTION- GENERAL PRINCIPLES

Use effective communication skills

Promote respect and dignity

5. INTERVENTION- COMMUNICATION PATTERNS

NON VERBAL ASPECTS

Look directly at the face when we talk with another person.

Keep an appropriate tone or volume of voice.

Maintain the appropriate physical distance.

Accompany the message we convey with our words with gestures and a proper body posture.

Be careful about the moment and place we choose to talk about important issues (avoid public spaces with people,
moments when you will not have enough time...).
5. INTERVENTION– COMMUNICATION PATTERNS
VERBAL ASPECTS (I)
First give the positive information, whatever has been done well.

Follow with the negative information with a positive approach.

Be specific: comment about the behaviour, not the person.

Avoid expressions such as “never”, “always” ...

Make questions, suggestions or requests, do not accuse or impose (make people get defensive and are useless to find
solutions).

Raise concerns when they arise, not accumulate them.

Focus on the present and not bring problems from the past.

Express your satisfaction for things he/she has done and that do not dislike. A positive note has much more influence on the
influence in the future conduct than criticism
5. INTERVENTION– COMMUNICATION PATTERNS

VERBAL ASPECTS (II)

Reinforce minimum attempts at dialogue initiative. Managing minor but enjoyable issues (sports, TV, recent events)

Accepting silences and lack of social initiative as part of the person’s problem.

Graduate the level of demand.

Not hyper stimulate. Do not make many demands and simultaneous stimulation.

Talk in an open and honest way about the issues raised.

Be tolerant (mistakes, passive attitudes, limitations…).

Appreciate attempts to progress, encourage her/him to try again.

Talk about different issues than mental disorder, do not allow it to monopolize her/his life.
5. INTERVENTION– COMMUNICATION PATTERNS

ACTIVE LISTENING

Listening without being distracted

Listening and paying attention:

• Verbal messages (what is being said).
• Non-verbal messages (what is being said with body language, pauses, facial expressions etc.).

Allowing time:
• Don’t rush.
• Allow for silences.
5. INTERVENTION– COMMUNICATION PATTERNS

EMPATHY
Recognizes the feelings of another person and communicates understanding in verbal or non-verbal ways

Shows respect.

Provides emotional support to person

Builds rapport, encourages dialogue, builds relationship with the person

CRISES
Mental disorders can evolve in the form of outbreaks: Periods of crisis - periods of normalcy or residual symptoms
Crises do not usually appear abruptly but from INESPECTIVE SYMPTOMS (Prodromes): they are alarm signals that indicate
that there is some problem

Insomnia or inversion day/night rythm

ALARM SIGNS Social rejection, isolation, fear and distrust
Absences in work or study center, avoiding going out.
Incapacity to concentrate
Alcohol and/or drugs abuse
Eating in a messy way
Deterioration of personal hygiene, strange dressing
Irritability
Hyper sensibility to stimulus (noises, light…)
Exaggerated worrying about one concrete question
Estrange behaviours
Abstract, non logic conversation
 UNDERSTANDING MENTAL HEALTH

3. CRISES: FACTORS

QUITING
There are some risky situations associated to crises
MEDICATION It is not possible to determine with certainty the
causes.
We can try to avoid the situations associated to
crises.
STRESSING
RISK DRUGS If we detect any risky situation we should inform
INTAKE
SITUATIONS
FACTORS the family, the professional of reference
(psychitrist, psicologist, nurse…), in order to

UNSTABLE prevent the crises.

ENVIRONMENT
5. CRISIS – WHAT TO DO? GENERAL PATTERNS

REDUCE DANGERS Prevent physical damages of the person and of the people around

Take measures to reduce destructive possibilities (remove objects).

PROVIDE SUPPORT Make the person feels he/she is heard, accepted, understood and supported
AND CONTAINMENT
Try to accompany in reducing the intensity of emotions.

Respond in a calm and controlled way..

Use effective communication skills

Promote respect and dignity

5. CRISIS – INTERVENTION ON SPECIFIC DIAGNOSIS

Keep physical distance

NERVOUS,
AGITATED, Remove dangerous objects.

UPSET Express our desire to help.

Move and talk calmly.

Take into account previous history episodes.

Do not contradict her/him

Do not react to your insults or threats

5. CRISIS – INTERVENTION ON SPECIFIC SITUATIONS

Adapt the relationship to his/her demand.

DEPRESSED
Don't be too effusive at first

Listen, do not force him/her to talk.

Avoid focusing conversations on your mood (introduce other general topics)..

Recognize her/his efforts and attempts to do things

Propose activities without forcing you (motivating, easy and with short-term results)

Do not hyperstimulate with many tasks

5. CRISIS – INTERVENTION ON SPECIFIC SITUATIONS

Be kind and open to dialogue but firm.

MANIAC
Do not try to dominate, neither to argue with him/her

Praise the right behaviors

Indicate inappropriate behavior but not criticize excessively.

Try to reduce the level of activity

5. CRISIS – INTERVENTION ON SPECIFIC SITUATIONS

Do not speak out for or against your delusional ideas. Take them as possible (not as
DELIRIOUS true).

Our interest must be directed to know your thoughts (not to censor them)

Do not try to dissuade or reason delirium

Show willingness, and accept his/her anxiety and worry. Make her/him perceive your
interest in helping her/him
5. CRISIS – INTERVENTION ON SPECIFIC SITUATIONS

Early detection: prodromes

PSYCHOPATHOLOGICAL
DECOMPENSATIONS Coordination with reference mental health services.

Identify which person is the one from whom best accepts the proposals.

Facilitate follow-ups with mental health services (consultations, taking medication ...)

Give support in the management of economic resources, even temporarily.

Review the programming of activities: distract the attention of the symptomatology

but without overloading.
Give emmotional support

Increase supervision.

Make norms and requirements more flexible.

5. CRISIS – INTERVENTION ON SPECIFIC SITUATIONS
Early detection: prodromes
AGRESSIONS
- Breaking limits: progressive: verbal-objects-people (low-high intensity):
- Empathize: active listening and partial agreement.
- Try to reassure him: decrease the tone of voice..

Protect users and professionals: taking them to another place if necessary.

Assess if it is necessary to manage an urgent assessment with the reference mental
health professional
Use behavior modification techniques..
Be very clear that an aggression is serious, and that you have to assess the situation
and the alternative solutions to implement (teach more appropriate ways of
communicating, negative consequences ...).

Consequences from the part of professionals: verbal, tasks, apologize, buy what has
been broken, expulsion for a period of time from the resource ...

If necessary call emergency service phone

5. CRISIS – INTERVENTION ON SPECIFIC SITUATIONS
If it were due to psychopathological decompensation: same measures as previous situation
SELF (agressions)
AGRESSIONS If the cause is depressed mood:
- They usually warn of suicide, sometimes saying goodbye to the closest people.
- When there have been previous attempts: it increases the probability that she/he will try again.
- The more planned the more dangerous act, but sometimes it is carried out equally. - Discussing
her/his ideas with a professional can help her/him to find other solutions.

Guidelines for suicide risk:

- It should be accompanied as much as possible, or if the risk is high, do not leave him/her alone.
- Make him/her see that we can find solutions and that there may be other possible futures.
- Support him emotionally.
- Don't blame him for his suicidal ideas.
- If it is very serious: hospital admission
Professional secret: the professional is not obliged to keep it when there is a vital risk to the user or to
third parties
Discuss the situation with your team
5. CRISIS – INTERVENTION ON SPECIFIC SITUATIONS

It is an indicator of medium-term risk if it is not intervened.

REFUSAL TO FOLLOW
THE RULES, TAKE PART
IN ACTIVITIES Recognize and assume limits: behavior modification:

Strengthen the minimum progress of the person in the involvement with the
different tasks..

Involve the user from the beginning in his Intervention Plan (Responsibility).

Explain to her/him why the different interventions are made..

Start with the minimums and then gradually increase..

5. CRISIS – INTERVENTION ON SPECIFIC SITUATIONS

It carries a risk of crisis or relapse in the disease.

DRUGS/ ALCOHOL
INTAKE
It can be a stimulus for other users with a history of consumption to restart their
behavior, or to start consumption for others.

Performances: Limit interventions at the time it is under the effects of the substance.

Promote the motivation of the person to reduce or abandon consumption, trying to

become aware of the problem.).

Provide internal and external control strategies (go to certain places and interact with
people who facilitate consumption, money management ...).

Do not punish him if he tells us: it is positive because it shows confidence in us

Reinforce by commenting but not approve of consumer behavior.

5. CRISIS – INTERVENTION ON SPECIFIC SITUATIONS

Risk of relapse if maintained over time.

REFUSAL TO
MEDICATION If it is for a timely shot: respond to an emotional aspect: Remember the importance
of following the pattern to be well.

Let some time pass and have another person offer the medication again.

He has to understand that the interest is for him not for the professional / family
member.
If the refusal to take the medication is continued: Inform the reference mental health
professional
Raise awareness of the need to take medication.

Be consistent in the indications

Do not give her/him medication in a hidden way or without her/him consent

5. CRISES INTERVENTION:COMMON ERRORS OF PROFESSIONALS

SUBMISSION
TO DEMANDS

LACK OF DO NOT PAY

KNOWLEDGE ENOUGH
PROTECCIONISM OR EXPERIENCE ATTENTION TO
ON MENTAL THE PERSON’S
HEALTH SYMPTOMS

IMPOSING OR
AUTHORITARIAN
ATTITUD
PROFESSIONAL ATTITUDE TOWARDS CRISES AND MH IN GENERAL

• Leave the person free, while still supporting him: We reinforce their independence at the same
time he/she feels supported.
• Tolerate his/her routine and his/her time to perform them: He/she needs his/her routines to feel
secure and control over his/her life.
• Much of his/her attitude and behavior is due to the symptoms of his/her illness and not to
conscious and intentional causes.
• Do not blame yourself if progress is not achieved. Try not to get frustrated. See what intervention is
done and where you can intervene from another point of view. Consult with the work team.
• Control your own impulses: Anxiety is transmitted around, our attitude and behavior towards the
user is a model. If we want them to be relaxed we must show ourselves relaxed.
“
UNIT 6: Self-care

”
UNIT 5: SELF CARE
Learning objectives

• Understanding than working with people with MHD could be stressful and
sometimes overwhelmed
• Understand the influence of biopsycosocial interventions by the own
experience
• Learning and practicing different techniques of self-care.
6. SELF-CARE

• Working in with people with MHD can be highly rewarding and gratifying: by regularly
making a significant positive impact in the lives of those with whom you work.

• But working in with people with MHD can also be emotionally demanding and
challenging; could be a stressful job and at times everyone can feel overwhelmed and
unable to cope.

• If we do not attend to our own functioning and wellness, we can be at risk of

developing problems with our professional competence

• The best way to learn about the influence of psychosocial interventions is to try them
on yourself as part of your own self-care.
6. SELF-CARE

Distress
• Despite its many rewards, working with people with MHD may cause
us to experience feelings of distress.
• Distress is described as the subjective emotional reaction we each
experience in response to the many stressors, challenges, and
demands in our lives (Barnett, Johnston, & Hillard, 2006).
• Distress is a normal part of life and we each experience it, whether in
response to working with difficult clients, coping with insurance
paperwork requirements, caring for an ill loved one, experiencing
financial concerns, and myriad other acute and chronic challenges
and stressors in our lives. While distress is a normal part of life,
distress left unchecked over time can lead to burnout.
6. SELF-CARE

Burnout
• Burnout, a term first coined by Freudenberger (1975), has three components:

o Emotional exhaustion,
o Depersonalization (loss of ones empathy, caring, and compassion), and
o A decreased sense of accomplishment.

• Each of these components fall along a continuum and one may experience varying amounts of each at
different times during one’s career.
• While there is not a specific agreed upon point where one is classified as “burned out,” it is vital that
we each are self-aware and monitor ourselves for these signs of burnout. While of course, prevention
is always best, when signs of burnout begin to develop it is hoped that we each will take a step back,
reassess our current situation, and make the needed changes in our lives to help us get back on track.
6. SELF-CARE

SELF CARE
Practicing self-care will help you:

• Identify and manage the general challenges that all hard-working professionals face, such as the potential for
stress and burnout or interpersonal difficulties.

• Be aware of your own personal vulnerabilities, such as the potential for retraumatization (if you have a trauma
history), vicarious or secondary traumatization (if you work with individuals who report their own traumatic
experiences), and compassion fatigue (which you can develop from a combination of burnout and vicarious
traumatization).

• Achieve more balance in your life, by maintaining and enhancing the attention you pay to the different domains of
your life in a way that makes sense to you.
6. SELF-CARE

SELF CARE
• Self-care is not simply about limiting or addressing professional stressors. It is
also about enhancing your overall well-being. There are common aims to
almost all self-care efforts:
• Taking care of physical and psychological health

• Managing and reducing stress

• Honoring emotional and spiritual needs
• Fostering and sustaining relationships
• Achieving an equilibrium across one's personal, school, and work lives
• Each of us may differ in the domains we emphasize and the balance we seek
among them.
6. SELF-CARE
• Self-care can involve so many different activities, it may include for example:
o getting adequate sleep each night,
o maintaining a healthy diet,
o engaging in regular exercise,
o spending time with family and friends,
o participating in various forms of relaxation to include meditation or yoga,
o attending to your spiritual and/or religious side,
o playing with your pet,
o engaging in artistic expression,
o doing pleasure reading, and so much more.

• It also involves:
Setting limits, saying ‘no’, maintaining healthy boundaries, and knowing your limits.

• Self-care also involves maintaining a healthy balance between various professional activities as well as between the
professional and personal parts of our life.
6. SELF-CARE ASSESMENT
Kramen-Kahn (2002) suggests the following questions to determine ones current level of personal self-care.
• Do you….
1. appear competent and professional?
2. appear warm, caring, and accepting?
3. regularly seek case consultation with another professional while protecting confidentiality.
4. at the end of a stressful day, frequently utilize self-talk to put aside thoughts of clients?
5. maintain a balance between work, family and play?
6. nurture a strong support network of family and friends?
7. use healthy leisure activities as a way of helping yourself relax from work? If work is your whole world, watch out! You do not have a
balanced life.
8. often feel renewed and energized by working with clients?
9. develop new interests in your professional work?
10. perceive clients’ problems as interesting and look forward to working with clients?
11. maintain objectivity regarding clients’ problems?
12. maintain good boundaries with clients, allowing them to take full responsibility for their actions while providing support for change?
13. maintain a sense of humor? You can laugh with your clients.
14. act in accordance with legal and ethical standards?
6. SELF-CARE ASSESMENT
ASSESS YOUR WARNING SIGNS
 I have disturbed sleep, eating, or concentration.
 I isolate myself from family, friends, and colleagues.
 I fail to take regularly scheduled breaks.
 I enjoy my work less than in the past.
 I find myself bored, disinterested, or easily irritated by clients.
 I have experienced recent life stressors such as illness, personal loss, relationship difficulties, financial problems, or legal
trouble.
 I feel emotionally exhausted or drained after meeting with certain clients.
 I find myself thinking of being elsewhere when working with clients.
 I find my work less rewarding and gratifying than in the past.
 I am feeling depressed, anxious, or agitated frequently.
 I am enjoying life less than in the past.
 I find myself experiencing repeated headaches and other physical complaints.

 I sit staring into space for hours and can’t concentrate on my work .
6. SELF-CARE ASSESMENT

CHECKLIST FOR POSITIVE COPING BEHAVIORS

 I take regularly scheduled breaks.

 I take vacations periodically and don’t bring work with me.
 I have friends, hobbies, and interests unrelated to work.
 I exercise regularly, have a healthy diet, and maintain and appropriate weight.
 I limit my work hours and caseload.
 I regularly participate in relaxing activities (e.g., meditation, yoga, reading, music).
 I regularly participate in activities that I enjoy and look forward to.
6. SELF-CARE

SELF CARE STRATEGIES

 Make adequate time for yourself. Schedule breaks throughout the day..
 Do things you enjoy. Engage in hobbies.
 Take care of yourself physically and spiritually.
 Take care of the relationships in your life.
 Say NO!
 Don’t isolate yourself.
 Keep in mind that self-care is a good thing and make time for self-care!
 Don’t try to be perfect, to have it all, or to do it all. Know your limits and be
realistic.
6. SELF-CARE TECHNIQUES

This is a technique for

reducing psychosocial
stressors

It cannot solve all

problems instantly,
especially if the
psychosocial stressors are
ongoing and/or
complicated. It can help to
alleviate and reduce some
of the stress that a person
is feeling

Source: WHO (2017) ECP module (https://www.who.int/mental_health/mhgap/trainingmanuals_tohp_ecp/en/

6. SELF-CARE TECHNIQUES

Source: WHO (2017) ECP module (https://www.who.int/mental_health/mhgap/trainingmanuals_tohp_ecp/en/

 Thanks for your attention!

María Carracedo
[email protected]
Tf: 0034 983 399 633 Ext. 128
COORDINATOR PARTNERS

COOSS Marche Fundación Intras Fokus ČR Praha

Italy Spain Czech Republic

KSDEO Edra
Greece

National and Capodistrian Panellinios ENALMH

University of Athens Athletics Club Belgium
Greece Greece
 www.project-website.com
[email protected] | facebook.com/ProjectName
 MODULE 2
Physical Activity/Exercise and
Mental Health

This project has been funded with support from the European Commission. This publication
[communication] reflects only the views of the author, and the Commission cannot be held
responsible for any use which may be made of the information contained herein.
“
COURSE CONTENTS & TOPICS

”
 UNDERSTANDING MENTAL HEALTH

CONTENTS
UNIT 1: Physical Αctivity/Exercise and Mental Health.

UNIT 2: Physical Activity/Exercise and Depression: Theory and Practice.

UNIT 3: Physical Activity/Exercise and Anxiety Disorders: Theory and Practice.

UNIT 4: Physical Activity/Exercise, Schizophrenia and other Psychoses: Theory and Practice.

UNIT 5: Physical Activity/Exercise and Cognitive Functioning (Dementia): Theory and

Practice.

UNIT 6: Physical Activity/Exercise and Substances/Eating Disorders: Theory and Practice.

“
UNIT 1: Physical Activity/Exercise and Mental
Health

”
UNIT 1: Physical Activity/Exercise and Mental Health
Learning objectives

• Know the facts about Physical Inactivity.

• Know the consequences of Physical Inactivity to Health.

• Know the benefits of PA/Exercise to Health.

• Know the benefits of PA/Exercise to Mental Health.

• Know the systems involved in linking PA/Exercise with well-being and MH.

• Know the types of PA/Exercise.

• Know how much PA/Exercise is best for Mental Health.

PA/Exercise and Health & Mental Health

Kostas Karteroliotis & Maria Koskolou

School of Physical Education & Sport Science
National and Kapodistrian University of Athens
 Presentation Outline
• Facts on Physical Inactivity
• Consequences of Physical Inactivity to Health
• Types of PA/Exercise
• Benefits of PA/Exercise on Health
• PA/Exercise and Mental Health
• Physical Exercise, Medication or Combination?
• How Much PA/Exercise is Best for Mental Health?
• PA/Exercise Recommendations for Mental Health
Pandemic of Physical Inactivity

July 2012
Pandemic of Physical Inactivity
Physical Inactivity: Europe
 Pandemic of Physical Inactivity
• 40 – 60 % of the EU adult population follows a sedentary lifestyle
• Approximately 25 % of the population is completely sedentary

https://ec.europa.eu/commfrontoffice/publicopinion/archives/ebs/ebs_183_6_en.pdf
 Common Reasons Not To Exercise
I don’t have the time
I don’t like to sweat
I’ll look silly
It hurts
I don’t know what to do
It’s not important
Consequences of Physical Inactivity to Health
Consequences of Physical Inactivity to Health

Katzmarzyk & Janssen. (2004) Can J Appl Physiol, 29, 90-115

 PA/Exercise and Health
Health Outcomes

Cardio- Metabolic Musculo- Cancer Functional Mental

respiratory Health skeletal Health Health
Health Health
(Diabetes, (Βowel, (Quality of (Anxiety,
(Heart Obesity) (Osteopo- Breast) Life, Depression,
Diseases, rosis) Functional Self- Concept)
Stroke) Indepen-
dence, Fall
Prevention)

Inactivity Increased mortality risk 3.2 million

(20-30%) deaths each year
(Physical Activity Guidelines Advisory Committee, 2008)
Health and Economic effects of PA/Exercise
 Physical Activity, Exercise, Physical Fitness

• Physical activity (PA)

Bodily movement produced by skeletal muscles that results in an
expenditure of energy.
• Physical fitness
A measure of a person's ability to perform physical activities that
require endurance, strength, or flexibility.
• Exercise
A subcategory of PA that is planned, structured, repetitive, and
purposeful in the sense that the improvement or maintenance of one or
more components of physical fitness is the objective.
(WHO, 2003)
Type of PA/Exercises (WHO)
 WHO: Guidelines

Objectives:
To achieve a minimum of 30 min. of Moderate-Intensity PA 5
days per week or at least 20 min. of Vigorous-Intensity PA 3
days per week.
30 min. a day  prevention of chronic diseases
60 min. a day  weight management

19
 Benefits of PA/Exercise

1h 40%
Lower
2h Risk
4h
7h

(US Department of Health and Human Services, 2008, https://stacks.cdc.gov/view/cdc/23099)

Walking & Cardiovascular Diseases (CVDs)

Walking 30 mins daily

provides best health
benefit (heart disease
prevention).

Walking 60 mins daily

can cause reversal of
heart disease.

https://www.ph.ucla.edu.cehd
Fitness & Mortality

• Low fitness is bad for

health
 Physical Activity and Cardiorespiratory Fitness as Major Markers of Cardiovascular
Risk: Their Independent and Interwoven Importance to Health Status

Fig 1 All roads go through physical activity and cardiorespiratory fitness status in determining cardiovascular
disease risk. Legend: PA, physical activity; CRF, cardiorespiratory fitness.
Myers , P., McAuley , C.J. Lavie , J., Despres , R.A, & Kokkinos, P. (2015). Progress in Cardiovascular Diseases, 57, (4), 306 – 314.
 Benefits of PA/Exercise
 Reduce the risk of the three leading causes of death:
 Heart disease, stroke, and cancer
 Control or prevent development of various other diseases
 Enhance cognition
 Manage depression
 Manage anxiety and stress
 Improve self-concept
 Improve sleeping habits
 Increase energy Levels
 Control body weight and help appearance
 Exercise & Cardiovascular Diseases (CVDs)

Physical inactivity is a serious risk factor for CVD.

High blood pressure (above 140/90) is one the main
causes of heart attack and stroke.
Exercise prevents atherosclerosis (clogged arteries).
Exercise reduces cholesterol levels (clog the arteries -
lead to heart attack and stroke).
(WHO, 2002)
Each year cardiovascular disease (CVD) causes 3.9 million deaths in Europe and
over 1.8 million deaths in the European Union (EU).
CVD accounts for 45% of all deaths in Europe and 37% of all deaths in the EU.
CVD is the main cause of death in men in all but 12 countries of Europe and is the
main cause of death in women in all but two countries.
Death rates from both ischaemic heart disease (IHD) and stroke are generally
higher in Central and Eastern Europe than in Northern, Southern and Western
Europe.
CVD mortality is now falling in most European countries, including Central and
Eastern European countries which saw considerable increases until the beginning
of the 21st century.
In 2015, there were just under 11.3 million new cases of CVD in Europe and 6.1
million new cases of CVD in the EU.
(European Cardiovascular Disease Statistics, 2017)
 PA/Exercise and Cancer

 PA/Exercise helps to prevent obesity, a major risk factor for

several types of cancer.

PA/Exercise activates antioxidant enzymes that protect cells

from free radical damage.

PA/Exercise enhances immune function.

(WHO, 2002)
 PA/Exercise and Diabetes
 Increase insulin sensitivity

 Control blood glucose

 Control Weight/Lower body fat

 Reduce risk of cardiovascular disease

(WHO, 2002)
PA/Exercise and Immune Function
 PA/Exercise and Depression/Anxiety
PA/Exercise can help prevent depression/Anxiety
 PA/Exercise is as effective as antidepressant medication for treatment of
depression.
PA/Exercise improves sleep habits
 PA/Exercise controls weight
 PA/Exercise enhances self-concept
(WHO, 2002)
 Exercise and Cognition
• Short-term benefits:
Boost alertness (possibly by triggering the release of epinephrine and nor
epinephrine)
Improves memory
Improves intellectual function
Improves creativity
• Long-term benefits:
Exercise slows and even reverses age-related decline in mental function
and loss of short-term memory
(A report of Surgeon general, Physical Activity and Health, 1996)
 PA/Exercise and Osteoporosis
Osteoporosis:
Progressive loss of bone mineral density
Occurs commonly in old age
Occurs at an earlier age and more
frequently in women than men

PA/Exercise:
Increases peak bone mass
Slows decline in bone mass
 PA/Exercise and Quality of Life
Increase self-esteem & self-concept
Increase feelings of enjoyment
Increase of mood states
Decrease feelings of depression
Decrease feelings of anxiety
 PA/Exercise and Social Benefits
Enhance social integration
Format new friendships
Improve social networks
Improve positive images
Reduced health and social care costs
 Physical Activity (PA) - Mental Health (MH)
 Does PΑ contribute and how?

 Can we talk about treatment or prevention without a healthy and

functional body?

 What is the relationship between PΑ and MΗ?

 PA and Health
Health Outcomes

Cardio- Metabolic Musculo- Cancer Functional Mental

respiratory Health skeletal Health Health
Health Health
(Diabetes, (Βowel, (Quality of (Anxiety,
(Heart Obesity) (Osteopo- Breast) Life, Depression,
Diseases, rosis) Functional Self- Concept)
Stroke) Indepen-
dence, Fall
Prevention)

Increased mortality risk 3.2 million deaths

Inactivity
(20-30%) each year

(Physical Activity Guidelines Advisory Committee,

(Physical Activity
2008)Guidelines Advisory Committee, 2008)
 1h 40%
Lower
2h Risk
4h
7h

(US Department of Health and Human Services, 2008, https://stacks.cdc.gov/view/cdc/23099)

 Some of the complex systems involved in linking PA with well-
being and MH

 It can be difficult to
determine the precise
“active ingredient” that
confers benefits

 PA is often associated with

other potentially
beneficial elements (social
interaction, fresh air,
exposure to green spaces
etc)

PA sets in motion a sustainable cycle of enhanced psychological resources (Glow, A., & Edmunds, S., 2014)
 Domain-Specific PA and Mental Health
• A meta-analysis of 98 studies has shown that the relationship between PA and
MH varies among different PA domains.
• Although lifestyle PA outside leisure time may improve people’s physical health,
such behaviors may not benefit MH.
• A number of psychosocial mechanisms explain the effect of PA on MH
PA during leisure time

Enhances self-efficacy and exposes individuals to challenges

Social interaction
that offer opportunities to develop confidence and a sense of
mastery

Autonomous motivation Distraction from stressful life events

(Lee White et al., 2017)

(Lee White et al., 2017)
 Anxiety Disorders - Depression and PA
The most common mental disorders
Mood disorders are a common problem and their symptoms are a serious public
health issue
The first attempts to understand the connection between PA and MH:

 An epidemiologuy study (Farmer et al.,

1988) involving 1,900 participants aged 25-
77 years showed: Physical inactivity may be
a risk factor for
 A survey of 1536 people over 15 years old
(Meyer, 1992) revealed that :
depressive symptoms.
 Treatment

Pharmacotherapy
Primary Health Care
Psychological interventions

The role of exercise as an adjunct to conventional therapies is gaining momentum.

A large number of recent studies demonstrate exercise to be effective in reducing

depression symptoms.

Indeed, a number of previous studies have found exercise to be as effective as

medication or psychological interventions.
(Stanton, R., & Reaburn, P., 2014)
(Stanton, R., & Reaburn, P., 2014)
 Results of studies
A study in the elderly (60-75 years old) showed that participation in
aerobics programs (3 times per week for 6 months):

Depression
control
Reduces levels
exper/tal
of depression

(Antunesetetal.,
(Antunes al., 2005)
2005)
 Results of studies
Anxiety

Reduces levels of anxiety

Quality of life

Improves quality of life

(Antunes et al., 2005)

 A meta-analyses of experimental studies
Positive effects of exercise, in healthy people and in
clinical populations regardless of gender and age
The benefits are significant, especially in subjects with
an elevated level of anxiety and depression
•More affective results

Rhythmic, aerobic exercises, using large muscle groups

(jogging, swimming, cycling, walking) of moderate
and low intensity.
Duration: 15-30 min.
Frequency: a minimum of 3 times/week in programs of
10 weeks (Guszkowska, 2004)
 Physical exercise, medication or combination?
A study of 3 experimental groups with major depression disorder (exercise,
medication and combined exercise and medication) after 4 months showed similar
rates of recession

65,5% 68,8%
60,4 %

No longer met DSM-

IV criteria for MDD

Exercise Medication Combination

(Blumenthal, et al., 1999 ) (Blumenthal, et al., 1999)

 Physical exercise, Medication or Combination?

6 months after completion of the study, the participants in the exercise group were more likely to recover
partially or totally and less likely to relapse
(((Babyak et al., 2000)
 How Much Exercise is Best for
Mental Health?
 There is a minimum level of exercise for physical health-related benefits
 Increasing levels of exercise lead to additional benefits
 Curvilinear association between physical activity and mental health
 Excessive exercise can be harmful to both physical and mental health

Optimal range: 2.5 to 7.5

hours/week

(U.S.
(U.S.
Department
Department
of Health
of Health
andand
Human
Human
Services,
Services,
2008;
2008;
Kim Kim
et al.,
et2012)
al., 2012)
 Happy Medium

(Ballantyne S., 2013) (Ballantyne S., 2013)

 Mens Sana in Corpore Sano…
In conclusion:
• Τhe number of patients suffering from mental
illness constantly increases

• Τhere is an urgent need for applying alternative,

non-pharmaceutical interventions

• PA can be utilized as a means of preventing and

enhancing the treatment of mental illness

• PA enhances MH and reduces the risk of mental

disorders

• It is a treatment without “side effects” and

financial costs
• It does not stigmatize
 Mens Sana in Corpore Sano…
The relationship between PA and MH varies according to the different combinations of
the exercise characteristics
Excessive exercise can lead to opposite results.
 .

Although the number of studies (for the effectiveness of PA) is limited compared to the
number of studies for the drug efficacy in mental illness, it has been shown that:

• The understanding of the specific factors that affect the above relationship facilitates:

The development of specially The improvement of the PA effectiveness

designed (customized) PA programs as an alternative, non-costly prevention
and guides and treatment approach
 PA/Exercise Recommendations for Mental Health
• Aerobic, rhythmic exercise of moderate intensity
• Resistance exercise
• Team and individual sports
• Expressive activity such as dance
• Daily movement – walking or cycling to work
• Green gyms
• Adventurous activity
• Health walks, nature walking

Currently no generic guidelines for exercise for mental health

“
UNIT 2: Physical Activity/Exercise and
Depression: Theory and Practice

”
 UNIT 2: Physical Activity/Exercise and Depression:
Theory and Practice
Learning objectives
• Know the facts about Depression (assessment and treatment of depression).
• Know of the relationship between PA/Exercise and Depression.
• Know the evidence base related to PA/Exercise and the prevalence of Depression.
• Know the research related to PA/Exercise and the incidence of Depression.
• Know the evidence base for the efficacy of PA/Exercise as a treatment for Depression.
• Know the evidence base for the efficacy of PA/Exercise for symptom management of Depression.
• Know the evidence base for the antidepressant effect of PA/Exercise: Potential mechanisms.
• Know the difference between PA, Physical Fitness, and Exercise.
• Know the types of exercise appropriate for the prevention/treatment of Depression.
• Know the basic principles of training appropriate for the prevention/treatment of Depression.
Unit 2. Physical Activity/Exercise and Depression:
Theory and Practice

Kostas Karteroliotis & Maria Koskolou

School of Physical Education & Sport Science
National and Kapodistrian University of Athens
 Presentation Outline
• Facts on Depression
• Physical Activity and the Prevalence of Depression
• Physical Activity and the Incidence of Depression
• Exercise and Treatment for Depression
• Exercise for Symptom Management
• The Antidepressant Effect of Exercise: Potential
Mechanisms
• Conclusions
 Facts on Depression
• Depression is one of the most common form of mental
disorder and its prevalence is increasing.
• Depression is a common illness worldwide, with more
than 300 million people affected.
• Lifetime prevalence of about 14% in Europe.
• Lifetime prevalence of about 19% in the United States.
• Women are affected twice as often as men.
(Andrade et al., 2003; WHO, 2018)
 Psychological Symptoms of Depression
• Continuous low mood or sadness
• Feelings of hopelessness and helplessness
• Low self-esteem
• Tearfulness
• Feelings of guilt
• Feeling irritable and intolerant of others
• Lack of motivation and little interest in things
• Difficulty making decisions
• Lack of enjoyment
• Suicidal thoughts or thoughts of harming oneself
• Feeling anxious or worried
Dailey, 2014
 Physiological Symptoms of Depression
• Slowed movement or speech
• Change in appetite or weight (usually decreased, but sometimes increased)
• Constipation
• Unexplained aches and pains
• Lack of energy
• Lack of interest in sexual intercourse
• Changes in the menstrual cycle
• Disturbed sleep patterns (e.g., problems going to sleep, waking in the early
hours of the morning)
Dailey, 2014
 Assessment of Depression

Beck Depression Inventory Scale

Zung Self-Rating Depression Scale

Hamilton Rating Scale for Depression

 Strategies for Treating Depression

• Pharmacological antidepressants
• Psychotherapies
– Noncompliance is frequent
– Can be expensive and have unwanted side-effects

(National Collaborating Center for Mental Health (UK), 2010)

 Strategies for Treating Depression
• Antidepressant medication and/or psychotherapy do not work for all
people.
• In a study that examined the effects of pharmacological
antidepressants, psychotherapies, or the combination of both,
revealed that the response rate following the first pharmacological
attempt was less than 50%
• This suggests that about half of patients did not experience significant
symptom improvements after the first treatment. Furthermore, the
response rate dropped following each subsequent strategy adopted
(switching to or combining with a second medication) (Sinyor et al.,
2010).
Meyer & Schuch, 2018
 Depression, Cardiovascular and Metabolic Outcomes
• Depression is also associated with poor cardiovascular and
metabolic outcomes.
• 30% of people with depression also have metabolic syndrome,
which is 54% greater than people without depression
(Vancampfort et al., 2014; Vancampfort et al., 2016).
• The rate of diabetes type II in people with depression is about
8%.
• This is a roughly 50% higher rate than people without
depression(Vancampfort et al., 2014, 2016).
 Physical Activity/Exercise and Depression
• Substantial evidence also supports the notion
that PA and depression are closely related.
• Cross-sectional studies revealed a clear
relationship between greater amounts of PA and
reduced current depressive symptoms in people
without a diagnosis of depression.
Exercise is Linked to Better Mental Health
 Physical Activity and Depression
• Farmer et al. (1988) found that greater depressive
symptoms were associated with little or no self-
reported PA across gender and race.
• Another study with 5877 adults aged 15-54 years),
indicated that regularly active adults had a 25% - 38%
reduced risk of having current major depression than
adults who were not regularly active (Goodwin, 2003).
 Physical Activity and Depression
• It has been also found a dose-response relationship between self-reported
PA and depression with a lower risk of depression in the regularly active
(8.2%) compared with the occasionally active (11.6%), the rarely active
(15.6%), and the never active (16.8%) (Goodwin, 2003).
• In a study with 424 depressed adults, it was found that greater PA was
related to lower levels of concurrent depressive symptoms (Harris et al.,
2006).
• This suggests that even in patients suffering from depression, those who
engage in a more active lifestyle may have lower symptom burden even in
the face of current clinical illness.
 PA and the Incidence of Depression
• Furthermore, there is research evidence that current PA levels
or a higher level of cardiovascular fitness is protective against
the development of depression (Schuch et al., 2016).
• Data from the Alameda County study has shown that
individuals who are active are less likely to develop
depression over 5 years (Strawbridge et al., 2002).
• Also, it has been found in an older study that PA is an
independent predictor of depressive symptoms 8 years later
(Farmer et al., 1988).
 PA and the Incidence of Depression
• Recent findings from a study with 33,908 Norwegian
adults found that baseline regular leisure-time exercise
was associated with a reduced risk of developing
depression over the next 11 years (Harvey et al.,
2018).
• Furthermore, the results from this study suggested
that a approximately one hour per week of PA was
enough to decrease the likelihood for developing
depression.
 PA and the Incidence of Depression
• A two-year study of adolescents found that physically
active adolescents had lower levels of depression
(Motl et al., 2004).
• Finally, findings from a number of research studies
have indicated that high PA participation is negatively
related to future subclinical depressive symptom
severity and a lower risk of developing clinical
depression (Mammen & Faulkner, 2013).
Effect of Physical Activity and Exercise on Depression
 Exercise as a Treatment of Depression
• Numerous meta-analyses have summarized the effects of exercise on
depressive symptoms in people with depression.
• Following an early meta-analysis by North and colleagues investigating the
effect of exercise on depressive symptoms (North et al., 1990) at least 18 other
meta- analyses have investigated this same topic.
• Of the 19 meta-analyses performed, all 19 have found evidence that exercise
reduces depressive symptoms in people with depression, with effect sizes
ranging from small to very large.
• However, the high heterogeneity (i.e., the difference in the size of the effects
across the studies) and subanalyses selecting only the studies with lower risk
of bias (Krogh et al., 2017) have sparked controversy regarding the true effect
of exercise on depression.
Effect of Physical Activity and Exercise on Depression
Strategies for Treating Depression
 Exercise is as Effective as Other Depression Therapies
A “meta” analysis of 35 clinical trials with 2326 participants.

Conclusion:

= =
Exercise Antidepressants Psychotherapy (CBT)
Mutrie, N., Richards, K., Lawrie, S., & Mead, G. (2018). Can Physical Activity Prevent or Treat Clinical Depression? The Exercise Effect on Mental
Health: Neurobiological Mechanisms. CRC Press. pp. 380-407.
Cooney, G. M., Dwan, K., Greig, C. A., Lawlor, D. A., Rimer, J., Waugh, F. R., … & Mead, G. E. (2013). Exercise for depression. Cochrane Database of
Systematic Reviews, (9).
 Exercise is as Effective as Standard Depression Therapies
Recently, an international team of researchers performed a meta-analysis of 55
clinical trials with 1500 participants.

Conclusion:  in depression scores

(5 points on a 23-point scale)

= What worked best:

Aerobic exercise of moderate to high-
intensity & at least partly supervised
Exercise

Schuch, F. B., Vancampfort, D., Richards, J., Rosenbaum, S., Ward, P. B., & Stubbs, B. (2016). Exercise as a treatment for depression: A
meta-analysis adjusting for publication bias. DOI: 10.1016/j.jpsychires.2016.02.023
 PA and Exercise Affect Depression?
• A meta-analysis by Cooney et al. (2013) found that for “studies with
adequate allocation concealment, intention-to-treat analysis, and blinded
outcome assessment, the pooled SMD for this outcome was not
statistically significant (—0.18, 95% CI —0.47 to 0.11)” (page 2).
• This conclusion is aligned with three of the four previous versions of the
“exercise for depression” Cochrane reviews (Cooney et al., 2013; Lawlor &
Hopker, 2001; Mead et al., 2009; Rimer et al., 2012;) and with one
subsequent meta-analysis published in 2014 in the JAMA, where the
authors state: “analysis of high-quality studies alone suggests only small
benefits,” along with “no association of exercise with improved
depression” (Cooney et al., 2014, p. 2433).
 PA and Exercise Affect Depression?
• Ekkekakis and Honey (2015) conducted a very detailed critique of the
Cooney and et al. (2013) study, identifying several methodological
issues, such as errors in the inclusion and exclusion criteria, the
uniformity of rules, the procedures followed in assessing methodological
quality and reporting errors.
• Considering the issues raised by Ekkekakis and Honey (2015), Schuch et
al. (2016b) updated the Cooney review, finding a significant SMD of 0.88
for depressive symptom reduction in “high-quality trials.”
• Overall, it appears that exercise has a moderate-to-large effect on
depression from meta-analyses, but that the heterogeneity in outcome
and the discrepancy among trials should be considered in interpreting
the results.
 Exercise for Symptom Management
• A single bout of exercise can elevate mood in patients who are
depressed and, when a patient is undergoing a period of heightened
symptoms, they may be able to use exercise as a tool for short-term
symptom relief.
• In 2005, Bartholomew et al. found that participants receiving
treatment for MDD had improved positive well-being and vigor after a
moderate- intensity treadmill session that did not occur after a quiet
rest session.
• This adds to evidence from a Master’s thesis by Nelson and Morgan
(1994) in which depressed female students (n ¼ 6) exercised at 40%,
60%, and 80% of their estimated maximum capacity with results not
supporting a dose-response relationship between exercise intensity
and mood improvements.
 Exercise for Symptom Management
• A more recent examination of this effect was performed by Meyer
et al. (2016), who found that, in 24 women with major depression,
a 20-min cycling bout at light, moderate, or hard intensity (rating
of perceived exertion (RPE) of 11, 13, or 15) resulted in a
significant decrease in depressed mood that was greater than the
effect of sitting quietly (i.e., control condition).
• Indeed, this effect lasted 30 min (the final assessment point) and
could have lasted longer.
• Further, this study provides support that the intensity of exercise is
not critically important in the antidepressant response to a single
session, corroborating the findings from Nelson and Morgan
(1994).
In 10
days
 Dunn, A., Trivedi, M. H., Kampert, J., Clark, C. G., & Chambliss, H. O. (2005). Exercise
treatment for depression. Efficacy and dose-response. American Journal of
Preventive Medicine, 28(1), 1-8.

16
14
12
Hamilton 10
Rating Scale 8 baseline
for depression 6 12 weeks
4
2
0
placebo low dose public health
control dose

The public health dose of exercise was more effective in reducing depression scores to a clinically acceptable
level than the lower dose or the control condition.
Frequency of exercise (3 or 5 days/week) was not important.
 The Antidepressant Effect of Exercise: Potential
Mechanisms
• Depression is a heterogeneous disease with a variety of
neurobiological symptoms and dysregularities.
 Neurological Basis for PA/Exercie and Depression
• Exercise has similar effects to antidepressants.
↑ Serontonin levels/availability.
↑ Norepinephrine levels (mostly animal studies).
↑ Dopamine activity; could address the motivational and anhedonic
symptoms of depression.
• Impact on neurotrophic factors and neurogenesis, especially in the
hippocampal region.
(Helmich et al., 2010)
 Neurological Basis for PA/Exercie and Depression
• Brain health in general may be dependent on PA.
•   endorphins.
•  insulin growth factor IGF-1. Implications for neurogenesis and
inflammation response
•  Inactivity  low grade inflammation.

• Twin studies suggest that relationship between voluntary leisure

exercise and anxiety and depression may be genetic (DeMoor et
al., 2010)
(Helmich et al., 2010)
Psychological Basis for PA/Exercie and Depression

• Provides immediate behavioural feedback for

accomplishing tasks.
•  self-efficacy and sense of mastery.

•  opportunities for social reinforcement.

• Social support context accounts for significant part of

the PA/Exercise and Depression relationship.
• Distraction from distress-inducing thoughts.
(Helmich et al., 2010)
 Conclusions
 Given that physical activity/exercise is beneficial to overall health
and mental well being, it may be considered a useful adjunct
treatment for depression.
 Using improved methodological standards, future research may
result in a higher level of evidence and thus may more clearly
demonstrate the role of PA as an adjunct treatment for
depression.
PA/Exercise Prescription for Depression
 Concepts
 Sport: Exercising governed by rules that combines physical activity and
other characteristics of the person.
 Health: State of complete physical, mental and social well-being and
not merely the absence of disease or infirmity (WHO).
 Physical Fitness: The ability to carry out daily tasks with vigor and
alertness, without undue fatigue and with ample energy to enjoy
leisure-time pursuits and to meet unforeseen emergencies. A healthy
fitness includes cardiorespiratory endurance, muscular strength and
endurance, flexibility, etc.
 Physical exercise: Physical activity that is planned, organized and
repeated to improve fitness.
 Concepts
• Physical activity: Any kind of voluntary body movement that a person does
over a given period of time: walking, dancing, stair climbing, etc.), performed
by skeletal muscles that spends an additional energy than the required to
maintain vital functions (breathing, circulation, etc.)
 Mild intensity (walking)
 I have a feeling of warmth.
 My breathing and my heart rate increase.
 Moderate intensity (dancing, swimming, cycling)
 The feeling of warmth increases and sweating begins.
 Breathing rate and pulse increase, but still allow us to talk
 Vigorous intensity (jogging and playing sports at an advanced level)
 Strong feeling of warmth.
 Breath starts to short.
 High pulse.
 Concepts
• Cardiorespiratory endurance: Oxygen uptake (VO2): Amount of
The ability of the lungs, oxygen consumed by the body
heart, and blood vessels to Maximal oxygen uptake
deliver adequate amounts (VO2max): Maximum amount of
of oxygen to the cells to oxygen the body is able to use
meet the demands of per minute of physical activity,
prolonged physical activity. expressed in l/min or ml/kg/min;
the best indicator of cardio-
respiratory or aerobic fitness.
 Concepts
• Aerobic Exercise: Exercise Anaerobic Exercise: Exercise
that requires oxygen to that does not require oxygen
produce the necessary to produce the necessary
energy (ATP) to carry out energy (ATP) to carry out the
the activity
activity
 Walking
 Internal Training
 Jumping rope
 Running Sprints
 Cycling  Swimming Sprints
 Rowing  Heavy Weightlifting
 Basic Principles of Exercise Training
• Frequency: How often is the exercise performed each week?

• Intensity: The exercise must be performed at a level that

challenges the cell/tissue/system for adaptations to occur. Totally
dependent on starting state.

• Duration: Length of each training session.

 PA/Exercise
Prescription for
Depression
 PA/Exercise
Prescription
for Depression
 Practical Recommendations

• Exercise done on a regular basis can be useful in treating

depression as well as in protecting against depression.
• Research consistently shows that 30 minutes of aerobic
exercise five times a week will significantly reduce
depression.
• Type of exercise doesn’t seem to matter.
 Guidelines for the Use of Exercise Therapy
• Obtain information from the individual as to what activities he or
she likes/dislikes.
• Exercise with the individual, to provide support and to model
correct behavior.
• Make the exercise adaptable to the individual’s lifestyle.
• Use the individual’s home environment.
• Monitor exercise dosage and modify as necessary.
• Help the individual realize that setbacks do occur, and devise
strategies to deal with them.
 Conclusion
 Physical exercise combined with psychological and dietary
interventions are reported to improve parameters of the
metabolic syndrome, cardiovascular fitness. and cognitive
performance on patients with depression.
 Moderate and high intensity training are deemed attractive
forms of adjunctive therapy of depression, adjustable to
patients’ age, performance, and preferences.
“
UNIT 3: Physical Activity/Exercise and Anxiety
Disorders: Theory and Practice

”
 UNIT 3: Physical Activity/Exercise and Anxiety
Disorders: Theory and Practice
Learning objectives
• Know the facts about Anxiety.
• Know the measurement of Anxiety
• Know the current treatment strategies for Anxiety
• Know of the relationship between PA/Exercise and Anxiety.
• Know the evidence base related to the effects of PA/Exercise on patients with Anxiety and
Stress-Related Disorders.
• Know the evidence base for the anxiolytic effects of PA/Exercise: Potential mechanisms.
• Know the exercise prescription, dose, and compliance for patients with anxiety and Stress-
related disorders.
Physical Activity/Exercise and Anxiety Disorders:
Theory and Practice

Kostas Karteroliotis & Maria Koskolou

School of Physical Education & Sport Science
National and Kapodistrian University of Athens, Greece
 Presentation Outline
• Facts on Anxiety
• PA/Exercise as a Treatment of Anxiety Disorder
• Physical Symptoms of Anxiety
• Assessment of Anxiety Disorders
• Strategies for Treating Anxiety and Stress-Related Disorders
• PA/Exercise Effects on Anxiety
• PA/Exercise as a Treatment of Anxiety Disorders
• The Anxiolytic Effect of PA/Exercise: Potential Mechanisms
• PA/Exercise Prescription for Anxiety Disorders
 Facts on Anxiety
• The proportion of the global population with anxiety
disorders in 2015 was estimated to be 3.6%.
• As with depression, anxiety disorders are more common
among females than males (4.6% compared to 2.6% at the
global level).
• Lifetime prevalence of about 7% in Europe.
• Lifetime prevalence of about 19% in the United States.
• Women are affected twice as often as men.
(WHO, 2017)
Facts on Anxiety
 PA/Exercise as a Treatment of Anxiety Disorder
 Anxiety disorders are debilitating conditions characterized by
excessive, chronic maladaptive anxiety symptoms that are
often accompanied by strong autonomic nervous system
activation, anxiety-related cognitions, and altered behavior
(e.g., avoidance).

Pathological anxiety was classified into six disorders: specific

phobia, social phobia or social anxiety disorder (SAD), GAD,
PD (with or without agoraphobia), obsessive - compulsive
disorder (OCD), and posttraumatic stress disorder (PTSD).
Herring, M. P. (2018)
 Brief Descriptions of Primary Anxiety Disorders, OCD, and PTSD Based on DSM-5
(American Psychological Association, 2013)
Disorder Primary Characterizations
Specific phobia Marked fear or anxiety about specific object or situation that almost always provokes immediate fear or
anxiety that is disproportional to actual danger, is avoided or endured with intense fear or anxiety, and lasts
6 months or more.
Social anxiety disorder Marked fear or anxiety about one or more social situations in which an individual may be scrutinized by
others that almost always provoke fear or anxiety that is disproportional to the actual threat posed by the
situation, is avoided or endured with intense fear or anxiety, and lasts 6 months or more.
Generalized anxiety disorder Excessive worry about a number of events or activities that occurs on more days than not for at least 6
months that is difficult to control, is associated with at least three associated symptoms, including
restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and disturbed sleep, and that
causes significant distress or impairment
Panic disorder Repeated unexpected panic attacks, or abrupt surges of intense fear or discomfort that strike without
warning or obvious source, crescendo within minutes, are accompanied by somatic symptoms (e.g.,
accelerated heart rate, sweating, trembling, fear of losing control, shortness of breath, and so on), and lead
to a month or more of persistent concern about additional attacks or their consequences and/or significant
maladaptive change in behavior related to attacks
Obsessive - compulsive disorder Presence of obsessions, compulsions, or both that are time- consuming and cause significant
distress/impairment; obsessions are recurrent and persistent thoughts, urges, or images that are intrusive
and unwanted, distressful, and cause the individual to attempt to ignore, suppress, or neutralize (most often
with compulsion); compulsions are repetitive behaviors or mental acts that an individual feels driven to
perform in response to obsession which are aimed at preventing or reducing anxiety and/or distress
Posttraumatic stress disorder Exposure to actual or threatened death, serious injury, or sexual violence that results in significant
impairment characterized by hyperarousal, intrusive re-experiencing, negative cognitions and mood, and
persistent avoidance of stimuli associated with traumatic events.
 Physical Symptoms of Anxiety
 feeling of restlessness, feeling "keyed  Nausea and/or diarrhea;
up"  "Butterflies" in the stomach;
 Shortness of breath, or a feeling of  Dizziness, or feeling faint;
choking;
 Hot flashes;
 Sweaty palms;  Chills;
 A racing heart;  Numbness, or tingling sensations;
 Chest pain or discomfort;  An exaggerated startle response; and,
 Muscle tension, trembling, feeling  Sleep disturbance and fatigue.
shaky;
 Behavioral Symptoms Cognitive Symptoms Emotional Symptoms
of Anxiety of Anxiety of Anxiety
Avoidance behaviors such as "What if _ happens?" Apprehension,
avoiding anxiety-producing "I must have certainty." Distress,
situations or places. "I can't possibly tolerate n Dread,
 Escaping from an anxiety- ot knowing_." Nervousness,
producing situation (like a "What do these physical Feeling overwhelmed,
crowded lecture hall). symptoms mean?" Panic,
 Engaging in unhealthy, risky, "People will laugh at me." Uneasiness,
or self-destructive behaviors. "I won't be able to Worry,
 Becoming overly attached to escape." Fear or terror,
a safety object or person "I am going crazy." Jumpiness or edginess
(e.g., refusing to go out, away "Oh my God, what's
from home, to school, or to happening to me?"
work in order to avoid
separation).
 Assessment of Anxiety Disorders
 Diagnostic Interviews
 Anxiety Disorders Interview Schedule for DSM-5
 Adult Version (ADIS-5)
 Diagnostic Screeners
 Psychiatric Diagnostic Screening Questionnaire
 Measures of Anxiety Symptoms
 State-Trait Anxiety Inventory
 Beck Anxiety Inventory
 Hospital Anxiety and Depression Scale
 Disorder-Specific Symptom Inventories
 Penn State Worry Questionnaire
 Yale-Brown Obsessive-Compulsive Scale
 PTSD Checklist
 Strategies for Treating Anxiety and
Stress-Related Disorders
• Pharmacological
• Negative side effects, including nausea and sexual
dysfunction.
• Cognitive-behavioral
• Noncompliance is frequent
• Can be expensive
• May improve some symptoms but worsen others.
 PA/Exercise Effects on Anxiety
• Several studies of the general population have found that
people who engage in more PA have a reduced risk of being
diagnosed with an anxiety disorder and less frequent and
severe anxiety symptoms (Baumeister et al., 2017; De Mello
et al., 2013).
• Conversely, physical inactivity has been identified as a risk
factor for the development of anxiety (Teychenne e al.,
2015).
Herring, M. P. (2018)
 PA/Exercise Effects on Anxiety

Adapted from Goodwin (2003).

 PA/Exercise Effects on Anxiety
• The findings of another study also support the notion that
self‐reported PA offers protection against the emergence of
anxiety regardless of demographic factors.
• Furthermore, higher PA/Exercise levels protects from
agoraphobia and post-traumatic disorder (Schuch et al.,
2018).
• In conclusion, clear research evidence suggests that
engagement in PA/Exercise appears to be protective for
anxiety symptoms and disorders in the general population.
Herring, M. P. (2018)
 PA/Exercise as a Treatment of Anxiety Disorders
• A number of meta-analytic reviews have supported the effects of
acute and chronic exercise on anxiety symptoms among
otherwise healthy adults, with effect sizes ranging from small to
moderate (e.g., Conn, 2010; Ensari et al., 2015; Gordon et al.,
2017; Rebar et al., 2015; Yin & Dishman, 2014; Wang et al.,
2014).
• They have included measures of state and trait anxiety, within-
and between-subjects designs, and focused on traditional (e.g.,
aerobic and resistance exercise) and alternative (e.g., tai chi and
qigong) forms of exercise.
Herring, M. P. (2018)
 PA/Exercise as a Treatment of Anxiety Disorders
• Recent reviews have found that exercise-based interventions are
primarily effective as standalone or adjunctive therapies for
reducing anxiety symptoms, with effect sizes ranging from small
to moderate in people with and without a diagnosed anxiety
disorder (Stonerock et al., 2015; Stubbs et al., 2017).
• Exercise-based interventions have been shown to reduce
symptoms in trauma and stress-related disorders, such as in
patients with post-traumatic stress disorder (PTSD) (Wipfli et al.,
2008).
Herring, M. P. (2018)
 PA/Exercise as a Treatment of Anxiety Disorders
• Even acute bouts of exercise have been shown to have a small, positive
effect on reducing symptoms of state anxiety (Ensari et al., 2015).
• An innovative recent study found that aerobic exercise in addition to
cognitive behavioral therapy improved symptoms in people with panic
disorder and agoraphobia (Bischoff et al., 2018).
• PA-based interventions have also been found to reduce anxiety
symptoms in patients with chronic physical health conditions (Herring
O’Connor, & Dishman , 2010).
• However, the majority of these studies have used aerobic exercise
reducing anxiety disorders.
Herring, M. P. (2018)
 Resistance Training as a Treatment of Anxiety Disorders

• Gordon, B.R., McDowell, C.P., Lyons, M., & Herring, M.P.

(2017). The effects of resistance exercise training on anxiety: A
meta-analysis and meta-regression analysis of randomized
controlled trials. Sport Medicine 47(12), 2521.
• A recent review suggests that resistance training has a small
moderate impact on reducing anxiety symptoms in clinical and
non-clinical populations.
 Resistance Training as a Treatment of Anxiety Disorders
• A growing body of literature has identified anxiolytic effects of resistance
exercise in human populations after both single-bout sessions and long-
term training.
• It has been found that resistance training at a low-to-moderate intensity
(<70% 1 repetition maximum) produces the most reliable and robust
decreases in anxiety.
• Anxiolytic effects have been found across different populations and
various dependent measures.
• In conclusion, recent research evidence provides support for the use of
resistance exercise in the clinical management of anxiety.

(Strickland & Smith, 2014)

 PA/Exercise as a Treatment of Anxiety Disorders

Jayakody, K., Gunadasa, S., & Hosker, C. (2014). Exercise for anxiety disorders: Systematic
review. British Journal of Sports Medicine, 48, 187-196.

 Exercise seems to be effective as an adjunctive treatment for

anxiety disorders but it is less effective compared with
antidepressant treatment.
Both aerobic and non-aerobic exercise (e.g., resistance
training) seems to reduce anxiety symptoms.
Further well-conducted Randomized Control Trials (RCTs) need
to be conducted to
 The Anxiolytic Effect of PA/Exercise: Potential
Mechanisms
• Different mechanisms that underlie the anxiolytic effects of
PA/Exercise.
• However, anxiety is a complex disorder with a variety of
neurobiological symptoms and dysregularities.
• Neurobiological Mechanisms for the PA/Exercie and Anxiety
Relationship
• Psychological Mechanisms for the PA/Exercie and Anxiety
Relationship

Herring, M. P. (2018)
 Neurological Mechanisms for the PA/Exercie and
Anxiety Relationship
• Adaptations in the Aminobutyric Acid (GABA)
• Exercise induces adaptations of GABA
• Adaptations in the Norepinephrine Neurotransmitter System
• PA enhances galatin
• PA inhibits norepinephric activity
• Adaptation in the Serotonin Neurotransmitter System
• PA releases serotonin

(Herring et al., 2014)

Psychological Mechanisms for the PA/Exercise and
Anxiety Relationship
 increased self-efficacy and self-esteem.
 increased opportunities for social reinforcement.
• Social support plays an important role of the
PA/Exercise and Depression relationship.
• Distraction from distress-inducing thoughts.

Herring, M. P. (2018)
 PA/Exercise Prescription for Anxiety Disorders
 Longer training programs are more effective than
shorter ones in producing positive changes in well-being.
 Reductions in state anxiety after aerobic exercise may
be achieved with exercise intensities between 30% -
70% of maximal heart rate.
 Exercise training is particularly effective for individuals
who have elevated levels of anxiety, but it reduces
anxiety even for people with low levels of anxiety.
Herring, M. P. (2018)
 PA/Exercise Prescription for Anxiety Disorders
 The anxiety reduction following exercise occurs regardless of
the intensity, duration, or type of exercise.
 Aerobic exercise can produce anxiety reductions similar in
magnitude to those with other commonly used anxiety
treatment.
 Resistance training can produce anxiety reductions similar in
magnitude to AE.
 Anxiety reduction after exercise occurs for all types of
participants.
Herring, M. P. (2018)
 PA/Exercise Prescription for Anxiety Disorders
 “Practitioners prescribing exercise to individuals with anxiety and/or
stress-related disorders should be prepared for nonadherence and
should remain aware that, though no single variable adequately
predicts exercise adherence, assisting individuals in taking personal
responsibility in exercise prescription, exercise program
implementation, and monitoring of compliance with exercise dose,
identifying modifiable barriers and developing strategies to overcome
barriers, and promoting enhanced self-efficacy and self-motivation
may facilitate adherence”.

(Herring, 2018)
“
UNIT 4: Physical Activity/Exercise,
Schizophrenia and other Psychotic Disorders:
Theory and Practice

”
UNIT 4: Physical Activity/Exercise, Schizophrenia and
other Psychotic Disorders: Theory and Practice
Learning objectives
• Know the facts about Schizophrenia (definition, epidemiology, symptoms).
• Know the treatment strategies for schizophrenia.
• Know the Physical Health problems of people with Schizophrenia.
• Know the research related to PA/Exercise and Schizophrenia.
• Know the Benefits of PA/Exercise for People with Schizophrenia.
• Know the evidence base for the efficacy of PA/Exercise Intervention Studies for People with
Schizophrenia.
• Know the facts about Schizophrenia (definition, epidemiology, symptoms).
• Know the research related to PA/Exercise, Bipolar Disorder and other psychoses.
• Know the types of exercise are appropriate in treating people with Serious Mental Disorders.
Unit 4: PA/Exercise, Schizophrenia & other Psychotic
Disorders: Theory and Practice

Kostas Karteroliotis & Maria Koskolou

School of Physical Education & Sport Science
National and Kapodistrian University of Athens
 Presentation Outline
• Facts on Schizophrenia and Serious Mental Disorders
• Treatment Strategies for Schizophrenia
• Physical Health of People with Schizophrenia
• PA/Exercise and Schizophrenia
• Benefits of PA/Exercise for People with Schizophrenia
• PA/Exercise Intervention Studies for People with Schizophrenia
• Facts on Bipolar Disorder
• PA/Exercise and Bipolar disorder
• PA/Exercise for People with Serious Mental Health Problems
 Schizophrenia and other Psychotic
Disorders

Schizophrenia is a severe mental disorder, characterized by profound disruptions

in thinking, perception, emotions, language, the sense of self and behavior.
Affects more than 21 million people worldwide.
 Ranks 12th place on the list of leading causes of global years lived with
disability.
 Approximately 15 new cases of schizophrenia per 100,000 persons in 1 year.
 Higher incident rates were seen in: (a) males compared with females, (b)
urban areas compared with nonurban areas, and (c) migrant populations
compared with native-born individuals.
(Ponizovsky, et al., 2003; WHO, 2017)
 Schizophrenia
Positive Negative
Main symptoms Delusions = fixed, false Represent loss of one’s usual
Positive, beliefs that are not experiences.
consistent with one’s Include social withdrawal, a
Negative, culture. reduced ability to feel
Cognitive Hallucinations = perceptual pleasure in life, and
disturbances in the absence diminished motivation or
of external stimuli. emotional expressiveness

Cognitive
Impairments in a wide range of cognitive functions, including attention,
working memory, executive function, and social cognition.

(Howes & Murray, 2014; Kahn et al., 2015)

 Schizophrenia
Social isolation - stigma

Individuals experience daily rejection and contempt from their social environment

Low self-esteem
High suicide rates
Depression

Schizophrenia typically begins in late adolescence or early adulthood

It is a treatable disorder
1 in 2 people living with schizophrenia does not receive care for the condition
 Treatment Strategies for Schizophrenia

 Antipsychotic medication, remains the cornerstone of treatment for

people with schizophrenia (Leucht et al., 2013).
 Psychosocial treatment strategies such psychotherapy/talking
therapy, cognitive behavior therapy, and vocational rehabilitation have
been also applied for people with schizophrenia (Galletly et al., 2016).
 Physical health and lifestyle modifications have been also applied to
target cardiometabolic risk factors for people with schizophrenia
(Suetani et al., 2017).

Suetani, S., & Vancampfort, D. (2018)

 Physical Health of People with Schizophrenia

People with schizophrenia have approximately 10 to 20 years

reduced life expectancy (Walker et al., 2015).
Suffer from various physical illnesses such as cardiovascular diseases
and diabetes (Lawrence et al., 2013; Moore et al., 2015).
Take antipsychotic medications which lead to weight gain (usually
occurs at the very early stages of antipsychotic treatment) (Correll et
al., 2014; Foley & Morley, 2011).
Receive poor mental health services (Mitchell et al., 2012).
Are less likely to receive optimal health care (Mitchell et al., 2009).
Suetani, S., & Vancampfort, D. (2018)
 PA/Exercise and Schizophrenia
The primary goal is to improve the physical health of people with
schizophrenia by reducing the cardiometabolic risk profile
(Docherty et al., 2016; Suetani et al., 2015).
Increasing PA and reducing sedentary behavior of people with
schizophrenia is rapidly gaining both research and clinical
attention as an important, feasible and effective behavior
modification target in this population (Rosenbaum et al., 2016).
Suetani, S., & Vancampfort, D. (2018)
 Benefits of PA/Exercise for People with Schizophrenia
 A number of studies have suggested benefits of PA for both the physical and psychological
well-being of people with schizophrenia (Rosenbaum et al., 2016).
 A systematic review of 20 studies with 695 participants found an improvement in
measures of physical fitness, as well as in reducing both positive and negative symptoms
of schizophrenia (Firth et al., 2015).
 In another recent study it was found that PA was effective in improving global cognition
with greater amounts of PA associated with larger improvement. It was also found that PA
interventions that were supervised by qualified PA professionals were more effective (Firth
et al. (2017) .
 In another systematic review, consisting of 19 studies and 594 participants with
schizophrenia, it was found that PA provision by qualified professionals and continuous
supervision of PA were associated with reduced rate of dropouts (Vancampfort et al.,
2016).
Suetani, S., & Vancampfort, D. (2018)
 PA/Exercise and Schizophrenia
 Cognitive dysfunction is a cardinal feature of schizophrenia that primarily
affects verbal learning, memory, attention, processing speed, and executive
function.
 There is abundant research confirming the effects of aerobic exercise on
cognitive and brain plasticity.
A study examined the immediate and maintenance effects of AE on patients with
schizophrenia, implementing a 12-week intervention program (3-6 times/week)

Participants completed assessments at pretest, posttest and 3-month follow-up

Group Α Group Β
Moderate-intensity treadmill exercise Stretching and toning exercise

(Su et. al., 2016)

 Physical Exercise and Schizophrenia
Processing speed Attention

Group Α Group Α

Group B Group B

Greater improvement in Group A, 3 months after the implementation of the program (processing speed and attention)

(Su et. al., 2016)

 Verbal learning Working memory
Άσκηση και Σχιζοφρένεια Group Α
Group Α

Group B

Group B

Improvement in learning and memory was observed only in Group A, 3 months

after the implementation of the program
 PA/Exercise Intervention Studies for People with Schizophrenia
 The Achieving Healthy Lifestyles in Psychiatric Rehabilitation (ACH- IEVE) trial
 A 18-month program with 291 overweight or obese individuals suffering serious mental disorder (SMD)
with 58% having a diagnosis of schizophrenia.
 After 18 months the mean weight loss for the intervention group was 3.4 kg, compared with 0.3 kg in
the control group.
 Also, 37.8% of people in the intervention group lost 5% or more of their initial weight, compared with
22.7% in the control group (Daumit et al., 2013).

 The STRIDE trial

 Involved consisted of 200 individuals with SMD and an initial BMI of over 27 kg/m2, with the majority
(98%) of participants having a clinical diagnosis of either schizophrenia or affective psychosis/bipolar
disorder.
 After 12 months, participants in the intervention group lost an average of 2.6 kg.
 The intervention group also had a significant decline in the fasting glucose level, while those in the
control group did not.
 Most of the weight loss in the intervention group occurred in the first 6 months (Green et al., 2015)
Suetani, S., & Vancampfort, D. (2018)
 PA/Exercise Intervention Studies for People with Schizophrenia
 The Shape study
 The program focused more strongly on the effect of PA in reducing weight over other lifestyle
interventions (40% of the 133 participants with SMD suffer from schizophrenia).
 This study compared the 12-month program with a control condition which involved free fitness club
membership and education.
 After 12 months, 40% of the intervention group achieved a clinically meaningful improvement in fitness
compared with 20% in the control group.
 However, there was no sig-nificant difference between the groups in terms of clinically meaningful
weight loss (defined as weight loss of more than 5% of the initial weight)(Bartels et al., 2013).
 In a recent study in the UK, 31 schizophrenic individuals participated in a 10-week individualized PA training
program aiming to achieve more than 90 min. of moderate-to-vigorous intensity PA per week.
 The study had a retention rate of over 80%, and participants were able to engage in on average 107 min. of
moderate to vigorous intensity PA per week.
 In addition, significant improvements in both positive and negative symptoms were seen compared with the
control group (Firth et al., 2018).
Suetani, S., & Vancampfort, D. (2018)
 The effects of Digital Interactive Games
(exergames) on Schizophrenia
Patients with schizophrenia engage in less physical activity compared with the general
population.
They have no interest in developing their health or improve their body image due to the
depressive and anxiety disorders that usually coexist.
A study in schizophrenic individuals showed that the exergames:
Improved the mood of the participants
Reduced feelings of tension and anxiety
Improved their self-confidence and sociability
Motivated the participants to continue to exercise with the exergame or with some
sport after the end of the study
(Shimizu, 2017)
 Bipolar disorder
 Bipolar disorder (or manic depression) is a chronic psychiatric condition associated
with severe disability and high mortality rates.
 Individuals experience episodes of elevated mood (mania) alternating with
episodes of depression.
 Theses episodes are associated with deficits in patients’ quality of life.
 It is estimated that the proportion of the adult population suffering from the
disease is 4% - 6%.
 Bipolar disorder often develops in a person's late teens or early adult years.
 Current treatment strategies include mainly antidepressant, antipsychotic, and
mood-stabilizing medications.

(Melo et al., 2016; Sylvia et al., 2013; Merikangas et al. 2011)

 PA/Exercise and Bipolar disorder
Pharmacotherapy is burdened by significant side effects, such as contributing to one′s
risk of cardiovascular disease which leads to high rates of morbidity and mortality.

Regular PA is associated with lower risk for premature mortality and improves risk
factors for cardiovascular disease.
Studies on the effect of PA on course of the disease indicate that:

less depressive symptoms

PA is associated with better quality of life

increased functioning
(Melo et al., 2016; Sylvia et al., 2013; Vancampfort, 2013)
 PA/Exercise and Bipolar Disorder
 Five reviews suggested that exercise is a potentially useful and important
intervention with regard to general health benefits of people with BD
exercise (Kucyi et al., 2010; Melo et al., 2016; Sylvia et al., 2010; Souza de Sa
Filho et al., 2015; Thomson et al., 2015) .
 Recent research (Subramaniapillai et al., 2016) demonstrated that
adolescents with BD experience similar exercise-induced emotional benefits
as their healthy peers following a 20-min bout of moderate in tensity
exercise (heart rate goal of 60% to 80% of the age estimated maximum
[220e0.7 × age]).
 In another study of the same research group (Metcalfe et al., 2016), it was
shown that 20-min bouts of aerobic exercise also impacts neural
deactivation deficits in attention and activation deficits in inhibition.
Vancampfort & Goldstein, 2018
 Psychosis
A study with data from 46 countries (low and moderate income-
LMICs) and 204,186 participants aged 18–64 years showed that:

Psychosis diagnosis (especially among males) is associated with physical inactivity

Increased Risk
Obesity Diabetes
Cardiovascular disease Chronic diseases
Early death
(Goff et al., 2005; Stubbs et al., 2016)
 Psychosis
PA is an important factor for the prevention and treatment of psychotic disorders
especially in lower-middle income countries (LMICs).

Only 0,5-2% of the health budget is allocated to the treatment and prevention of
these disorders in LMICs.
Cases not treated exceed 90%.
Scientists recommend:
The increase of PA in daily life for patients with psychotic disorders
Continued medical education to equip staff on the importance of PA
Implementation of customized programs in public health care institutions
 Α Complex Relationship
Individuals in a manic or hypomanic state tend to be exercising at
greater frequency than individuals currently depressed suggesting a
complex relationship between bipolar disorder and PA

Exercise is a Stimulate them

Regulate their “double-edged with affective
emotions sword” dysregulation
Bring structure to for bipolar Increases body
their chaotic lives disorder energy
(Wright et al.,
Is associated
2012)
with more manic
symptoms
(Melo et al., 2016; Sylvia et al., 2013;)
PA/Exercise for People with Serious Mental Health Problems
A recent literature review of the literature concluded that most PA
intervention studies have shown that benefits demonstrated during the
intervention period disappear once the intervention is withdrawn
(Gates et al., 2015).
Programs should be designed to benefit people with schizophrenia
and other psychotic disorders in the long term (over 12, 18, or more
years).
Future PA interventions should examine the potential of telephone,
mobile technology, and social media to augment face-to-face
interventions and enhance treatment effects beyond the end of the
intervention.
Suetani, S., & Vancampfort, D. (2018)
“
UNIT 5: Physical Activity/Exercise and
Cognitive Development (Dementia): Theory
and Practice

”
UNIT 5: Physical Activity/Exercise and Cognitive
Development (Dementia): Theory and Practice
Learning objectives
• Know the facts about the relationship between PA/Exercise and Cognition.
• Know the facts about the relationship between PA/Exercise and Brain function
• Know the facts about Dementia and Alzheimer’s Disease (ΑD)
• Know the evidence related to PA/Exercise and Prevention of Dementia and AD
• Know the mechanisms by which PA/Exercise may affect Dementia and AD
• Know the Clinical Control Trials (CRTs) of the impact of PA/Exercise on Dementia and AD
• Know the types of PA/Exercise programs related to Dementia and AD (aerobic training, strength
and balance training, flexibility training, duration, frequency, and intensity)
•
Unit 5: Effects of PA/Exercise on Cognitive Function: Theory
and Practice

Kostas Karteroliotis & Maria Koskolou

School of Physical Education & Sport Sciebce
National and Kapodistrian University of Athens
 Presentation Outline
• Facts on Cognition
• PA/Exercise and Cognitive Function
• Facts on Dementia and Alzheimer’s Disease
• PA/Exercise and the Prevention of Dementia and Alzheimer’s
Disease
• Mechanisms by which PA/Exercise may affect Dementia
• Conducting PA/Exercise programs in Dementia and
Alzheimer's disease.
 Mens Sana in Corpore Sano
 The well-known phrase «Mens Sana in
Corpore Sano» is Latin and belongs to a
satirical poet Juvenal (60-127 AD).

He was the first to speak about the

beneficial effects of exercise on health.

Aristotle had said that three things

needed education: Nature, Learning, and
Exercise.
 Exercise is Medicine!!
 The positive relationship between
Exercise/Physical Activity and health in both
adults and children has been well documented
in previous as well as in recent studies.
Systematic reviews and meta- analyses have
demonstrated that Exercise/Physical Activity
improves children’s cardiovascular function,
musculoskeletal development, and mental
health and is an important factor for the
prevention and treatment of childhood
obesity.
Janssen & LeBlanc, 2010
 PA/Exercise, Cognitive Function and School Performance
• In addition, PA/Exercise is a key factor that is positively related
with cognitive function and academic achievement.

Castelli et al., 2007

 Cognition
 Cognition refers to a range of mental
processes relating to the acquisition,
storage, manipulation, and retrieval of
information.
It underpins many daily activities, in
health and disease, across the age span.
Cognition can be separated into multiple
distinct functions, dependent on
particular brain circuits and
neuromodulators.
.
 PA/Exercise and Cognitive Functions
Physical &
Psychological
Health

PA/Exercise Cognitive
Functions

Academic
Achievement
Search in PubMed «PA and Brain»
(1970 - 2015)
 How PA/Exercse Affects the Function of Brain
PA/Exercise Enhances Brain Plasticity:

Production of BDNF (Brain Derived Neurotrophic Factor)

Development of neurons in Hippocampus (Center for learning and memory)
(Neurogenesis)
Development of new nerve synapses
Development of new blood vessels in the brain (Angiogenesis)
Better oxygenation (more oxygen to the brain)
 1. The Protein BDNF Enhances Brain Plasticity
2. BDNF is Miracle-Grow for the Brain

• Brain plasticity is the ability of

the brain to modify its structure
and its function as a result of
increased physical activity and
social interaction, among others.

BDNF (Brain Derived Neurotrophic Factor) Ratey

 BDNF is Miracle-Grow for the Brain
• Exercise triggers BDNF protein which supplies the nerve
synapses the necessary information they need to receive
information, to push, store, and use them (Cotman, 1995).

Source: http://www.hdac.org/images/articles/synapse.jpgg
High-Intensity Aerobic Exercise Acutely Increases Brain-
derived Neurotrophic Factor (BDNF)

• High intensity Aerobic

exercise can elicit acute,
transient increases in
BDNF and cortisol in
young, healthy, and
physically active,
nondepressed, and mild
to moderately depressed
individuals.
Ross et al. (2019). Med. Sci. Sports Exerc., 51(8), 1698–1709
Fitness and Brain Plasticity

https://www.bodbot.com/Cognitive_Health.html
 Exercise Increases Neurogenesis in Hippocampus

Neurogenesis helps the

development of new brain
cells (neurons) in the
important center of the brain
named Hippocampus.
 Hippocampus

Volume Crucial in learning and

memory Neurogenesis
It has been shown that a large volume of the
Research in mice has
hippocampus is associated with better
cognitive function shown that exercise
enhances the
Mild-to-moderate exercise over a period of 1
formation of new
year appears to prevent hippocampal
atrophy (Duzel et al., 2016) and increases neurons
hippocampal volume (Erickson et al., 2009)
 Hippocampus of the Brain
It plays an important role in learning,
memory, and attention.
Converts short-term memory to long term
memory.
Improves spatial orientation.
Carries Faster Oxygen and Glucose in the
Brain(Angiogenesis)
 Research Studies about the Relationship Between
Exercise/Fitness and Cognitive Functions in Children

Charles Hillman
&
Laura Chaddock

University of Illinois
at Urbana-
Champaign
 The Effect of PA/Exercise on the Brain
The brain before and after walking
Specifically, exercise affects :
Cognitive functions (attention, memory, speech, etc.)
Behavior
Academic performance
Research/Scan from Dr Charles Hillman University of Illinois

After 20 min of sitting quietly After a 20 min of walking

(Hillman et al., 2009)
 Hillman, C.H., et al. (2005). Aerobic fitness and neurocognitive function in
healthy preadolescent children. Medicine & Science in Sport & Exercise,
37(11),1967-1974.
 Examination of the relationship between age, aerobic fitness, and cognitive
function by comparing high- and low-fit children.
 24 children (M=9.6 yrs) were grouped according to their fitness level (high, low).

 Fitness was assessed using the Fitnessgram test, and cognitive function was
measured by neuroelectric and behavioral responses to a stimulus
discrimination task.
 It was found that high-fit children compared to low-fit children had:
Faster cognitive processing speed and reaction time, better attention and
working memory.
 Hillman, C.H., et al. (2009). The effect of acute treadmill walking on cognitive
control and academic achievement in preadolescent children. Neuroscience,
159, 1044-1054.
• 20 children 9-10 yrs old participated in the study.
• 10 children walked for 20 min. on a treadmill (60% Μax) followed by a
cognitive test, whereas the other 10 children participated on the
cognitive test without walking .
Composite Attentional Allocation
of 20 student ’s taking the same test.

3 µV 8

After 20 minutes of After a 20 minutes of

Sitting Quietly Walking

(Hillman et al., 2009)
Erickson, K. et. (2013). Physical activity and brain plasticity in late adulthood. Dialogues in
Clin Neurosci . 25, 99-108.
 Aerobic Exercise and Brain Function in Older Adults

In healthy adults, brain volume

increased with 6 months of aerobic
exercise (colors=areas showing an
increase) (Colcombe et al., 2006)

In adults at increased risk for Alzheimer’s dementia

(e.g., with mild cognitive impairment), exercise
increased brain metabolic activity in regions that
are first affected by the disease (Porto et al., 2016)
 Smith, P.J. et al. (2010). Psychosomatic Medicine, 72, 239-52.

• Meta-analysis of 29 RCTs in subjects without dementia.

• Aerobic exercise for 1-18 mos.

• Modest improvement in memory, attention, processing speed, and

executive function.
 Ahlskog, J.E. et al. (2011). Mayo Clin Proc. 86(9), 876-84.
• Aerobic exercise works for improving and maintaining cognition in
healthy seniors
• 30 minutes of moderate intensity, 5 d/wk?
• 20 minutes vigorous exercise, 3 d/wk?
• Threshold or graded effects? A little may be better than nothing.
• Challenges for developing routines in people with physical limitations,
limited resources
• Combined aerobic and resistance may work best (Suzuki, et al. 2013)
 Dementia and Alzheimer’s Disease (ΑD)
Dementia is defined as a serious
disorder of the higher cognitive functions

Alzheimer's disease is a progressive

neurodegenerative disease that affects
memory, cognitive judgment etc.

The bodily functions gradually

decrease, ultimately leading to death

AD is the leading cause of dementia in older ages > 65 followed by vascular dementia, LEWY body disease
and frontal lobe dementia
(Τσολάκη, Μ., 2002; http://alzbr.org/alzheimers-disease-dementia)
 Dementia and Alzheimer’s Disease (ΑD)
Dementia is defined as as serious disorder of
the higher cognitive functions

Alzheimer's disease is a The bodily functions gradually

progressive decrease, ultimately leading to death
neurodegenerative
disease that affects 46,1 % increase in AD –
memory, cognitive associated mortality from
judgment etc. 2002 to 2006.

AD is the leading cause of dementia in older ages > 65 followed by vascular dementia, LEWY body disease
and frontal lobe dementia
(Τσολάκη, Μ., 2002; http://alzbr.org/alzheimers-disease-dementia)
 Dementia and Alzheimer’s Disease (ΑD)
2000-2013
Pharmacological treatment 71% increase in deaths due to AD
14% decrease in heart disease
Medication:
 Slows the progression of Exercise has been explored as a viable
AD in later stages means of prevention and treatment for
Contributes minimally early-stage and late-stage disease due to:
on early stages of disease
Provides some  Its relative safety with few side effects
symptomatic relief
Does not achieve a definite
cure
Larger amount of research for
the drug efficacy
(Cass, S. P., 2017; Ströhle, et al., 2015)
Hebert, L.E., Weuve, J., Scherr, P.A., & Evans, D.A. (2013). Alzheimer disease in the United
States (2010-2050) estimated using the 2010 Census. Neurology, 80(19), 1778-1783.
 Dementia and Alzheimer’s Disease (ΑD)
Εxercise may Physiology of cardiovascular system
affect :  Hippocampal volume and neurogenesis

https://en.wikibooks.org/wiki/Exercise_as_it_relates_to_Disease/Physical_Activity_with_Cognitive_Tasks_Improves_Executi
ve_Functioning_and_Reduces_Falls_in_Elderly_with_Alzheimer%27s_Disease
 Physiology of Cardiovascular System
Adverse effects of aging on brain blood flow and cognition.
Moderate-intensity exercise results in acute augmentation of
blood flow to the brain.

(Barnes, 2015; Bailey et al., 2013)

 Results of studies

 Meta-analysis of 6 prospective epidemiological studies.

 Published from 1990 to 2007.

 Meta-analyses of RCTs of Effects of Exercise in Dementia

(2004).
 Meta-analyses of RCTs of Effects of Exercise in Dementia
Heyn (2004). Arch Phys Med Rehabil. 85, 1964.

• 1
• 0.9
• 0.8
• 0.
0.6
Effect Size 0.5
0.4
No Exercise
0.3 Exercise
0.2
0.1
0
Physical Cognitive Behavioral
Function Function Disturbance

Also, exercise caused significant increases in aerobic fitness, strength, and flexibility
 Results of studies
PA was found to be associated with a 43% reduced risk of AD. (Geda et al., 2010)

Physical activity, even of mild or moderate intensity, is a means of

preventing dementia.
A priority by the G8 nations. (Norton et al., 2014)

It is not clear whether this effect depends on the frequency or intensity of
the exercise.
However, higher levels of PA appear to reduce the risk of impairment of
cognitive functions. (Smith et al., 2010)
A Prospective Study of PA and Cognitive Decline in Elderly Women (Yaffe et al., 2001)

5925 predominantly white

community-dwelling
women (aged ≥65 years)
were recruited from 4
clinical centers .
 Significant benefits in
patients with Mild Cognitive
Impairment (MCI) or
increased risk of AD.
 Women with higher levels Percentage decline in age-adjusted modified Mini-Mental State Examination
(mMMSE) score during the 6- to 8-year follow-up as a function of physical
of baseline physical activity activity (blocks [1 block ≈ 160 m] walked). The median numbers (ranges) of
blocks walked per week in the lowest, second, third, and highest quartiles were
were less likely to develop 7 (0-22), 28 (23-49), 77 (50-112), and 175 (113-672), respectively. The difference
cognitive decline. between women in the higher quartiles and those in the lower quartiles was
significant (P<.001).
 Results of studies
Physical Activity and Alzheimer’s Disease: A Systematic Review (Stephen et al., 2017)

 Physical activity was inversely associated with risk of AD in most studies

(n = 18).
Leisure-time physical activity was particularly protective against AD, but
 This is not the case with work-related PA -Individuals who are physically
active at work tend to be more sedentary during leisure time.
 Leisure-time physical activities have been indicated also as important
sources of social and cognitive stimulation.
 PA performed across the whole life span may contribute to maintenance
of cognitive function in old age.
 Can Exercise Improve Cognitive Symptoms of Alzheimer's Disease?
 Nineteen studies with 23 interventions
including 1,145 subjects with a mean age of 77.0
± 7.5 were included. Most subjects were at risk
of AD.
 Moderate‐intensity exercise training performed
approximately 3 days per week for
approximately 45 minutes per session resulted
in modestly better (d+ = 0.47, 95% CI = 0.26–
0.68) cognitive function than in controls (P <
.001).
 Exercise training may delay the decline in
cognitive function that occurs in individuals who
are at risk of or have AD, with aerobic exercise
possibly having the most favorable effect.
(Panza et al., 2018)
 Results of studies
However, there is a controversy in the field regarding the role of
PA/Exercise on dementia and AD.
PA had a beneficial significant effect against vascular dementia in Japanese
American men but not to AD (Gelber et al., 2012).
Verdelho et al. (2012) found similar results in a study conducted in Europe.
Although globally high levels of PA/Exercise are associated with decreased
risk of AD, the magnitude of the relationship is rather weak and not always
significant after adjusting for confounding factors (Daviglus et al., 2011).
 Conducting PA/Exercise Programs in Dementia and
Alzheimer's Disease

• Aerobic Training:
• Walking, treadmills, stationary bikes, swimming, biking, dancing
• Strength and Balance Training
• Resistive bands, weight machines, balance training
• Flexibility training
• Duration and Frequency
• Intensity
• Moderate and High intensity exercise and activities
“
UNIT 6: Physical Activity/Exercise and
Substances/Eating Disorders: Theory and
Practice

”
UNIT 6: Physical Activity/Exercise and
Substances/Eating Disorders: Theory and Practice
Learning objectives
• Learning about addiction and frequently observed types of addiction
• Understanding the significant role of physical activity in the treatment of addiction
• Identifying conditions at which exercise can be harmful
• Learning about the most common eating disorders and their prevalence in sports
• Understanding the detrimental effect of compulsive exercise used by patients with eating
disorders
• Knowing the therapeutic benefits of exercise in eating disorders
• Getting informed about the appropriate exercise guidelines for eating disorders and strategies on
how to incorporate exercise in the therapy of eating disorders
Unit 6: PA/Exercise and Substances/Eating Disorders: Theory and
Practice

Maria Koskolou & Kostas Karteroliotis

School of Physical Education & Sport Science
National and Kapodistrian University of Athens, Greece
 Presentation Outline
• Facts on Addiction
• Addiction and the Role of Physical Activity
• The Role of Physical Activity in the Treatment of Addiction
• Optimal Exercise
• Addiction to Exercise – Compulsive Exercise
• Eating Disorders - Facts on Eating Disorders and Exercise
• Eating Disorders and Sports
• Exercise and Eating Disorders – Diagnosis, Meaning, Measurement, Features,
Prevalence, Prons and Cons
• Exercise Recommendations for Eating Disorders - Compliance
• Therapeutic Benefits of Exercise In Eating Disorders
• Strategies for Incorporating Exercise in the Therapy of Eating Disorders
• Conclusions
 Addiction - Facts
Alcohol
Drugs A global problem for public health
Smoking
In the US, 9% of the population over the age of 12 are addicted to alcohol and drugs and 23% are smokers
(Substance Abuse and Mental Health Services Administration, 2010)

Serious health consequences:

4% of deaths worldwide are attributed to alcohol (Rehm et al., 2009)
Despite smoking showing significant decline over the last 50 years,
it remains the leading cause of death in developed countries (Doll et
al., 2004)
 Addiction - The role of physical activity
• Cognitive-Behavioral Therapy and medications only have temporary effects.
• 80% of patients relapse within 12 months (Marlatt & Donovan, 2005).
• Effective "interventions" such as physical activity are required not only for
treatment but also for prevention.

• Evidence shows that the physically active are:

Less likely to start smoking More likely to try to quit smoking

(Kaczynski et al., 2008) successfully (deRuiter et al., 2008)
The effect of exercise on desire to smoke

Immediate effect of a 10-minute static bike exercise on

the desire to smoke in abstinent smokers
 The effect of exercise on abstinence from alcohol and drugs

(Brown et al., 2010)

 Addiction - The role of physical activity in the treatment
Individuals who consume large amounts of alcohol are less active (Liangpunsakul, Crabb & Qi, 2010)

Physically active teenagers report less use of prohibited substances with less chance of being used as
adults(Field, Diego & Sanders, 2001) with less chance of being users as adults (TerryMcElrath & O’Malley,
2011)
Psycho-social benefits
Reduction of desire and deprivation syndrome, improved mood, relief from stress, athlete’s identification card,
increasing self-efficacy, etc.
General health benefits
Neuro-biological benefits
Reduced cardiovascular risk,
Increased
improved physical fitness, better abstinence
Regulation of dopamine, opioids
control of body weight and cortisol
 Addiction - Is exercise always good?
 There is a minimum level of exercise for health benefits
 Increasing levels of exercise lead to additional benefits
 “Too much” is not always good
 Excessive exercise can be harmful to both physical and
mental health

Optimal range: 2.5 - 7.5

hours/week

(U.S. Department of Health and Human Services, 2008; Kim et al., 2012)
OPTIMAL EXERCISE - GOLDEN MEAN

(Ballantyne S., 2013)

 When does exercise have undesirable results?
Physical activity can change from a protective factor to a risk factor:

Addiction to Exercise - Body Dysmorphic Disorder

Compulsive Exercise
Eating Disorders

Clow A. & Edmunds S., 2014

 Addiction to exercise - Compulsive exercise
• It was discovered accidentally in an attempt to study the effect of exercise on sleep of
individuals who exercised 5-6 times a week (Baekeland, 1970)
• Until then: «exercise dependence was a positive dependence»
• Obsessive increase in exercise leads to overuse injuries, problems with work and
family, and inability to set a limit on it
• People who exercise excessively often suffer from:

stress low self-esteem

depression excessive concern about weight

bad perception of body image

(Baekland, F.,1970; Lichtenstein et al.,2013)

 Eating disorders
The most clinically relevant diagnoses are anorexia nervosa, bulimia nervosa, and
binge eating disorder.
 Anorexia nervosa is characterized by a distorted perception of
one’s body (weight, size, or shape), and appearance as too fat and
an intense fear of gaining weight, even when severely underweight.
 Bulimia nervosa is characterized by repeated episodes of binge
eating, followed by inappropriate compensatory behaviors such as
self-induced vomiting, misuse of laxatives, fasting, or excessive
exercise.
 Binge eating disorder is characterized by recurrent episodes of
binge eating and a sense of lack of control over eating.
These diagnostic features may be accompanied by several somatic, psychiatric, behavioral,
and social disturbances.
(APA, 2013)
 Body Dysmorphic Disorder (BDD)

Those who suffer from this disorder:

 constantly detect imperfections in their body

 perceive their image in the mirror distorted
 are unable to control the frequency of annoying and repetitive thoughts about their supposed
"imperfections“

Common characteristic: lack of satisfaction with body image and muscular system

Exercise increases muscle mass Increased tendency for muscularity (muscular dysmorphic
disorder or muscular dysmorphia)

(Pope, Phillips & Olivardia, 2000)

 Eating disorders and exercise - Facts

Compulsive exercise is often associated with disordered eating habits and a strict diet

It accompanies diseases such as Nervous Anorexia or Bulimia

Individuals with Anorexia use exercise to get rid of calories

Individuals with Bulimia use exercise to “punish” themselves

43% of individuals with eating disorders exercise excessively (Shroff et al., 2006)

80% of the patients reach the restrictive type of Anorexia Nervosa (Dalle et al., 2008)
 Eating Disorders and Sports
Eating disorders is one of the major health problems that athletes face
AN BN EDNOS* TOTAL

Athletes 4,8% 8,1% 19,9% 32,8%

Non athletes 4,2% 17,2% 21,4%
-
*EDNOS: Eating Disorder Not Otherwise Specified
It depends on:
The type of sport
Artistic sports (40-42%), sports with weight class (30-35%), gravity sports (22-42%)
The level
High-level athletes often exhibit symptoms of abnormal eating behavior
(Torstveit et al., 2008; Sundgot-Borgen & Garthe, 2011)
 Eating disorders in athletes (1)
Researchers examining eating disorders in athletes often characterize sports based on the
type of pressure that may be exerted on athletes with respect to body image and the
development of eating disorders:

(a) lean sports (e.g., distance running, dancing, gymnastics),

(b) aesthetically judged sports (e.g., gymnastics, equitation),
(c) sports with weight class or weight requirements (e.g. ski
jumping, wrestling, jockeying), and
(d) sports with revealing uniforms (e.g. swimming, female
volleyball, female track and field)

(Reel et al., 2010)

 Eating disorders in athletes (2)
There is converging evidence to suggest that high percentages (upwards of 50%) of
athletes in “non-lean” sports engage in unhealthy weight control behaviors (e.g., self-
induced vomiting, restricting) (Thompson and Sherman 2010).
Athletes regardless of sport affiliation are not immune to the development of eating
disorders; therefore, we should not overlook athletes who are participating in sports that
do not include judging based on appearance, weight classes, weight requirements, or
revealing uniforms (Sherman and Thompson 2009) .

Thus, eating disorders

(a) affect both males and females,
(b) can occur at nearly any age, and
(c) affect athletes across sports.
(Selby and Reel, 2011)
Health problems and complains in patients with eating disorders
Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder

Body Mass Index (ΒΜΙ) <17.5 kg/m2 20-25 kg/m2 >25 kg/m2

Cardiovascular disturbances
Skeletal disturbances (osteoporosis)
Metabolic disturbances (sensitivity to cold, sleep abnormalities,
hypothermia, hyper-cholesterolemia, obesity, physical inactivity).
(Mitchell and Crow, 2006; Mehler et al., 2010)
 Exercise in the diagnostic criteria of eating disorders
In Anorexia Nervosa:
Excessive exercise often precedes the onset of the
disorder, and increased activity accelerates weight
loss over the course of the disorder.
In Bulimia Nervosa:
Excessive physical activity is considered as an
inappropriate compensation to prevent weight gain.

In Binge Eating Disorder:

A lack of physical activity and a sedentary lifestyle are present.
 The meaning of exercise in eating
disorders
In many cases exercise becomes the central activity in the daily lives of patients with eating disorders. The
need for movement can take many forms

Individual differences based on history, personality, preferences

Periods of increased and decreased physical activity levels may alternate

• Overt exercising obsessively at high intensity (swimming, running, cycling)

• Covert exercising in secret (sit-ups, extreme standing, going up and down the stairs)

• Quantitative exercise characteristics (duration, frequency, intensity) that exceed the recommendations for
good health and injury prevention
• Qualitative exercise characteristics (highly demanding compulsory exercise performed with a strict
schedule, prioritized over other activities, and a sense of guilt and anxiety over missed exercise sessions)

(Probst et al., 2014; Johnston et al., 2011)

 Measurement of the level of physical activity
in patients with eating disorders
 Specific questionnaires are used to measure the level of physical activity in patients with eating disorders in
combination with accelerometers and simultaneous evaluation of other parameters (e.g. body image,
perfectionism, obsessive-compulsive features).

Several questionnaires assessing the context of physical activity are available:

 Eating and Exercise Behavior Questionnaire (Brandon et al., 1988),
 Obligatory Exercise Questionnaire (Pasman and Thompson, 1988),
 Commitment to Exercise Scale (Davis et al., 1993),
 Reasons for Exercise Inventory (Cash et al., 1994),
 Exercise Dependence Questionnaire (Ogden et al., 1997),
 The Physical Activity and Unrest Questionnaire (Probst, 2003; Ferri, 2008),
 The Exercise Dependence Scale-Revised (Downs et al., 2004),
 Exercise Addiction Inventory (Griffiths et al., 2005),
 Compulsive Exercise Test (Taranis et al., 2011),
 Exercise and Eating Disorder Questionnaire (Danielsen et al., 2015)
 Features of high exercise levels in eating disorders
Voluntary increase in physical activity not for pleasure or for health reasons but for
weight control (burning calories, ignoring hunger ignorance) and appearance.
Exceptional alertness and careful control of calorie intake with
foods against calorie consumption with exercise.
Denial of feeling tired. Where others sustaining the same effort
may tire, they continue regardless of their poor physical
condition without complaints.
The movement behaviors of patients with eating disorders exhibit
compulsive characteristics that resemble compulsory rituals. They
constantly feel an inner agitation and an involuntary or irresistible urge to
do something constantly. They do not find peace and feel guilty if they are
not sufficiently physically active..!
(Van Steelandt et al., 2007; Mond et al., 2006).
 Prevalence of high levels of exercise in eating disorders
 High levels of physical activity are in the range of 37-81% in
patients with anorexia nervosa and 20-57% in patients with bulimia
(Davis and Kaptein, 2006; Shroff et al., 2006).
 Excessiveexercise is more common in patients who are
overwhelmed by anorexic preoccupations regarding
weight and shape than in individuals whose disorder
appears to relate tofamily problems and attempts to
manipulate the environment. (Beumont et al., 1994).
 Energy expenditure decreases with age and the
duration of suffering from the disorder (Soundy et al.,
2018).
 High levels of exercise in eating disorders: prons and cons
Advantages
 Compulsion is a way to reduce negative feelings
 Physical activity reduces stress, bodily tension, negative mood and increases tolerance.
Disadvantages
Because of the high physical demand concerns are raised about:
• heart problems
• musculoskeletal problems
• osteoporosis
• stress fractures,
• severe dehydration,
• amenorrhea
• reproductive problems
(Van Steelandt et al., 2004, 2007).
 Strength training for eating disorder patients
A supervised progressive power training program based on strength training (low
intensity and high duration of stimuli) aims at:
 physiological changes ► increasing muscle mass
 psychological changes
▼
helping eating disorder patients view strength as being useful for:
 mastering their body,
 developing self-confidence, self-sufficiency, and independence
 decreasing hostility toward their body
 Aerobic training for eating disorder patients
Aerobic or cardiovascular fitness
 is the most important component of physical fitness
 is improved by activities such as walking, jogging, running, swimming, skating, cycling, stair climbing, and
cross-country skiing

 Physiological benefits ► Aerobic fitness increases the capability of the cardiovascular system to supply
oxygen and energy resulting in many physical health benefits:
 decreasing the risk of cardiovascular diseases, stroke, high blood pressure,
 decreasing the risk of diabetes
 increasing bone mass
 Psychological benefits ► Aerobic fitness:
 is an effective approach to combat anxiety, stress, and depression
 may lead to an increase in self-esteem
 Exercise Recommendations
for Patients with Eating Disorders
 The guidelines of the American College of Sport Medicine (2013) accepted worldwide as the minimum
recommendations to remain healthy are also appropriate for patients with eating disorders:

 According to these guidelines it is suggested:

 moderate (cardiorespiratory) exercise of ≤30 min/day on ≤5 days/week for a total of ≤150
min/week
OR
 vigorous activity of ≤20 min/day on ≤3 day/week for a total of ≤75 min/week

A major issue is that the majority of patients with eating disorders are not satisfied
with these guidelines. Some patients with anorexia nervosa will engage in substantially
more exercise than prescribed, whereas most patients with binge eating disorder do not
reach these recommendations.
(American College of Sport Medicine, 2013; Probst, 2018)
 Compliance of patients with eating disorders with
exercise recommendations
The majority of patients with eating disorders are not satisfied with the guidelines of the American College
of Sport Medicine (2013) .
Some patients with AN engage in substantially more exercise than prescribed, whereas most patients with
BED do not reach these recommendations.

There is need for a supervised fitness training program by an expert therapist who:
is familiar with flexible exercise programs
is familiar with the physical consequences of undernutrition or overnutrition

e.g. during refeeding, a fitness training program supervised by such a therapist may increase the
patients’ fat-free mass and redirect their hyperactivity in a healthy way, thereby reducing their fears of
weight gain and improving their sense of self-control.

(American College of Sport Medicine, 2013; Probst, 2018)

 Controversial statements
about exercise in eating disorders
On the one side:
Exercise combined with abnormal eating behavior has a negative effect on restoring
weight.
Exercise is an unhealthy way of controlling body weight and serves to alleviate anxiety.

On the other side:

 Exercise leads to physical and psychological improvements in health and well-being and
may help patients in the weight restoration process.
As a result of loss in bone density and osteoporosis exercise is limited, but exercise may
also help reduce osteoporosis.
(Probst, 2018)
 Is exercise good for patients with eating disorders?
 In the past, exercise was a contraindication for people with eating disorders mainly
because of ignorance and fear of worsening the disorder.
 Isometric exercise was later used as a reward for patients with anorexia nervosa who
gained weight.
 Nowadays, therapists are convinced that physical activity, in addition to improving
physical health, has significant psychosocial effects (ie, improving the sense of well-
being, quality of life and preservation of autonomy) for patients with eating disorders.

 However, it is still a challenge for clinicians to find an optimum in the often

problematic behavior of people with eating disorders with regard to exercise.

(Ziemer and Ross, 1970; Bratland-Sanda et al., 2009)

 Benefits of incorporating physical activity
into the treatment for anorexia nervosa
Individuals with anorexia nervosa have a reduced bone mineral density and an
increased risk of osteoporosis and risk of fractures.
The incorporation of supervised physical activity or exercise training into the
treatment for AN has occurred without significant negative side effects .
The benefits include:
increased strength and self- efficacy (Michielli et al., 1994)

strength and cardiovascular fitness (Ng et al.,, 2013)

bone density (Rigotti et al., 1984)

 Is exercise harmful in patients with eating disorders?
The answer is difficult because of the uniqueness of each case and the complexity of the
problem.

Based on clinical studies:

 Exercise in the treatment of patients with anorexia nervosa does not have a detrimental impact on
BMI or eating disorder symptoms
 Forbidding exercise has opposite effects; it appears better to allow activity to a certain degree than to
forbid patients to be involved in activities, which leads to therapy resistance, a struggle with the
therapist and hidden activities
 In general, only minimal improvements in fitness and strength were noted, which may have been a
result of insufficient training loads of short duration and small sample sizes.

The therapist must investigate the physical and psychological needs and strike the
balance between what is therapeutically acceptable and what is acceptable for the
patient.
(Probst, 2018)
 Psychoeducation for exercise
in the therapy program for eating disorders
 Psychoeducation refers to the process of providing education and information regarding a specific
topic to patients with eating disorders and their family. It enables patients to address the
challenges better and experience more control and better well-being.

 Psychoeducation is considered as an essential component of the therapy program for eating

disorders.
The goals are (Probst, 2001):
to clarify the positive and negative effects of physical activity
to help patients understand the effects of exercise from physiological and psychological points
of view including the risks
to help patients better understand the effects of low body weight/fat on health,
maturation, growth, and osteoporosis.

(Probst, 2018)
 Physical activity in the treatment of eating disorders -
Recommendations for clinical practice (1)

 Listening to the story of the patient including premorbid exercise behaviors and preferences, in
order to make a realistic individual program.

 Assessment of the activity levels, physical fitness, and health risks

 Referral to a medical dosctor If physical or psychological risks, for instance self-harm behavior,
are present.
 Psychoeducation to reduce the gap between the therapist’s and the patient’s point of view.

 Better allowing than forbidding patients to engage in controlled physical activities, unless there
are medical or therapeutic reasons.

(Probst, 2018)
 Physical activity in the treatment of eating disorders -
Recommendations for clinical practice (2)
A healthy balance between (physical) activity and nutritional intake must be supported.
Physical activity cannot compromise the weight restoration and must be medically safe.
The following rules may be taken into consideration:
 BMI < 12 kg/m2: limited light-intensity activities only after medical agreement
 BMI < 14 kg/m2: light housekeeping activities
 BMI ¼ 14-16 kg/m2: physical activities that focus on strength training supervised by a specialized
professional (e.g., physiotherapist or exercise physiologist)
 BMI ¼ 16-18 kg/m2: patients receive more responsibility and autonomy. Strength and cardiovascular
training is acceptable. The role of the specialized professional is coaching the patient.
 BMI > 18 kg/m2: patients receive complete autonomy; full sport participation is allowed.

(Probst, 2018)
 Physical activity in the treatment of eating disorders -
Recommendations for clinical practice (3)
Planning of an individualized and tailored exercise program following the FITT principles: frequency,
intensity, type, and time based on the needs of individual patients
Adopting a group exercise approach for social contact, support, and interpersonal interactions.

Making a written agreement in some cases.

Advice of an expert in obsessive-compulsive disorders , if compulsive features of physical activity are
identified.
Avoiding sport competition during therapy. Training may be allowed once medically cleared and preferably
under supervision.

Training may be allowed once medically cleared and preferably under supervision.
In general, although arbitrary and individual, for nonathletes, more than 1 h of vigorous exercise more than
five times per week may be dangerous and may be an indicator for developing an eating disorder.

(Probst, 2018)
 Therapeutic advantages of supervised exercise
in eating disorders
Therapeutic advantages provided by the suggested clinical practice:
the physical activity intensity and the heart rate are controlled
the opportunity for the patient to engage in hidden or “secret” physical activities decreases

the drive for physical activity is reduced

the patients receive the message that “being fed” is not the sole focus of treatment

it helps patients cope with shape and weight changes as a result of the recovery process;

the patients are given more responsibility, and compliance to treatment is enhanced
it positively influences their physical and psychological well-being while maintaining good physical condition
it stimulates social contacts

(Probst, 2014)
 Strategies for including exercise
as part of an eating disorder (1)
Based on a literature review by Cook et al. (2017) the following 11 core themes, principles or strategies have
been identified for how exercise has been, or may be, efficaciously included as part of an ED:
1. Team Approach— A multidisciplinary team of experts in exercise, nutrition, mental health, medicine, and
physical therapy should work collaboratively to develop individually tailored exercise programs, with
participation contingent upon adherence to ED therapy. The team also should closely monitor ED patients to
ensure safety.
2. Medical Concerns/Contraindications—Safety is the primary concern when adding exercise to ED therapy
and all precautions must be taken to prevent harm. Beginning an exercise routine generally presents minimal
health risks; however, ED patients present additional physiological and psychological concerns beyond that of
an individual without an ED.
3. Screen for Exercise-related Psychopathology—Identifying individuals that endorse pathological attitudes
and behaviors toward exercise (e.g., exercise dependence, exercise addiction, compulsive exercise, etc.) may
indicate when unsupervised exercise will exacerbate ED pathology.

( Cook et al., 2017)

 Strategies for including exercise
as part of an eating disorder (2)
4. Create a Written Contract—A written contract that details program rules, goals, outcomes, expectations,
and contingencies for progression and regression of exercise activity should be agreed upon by all members of
the treatment team and the patient to foster an inclusive and collaborative exercise program that
compliments standard ED treatment.
5. Include a Psycho-educational Component—Psycho-education is a main component of cognitive-behavioral
therapy and has been described as a key component to most ED specific exercise programs.

6. Focus on Positive Reinforcement—Unsupervised exercise may result in over-exercise due to the reinforcing
value of exercise; thereby allowing negative consequences of overtraining and burnout. Thus, programs have
attempted to manage excessive or unhealthy patterns of exercise by making exercise available contingent on
treatment compliance.

7. Create a Graded Program—The careful and incremental application of exercise is paramount in successfully
managing exercise delivered in therapy. Thus, graded exercise programs beginning with small amounts of low
intensity exercise should be emphasized.
( Cook et al., 2017)
 Strategies for including exercise
as part of an eating disorder (3)
8. Start With Mild Intensity and Slowly Build to Moderate—A primary goal must be to initially limit ED
individuals' to short bouts of mild intensity activities that will allow the gradual conditioning of physiological
systems.
9. Mode of Exercise—Amounts of aerobic and resistance exercises should be tailored for the physiological and
psychological needs of the patient. E.g., successful programs describe resistance training for weight
restoration in AN, and aerobic activity for weight loss, reductions in drive for thinness, bulimic symptoms, and
body dissatisfaction in bulimia nervosa.

10. Nutrition—Dietitians with expertise in ED refeeding and weight restoration must be a part of the
treatment team. Exercise should not be attempted until the individual with an ED has made sufficient
progress in weight stabilization (for those with bulimia nervosa) and caloric and nutritional consumption to
support the activities chosen.
11. Debriefing—Preferably during the exercise session, but certainly afterward, the individual should be
“debriefed” regarding sensations, emotions, and thoughts evoked by exercising.
( Cook et al., 2017)
 Conclusions

 Sports are good and physical activity is beneficial to health in overcoming addictions.

 However, in some cases, sports and exercise are used for other reasons than health.

 Facing the issue of exercise in eating disorders is a challenge for health care providers.

 The approach to dealing with this issue depends on the context of the patient.

 Knowing the patient’s condition and setting the limits is essential.

Learn about your condition - Set your limits
COORDINATOR PARTNERS

COOSS Marche Fundación Intras Fokus ČR Praha

Italy Spain Czech Republic

KSDEO Edra
Greece

National and Capodistrian Panellinios ENALMH

University of Athens Athletics Club Belgium
Greece Greece
 www.project-website.com
[email protected] | facebook.com/ProjectName
This project has been funded with support from the European Commission. This publication
[communication] reflects only the views of the author, and the Commission cannot be held
responsible for any use which may be made of the information contained herein.
How the age variable can affect the mental
health
Vittorio Lannutti
Sociologist - Educator
Coo.S.S. Marche
INTRODUCTION
The relevance of age, sex, culture and hereditary factors have
been overlooked in the last decade.
Recently their importance has been taken into consideration

Sex, gender and health

It has long been assumed that sex, rather than gender,
determines health
In most countries, male life expectancy is lower than that of
females and this is projected to continue, but lastly the male
disadvantage has decreased
Age and the lifecourse: healthy ageing
Lifecourse perspectives depend on age, sex and hereditary factors

Illness and ageing are often linked

Old age is often portrayed as a period of decrepitude and decline

According to some researchers the ‘mask of ageing’ is socially

constructed, rather than biologically determined

The concept of positive and healthy ageing has been promoted as

the way forward for older people (consequence of changes to the
age structure of the population)
It is recognised that behavioural, social and
environmental factors all have a part to play

Attention has been given to the relationships

between ageing, activity and health

Particular emphasis has been given to the role of

physical activity throughout the lifecourse and into
later life
 PROPENSITY TO DEPRESSION

In the most of Eu countries countries the propensity to

report depression disorder is high among elderly people over
65 years of age:
- this increase is mostly contained in most European
countries,
- in Italy its value roughly doubles compared to the average
(11.6%, the increase is 1.7% in the EU),
- higher prevalences are observed only in Portugal (18.9%)
and Spain (13.7%)
It is widespread tendency towards unhealthy or
health-risk behaviors among young and adult
depressed or with chronic anxiety

In Italy, the 28.3% of who those suffer from

anxiety or depression habitually smokes, against
the 20.6% of the peers who do not have the same
pathologies
WHO - suicide:
- nearly 800,000 people die by suicide every year

- in the young people (15 - 29), suicide is the second leading

cause of death

- in Italy, in 2015, 3,988 suicide deaths (6/100,000 inhabitants)

- in Europe the rate is 11/100,000 inhabitants

- in Italy the risk of suicide of elderly population increases in

relative terms, more than in Ireland, Greece, the United Kingdom,
Cyprus and Malta
Passi: depression and quality of life in Italy

- 6% of adults (18-69) report depressive symptoms and perceive

their psychological well-being compromised

- depressive symptoms are more frequent with age (almost 8%

among 50-69), among women (less than 8%), among the socially
disadvantaged classes due to economic difficulties (14%),
education, among precarious workers (8%), among those who
have a chronic disease (13%) and among those who live alone
(8%)

- 70% of the Italian adult population consider their overall health

status to be positive
In Italy - over-64s
- 21% report depressive symptoms and perceive their psychological
well-being compromised for 18 days in a month,

- depressive symptoms are more frequent with increasing age (25%

after the age of 75), among women than men (26% vs 14%),
among those reporting many economic difficulties (41%), and
among those reporting have multi-chronicity (36% vs. 11% among
those who do not report any chronic disease),

- 59% of disabled elderly suffer from symptoms of depression

- 21% of people with depressive symptoms do not ask anyone for

help
 People with symptoms of depression (n = 7952) (pool Pda 2009-2010)
Features Modalities %
Total 21,6
Age cohorts
65-74 18,8
75 and over 25,3
Gender
male 22,3
female 25,1
Education
low 24,3
high 25,7
 AGING AND SOCIAL ISOLATION
2/3 of people with symptoms of depression require help
to:

- health workers or doctors (almost half)

- trusted people (20%)

- many people do not ask anyone for help

Social isolation:
- associated with many aspects of health status and the
use of health resources,
- is a multidimensional concept, to the construction of
which contribute both "structural" aspects and aspects of
a "functional" nature
- the absence or scarcity of social relationships
constitutes one of the major risk factors for health like
cigarette smoking, alcohol abuse and obesity
In the elderly social isolation is related to:
- the decline of cognitive abilities
- a worse state of health (psychic and physical)
- an increase in mortality.

Loneliness and social isolation: a greater use and longer duration of

hospitalizations, malnutrition, alcohol abuse or the risk of falling.
Social relationships can influence the state of health through:
- information exchange,
- emotional support,
- material help,
- promoting the adoption of healthy behaviors
Risk of social isolation (n=8348) (pool dati Pda 2009-2010)
Features Modalities %
Total
Age cohorts 8,7
Features
65-74 6,4
75 and over 12,1
Gender
male 8,6
female 11,1
Education
low 11,5
high 8,9
 YOUTH AND MENTAL HEALTH
Adolescence: crucial phase of the building of identity
Difficulties experienced can be solved in constructive/dialectic way
Transition into adulthood - confusion, isolation
Not an unidirectional mechanism of socialization
Awareness of a possible discordance as they perceive
themselves/how they feel perceived by others
This discrepancy push them to evaluate if to conform or to
differentiate themselves to the expectations of the others
Acquisition of skills to analyze themselves
In the relationship the adolescents bring into play themselves in
order to confer a new sense to the own identity
Biological maturity precedes psychosocial maturity
The changes in adolescence have health consequence not
only in adolescence but also over the life-course

Study HBSC (2014) – Italy: students of 11, 13 and 15 years

about the perception of the state of health
- the perception (postive or negative) of mental health is
associated with scholastic performances and with the
relationship of communication with parents
- 90% consider themselves in "good health”
Suicide is among the top five causes of mortality, apart from
the African Region and boys in the Eastern Mediterranean
Region
5% - 15% of younger adolescents (ages 13–15) reported a
suicide attempt in the 12 months before the survey
Fewer than 25% adolescents meet recommended
guidelines for physical activity
According to many adolescents mental health issues are
among the leading risk factors for death (suicides) and are
the most important health problem for them
They would like more access to mental health care
Suicide attempts are not widely monitored
Main causes of suicide among adolescents are:
- feelings of hopelessness and helplessness
- no solutions/no control to change their situations
- trying to escape feelings of pain, rejection, hurt, being unloved,
victimization or loss
- feelings are unbearable and without an end
- afraid of disappointing others such as their parents
- bullying/cyberbullying
- abuse
- a detrimental home life
- loss of a loved one or even a breakup
Often, many of these environmental factors occur together to cause
suicidal feelings and behaviors
The good support networks (family, peers, extracurricular sport, social, or
religious associations) are very important to help adolescents in crisis
Specific circumstances can contribute to an adolescent's consideration of
suicide.
The critical situations in which adolescents think to not have control are:
- divorce
- a new family formation (e.g., step-parents and step-siblings)
- moving to a different community
- physical or sexual abuse
- emotional neglect
- exposure to domestic violence
- alcoholism in the home
- substance abuse
Behaviour changes to watch in order to understand suicidal tendencies are:
- withdrawal from family and peers
- loss of interest in previously pleasurable activities
- difficulty concentrating on schoolwork
- neglect of personal appearance
- obvious changes in personality
- sadness and hopelessness
- changes in eating patterns, such as sudden weight loss or gain
- changes in sleep patterns
- general lethargy or lack of energy
- symptoms of clinical depression
- violent actions, rebellion, or running away
- drug and alcohol use
- symptoms that are often related to emotional state (e.g., headaches, fatigue,
stomach aches)
- loss of ability to tolerate praise or rewards
Some adolescents with suicidal tendencies hide their
problems underneath a disguise of excess energy

Explicit signs are low self-esteem and self-deprecating

remarks

Previous suicide attempts are cries for help

Almost half of 14- and 15-year-olds have reported feeling

some symptoms of depression

Symptoms of depression in youth are often overlooked or

passed off as being typical "adolescent turmoil"
The easy access to firearms, drugs, alcohol, and motor
vehicles can lead teens to suicide
The prevalence of suicide attempts ranges widely
Many high income countries report rates of 5–10%
In several low and middle income countries the rates are 15%
In a few countries more than 33% adolescents attempted
suicide
In Europe and the Americas, adolescent girls are nearly twice
as likely to attempt suicide as boys.
WHO found that many mental disorders usually start during
childhood or adolescence
Half of all lifetime mental disorders appear to start by age 14
In high income countries fewer than half of adolescents
with mental health problems receive needed care
In low-middle income countries access to treatment is
scarce
Being bullied is linked to a wide range of mental,
psychosocial, cognitive/educational and health problems
In about half of the countries, more boys than girls report
being bullied
Bullying is declining in most high income countries in
Europe and the Americas
 THE ACTIVITIES OF NATIONAL TWIN REGISTRY
It is possible to estimate gene influences (heritability) and
environment on mental health
NTR – relationship: the ability to self-regulate emotions-
quality of sleep in adolescence. The preliminary results on
a sample of twins aged 14-17 confirm the existence of
this relationship
Mental health: as a result of the joint action of the
prevention of pathological states-the promotion of states
of well-being
It exists a substantial genetic component for self-esteem
and satisfaction for life, while for optimism a predominant
contribution of environmental experiences emerged
DIFFERENCES OF SELF-PERCEPTIONS AND ATTITUDES TO SEEK HELP
Developmental sport psychology research: young and older adults
differ in their self-perceptions, social influences, emotional
responses, motivations, and self-regulation with regard to sport and
exercise participation

Developmental factors, such as age, could potentially influence

mental toughness

Older age is associated with more positive help-seeking attitudes

Women exhibited more favorable intentions to seek help
than men
Older adults exhibited more favorable intentions to seek
help than younger adults
Negative attitudes related to psychological openness
might contribute to men’s underutilization of mental
health services
Need for education to improve men’s help-seeking
attitudes and to enhance older adults’ willingness to seek
specialty mental health services
How the gender variable can affect the mental
health
Vittorio Lannutti
Sociologist - Educator
Coo.S.S. Marche
 Introduction
Sex: men/women on the basis of their biological characteristics
Gender: different features socially constructed.
Gender influences the control men and women have over the determinants
of their health:
- economic position,
- social status,
- access to resources.
Material and symbolic positions that men and women occupy in the social
hierarchy
Gender interacts with other variables: age, family structure, income,
education and social support, and with a variety of behavioural factors
Sex and gender affect biological vulnerability, exposure to health
risks, experiences of disease and disability, and access to medical
care and public health services

Gender-sensitive research is more likely to lead to improved

outcomes in treatment and preventative interventions

The role of gender in public health is now widely acknowledged

Gender has profound implications for many other aspects of mental

health disorders, on sufferers and their families, the burden of care
(which most frequently falls on women), and the stigma associated
with mental health problems
 Some data to start with
Statistics on mental disorders conceal the considerable differences
men/women in the prevalence of specific types of MD and at
different stages of the life-cycle

Women are more likely than men to suffer from poor mental
health: depression and eating disorders

The rates of substance abuse are more than three times higher in
adult men than in adult women

The more severe mental illnesses: schizophrenia and bipolar

disorders are equal in men and women
Tipology of disease Prevalence
Depression W 41,9%, M 29,3%
Depression, organic brain syndromes and Older adults
dementias
Violent conflicts, civil wars, disasters, and Women and children.
displacement
Rate of violence against women Ranges 16% - %0%
Rape or attempted rape in their lifetime. At least one in five
women
Depression, anxiety, psychological distress, sexual violence,
domestic violence and escalating rates of substance use affect more
women than men
Women's poor mental health caused by a combination of:
- their multiple roles,
- gender discrimination,
- factors of poverty (hunger, malnutrition),
- overwork,
-domestic violence and sexual abuse
Sense of loss, inferiority, humiliation or entrapment – depression
Up to 20% of those attending primary health care in developing
countries suffer from anxiety and/or depressive disorders. In most
centers, these patients are not recognized and therefore not treated
Communication difficulties health workers/women makes a
woman's disclosure of psychological and emotional distress
difficult, and often stigmatized
3 main factors which are highly protective against the
development of mental problems:
- having sufficient autonomy to exercise some control in
response to severe events;
- access to some material resources that allow the possibility
of making choices in the face of severe events;
- psychological support from family, friends, or health
providers is powerfully protective
 Gender and Mental Health: why this connection?
Gender:
- determinant of mental health and mental illness
- has significant power regarding differential susceptibility
and exposure to mental health risks and differences in
mental health outcomes
- gender differences in rates of overall MD (schizophrenia
and bipolar disorders), are negligible
It is predicted that depression will be the second leading
cause of global burden of disease by 2020
• Depression is twice as common in women compared with men
• With identical symptoms, women are more likely to be diagnosed
as depressed than men
• Men predominate in diagnoses of alcohol dependence
• Depression and anxiety: common comorbid diagnoses - need for
gender awareness training to overcome gender stereotypes
• Comorbidity is associated with mental illness of increased
severity, higher levels of disability and higher utilization of
services
• Women have higher prevalence rates than men of both lifetime in
three or more disorders
• Depression and anxiety are the most common comorbid disorders
• Other disorders that predominate in women: agoraphobia,
panic disorder, somatoform disorders and post traumatic
stress disorder
• To reduce the overrepresentation of women depressed it needs
a multi-level, intersectoral approach, gendered mental health
policy
• Main gender risks are exposure to poverty, discrimination and
socioeconomic disadvantage
• Low rank is a powerful predictor of depression
• Globalization has overseen a dramatic widening of inequality
• For poor women in DC undergoing restructuring, rates of
depression and anxiety have increased significantly
• Increased sexual trafficking of girls and women
• The mental health costs of economic reforms need to be carefully
monitored
• Severity and the duration of exposure to violence are highly
predictive of the severity of mental health outcomes: rates of
depression in adult life are 3 to 4 fold higher in women exposed to
childhood sexual abuse or physical partner violence in adult life;
following rape, nearly 1 in 3 women will develop PTSD compared
with 1 in 20 non victims
• Women are at significantly increased risk of violence from an
intimate and are over represented amongst the population of
highly comorbid people who carry the major burden of psychiatric
disorder
 Gender, human rights and the global burden of
disease
• It is fundamental to consider gender-based
discrimination and gender-based violence

• A human rights framework is needed

• It has to be considered the serious violations of

their rights as human beings including sexual and
reproductive rights suffered by women
 Gender and patterns of mental disorder
Depression and anxiety, often associated with somatic complaints,
affect around 1 in 5 people in the general community

General population studies indicate that lifetime prevalence rates

are a range from 0.1% to 3% for schizophrenia and from 0.2% to
1.6% for bipolar disorders

Gender is related to differences in risk and susceptibility, the

timing of onset and course of disorders, diagnosis, treatment and
adjustment to MD
Schizophrenia:
- men typically have an earlier onset of symptoms than
women and poorer premorbid psychosocial development and
functioning;
- women experience a higher frequency of hallucinations or
more positive psychotic symptoms than men
Bipolar disorder:
-- gender differences are just in the course of the illness
- women are more likely to develop the rapid cycling form of
the illness, exhibit more comorbidity and have a greater
likelihood of being hospitalized during the manic phase of the
disorder
Women with schizophrenia have higher quality social relationships than
men, but..
a cross national survey drawn from Canada, Cuba and the USA found
that this was only true for Canadian women; Cuban men reported higher
quality of life than Cuban women
a Finnish study on gender differences in living skills (self care, shopping,
cooking) found that half the men but only a third of the women lacked
these skills that are so important for independent living
Skills inculcated through gender socialization can affect long term
adjustment to and outcome of a severe mental disorder
Gender specific exposure to risk also complicates the type and range of
adverse outcomes associated with severe mental disorder
When schizophrenia coexists with homelessness, women experience
higher rates of sexual and physical victimization, and more comorbid
anxiety, depression and medical illness than men
 Gender and Depression
It is most significantly to the global burden of disease
It is the most frequently encountered women’s mental health
problem
Unipolar or major depression occurs twice as often in women as in
men
A significant reduction of women depressed should reduce the
global burden of disease and disability
It is predicted to be the second leading cause of global disease
burden by 2020
Comorbidity contributes significantly to the burden of disability
caused by psychological disorders
Studies conducted in Usa, Puerto Rico, Canada, France, Iceland, Taiwan,
Korea, Germany and Hong Kong: women predominated over men in lifetime
prevalence rates of major depression

Female gender is a significant predictor of relapse

National Comorbidity Survey: Prevalence rates of selected disorders
Lifetime Lifetime 12 Month 12 Month
Mental Disorders Prevalence Prevalence Prevalence Prevalence
Female Male Female Male
Major depressive
21.3% 12.7% 12.9% 7.7%
episode
Alcohol
8.2% 20.1% 3.7% 10.7%
dependence
Antisocial
personality 1.2% 5.8% NA NA
disorder
 Suicidal behaviour
Key risk factors for suicidal behaviour are
- mental disorder
- cultural factors
- social and economic factors
Male:female differences are likely to account for at least some of the
observed differences in suicide rates between men and women
In many cases these risk factors interact with one another in complex
ways
Completed suicide rates are higher in men
Suicide attempts rates are higher in women
Gender-based violence is a significant predictor of suicidality in women
Women have twofold higher rates of PTSD than men
The male excess for completed suicide has been partly attributed to
the use of more lethal methods like guns (cultural differences about
using of weapons)
Women tend to opt for "softer", less lethal means, such as pills and
cutting
Increased rates of suicide, particularly among men during periods
of economic recession and high unemployment
Economic reforms and increase in unemployment have been linked
a rise in all-cause mortality in men (East Europe and some of the
former members of the USSR)
In East Europe male suicide rates are over three times as high as
those of men in most West Europe
It is likely that the differential impact on men and women of the
rapid economic transition in eastern Europe (increasing poverty and
unemployment), is linked to gendered differences in social roles
and expectations

Men who are faced with unemployment and economic crises in

societies where their primary role is that of breadwinner are
probably at greater risk for suicidal behavior

It is important the role of smoking and drinking, used by men to

cope with difficult life events
 Gender and Comorbidity
Depression and anxiety are common comorbid diagnoses and
women have higher prevalence than men
Almost 50% of patients with at least one psychiatric disorder
have a disorder from at least one other cluster of psychiatric
disorders
Women predominate in: depressive episode, agoraphobia, panic
disorder, anxiety, somatization, hypochondriasis, somatoform
pain
Psychiatric comorbidity with depression is a common factor in
women’s mental health
Comorbidity is associated with increased severity, higher levels of
disability and higher utilization of services
It is concentrated in a small group of people
Highly comorbid people have been found to carry the major burden
of psychiatric disorder
Women had significantly higher lifetime and 12 month comorbidity
of three or more disorders than men
The multi-country WHO study on Psychological Problems in General
Health Care:
- panic attacks and a diagnosis of panic disorder were frequently
associated with the presence of a depressive disorder
- women predominate in all three disorders- panic attacks, panic
disorder and depressive disorder
- combination of these disorders resulted in a long lasting and
severe disorder that was linked to a higher rate of suicidality
 Comorbidity and compounding over time
Clinicians, policy makers and researchers want to understand why
psychological disorders compound and proliferate over the life course of
women in particular, in order to devise effective interventions
The risk of onset of physical disability, even after controlling for the
severity of the physical disease, increased 1.5 fold three months after
the onset of a depressive illness and 1.8 fold at 12 months
The risk of onset of social disability increases from a 2.2 fold risk at 3
months to a 23 fold risk at 12 months
It is very important to identify women who have a history of and/or are
currently experiencing violent victimization
Higher rates of depression and PTSD increase when victimization goes
undetected, so there is a more costly utilization of the health and
mental health care system
 GENDER BIAS
Research
The relationship of women’s reproductive functioning to their
mental health has received protracted and intense scrutiny over
many years
The impact of biological and reproductive factors on women's
mental health is strongly mediated or disappears when psychosocial
factors are taken into account
The contribution of men’s reproductive functioning to their mental
health has been virtually ignored
Some studies have revealed that men are emotionally responsive to
many of the same events as women, such as experience depression
following the birth of a child, moreover there is a high level of
correlation between parents regarding depressive symptoms
Treatment

Female gender: significant predictor of being prescribed

psychotropic drugs

Women are 48% more likely than men to use psychotropic

medication after statistically controlling for demographics,
health status, economic status and diagnosis

Women are more likely to seek help from and disclose

mental health problems to their primary health care
physician
Men are more likely to seek specialist mental health care
and are the principal users of inpatient care

Men are also more likely than women to disclose problems

with alcohol use to their health care provider

Despite these gender differences, many people with

psychological disorders do not go to their doctors

If help is not sought in the year of onset of a disorder,

delays in help seeking of more than 10 years are common
in many countries
Funding, organization and insurance
The organization and financing of mental health care are:
- an important contribution to social capital
- an indicator of access and equity in mental health care
Women's overrepresentation amongst poor means that cost will be a
significant barrier to mental health care
A 'user pays' system will further disadvantage poor women, over
represented amongst people with depression, anxiety, panic disorder,
somatization disorder and PTSD
If access to care is not blocked by cost considerations, those in greatest
need are likely to seek treatment
Single motherhood status is the strongest independent predictor of
mental health morbidity and utilization of mental health services
Low income is highly related to single motherhood status
Gender sensitive services
To reduce gender disparities in mental health treatment, gender
sensitive services are essential
Services must be tailored to meet their needs
To ensure that the assistance available is also meaningful the full range
of patients’ psychosocial and mental health needs must be addressed
Services should adopt a life course approach
With regard to the doctor patient relationship, preferred health care
providers are those who show a sense of concern and respect and are
willing to talk and spend time with patients
Services need to be aware of the impact of parents' role on women
with mental illness or substance use disorders
Violence and severe mental illness
Violence-related mental health problems are poorly
identified
Women are reluctant to disclose a history of violent
victimization unless physicians ask about it directly
Violent victimization in childhood predicts admission to
a psychiatric facility during adulthood
A New Zealand study: women whose childhood sexual
abuse involved penetrative sex, were sixteen times
more likely to report psychiatric admissions than those
who had been subjected to lesser forms of abuse
Gender and risk
Impact of gender in mental health is compounded by its
interrelationships with education, income, employment, social roles
and rank
There are strong, albeit varying, links between gender inequality,
human poverty and socioeconomic differentials in all countries
Gender differences in material well being and human development
are widely acknowledged
Women’s health is inextricably linked to their status in society
It benefits from equality, and suffers from discrimination
The status and well being of countless millions of women world-
wide remain low
Gender and work

The weakening of worker protection laws as well as their

overrepresentation amongst sex workers, represent
significant threats to mental and physical health and
violations of women’s human rights

The workplace is another area where rank is predictive of

depression and linked to gender

Work characteristics are closely allied to employment grade

and make the largest contribution to explaining differences in
well being and depression
Women are more likely to occupy lower status jobs with
little decision-making discretion

Relationship between various objective measures of rank

and the increased likelihood of poor health, depression
and anxiety

Low educational status, unemployment, low employment

status and pay, insecure, ‘casual’ employment, single
parent status, homelessness and insecure housing tenure
and inadequate income, poor social support and
diminished social capital
Gender roles
Women of reproductive age may carry the triple burden of
productive, reproductive and caring work
Gender differences in rates of depression are strongly age related
The largest differences occur in adult life
Multi country WHO study on Psychological Problems in Primary
Care: when social role variables were matched between women and
men the female excess in depression was reduced by 50% across
all centres in the study
Gender roles intersect with critical structural determinants of health
(social position, income, education and occupational and health
insurance status)
Role patterns of women are not evenly distributed across income levels
Low income mothers - higher levels of depression
Poor women are exposed to more frequent, more threatening and more
uncontrollable life events: illness and death of children and the
imprisonment or death of husbands
They face:
- more dangerous neighbourhoods
- hazardous workplaces
- greater job insecurity
- violence and discrimination
Abortions, experiencing sexual abuse, other forms of violence and
adversity in childhood or adult life contribute to poorer mental health
These factors work to reduce the degree of autonomy, control and
decision making latitude possible for women on low incomes
Economic policies
Connection among rising income inequality - increasing rates of
common mental disorders - increased rates of mortality from
physical conditions - increased mental health related mortality
associated with substance use disorders and suicide
In Russia:
- significant falls in life expectancy include fast economic change
- high turnover of the labour force
- increased levels of crime
- alcoholism
- inequality
- decreasing social cohesion
Impact of globalization and structural adjustment programmes is
especially severe in the poorest nations

It occurs in gender distinct ways because of the separate roles men

and women play

Cutbacks in public sector employment and social welfare spending

can cause the costs of health care, education and basic foodstuffs to
become unaffordable, especially to poor women

Evidence on the gender specific effect of restructuring on mental

health show significant associations between high rates of
depression, anxiety and somatic symptoms and female gender, low
education and poverty
Gender inequality accompanies but is also worsened by
economic inequality and rising income disparity

The result of this interaction is a steep rise in the very mental

disorders in which women already predominate.

Economic policies that cause sudden pose overwhelming

threats to mental health

An increase in the number of disruptive, negative life events is

paralleled by an increase in the numbers of women becoming
depressed
Research carried out in GB:
- 85% of women who developed ‘caseness’ for depression
in a 2 year study period experienced a severe event in
the 6 months before onset
- depression was accompanied by low self-esteem and
inadequate support
- the matching of a current severe event with a
pronounced ongoing difficulty was also critical to the
onset of depression
- most important of all was the experience of humiliation,
defeat and a sense of entrapment, often in relation to a
core relationship
Research based studies of women in Zimbabwe, London,
Spain:
- women meeting the criteria for depression varied from a
low of 2.4% in the Basque Country to a high of 30% in
Zimbabwe
- negative, irregular, disruptive life events were found to
trigger depression in all Countries
- a strong linear relationship exists between the number
and severity of events and the prevalence of depression
Impact of gender-based violence on mental health
Gender differentiated levels of susceptibility and exposure to the
risk of violence place stringent limitations on women's ability to
exercise control over the determinants of their mental health
Social research indicates that depression in women is triggered by
situations that are characterized by humiliation and entrapment and
that this occurs in relation to 'atypical events'
Violence in the home tends to be repetitive and escalate in severity
over time and encapsulates all three features identified in social
research on depression in women:
- humiliation
- enforced inferior ranking and subordination
- blocked escape or entrapment
Violence-physical, sexual and psychological - high rates of
depression and comorbid psychopathology
Psychological disorders are accompanied by multi somatisation,
altered health behaviours, changed patterns of health care
utilization and health problems affecting many body systems
Being subjected to the exercise of coercive control leads to
diminished self esteem and coping ability
Violent victimization increases women’s risk for unemployment,
reduced income and divorce
Gender based violence is a particularly important cause of poor
mental health because it further weakens women’s social position
Female victims of sexual violence make up the single largest group
of those suffering from PTSD
The likely causal role of violence in depression, anxiety and other
disorders such as posttraumatic stress disorder is suggested by:
• three to four fold increases in rates of depression and anxiety in
large community samples amongst those exposed to violence
compared with those not exposed
• severity and duration of violence predicts severity and number of
adverse psychological outcomes (impact of domestic violence and
childhood sexual abuse)
• marked reductions in the level of depression and anxiety once
women stop experiencing violence and feel safe compared with
increases in depression and anxiety when violence continues
The female excess in depression and other disorders reflects
women’s greater exposure to a range of stressors and risks to their
mental health, rather than an increased, biologically based
vulnerability to psychological disorder
How cultural variable can affect the mental
health
Vittorio Lannutti
Sociologist - Educator
Coo.S.S. Marche
 Introduction
The concept of culture:
- intellectual and material heritage,
- heterogeneous/integrated,
- sometimes internally antagonistic,
- durable but subject to continuous transformations
Consisting of:
- values,
- norms,
- definitions,
- languages,
- symbols,
- signs,
- behavior patterns,
- mental and bodily techniques,
- a cognitive, affective, evaluative, expressive, regulatory,
manipulative function;
- objects,
- supports,
- material or physical vehicles;
- material means for the production and social reproduction of man
produced and developed entirely through work and social
interaction
Prevalence rates of common mental disorders vary considerably
between countries

It is fundamental to find meaningful empirical instruments for

capturing the latent construct of ‘culture’ of mental disorders

It bears upon what all people bring to the clinical setting

Variations in how people communicate their symptoms

Some aspects of culture may also underlie culture-bound syndromes

It is important to consider if people seek help, what types of help

they seek, what types of coping styles and social supports they have,
and how much stigma they attach to mental illness
It influences the meanings that people impart to their illness

Users of MH services carry diversity inside the service

The cultures of the clinician and the service systems affect the
clinical approach and shape the interaction with the MH user

Culture and social contexts shape the MH of minorities and

alter the types of MH services they use

Cultural misunderstandings patient

 Culture of patient
The culture of the patient influences: MH, mental illness, and way
to use of health care

Cultural characteristics of a group may invite stereotyping of

individuals based on their appearance or affiliation

Culture affects the way in which people describe their symptoms

Cultures differ in the meaning and level of significance and concern

they give to mental illness

Every culture has its own way of making sense of the subjective
experience (MH)
Each has its opinion on whether mental illness is real or imagined:
who is at risk for it, what might cause it, and its level of stigma

Mental illness can be more prevalent in certain

cultures/communities:
- the prevalence of schizophrenia is consistent throughout the
world
- depression, PTSD, and suicide rates are more attributed to
cultural and social factors

In US some Asian groups prefer avoidance of upsetting thoughts

about personal problems rather than outwardly expressing that
distress
Cultural factors often determine how much support people have
from their families and communities in seeking help

It has a significantly impacts a person’s quality of life and can cause

severe distress and secondary health effects

The symptoms of mental disorders are found worldwide

Cultural and social context weigh more heavily in causation of

depression

Social and cultural factors play a greater role in the onset of major
depression
Factors often linked to ethnicity can increase the likelihood of
exposure to types of stressors

Cultural and social factors have the most direct role in the causation
of PTSD

Traumatic experiences are particularly common for certain

populations: combat veterans, inner-city residents, immigrants from
countries in turmoil

There are high rates of PTSD in communities with a high degree of

pre-immigration exposure to trauma
 Family factor
Family life influences MH
Family factors protect against, or contribute to, the risk of
developing a mental illness
Family risk and protective factors for mental illness vary across
ethnic groups
Researches on family factors and mental illness deals with
relapse in schizophrenia
Studies in GB: people with schizophrenia who returned from
hospitalizations to live with family members who expressed
criticism/hostility, or emotional involvement were more likely to
relapse than were those who returned to family members who
expressed lower levels of negative emotion
Other studies reconceptualized the role of family
A study comparing Mexican American/white families
found that different types of interactions predicted
relapse:
- in Mexican American families, interactions featuring
distance or lack of warmth predicted relapse for
schizophrenics
- in white families, the converse was true
So, culturally based family differences may be related
to the course of mental illness
 Coping Styles
How people cope with everyday problems and more extreme
types of adversity

Some Asian American groups tend not to dwell on upsetting

thoughts, thinking that reticence or avoidance is better than
outward expression - suppression of affect

African Americans tend to have an active approach in facing

personal problems, rather than avoiding them

A better understanding of coping styles has implications for

the promotion of MH
 Treatment Seeking
Ethnic minorities in US seek less help in MH services than whites, so they
are underrepresented in MH services

Treatment seeking denotes:

- the pathways taken to reach treatment and the types of treatments
sought;
- the final outcome of contacts after that the MH disorder has been
recognizes

Some minority ethnic groups are more likely than whites to delay
seeking treatment until symptoms are more severe

In some cases they turn to informal sources of care: clergy, traditional

healers, and family and friends
Some African Americans prefer therapists of the same ethnicity
(development of ethnic-specific programs that match patients to
therapists of the same culture)

Many African Americans also prefer counseling to drug therapy

Many ethnic minorities are less inclined than whites to seek MH

treatment because of:
- cost
- fragmentation of services
- societal stigma on mental illness
- mistrust
- limited English proficiency
 Mistrust
Mistrust is a major barrier to the receipt of MH treatment by ethnic
minorities

Mistrust of clinicians by minorities arises from:

- historical persecution,
- present-day struggles with racism and discrimination,
- documented abuses and perceived mistreatment

In US a survey found that 12% of African Americans and 15% of

Latinos, in comparison with 1% of whites, felt an unfairly or disrespect
treatment by MH operators

Immigrants and refugees feel extreme mistrust of government, based

on atrocities suffered in their country of origin
 Stigma
Gradualness in the intolerance towards the stranger

Prejudice - cognitive mechanism: distinction of the 'objects' in pre-

established categories (the reality and the strangers are ranked in
mental categories)

Prejudice - ground for the origin of stereotypes: rigid and standardized

representations of social groups (negative and stigmatized evaluations)

Stereotype and prejudice are complementary to ethnocentrism

Ethnic prejudice and ethnocentrism determine racism and xenophobia

Mental illness stigma: devaluing, disgracing, disfavoring

Discrimination

Inequitable treatment

Denial of citizenship rights

Consequences of stigmatization:
- denying resources
- disadvantages at the economic, social, legal, and institutional levels
- difficulties to seek treatment
- difficulties to adhere to treatment regimens
- difficulties to find a job
- difficulties to live successfully in community settings
Attitudes toward mental illness vary

Cultural and religious teachings can influence beliefs about mental illness

Beliefs about mental illness can affect patients’ readiness and willingness
to seek and adhere to treatment

Understanding individual and cultural beliefs about mental illness is useful

to deliver effective approaches to MH care

Each individual’s experience with mental illness is unique

Different attitudes of stigmatization of American Indian tribes towards

mental ill: totally or partially

In Asia mental illnesses are often stigmatized and seen as a source of

shame
Perception of causes of mental illness can influence the stigmatization

Study in which Chinese Americans and European Americans were

involved: genetic attribution of mental illness significantly reduced
unwillingness to marry and reproduce among Chinese Americans, but it
increased the same measures among European Americans

World Mental Health Surveys: stigma was closely associated with

anxiety and mood disorders among adults reporting significant disability

Stigma leads to diminished self-esteem and greater isolation and

hopelessness

Stigma can also be against family members

Experience of symptoms, a cross-cultural studies about Asian
Americans living in Los Angeles:
- 12% would mention their MH problems to a friend or relative
(versus 25% of whites),
- 4% would seek help from a psychiatrist or specialist (versus 26%
of whites)
- 3% would seek help from a physician (versus 13% of whites)

Public attitudes toward mental illness, in a study of stigma in the

US emerged:
- people with mental illness were perceived as dangerous and less
competent to handle their own affairs
- ethnicity doesn't influence the degree of stigma
In US minorities hold similar or stronger, stigmatizing
attitudes toward mental illness than do whites

Societal stigma keeps minorities from seeking needed

mental health care

Stigma affects the self-esteem both of patients, and of

family members

Stigma is very powerful in the deterring people from

seeking help
A majority of all people with diagnosable mental disorders
do not get treatment

Presenting MH care services in culturally-sensitive ways

could increase access to and usage of MH care services

Conceptualizations and treatments for depression should

take into account diverse perspectives on mental illness in
order to maximize the effectiveness of MH care delivery
programs
 Immigration
Migration, a stressful life event, can influence MH
Acculturative stress occurs in the process of adapting to a new culture
Refugees experience more trauma
The psychological stress-immigration tends is often concentrated in
the first three years
According to studies of Southeast Asian refugees:
- first year - initial
- second year - strong disenchantment and demoralization reaction
- third year - gradual return to well-being and satisfaction
Immigration per se does not result in higher rates of mental disorders
Traumas experienced by adults and children from war-torn countries -
PTSD
 Overall Health Status
The burden of illness is higher in ethnic minorities
Higher rates of physical disorders among ethnic minorities hold
significant implications for MH
Chronic physical illness is a risk factor for mental disorders
Ethnic minority groups who already have both a mental and a
physical disorder are more likely to have their mental disorder
misdiagnosed
People with comorbid disorders are:
- treated with more drug interactions and side effects
- more likely to be unemployed and disabled, than who have a
single disability
Interrelationships mind/body
 Culture of the Clinician
Professionals have a "culture":
- a shared set of beliefs, norms, and values
- jargon, orientation and emphasis in their their way of looking at the
world
Western medicine: the primacy of the human body in disease
MH professionals trace their roots to Western medicine
- the first forms of biological psychiatry in the mid-19th century
(advances in pharmacological therapy)
- the advent of psychotherapy (psychoanalysis)
Today many forms of psychotherapy - verbal communication
patient/therapist
Best today's treatments for specific mental disorders combine
pharmacological therapy and psychotherapy
Most clinicians: interrelationship body-mind-environment

Possible different visions clinicians/patients about

symptoms, diagnoses, treatments

When clinician and patient do not share the same ethnic

or cultural background, cultural differences emerge

Clinicians should understand how their relationship with

the patient is affected by cultural differences
 Communication
The emphasis on verbal communication

The diagnosis and treatment mostly depend on verbal

communication patient/clinician about symptoms, their
nature, intensity, and impact on functioning

Overt and subtle forms of miscommunication and

misunderstanding can lead to misdiagnosis, conflicts
over treatment, and poor adherence to a treatment
plan
 Clinician Bias and Stereotyping
Misdiagnosis can be due to clinician bias and stereotyping of
minorities
Clinicians reflect attitudes and discriminatory practices of
their society
Racism and discrimination have diminished, but there are
traces which are manifest in less overt medical practices:
- diagnosis
- treatment
- prescribing medications
- referrals
In US African American patients are subject to over
diagnosis of schizophrenia and under diagnosed for
bipolar disorder, depression, anxiety

Minority patients are less likely than whites to receive the

best available treatments for depression and anxiety

Possibility that institutional factors and attitudes that were

common to black and white physicians contributed to
lower rates of utilization by black patients
 Service Settings and Sectors

MH services are provided by numerous types of

practitioners in different settings:
- home,
- community,
- institutions,
and sectors:
- public or private primary care,
- specialty care
The current availability of services is in sharp contrast
to the institutional orientation of the past

Today's best mental health services extend beyond

diagnosis and treatment to cover prevention and the
fulfillment of broader needs

Services are:
- formal (professionals)
- informal (volunteers)
There are four major sectors for receiving MH care:

1. services - mental hospitals, residential treatment

facilities, community MH centers, day treatment
programs, rehabilitation programs with specialized MH
professionals

2. general medical and primary care sector (primary

care physicians, nurse practitioners, internists, and
pediatricians) in clinics, offices, community health
centers, and hospitals;
3. human services sector - social welfare (housing,
transportation, and employment), criminal justice,
educational, religious, and charitable services;

4. voluntary support network - self-help groups and

organizations devoted to education, communication,
and support

Users can exercise choice in treatment between

psychotherapy, counseling, pharmacotherapy
(medications), or rehabilitation
 Culturally Competent Services
Tremendous changes in MH service delivery were in the last four
decades
Social factors:
- civil rights movement,
- the expansion of MH services into the community,
- the demographic shift toward greater population diversity
Huge variations in utilization minorities/mainstream
It has discovered the influence of culture on MH
Major differences were found in some mental disorders, idioms for
communicating distress, and patterns of help-seeking
Self-examination by the MH field and the advent of user and family
advocacy
Key elements of therapeutic success depend on:
- rapport and the clinicians' understanding of patients' cultural
identity,
- social supports,
- self-esteem,
- reticence about treatment due to societal stigma
Insistence by stakeholders to deliver services responsive to
the cultural concerns of ethnic minority groups
Humanistic values and intuitive sensibility
Tailoring services to the specific needs of these groups
improves utilization and outcomes
Cultural competence underscores the recognition of
patients' cultures

Services tailored to culture would encourage minorities to

get treatment

Cultural competence represents a fundamental shift in

ethnic relations

Participation of users, families and communities helping

service systems design and carry out culturally
appropriate services is also essential
 Racism, Discrimination, and Mental Health
Racism and discrimination: beliefs, attitudes, and practices that
denigrate individuals or groups because of phenotypic characteristics or
ethnic group affiliation

Discrimination in housing rentals and sales and in hiring practices

Racism and discrimination also in the administration of medical care

Racism and discrimination: from demeaning daily insults to hate crimes

Racism and discrimination can be perpetrated by institutions or

individuals, acting intentionally or unintentionally
General Social Survey (in US): significant percentage of whites held
disparaging stereotypes of African Americans, Hispanics, and Asians

Minority groups commonly report experiences with racism and

discrimination to be stressful

African Americans and Hispanic Americans reported higher overall

levels of global stress than did whites

Some studies link the experience of racism to poorer mental and

physical health

Racism linked with hypertension among African Americans

Discrimination is associated with psychological distress, lower well-

being, self-reported ill health, and number of depression
Racism and discrimination are clearly stressful events
US researchers asked how racism may jeopardize MH of
minorities. Three general ways are proposed:
1. Racial stereotypes and negative images can be
internalized, denigrating individuals' self-worth;
2. Racism and discrimination by societal institutions
have resulted in minorities' lower SES in which poverty,
crime, and violence are persistent stressors that can
affect MH;
3. Racism and discrimination are stressful events that
can directly lead to psychological distress
 Poverty and Mental Health
People living in poverty have the poorest overall health (also
MH)
People in the lowest SES are about 2-3 times more likely than
those in the highest strata to have a mental disorder
An environment is conducived to violence when has:
- disadvantaged community marked by economic and social
flux,
- high turnover of residents,
- low levels of supervision of teenagers and young adults
Young ethnic minority men from such environments perceived
as prone to violent behavior – higher rates of arrested for
violent crimes
Exposure to community violence leaves immediate/long-term
effects on MH
Poverty related to poorer MH:
1. people poor are more likely to be exposed to stressful social
environments
2. having a mental disorder can lead to poverty
So poverty is a consequence of mental illness
Poverty and SES don't play an exclusive role
A lower SES by itself does not explain ethnic disparities:
- Mexican American immigrants in US even if impoverished, enjoy
excellent mental health
- immigrants' culture is a protection against the impact of poverty
Organization of public and private services for
mental health
Vittorio Lannutti
Sociologist - Educator
Coo.S.S. Marche
 European level
The promotion of mental health and the prevention and
treatment of mental disorders are objectives were adopted by:
EU-MS, European Commission and Council of Europe
WHO Regional Office for Europe has developed this Action Plan in
partnership with the leading actors in MH
The Action Plan is fully aligned with the values and priorities of
the new European policy framework for health and well-being,
Health 2020
It is closely interrelated with other WHO programmes and it
covers mental health and mental disorders across the life-
course
 MH in Europe: status and challenges
EU is facing diverse challenges affecting the (mental) well-being
Challenges common to MS:
- maintaining the well-being of the population,
- making a commitment to the rights and empowerment of
service users and their families,
- guaranteeing access and quality of care
Policies across government can increase mental well-being and
reduce exposure to risk factors
MH problems are the main cause of disability and early
retirement in many countries and a major burden to economies
Commitment to deinstitutionalization, but different
outcomes
Care and treatment should be provided in local settings
Large mental hospitals often lead to neglect and
institutionalization
Focus on multidisciplinary MH staff in community-based
facilities
A large proportion of people with mental disorders has
difficulties to access to treatments
Reforms need to achieve higher confidence in the safety
and effectiveness of care
The life expectancy of people with MH problems is many
years shorter than other population
Lack of awareness and stigma play an important part
All sectors of society have a responsibility for MH
It can still be difficult to identify who is in charge of
coordinating action
The importance of choice and partnership emphasizes the
need for transparent information and accountability to
inform all stakeholders about quality of care and
interventions, and to demonstrate the need for
improvement and the potential for innovation and change
 European values and vision for mental health
3 complementary values and accompanying visions inspiring
this Action Plan:
a) Fairness: everyone is enabled to reach the highest
possible level of mental well-being and is offered support
proportional to their needs
b) Empowerment: all people with MH problems have the
right, to be autonomous, having the opportunity to take
responsibility for and to share in all decisions affecting their
lives, MH and well-being.
c) Safety and effectiveness: people can trust that all
activities and interventions are safe and effective, able to
show benefits to population MH or the well-being of people
with MH problems
 European MH Action Plan: scope
Scope of the Action Plan proposes a three-pronged,
interdependent, indivisible and mutually-enforcing approach
a) Improve the mental well-being of the population and
reduce the burden of mental disorders (special focus on
vulnerable groups)
b) Respect the rights of people with MH problems and offer
equitable opportunities to attain the highest quality of life
c) Establish accessible, safe and effective services that meet
people’s mental, physical and social needs and the
expectations of people with MH problems and their families
 European MH Action Plan: objectives
Actions should be prioritized according to needs and resources
at national, regional and local levels
The 4 core objectives are:
a) everyone has an equal opportunity to realize mental well-
being;
b) people with MH problems are citizens whose human rights
are fully valued, protected and promoted;
c) MH services are accessible and affordable, available in the
community according to need; and
d) people are entitled to respectful, safe and effective
treatment
The 3 cross-cutting objectives are:
e) health systems provide good physical and
mental health care for all;
f) MH systems work in well-coordinated
partnerships with other sectors; and
g) MH governance and delivery are driven by good
information and knowledge
 MH services are accessible and affordable, available in the
community according to need
Centrality of psychological, biomedical socioeconomic and cultural
matters
In all UE countries: shift from institutional psychiatry to community
based MH care
Large asylums have been closed in some countries, while closure
plans are in place in others - reduced number of psychiatric beds in
most countries
Primary care is the first point of access
The stigma of accessing primary care is low
Settings are accessible and brief interventions can be delivered
efficiently
MH services that are local and community-based, organized around
the needs of a population catchment area, that provide and
integrate:
- information and means to help oneself or support family
members,
- primary care linked services for treatment of common MH
problems,
- community MH services for prevention, treatment and
psychosocial rehabilitation,
- beds available as a last resort in settings such as health centres or
district general hospitals for people requiring intensive care,
- support in residential homes for people with long term MH
problems and some regional or national services for special
conditions including forensic services.
Community services often rely on the commitment of
families, that should benefit from the necessary support,
education and the provision of resources
Necessity of competent staff
Changes in service structure and ways of working require
- changes in workforce numbers and skill mix in all parts
of the MH services
MH care in Europe is usually, but not always, free of user
charges at the point of entry
Payment or co-payment may be required for specialized
services in some countries
Health systems provide good physical and mental health care
for all
The high burden of disease posed by MH problems is
exacerbated by many co-morbidities and interactions between
mental and physical (ill) health
Disparities in health care access, provision and utilization have
a role in determining the morbidity and mortality gap between
people with mental disorders and the rest of the population
(this gap is increasing)
Mental disorders are risk factors for a range of physical
diseases
Poor mental health adversely affects the course and outcome
of many physical diseases
 MH systems work in well coordinated partnership with other
sectors
It is essential a combination of services working in partnership
Agencies need to determine their roles and responsibilities and
organize appropriate coordination systems
In many countries, funding streams for mental health, public
health and social care services originate from different sources
and budgets, resulting in payment or reimbursement rules
that can hinder good practice
In some circumstances, service users and their families know
best how to allocate resources effectively and efficiently, and
this also empowers them
 Italian level - The organization of MH services

Implementation of 180 Law:

-78-98: experimentation of the reform
-First project aimed at protecting MH 1994 -
historic step
-Second project to safeguard MH 1999-2000:
-it confirms the contents of the law 180,
-the Department of Mental Health (DMH) becomes
the organizational and coordination structure
 The objective project to protect mental health
Useful for qualitative and quantitative development of psychiatric
assistance for 5 fundamental reasons:
1) final overcoming of the asylum
2) It identifies the DMH as the most suitable organizational model
for therapeutic continuity and unitarity of interventions
3) It defines the DMH as an integrated set of structures and
services with unique management and coordination
4) PDSC, even if located in a general hospital, is an integral part of
the DMH
5) It requires verification of the quality of services and
interventions
Tasks of the DMH

therapeutic

rehabilitation

social reintegration
Therapeutic task:
ambulatory and home psychiatric activities, emergency and
crisis response interventions

Rehabilitation task:
act to develop the person's skills (few or many), to improve
his or her autonomy and relationships

Social reintegration task:

create the conditions necessary to include the person in the
collective life (therapeutic and rehabilitative programs,
economic and relational resources, work and housing
opportunities)
 The operational units of the DMH (objective
project)
• Mental Health Center (MHC)

• Psychiatric Service of Diagnosis and

Care (PSDC)

• Residential and semi-residential

structures (RS)
 The DHM of Trieste
4 MHC 24 h

1 University Psychiatric Clinic / MHC (8 beds of which 4

territorial)

1 Qualification and Residency Service (QRS) (coordinates

social cooperatives, training and job placement)

1 PDSC (6 beds at the general hospital)

 The Mental Center Health
Place of acceptance and exchange, opportunity for
relationship, possibility of staying at least temporarily out
of a difficult family situation
The MCH to work well should:
- manage a population between 50,000 and 80,000
inhabitants,
- being accessible without difficulty even with public
transport
 Functions, activities, programs of the MHC
Recognition and crisis management in the 24-hour
Individualized rehabilitative treatment programs
Protagonism, participation and user involvement
Information and training for family members
Promotion of self-help activities
Facilitation of associations
Recreational and recreational activities
Basic, professional and social enterprise training activities, job
placement
Consulting service in prison
Integration with health districts
Family doctor involvement (Health Tutor)
Prevention of discomfort related to the loneliness of the
elderly
Suicide prevention
Gender differences and MH
Relations with the cultural agencies of the city
 Services of Mental Health Center
- Night hospitality:
For variable periods of time (from one night to several weeks)
Acceptance for the purposes of Mandatory Healthcare is also
normally carried out in the MHC
- Day hospitality:
For a few hours, or for the whole day, it is proposed to offer a
condition of temporary protection or protection during the crisis, to
alleviate the family
- Outpatient visit:
During the outpatient visit, news and opinions are exchanged with
the person and / or family members, or action is taken in crisis
situations
- Home visit:
Programmed or urgent, it allows the knowledge of
the living conditions of the person and his family
- Individual therapeutic work:
Meetings with family members to verify and
discuss the dynamics and conflicts, in order to
promote greater knowledge and participation in
problems
- Goup activity:
Meetings in which the exchange of information on
common problems strengthens the ability to know
each other. Main purpose: to activate the social
network
- Habilitation and prevention interventions:
Initiatives to initiate paths to access information and
culture, training and job placement
- Support for access to social rights and
opportunities
- Housing support:
Programs carried out at home to support daily life
skills and preserve or re-learn social and interpersonal
skills of group life. Support for residential activities
- Consulting activity
Interventions in: health services or hospital wards,
prison, district offices, public and private retirement
homes
- Telephone:
Active at least 12h a day for reports, suggestions,
appointments, checks even in case of emergencies
 Psychiatric Service of Diagnosis and Care (PSDC)
The interface between hospital and territory
- Structure for emergencies / emergencies
- placed inside a general hospital
- open 24 hours a day, 7 days a week
- place of transition (improper use in many realities)
- implements Compulsory Healthcare (CH) and Voluntary Health
Treatment in admission conditions
- psychiatric counseling to other hospital divisions and to the
emergency room
- connected to the MHD (administratively, functionally,
operationally)
- a bed every 10,000 inhabitants
- max 16 beds
- adequate spaces to guarantee respect for privacy and rights also for
people in CH
- spaces for common activities
- open doors
- no containment
- reduce the duration of hospitalization, in line with the principle of
territoriality of care
- hospitalization never replacing the taking charge of the MHC but only an
exception motivated by very particular needs
- possibility of maintaining contacts with one's environment for easier
overcoming of crisis situations
- guarantee the continuation and territoriality of the care by the MHC
 Residential Structures
Respond to people's housing needs
- Extra-hospital facilities where part of the therapeutic,
rehabilitation and social integration program takes place
- Providing a network of relationships and emancipatory
opportunities is not just a housing solution
- Location in urbanized and easily accessible areas
- Managed by DMH or private social and / or business (DMH project
owner)
- Access and discharge based on personalized therapeutic program
agreed with MHC operators, RS operators, person, family
members and / or other reference persons
- 2 places / 10,000 inhabitants
Therapeutic community:
- structure with high therapeutic rehabilitation intensity
- operators 24 hours a day
- particularly active individual and empowering individual
programs
Apartment groups:
- operators 12 h per day
- people with a reasonable level of skill and autonomy
- individual programs aimed above all at social integration
and to guarantee a useful and dignified housing possibility
Housing houses or cohabitation centers:
- more people encouraged to live together and
share the apartment and the management costs
- operators only a few hours a day or by
necessity
guarantee integration with the surrounding
social structure, ensuring them a decent living
 Residential Structures: what shouldn't be

Substitute places of the asylum

Places of passive and chronic abandonment

Places of management of the psychiatric crisis

 The semi-residential centers
- They host people by day
- They provide individual and group rehabilitation
therapeutic programs
- They can be located in the same structure that hosts the
CSM
- Day Hospital: Particular attention is given to intensive
therapeutic programs even in crisis conditions
Day center: Special attention is paid to training and
socialization paths
 The Italian mental health-care reform: outcames
Decreased of patients in psychiatric hospitals/wards (78 538 in
1978 - 7704 in 1998)

Currently there are 10 beds/100.000 in psychiatric wards and 46

beds/100.000 in community residential facilities

Wide differences between geographical areas

Decreasing the number of psychiatric beds is not linked to

increased suicide rates

OECD: suicide rates have remained stable in Italy

After Law180 number of compulsory admissions progressively
declined: more than 20 000 in 1978 - less than 9000 in 2015
Proportion of compulsory psychiatric admissions progressively
declined between 1978 and 2005 and remained stable thereafter,
in 2015 they were less than 5% (8815) of all 187205 psychiatric
admissions
Decreasing the total number of psychiatric beds does not lead to
increased use of psychiatric forensic facilities
In 2016, after the phasing out of forensic psychiatric hospitals,
there were 541 individuals placed in new residential facilities and
201 individuals with mental disorders placed in psychiatric units in
prison
Italy has invested in psychiatric beds placed in community
residential facilities
 How to approach patients with MH
problems on the basis of three variables

Vittorio Lannutti
Sociologist - Educator
Coo.S.S. Marche
Before proposing physical activity the reference
psychiatrist must be consulted in order to obtain
information about:

- the possible cardiovascular and metabolic diseases.

- the side effects of the drugs,

so the instructor is able to assess how far he can go

with the patient in proposing physical exercise
Sketching a project, in which the patients themselves
should also be involved in order to establish:
- the intervention,
- the amount of physical activity time,
- the observation time of how the patient reacts to
the proposed exercise,
- the assessment of the limits and physical
possibilities of patients and changes,
- the attention to the patient's diet and changes
EAP: physical activity (aerobic), is useful and
should be practiced regularly to:

-improve well-being and health on various

fronts,

-it is a real adjunctive therapy effective in

treatment of psychiatric illnesses
Benefits - reduction of the risk of developing:
- hypertension,
- acute and chronic cardiovascular diseases,
- diabetes/overweight,
- impoverishment of bone mass and osteoporosis,
- attenuation of psychiatric symptoms,
- improvement of physical, mental and intellectual
functionality (possible slowing down of the cognitive decline)
- beneficial effects of the movement on sleep at night
To get the maximum benefits, people with
depression should do aerobic physical activity or a
mix of aerobic training and endurance at least 2-3
times a week, for about 45-60 minutes per session

One can choose the discipline that one prefers, in

relation to age and individual physical potential, in
every case they have to be performed under the
supervision of a competent instructor
In the case of schizophrenia, the EAP recommends
at least 150 minutes of moderate-to-vigorous
physical activity per week

One should not expect miracles from physical

activity, but the additional benefit it can bring is
demonstrated
 Working with young

Broader population health interventions are

required to :

- prevent disengagement from physical activity,

- reduce sedentary behaviors in young people

generally, particularly those at risk of developing
mental health problems
Studies indicate the potential for exercise
interventions in improving depression symptoms in
young people
The age range of 12–25 years is a critical time to
intervene to:
- promote early recovery,
- limit negative consequences to social and vocational
functioning
- maximize the opportunity to establish positive long-
term health-related behaviors
These kind of interventions are highly acceptable and
non stigmatizing
Interventions for young people should:

- promote exercise as a pleasant and enjoyable

activity to maximize adherence and sustained
engagement,

- track the long-term health and MH outcomes as

essential to demonstrate the longer-term effects
of exercise in young people’s lives
Exercise is:

- efficacious in reducing key clinical symptoms,

- can be delivered alongside usual treatment for

early psychosis

Individualized exercise training - improving

symptomatic, neuro cognitive and metabolic
outcomes in first-episode psychosis/early stages of
illness
Carter T, Morres ID, Meade O, Callaghan (2016) reported
some recommendations:

- Group-based and supervised light- or moderate-intensity

exercise activities three times a week for a period of
between 6 to 12 weeks could bring about an
improvement in depression

- Exercise seems to be equally effective for both moderate

and severe depression in both inpatient and outpatient
settings
Age group 5–17, appropriate levels of physical activity
contribute to the development of:
- healthy musculoskeletal tissues,
- healthy cardiovascular system,
- neuromuscular awareness,
- facilitates maintenance of a healthy body weight
Physical activity has been associated with
psychological benefits in young people
 Working with adults

Report WHO (2010) - recommendations for level of

physical activity needed for prevention of non-
communicable diseases:

- age 18 - 65, to take at least 150 min of moderate-

intensity aerobic activity throughout the week

- performed on 2 or more days per week

The recommendations are (Paterson, Murias, 2014):

- perform moderate- to vigorous-intensity aerobic

activities to enhance cardio respiratory fitness,

- perform a minimum of 150 min/wk of moderate-

intensity activity that amounts to an energy
expenditure of approximately 1000 kcal/wk (or ~90
min/wk of vigorous exercise)
- gain additional benefits from adding 2 sessions/wk of
muscle-strengthening activities

- balance and mobility are limitations, include balance-

related activities

- structured exercise-training programmes, usually

consisting of 30 min/ session of moderate- and
vigorous-intensity exercise, have been shown to be
effective and safe
Improvements observed in psychosocial functioning and
verbal short-term memory

Increases in cardiovascular fitness and processing speed

associated with the amounts of exercise

High-intensity exercise and low-intensity exercise -

decreasing overall anxiety sensitivity

High-intensity exercise had several distinct advantages

over low-intensity exercise
High-intensity exercise group reported significantly less
fear of anxiety-related bodily sensations at post-
intervention compared to comparison group

There are limitations to using high-intensity aerobic

exercise as an intervention for anxiety sensitivity

Aerobic exercise may prove to be an invaluable treatment

alternative for individuals with high anxiety sensitivity
who cannot or will not consider more traditional means
of intervention
 Working with elderly
Physical activity and exercise influence MH
Impairments in physical capacity and dependence in ADL are
common among older people in residential care facilities
Increased physical capacity and independence in ADL may
be important for MH:
- improved self-esteem and ability to participate in social
activities
- enhancing the possibilities of increasing the level of daily
physical activity
People with dementia often have difficulties to initiate
physical activities
Epidemiological studies have provided evidence of the
effectiveness of PA in increasing active life expectancy and
in preventing:

- functional losses leading to loss of independence and well-

being and some aspects of cognitive losses and depression

- disease and all-cause mortality

Regular physical activity is generally associated with

psychological well-being, although there are relatively few
prospective studies in older adults
Pasco et al.:

- higher levels of habitual PA are protective against the

subsequent risk of development of de novo depressive
and anxiety disorders

- therapeutic effects of exercise in the treatment of

depression are established

- exercise is a viable lifestyle candidate for the primary

prevention of high prevalence MH disorders
Erickson & Kramer (2008): 6 months of moderate
levels of aerobic activity are sufficient to produce
significant improvements in cognitive function

Improvements accompanied by altered brain

activity measures and increases in prefrontal and
temporal grey matter volume
Moderate levels of exercise can serve as:

- a preventive measure against age-related

cognitive and brain deterioration

- a treatment to reverse decay and cognitive

deficits already present in older adults
According to one meta-analysis, the combination
of aerobic and non-aerobic regimens produces
greater benefits to cognitive function than either
type of exercise by itself

There is mounting evidence that exercise has

beneficial cognitive and neural effects on a
number of populations besides those with
dementia, including children, multiple sclerosis
patients, and Parkinson’s patients
 Differences in reaction to physical activity based on
gender
Zhang et al (2015) analyzed the relation between
depressive symptoms and PA among mildly and
moderately depressed individuals: a regular physical
activity reduces depressive symptoms
PA is an effective tool to combat depression
To reduce depressive symptoms for individuals with a
record of bad PH, the amelioration of depression would
have to be accomplished along with PA and other means
A moderate to vigorous intensity exercise program is a
promising strategy for reducing anxiety sensitivity (AS)

Medina et al. (2014): the effects of exercise on MH outcomes

may vary as a function of gender, with men benefitting more
than women

These interventions should be different in women than men

at least as it relates to anxiety reduction

Studies that compare types of exercise modalities and doses

can help refine the knowledge needed to develop
individually tailored exercise interventions
From the psychosocial perspective, it is thought
that women's biological tendencies for increased
worrying are often strongly reinforced by gender-
related norms

The predominance of women suffering from

anxious or affective disorders is most likely due
to a combination of these fundamental
differences at the biological and psychosocial
levels
 Differences in reaction to physical activity based on culture
A social gradient exists in PA behaviour

This gradient is established to a large extent in childhood

and prevails across the life course

Physical inactivity in the socially deprived might accentuate

the effects of psychosocial stress and partly account for the
established social disparities in health and well-being

Adverse socioeconomic position is linked with lower PA and

greater sedentary behaviour (poorer education)
Brodersen et al. (2006) assessed the developmental trends
in PA and sedentary behaviour in British students (11–12
years). Results:
- Asian students were less active than whites, also true of
black girls but not boys
- Black students were more sedentary than white students
- Levels of sedentary behaviour were greater in respondents
from lower SES
- Most differences between ethnic and SES groups were
present at age 11 years, and did not evolve over the
teenage years
PA declines and sedentary behaviour becomes
more common during adolescence
Ethnic and SES differences are observed in PA and
sedentary behaviour in youth, that anticipate
adult variations in health risks
Adolescents of lower SES engage in more
sedentary behaviour, but physical activity differs
by SES only in girls
Earlier intervention
PA is an important factor in determining health outcomes
among ethnic minority groups, who reside in more
socially deprived areas
PA interventions need to be targeted to socially deprived
groups, but it is important to understand the
environmental barriers to PA in deprived areas
PA programmes should be tailored to the individual and
contain multiple components:
- goal setting,
- problem solving,
- self-monitoring,
- supervised exercise
Changing health behaviour in low-income groups
can be challenging and complex and requires a
collaborative approach among different actors

Interventions should be applied during both

childhood and adult life
TO SPREAD PA TO ENHANCE MH

Vittorio Lannutti
Sociologist - Educator
Coo.S.S. Marche
 Towards a new public health
Public health has a broad scope:
- control of communicable diseases
- the original impetus for public health work
- to the leadership of intersectoral efforts to promote
health
Public health: a social and political concept, aimed at
improving health, prolonging life and improving the
quality of life among whole populations
Health promotion, disease prevention and other forms of
health intervention
Health promotion strategies are based on the question of
how health is created, and it aims to offer people more
control over the determinants of their health
It needs to shift the debate about MH away from a singular
focus on the health sector to a focus on areas such as:
- employment,
- education,
- transport,
- housing,
- criminal justice,
- welfare,
- built environment
Success in promoting MH: involvement and support of
the whole community and the development of
collaborative partnerships with a range of agencies
throughout the public, private and nongovernment
sectors

MH promotion needs to occur within the health sector

and in all other sectors that influence the way in
which people live, love, are educated and work
 The onset of mental illness
Half of all chronic mental illnesses begin by age 14
When students learn about MH are able to effectively recognize signs
and symptoms related to MH issues and know where to turn for help
In turn, the stigma that surrounds mental health will decrease
Depression in adolescents has doubled between the mid 1980s and
2000s:
- the prevalence of MDD is now ranging from 4% to 8%,
- 12% of children/adolescents may have sub threshold symptoms of
depression,
- 20% of young people experience at least one episode of major
depression before they reach 18 years of age
 Mental health education
There are four key MH literacy components important
to everyone’s well-being and success:
1. Understanding how to obtain and maintain good
MH;
2. Decreasing stigma related to MH;
3. Enhancing help-seeking efficacy (know when,
where, and how to obtain good health with skills to
promote self-care); and
4. Understanding mental disorders and treatments
PA helps to improve cognitive performance and academic
achievement

Negative associations MH-sedentary behaviour

MH: important throughout the life cycle, affecting thinking

and learning, feelings and actions

In childhood and adolescence, MH: attaining

developmental and emotional milestones, while learning
healthy social skills and how to cope with challenging
situations
Mentally healthy children/youth have a positive quality of life and
can function well at home, in school, and in their communities

When young people are educated about MH, the likelihood of health
and well-being will lead to effective signs and symptoms

CDC: Focusing on healthy behavior during childhood is more

effective than trying to change unhealthy behavior during
adulthood

Health education that respects the importance of MH helps young

people and their families and communities feel more comfortable
seeking help, improve academic performance and save lives
In USA: a satisfactory program in health education
developed in accordance with the needs of pupils in all
grades must include instruction in the several
dimensions of health, and must:

- Encompass MH and the relation of physical and

mental health; and

- Enhance student understanding, attitudes and

behaviors that promote health, well-being and human
dignity
ACEs:
- stressful or traumatic events that can lead to social,
emotional and cognitive impairment,
- adoption of high-risk behaviors, disease, and early death
Children who experience these traumatic events often struggle
in school
The cumulative effect of trauma and toxic stress can be
significant and result:
- unhealthy behaviors,
- inability to focus and process information
- challenging responses to classroom and social situations
Recommendations to promote MH in the educational setting:

• Support children and youth in the development of: o

Positive routines and practices; o PA, exercise and play; o
Good nutrition; o Regular sleep habits; o Stress management
skills; and o Caring relationships

• Institute efforts to reduce stigma around mental health.

• Foster warm and caring relationships

• Promote positive school climate and culture

• Support development of social-emotional skills and
help-seeking behaviors

• Provide support to students with concerns about the MH

of self, friends and family

• Adopt use of an interdisciplinary partnership approach

with community resources

• Develop support for school staff for their own mental

health and wellness
A child’s brain and other systems develop most rapidly
through the first three years of life

Adolescence is a second critical developmental stage

Potentialities acquired in childhood can blossom into skills,

behaviours and opportunities - well-being in adolescence
and later to a more productive adulthood

The right investments and opportunities may offer a

second chance to young people who missed out during
childhood
Mental toughness (MT):
- control (emotional and life)

- commitment

- challenge

- confidence (interpersonal and in abilities)

Health interventions are required to prevent
disengagement from PA and reduce sedentary
behaviors in young people, but particularly those
at risk of developing MH problems

Physical exercise appears to improve depressive

symptoms in adolescents (antidepressant effect)

Exercise may be a useful treatment strategy for

depression
Multiple Dimensions of Addressing Mental Health Well-
being
Education on the importance of the mind-body
connection enhances student understanding, attitudes
and positive behaviors

MH as something more than an illness

CDC: MH in childhood/adolescence is to attain

developmental and emotional milestones, learning
healthy social skills and coping with challenging
situations
Mentally healthy children/youth have a
positive quality of life and function well at
home, in school, and in their communities

A comprehensive MH wellness approach

includes a focus on physical education,
health education, and nutrition
 Physical Education and MH
PE is directly connected to MH, emotional health and
overall well-being

PE teaches students how to achieve lifelong commitment

to PA, MH

Forming positive habits and routines (PA) contributes to

one’s wellness account

Moderate amounts of PE can increase mood and self-

esteem
A quality PE program focuses on the following:

- Decreases in obesity and chronic illnesses;

- Reduction of stress and anxiety;

- Instills self-confidence and self-esteem;

- Promotion of assertiveness, independence, and self-control;

and

- Encourages healthier eating habits through proper nutrition

 Physical Activity and Classroom Functioning and Learning
PA - significant improvements in MH and cognitive functioning

Late adolescence is characterized by increased stress and an

increase in MH problems, which likely persist and reach a peak in
early adulthood

PA is especially important during late adolescence

Considerable public attention has been given to emphasizing the

relationship of physical activity and school learning and behavior
Tomporowski et al.: exercise fosters the emergence of children's
mental functions, particularly executive functioning

Others report that:

- providing short physical activity breaks during the school
improved on-task behavior

- after exercise, students were sharper, more attentive, less

impulsive and fidgety, and sustained their attention longer

- PA increased concentration on the academic material in the

classroom
- participation in a PA program improves muscular capacities,
motor skills, behavior, and level of information processing of
children with ADHD

- promote PA through comprehensive school PA programs,

including recess, classroom-based physical activity, intramural
physical activity clubs, interscholastic sports, and physical
education

- ensure that PE is provided to all students in all grades and is

taught by qualified teachers

- work with community organizations to provide out-of-school-

time physical activity programs and share PA facilities
Prominently mentioned strategies for increasing PA during
school hours include:
- providing enhanced PE that increases lesson time, is
given by trained specialists (instructional practice at a
moderate to vigorous PA level)
- taking classroom activity breaks
- creating activity sessions before and after school while
providing adequate space and equipment
- participating in active transportation (walking and biking
to and from school)
- encouraging physical activity during recess, lunch and
other breaks, with organized activities and game equipment
available
 The Relationship Between School Climate and Well-being
School climate affects an individual’s sense of safety,
acceptance, safety, wellness and connected with others
A school climate that supports healthy emotional
functioning involves structures that offer preventive and
responsive supports
Elements of support include:
- fostering safety
- promoting a supportive academic
- disciplinary, and physical environment
- encouraging and maintaining respectful, trusting, and
caring relationships throughout the school community
Creating an environment where the mental well-being of
all is valued and fostered, free from stigma, is essential to
helping students feel safe and accepted

Schools should support social-emotional learning and MH

for all students as essential components of health and
wellness

Everyone within the school environment succeeds when

everyone feels accepted, valued, and respected
 Health Education
Health education teaches about physical, mental,
emotional and social health

Health education develops positive health attitudes

Comprehensive health education curricula are important

to motivate students to improve and maintain their
health, prevent disease, and reduce risky behaviors
(drugs, alcohol and tobacco; sexuality; injury; nutrition,
and disease)
 The Role of Motivation
Some students are highly motivated to pursue
physical activity/some are not
Efforts to enhance student PA must:
- address differences in motivational readiness,
- develop processes that promote engagement during
school and beyond
In establishing opportunities for participation in PA
schools should provide a wide range of options
 Mental Health Resources Fostering School and Community
Agency Partnerships
Facilitating the relationship schools-community agencies
is:

- critical to positively impact school climate to support all

students (especially those who have MH needs)

- can facilitate access to existing services in new ways

So student wellness can be enhanced, fostering a

healthier overall school climate
Quality of the school climate may be the single most
predictive factor to promote student achievement

Assessments:
- can be formal or informal, and brief or more
complex
- should be conducted at regular intervals

Following an assessment, districts should focus their

attention on building and strengthening school and
community partnerships that are most needed
Schools are places where a considerable amount of PA takes place

The degree to which the PA is fully integrated into school varies

with the amount of public concern about health matters and
advocacy for PE and sports

The trend continues to be one of ad hoc and piecemeal initiatives

For the future, the question remains: How should schools embed a
regular, well integrated, and equitable focus on physical activity
into its other concerns for promoting healthy development and
addressing student’s problems?
 www.project-website.com
[email protected] | facebook.com/ProjectName
 MODULE 4
Psychosocial Dimensions of
PA/Exercise/Sport and Mental
Health

This project has been funded with support from the European Commission. This publication
[communication] reflects only the views of the author, and the Commission cannot be held
responsible for any use which may be made of the information contained herein.
“
COURSE CONTENTS & TOPICS

”
 UNDERSTANDING MENTAL HEALTH

CONTENTS
UNIT 1: Motives – Motivation: Theories and Practical Implications – Part I.

UNIT 2: Motives – Motivation: Theories and Practical Implications – Part II.

UNIT 3: Theories in Motivation: Self-motivation.

UNIT 4: Social Benefits in Sport and PA: Socialization & Other Benefits.

UNIT 5: Benefits of Exercise and PA Participation: Mental Illness Consequences to Social

Well-being & Stigma.

UNIT 6: Barries Toward Exercise & PA Interventions for Physical Activity Participation
Improvement.
“
UNIT 1: Motives – Motivation: Theories and
Practical Implications – Part I

”
Learning objectives
 Know the current situation of exercise participation and attitude toward
exercise.
 Know the role of behavior modification in exercise participation.
 Know the definition of motivation and motive.
 Know the role of motivation in exercise participation.
 Know the role of motivation in mental ill exercise participants.
 Know the motive characteristics and types in mental ill exercise
participants.
 Know the motivational theories in exercise participation.
 Know the early theories in exercise participation (drive theory, self-
actualization theory)
 Know the use of transtheoretical model – stages of change model in
behavior modification for exercise participation.
 Motives – Motivation
Theories and Practical Implications
PART I

Nektarios Stavrou & Maria Psychountaki

Faculty of Physical Education & Sport Science
National & Kapodistrian University of Athens
https://images.app.goo.gl/7R3bRYHPWYT5RD1E9
“Why we do what we
do?”
Which is the motive;
Which is the value of the
motive;
Which is the difficulty of
the situation;
Which is the probability
of success or failure;
Which is the situation;

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Exercise/Exercise-Dropout Cycle

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A “toxic” physical activity environment
We live in a “toxic” fitness and wellness environment
 Physical inactivity is predominant
 Learned behaviors; children watch adults
 Drive short distances
 Automatically use elevators, remote controls, etc.
 Order super-sized fast foods
 Use recreational time to watch TV or surf the Internet
 Smoke, drink, and abuse other drugs
 Engage in risky behaviors, such as not wearing
seat belts
A “toxic” physical activity environment
 Escalators are more accessible than stairways
 Automatic doors provide unimpeded movement
 Exercise trails are sparse
 Sidewalks do not exist or are in disrepair
 Safety concerns keep citizens indoors during leisure
hours
Ways to improve exercise participation
 Motivation
 Gain knowledge about why change
is necessary
 Set goals “The sooner a healthy
 Competence lifestyle program is
 Work to master skills implemented, the
 Select activities where skill exists greater will be the
health benefits and
 Confidence quality of life ahead.”
 Give the healthy behavior a fair try
 Visualize success
 Divide goals into smaller objectives
Behavior modification
 Convincing research is not enough to cause change in people
 The science of behavioral therapy has shown that most
behaviors are learned from the environment
Home, community, country, and culture
Family, friends, and peers; schools and workplaces; television, radio,
and movies

Behavior modification: the process of permanently

changing negative behaviors to positive behaviors that
will lead to better health and well-being
Examples of motivated behaviors
Motive - Motivation
Motive refers to people’s stable tendency to
get a reward or to avoid a punishment that
might differ between persons
… something (such as a need or desire) that
causes a person to act.

Motivation refers to the process of

interaction among person’s motives,
expectation and strength of the motivation

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Motive
… is defined as a type of need that humans
experience in order to achieve or accomplish specific
goal or goals.

Behavior = Motives Χ Ability

Behavior/ Attitudes Hereditary
performance in Emotions characteristics
a specific Experience
situation Learning
Motive
… is anything that moves, pushes, or drags the person
into action.

… “hypothetical internal (psychological) processes or

situations" of the body, which trigger behavior and
push the body toward a goal».

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Motives can be
A) Native: They have an inherited basis

B) Acquired: Through the process of learning and

interacting with the environment
Motivation theories
1. Behavioral theories: emphasis on persons
experiences and behavior enhancing.
2. Psychodynamic theories: claim that behavior is
determined by internal (subconscious) forces.
3. Cognitive theories: emphasize the decision-
making process and the value-expectation
relationship.
Motives’ characteristics
• Start/principle: starting behavior (what activates the
athlete)
• Effort: degree of activation - excitation (how much
effort it takes)
• Persistence: duration of effort
• Choice: interest, tendency or choice

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Motives
• Physiological: They serve the function of the body
and physical homeostasis.
• Biological: They serve the survival, preservation and
reproduction of the human life
• Psychological: They refer to one's temperament,
personality, and dealings with the physical and social
environment (Evans, 1975).
Motives
■ Motives are idiosyncratic, personal predispositions
to structures, persons, or objects that have either a
negative or a positive value (Huckhausen, 1991).
■ Incentives are an indispensable element in shaping
the intention of action.
✺ Preparing for action
✺ Formation request
✺ Desire rating
Motivational theories
 Instinct theory of motivation (Freud)
 Drive theory (Hull)
 Protection motivation theory (Rogers, 1959, 1961)
 Humanistic theory of motivation (Maslow, 1970)
 Achievement motivation theory (Atkinson, 1966)
 Self-efficacy theory (Bandura, 1977, 1982, 1997)
 Competence motivation theory (Harter, 1978)
 Attribution motivation theory (Heider, 1958;
Weiner, 1985)

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Motivational theories
Goal orientation theory (Nicholls, 1984, 1989)
Flow theory (Csikszentmihayi, 1975, 1982; Jackson, 1992, 1996)
Self-determination theory (Deci & Ryan, 1985, 1991)
Cognitive evaluation theory (Deci & Ryan, 1985)
Integrative theory of intrinsic and extrinsic
motivation in sport (Vallerand & Losier, 1999)
Instinct theory of motivation
Instincts are automatic, involuntary reactions, or patterns
of behavior that are observed following specific stimuli.
 Biological or genetic programming as the cause of
motivation.
 All humans have the same motivation.
 Root of all motivations is dependable upon our
motivation to survive.
 Fails to describe more complex situations
Life instinct
Death instinct https://images.app.goo.gl/qjpU8pCbAh8huJp16
Freud’s Drive Theory

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Drive theory of motivation
The source of behavioral energy is referred to as
momentum and the driving factor of behavior as habit.
Central points of the theory
 Physiological needs
 The pursuit of homeostasis by the human body (e.g.,
food).
 Drive reduction when homeostasis is achieved in the
body
Theory overlooks the importance of human's cognitive
and emotional processes.
Drive theory of motivation

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Protection motivation theory
People motivated to take action to protect themselves
from a health treat, according to:
 Severity: perceived severity of threat.
 Vulnerability: perceived probability of its occurrence.
 Response efficacy: perceived efficacy of advocated
response
 Self-efficacy: perceived self-efficacy to perform a
response
Protection motivation theory (Rogers, 1961)

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Protection motivation theory (Rogers, 1961)

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Self-actualization theory
Self-actualization – Humanistic Psychology

The desire to fulfill and fulfill one's potential.

Maslow designed a hierarchically structured multi-
motivation system.
Self-fulfillment, at the highest hierarchy, presupposes the
fulfillment of fundamental needs.
Fundamental needs do not induce the individual to exhibit
a particular behavior, but to select a series of behaviors to
satisfy the need.
Self-actualization theory
Maslow’s Hierarchy of Needs

 Self-Actualization
 Esteem
 Love and commitment
 Safety
 Physiological
Self-actualization theory
Maslow’s Hierarchy of Needs

 Self-actualization
 Self-esteem
 Love and belongingness
 Safety and security
 Physiological needs

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Self-actualization theory (Maslow, 1964)

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Self-actualization theory
The hierarchy is supported in their/the
 power,
 order of development in one's life,
 evolutionary order of appearance and
 extent that it must be satisfied in order for the individual
to survive.

The action of a higher need manifests itself when the

previous need of the scale is satisfied.
Self-actualization theory
 Failure to satisfy a basic need leads to physiological or
psychological dysfunction.
 Correcting the lack of satisfaction reduces the
malfunction.
 Ongoing satisfaction prevents malfunction & limits its
requirements.
 Satisfying one need is probably preferred over another.
Transtheoretical model
Stages of change model
(Prochaska & DiClemente, 2005)
The Process of Change
 Transtheoretical Model
Stages of change
Processes of change
o Techniques of change
Stages of Change
 Precontemplation stage: Stage of change in which
people are unwilling to change behavior.
 Contemplation stage: Stage of change in which people
are considering changing behavior in the next 6 months.
 Preparation stage: Stage of change in which people are
getting ready to make a change within the next month.
 Action stage: Stage of change in which people are
actively changing a negative behavior or adopting a new,
healthy behavior.
Stages of Change (cont.)
 Maintenance stage: Stage of change in which people
maintain behavioral change for up to 5 years
 Termination/adoption stage: Stage of change in which
people have eliminated an undesirable behavior or
maintained a positive behavior for over 5 years
 Relapse: To slip or fall back into unhealthy behavior(s)
or fail to maintain healthy behaviors
Stages of Change Model
Stages of Change Model

Model of
progression &
relapse

Applying specific
processes during each
stage of change
increases success rate
Stages of Change Model
1. I currently ____, and I do not intend to change in the
foreseeable future.
2. I currently ____, but I am contemplating changing in the
next 6 months.
3. I currently ____ regularly, but I intend to change in the next
month.
4. I currently ____, but I have done so only within the last 6
months.
5. I currently ____, and I have done so for more than 6 months.
6. I currently ____, and I have done so for more than 5 years.
Process of Change
• Consciousness-raising • Self-reevaluation
• Social liberation • Countering
• Self-analysis • Monitoring
• Emotional arousal • Environmental control
• Positive outlook • Helping relationships
• Commitment • Rewards
• Behavior analysis
• Goal setting

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TEN Processes of Change
1. Consciousness-raising (get the facts): increasing
awareness via information, education, and personal
feedback about the healthy behavior.
2. Dramatic relief (pay attention to feelings): feeling fear,
anxiety, or worry because of the unhealthy behavior,
or feeling inspiration and hope when they hear about
how people are able to change to healthy behaviors.
3. Self-reevaluation (create a new self-image): realizing
that the healthy behavior is an important part of who
they are and want to be.
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TEN Processes of Change (cont.)
4. Environmental reevaluation (notice your effect on
others): realizing how their unhealthy behavior affects
others and how they could have more positive effects by
changing.
5. Social liberation (notice public support): realizing that
society is more supportive of the healthy behavior.
6. Self-liberation (make a commitment): believing in one's
ability to change and making commitments and re-
commitments to act on that belief.
7. Helping relationships (get support): finding people who
are supportive of their change.
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TEN Processes of Change (cont.)
8. Counter-conditioning (use substitutes): substituting
healthy ways of acting and thinking for unhealthy
ways.
9. Reinforcement management (use rewards): increasing
the rewards that come from positive behavior and
reducing those that come from negative behavior.
10.Stimulus control (manage your environment): using
reminders and cues that encourage healthy behavior
as substitutes for those that encourage the unhealthy
behavior.
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Applicable Process of Change in Each Stage
Process of Change
Using the same plan for every individual who wishes to
change a behavior will not work
Plans must be personalized
Timing is important in the process of willful change

Acknowledge that there is a problem

 Identify the behavior to change (increase physical
activity, stop overeating, quit smoking)
 List advantages and disadvantages of changing the
specified behavior
Process of Change
 Using the same plan for every individual who wishes to
change a behavior will not work.
 Plans must be personalized.
 Timing is important in the process of willful change.
 Decide positively that he/she (you) will change.
 Identify the stage of change.
 Set a realistic goal (SMART goal), completion date, and
sign a behavioral contract.
Process of Change
 Define your behavioral change plan: List processes of
change, techniques of change, and objectives that will
help you reach your goal
 Implement the behavioral change plan
 Monitor your progress toward the desired goal
 Periodically evaluate and reassess your goal (SMART:
Specific, Measurable, Acceptable, Realistic, and Time specific goals)
 Reward yourself when you achieve your goal
 Maintain the successful change for good
Practical implications for trainees
 Developing positive cognitive “beliefs” behavior
 Explain the contribution of exercise to physical and
mental performance.
 Explain the contribution of exercise to prevention
diseases.
 Developing positive emotional “beliefs”
 Emphasize the benefits of exercise in euphoria, stress
reduction, mood improvement, self-esteem.
 Highlight the importance of movement, emphasize the
creative use of leisure time through exercise.
Practical implications for trainees
 Developing positive social “beliefs”
 Emphasize the impact this particular behavior will have on important
people, e.g. "Coming to the gym 3 times/week is something that your kids (your
spouse, your friend) would really appreciate and admire."
 Related behaviors
 Give as many ideas as possible for an active lifestyle.
 Emphasize the importance of avoiding car and elevator use.
 Indicate the importance of the choice of walking or cycling.
 Give examples of other people who are practicing regularly.
Practical implications for trainees
 Each message must be specific to the people to whom
it is addressed. The information contained therein
should be as relevant as possible to the age group to
which it is addressed, and the message should respond
to the cognitive and linguistic level of the recipients and
increase interest about exercise activity (Kosmidou,
2007).
Process of Change: Critical thinking
Your friend John is a 20-year-old student who is not
physically active suffering from depression. Exercise has
never been a part of his life, and it has not been a priority
in his family. He has decided to start a jogging and
strength-training course in 2 weeks. Can you identify his
current stage of change and list processes and techniques
of change that will help him maintain a regular exercise
behavior?
Review Questions
1) Based on Maslow’s hierarchy theory self-actualization
does not presupposes the fulfillment of fundamental
needs
TRUE FALSE

2) Please indicate the sequence of stages of change

phases in exercise participation:
Maintenance, preconteplation, action, preparation,
termination, relapse, contemplation
Video – Links
• Introduction to Health Behavior Theories: https://www.youtube.com/
watch?v=OexKKEUIgSU
• Theories of Motivation: Instinct, Drive Reduction & Arousal: https://study.com
/academy/ lesson/intro-to-motivation.html
• Incentive Theory: https://www.khanacademy.org/test-prep/mcat/behavior/
physiological-and-sociocultural-concepts-of-motivation-and-attitudes/v/incentive-
theory
• Freud's Psychoanalytic Theory on Instincts: Motivation, Personality and
Development: https://www.youtube.com/watch?v=7vFf5CS27-Y
• Behavioral Change: https://www.youtube.com/watch?v=gfNndP-NeLc
• Transtheoretical Model of Behavioral Change: https://www.youtube.com/
watch?v=oO80XyBDrl0
• Drive-Reduction Theory: https://www.youtube.com/watch?v=OB86iaquQmM
“
UNIT 2: Motives – Motivation: Theories and
Practical Implications – Part II

”
Learning objectives
 Know the role of self-confidence in exercise participation.
 Know use of self-efficacy theory in exercise participation of mental ill people.
 Know the practical implications for self-efficacy in the increase of exercise
motivation.
 Know the role of success and failure in exercise participation.
 Know use of competence motivation theory in exercise participation of mental ill
people.
 Know the practical implications of perceived competence of mental ill person in
the increase of exercise participation.
 Know the role of locus of causality and stability in the exercise motivation of
mental ill people.
 Know the role of effort, personal goals and improvement in the increase of
exercise participation of mental ill people.
 Know the role of personal improvement of exercise participation of mental ill
people.
 Motives – Motivation
Theories and Practical Implications
PART II

Nektarios Stavrou & Maria Psychountaki

Faculty of Physical Education & Sport Science
National & Kapodistrian University of Athens
Self-efficacy theory)
(Bandura, 1977, 1982, 1986, 1997)

https://images.app.goo.gl/n3AoaHidqukE7RCeA
Self-efficacy theory
The perception of one’s ability to perform a task
successfully is a situation-specific form of self-confidence.

• Self-efficacy provides a model to study the effects of self-

confidence on performance, persistence, and behavior.
• Self-efficacy is important when one has the requisite
skills and sufficient motivation.
• Self-efficacy affects an exercise participants’s choice of
activities, level of effort, and persistence.
Self-efficacy theory
Self-efficacy refers to …
«the individual's belief in his or her own ability to
organize and execute a series of actions required to
achieve specific actions, goals» (Bandura, 1997, p. 3).

 Self-efficacy is positively related to motivation.

 … leads to positive attitude and more effort & persistence
Self-efficacy is an integral part of social cognitive theory.
 Self-efficacy is a form of situational self-confidence.
Self-efficacy theory

https://images.app.goo.gl/PpJtJEP9W73DJHwS9
Self-efficacy theory
 Self-efficacy is positively related to motivation.
 … leads to positive attitude and more effort & persistence
of exercise participants with mental health.

 Task-related self-efficacy increases the effort,

persistence, and strategy towards challenging tasks in
exercise participants with mental health, which in the
following
 increases the likelihood that they will be achieved.
Self-efficacy theory
 Personal trainers can use the sources of self-efficacy to
help influence the efficacy levels of people with mental
ill.
 This can be as simple as creating short-term success by
designing a workout that the client with mental ill can
master.
 Each workout should build on previous accomplishments
on exercise participants with mental ill.
High self-efficacy exercise participants
 exercise harder
 insist more on the successful and complete execution of
an effort
 achieve higher goals

 High self-efficacy in an action can be generalized in

other activities (mental health)
 Improving individual self-efficacy contributes positively
to improving group self-efficacy.
Practical implications for trainees
 Each person has his/her own criteria of success,
achievement and goals and this must be respected.
 To enhance person's self-esteem and body image,
trainees should avoid providing evaluations (directly or
indirectly) parameters such as fitness, physical strength
and appearance.
 Several types of exercise are effective in increasing self-
esteem, but most evidence exists on the value of
aerobic exercise and resistance training, with the latter
showing greater efficacy in the short term.
Practical implications for trainees
 Aerobic exercise, jogging, and weight training are
activities that can help improve self-esteem. Exercising 3
or 4 times a week is more effective.
 An exercise program should last at least 12 weeks in
order to benefit participants' self-esteem. Exercise
programs that have the element of competition are not
suitable for improving people's self-esteem (Fox, 2000;
Leith, 1994).
Practical implications for trainees
 Self-efficacy in exercise and participation in physical
activity programs can be increased
 through appropriate intervention programs,
 through participation in exercise programs,
 is associated with positive feelings for exercise and
 decreases after a period of rest (Biddle et al., 2007).

A meta-analysis of 36 studies concludes that physical

activity has a positive effect on self-efficacy and mental
well-being in older adults (Netz, Wu, Becker, & Tenenbaum, 2005).
Practical implications for trainees
 Trainees should adjust the increase in the intensity of the
exercise gradually to create a sense of success, that is, a gradual
increase in the distance person swims or runs, a gradual increase
in strength training or a gradual learning of the steps of a new
dance. One has to go from simple to complex.
 Long-term priority is exercising and maintaining participation
and is less interested in achieving goals such as losing weight,
improving strength, or changing body image (Buck-Worh &
Dishman, 2002).
Practical implications for trainees
 Trainees should try to convince people with mental
health that are capable of exercising. They should
encourage and reassure people that they can do it. Ask
them to think positively.
 In life, what matters most is what exercise participant
believe, rather than what actually happens. However,
expectations must be realistic and based on real data.
Before adopting someone else's beliefs, one must check
whether they are true (Theodorakis, Goudas, &
Papaioannou, 2003).
Self-efficacy: Critical thinking
Your friend Maria is a 20-year-old obese student who is
not physically active suffering from anxiety. Exercise has
never been a part of her life, although her parents are
physically active. He has decided to start a jogging and
strength-training course in 2 weeks. Which are the main
points that you will take care in the beginning of her
exercise program based on self-efficacy theory that will
help her maintain a regular exercise behavior?
Social Cognitive Theory

https://images.app.goo.gl/jxap1j6kA6K9iSPs7
Social Cognitive Theory
 Self-efficacy
 Personal influence
 Personal control

If the exercise participant feels that they have control and

can produce specific results they will show higher levels of
motivation, persistence, and commitment.
Social Cognitive Theory

https://images.app.goo.gl/U3683m5FJTbHfBBN6
Competence theory motivation
(Harter, 1978)
Competence theory of motivation
Competence motivation theory is a
conceptual framework designed to explain
individuals' motivation to participate,
persist, and work hard in any particular
achievement context. The central thesis of
the theory is that individuals are attracted
to participation in activities at which they
feel competent or capable.

 Feelings of competence are the primary

factors in motivation (academic, social,
physical)
 High competence
motivation

Self-efficacy, Low competence

positive affect & motivationς
competence feelings
Negative Fewer mastery
affect attempts

Successful Unsuccessful Exercise

performance performance drop-out

Innate motivation to be
competent in exercise: Competence motivation theory
Mastery attempts (Harter, 1978)
Competence theory of motivation
 “Perceived competence” predicts:
Cognitive outcomes
 Affective outcomes (enjoy, anxiety)
 Behavioral outcomes (performance)

 The feeling of competence is "reciprocally" linked to the

intensity and type of motivation of the individual.
 Successful execution and learning new skills will lead
the exercise participant to positive emotions and vice
versa.
Competence theory of motivation
 Adequate motivation of people with mental health can
be increased through successful efforts.
 People with mental health with low levels of
competence are less likely to insist on execure their task
and give up more easily.
 Mental health people with low self-efficacy have higher
negative emotions (anxiety, frustration, etc.).
 Personal improvement (secondarily the result) improve
the feeling of competence.
Competence theory of motivation
 Reasons for increased exercise motivation and
participation of mental ill people
 Support of social environment (family, trainers etc.)
 Friendship
 Acceptance
 Positive feedback
 Personal goals and improvement

High motivation leads to the successful execution of a project, and

a high sense of self-efficacy contributes to successful performance.
Theory of achievement motivation
(Atkinson, 1966)

https://images.app.goo.gl/zeVDvzwNQr6aSRwd7
Achievement motivation theory
Achievement situation is ...
any circumstance in which the individual knows that his or
her effort will be evaluated (by himself or others) on the
basis of certain formal criteria and that the consequences
of his or her actions will include either a favorable
assessment or a non-favorable judgment (failure)
(Atkinson, 1966).
• The individual to hold himself personally responsible for
the result of his effort.
• The individual to be aware of the result.
Achievement motivation theory
• The individual to hold himself
personally responsible for the
result of his effort.
• The individual to be aware of the
result.
• There is some doubt about the
chances of his attempt to
succeed.
Achievement motivation theory
The component of achievement
motivation is the result of the
'collision' of two opposing tendencies,
which refer to
 the tendency to approach success
and
 the tendency to avoid failure.
Achievement motivation theory
The component of achievement
motivation is the result of the
'collision' of two opposing tendencies,
which refer to
 the tendency to approach success
and
 the tendency to avoid failure.
AMT suggests that motivation…
 is a function of the interaction
between one’s need for
achievement/fear of failure and
the difficulty level of the task
 will decrease when individual
attributes failure to
 stable factors like ability and
task difficulty.
 unstable factors like effort.
AMT suggests that …
the tendency to engage in any particular achievement-
oriented behavior depends on the probability of success
and the incentive value of success, as well as need for
achievement.
1. Motive of success
2. Probability of success
3. Incentive value of success

 Previous successful performance

 Social comparison of success
AMT: Tendency to success
… is the desire of the individual, which varies
from person to person, to perform an action or
action successfully.

Ts = Mas Χ Ps Χ Vs
Tendency to Motive to Probability Incentive
approach achieve of success value of
success success success
AMT: Tendency to avoid failure
... is a personality trait that prevents a person
from performing an action. It is due to the
feeling that his efforts will not be successful.

Ταf = Mαf Χ Pf Χ Vf
Tendency Motive to Probability Incentive
to avoid avoid of failure value of
failure failure failure
 Achievement Motivation Theory

https://images.app.goo.gl/whfQa43XVHC1rpfn9
AMT: Practical Implications for trainees
 Seek to maximize effort and improve competence by
giving exercise participants the opportunity to succeed
(appropriate exercise selection, programming).
 Evaluate primarily and mainly (or even only) the
exercise participants' effort and not the victory or the
defeat.
 Attribute failure to effort (room for improvement
through exercise participation).
AMT: Practical Implications for trainees
 If the causes of failure are attributed to constant and
stable factors (ability, difficulty of the task), exercise
participants with mental health are likely to be led to
new failures.
 Educate exercise participants in the positive
interpretation of their results and efforts.
 The trainees should know that not all exercise
participants with mental health issues are ready for the
same difficulty of exercise or physical activity
(abandonment of exercise program, changing the environment).
 Goal orientation theory
(Duda, 1989; Νicholls, 1984, 1989)
Task & ego orientation
Goal orientation theory
 Effectiveness of goals
 Directs attention – helps you
focus
 Mobilizes effort – you set your
alarm clock
 Increases persistence – you
keep showing up
 Promotes invention – you
simply find a way up the
mountain

https://images.app.goo.gl/4GbFnhFjj11qJ4pZ7
Goal orientation theory – Type of goals
 Learning Goals
Mastery orientation
 Improve understanding
“Task-Involved” learners
 Risk-takers
 Comments taken as feedback
 Cooperative with other learners
 Lost in their work
 Personally responsible

https://images.app.goo.gl/cfxyagb8XV8H2TN97
Goal orientation theory – Type of goals
 Performance Goals
 Comparison orientation
 Judge quality of work by other’s work
 “Ego-Involved” learners
 Risk-Avoiders
 Comments taken as criticism
 Competitive with other learners
 Parades successes & hides failures
 Many excuses
 Most likely to cheat, use short cuts, etc

https://images.app.goo.gl/stC8TpPD4z3SKpHYA
Attribution theory
(Weiner, 1972, 1979, 1984)
Attribution theory
Locus of causality: Internal vs external
Stability: Stable vs unstable

https://images.app.goo.gl/pYFnjCSqgHpmSfnx5
Attribution theory

Locus of control
Internal External

Task
Stable Ability
Stability

difficulty

Effort/
Unstable Luck
motivation
Attribution theory
 Stability
 Stable or unstable causes of a result
 Locus of causality
 Internal or external locus of control
 Controlability
 Exercise
situation

Perceived Perceived
success failure

Causal attribution Causal attribution Causal attribution Causal attribution

in stable factor in unstable factor in stable factor in unstable factor
(ability) (motivation/effort) (task difficulty) (luck)

Feeling that Feeling that Feeling that Feeling that

future success future success future failure future failure
in expected in expected in not certain in not certain

Causal attributions
Attribution theory
 Exercise participants with a high need for achievement
 attribute success to internal factors (ability)
 insist/persist longer after a failure
 attribute failure to unstable or external factors (effort, luck)
 Exercise participants with low motivation for
achievement attribute success to external factors
(exercise difficulty, luck) and failure to internal factors
(ability)

Continuous interaction of causes of performance and

motivation
Motivation: Practical Implications for trainees
 The trainees who emphasizes the
effort helps increase the
participant’s exercise motivation.
 Exercise participants with low
perceived ability and orientation
avoid ebbing or executing difficult
exercises and exhibit higher
anxiety.

https://images.app.goo.gl/SMooTAkPkAp6rCuh6
Motivation: Practical Implications for trainees
 The role of perceived competence is critical when the
environment is not project oriented.
 Exercise participants focused on personal improvement,
regardless of their ability, show greater motivation.
 Exercises should be characterized by innovation, variety
and create pleasure and fun in exercise participants
 Exercises should be personally difficult, i.e., they must
respond to the individual abilities of the athletes
(adjusting degree of difficulty, personal adjustment for
improvement).
Motivation: Practical Implications for trainees
 The implementation of the exercises at the individual
level must be accompanied by a specific personal goal.
 Design and encourage the use of collaborative
development exercises.
 Give exercise participants the opportunity to choose
their exercise characteristics (type, intensity, intensity,
duration) as it increases commitment.
 Involvement of exercise participants in decision
making.
Motivation: Practical Implications for trainees
The importance of personal improvement
in individuals with mental health issues
Evaluation test
 Avoid reporting average performance.
 In evaluation tests,
… benchmarks should not be the best
performance, but the exercise
participant’s previous performance
(personal improvement) is required.

https://images.app.goo.gl/av98bya9vEjA8edm9
Motivation: Practical Implications for trainees
 The importance and the type of feedback
 Feedback / rewarding as reinforcement and not as a
way to control or pressure the exercise participant.
 Provide feedback and reinforce it in a positive way.
 Refer to the proper execution of the exercise and do
not just report the mistake he made.
 Remember that mistakes are part of learning.
Motivation: Practical Implications for trainees
 Trainees should create a climate of euphoria and
excitement during physical activity and exercise.
 The goal of coaching is to improve everyone's personal
lives.
 Avoid social comparison criteria
 Inheritance - personal improvement
Emphasis on the value of effort.
 Importance of personal commitment (type of
activity, intensity, duration, frequency)
 Setting goals for improvement
Motivation: Practical Implications for trainees
 The effort is important, not the result.
 Effort: internal factor
 Result: external factor
 Strengthening the overall concept of health (physical
appearance, mental health, personal development,
social relationships, skills improvement).
 Trainees should explain the purpose of the training
program.
 Emphasis on the value of cooperation among exercise
participants.
Review Questions
1) Based on competence theory of motivation, indicate
which of the followings can increase exercise participation
of mental ill persons
• Family and friends support YES NO
• Friendship YES NO
• Acceptance YES NO
• Positive feedback YES NO
• Personal goal and improvement YES NO
2) Which are the sources of self-efficacy in exercise
participation?
Video - Links
• Self-efficacy: https://socialsci.libretexts.org/Bookshelves/
Psychology/ Book%3A_Psychology_(Noba)/Chapter_3%3A_
Personality/3.08%3A_Self-Efficacy
• Social Cognitive Theory:
https://study.com/academy/lesson/albert- bandura-social-
cognitive-theory-and-vicarious-learning.html
• Social Cognitive Theory: https://www.youtube.com/watch?v=
S4N5J9jFW5U
• Achievement Motivation Theory: https://study.com/academy/
lesson/ achievement-motivation-theory-definition-quiz.html
• How we can state motivated: https://sciencetrends.com/social-
cognitive-theory-and-exercise-how-can-we-stay-motivated/
“
UNIT 3: Theories in Motivation: Self-
motivation

”
Learning objectives
 Know the role of self-determination in exercise participation.
 Know how to use of self-determination theory in exercise participation of mental
ill people.
 Know the practical implications for self-determination in the increase of exercise
motivation.
 Know the role of basic psychological needs in exercise participation of mental ill
people.
 Know the role of intrinsic and extrinsic motivation in exercise participation.
 Know the importance of extrinsic to intrinsic motivation (regulation).
 Know the role of self-motivation in the exercise motivation of mental ill people.
 Practical ways of self-motivation in the increase of exercise participation of mental
ill people.
 Know the role of personal improvement of exercise participation of mental ill
people.
 Theories in Motivation
Self-motivation

Nektarios Stavrou & Maria Psychountaki

Faculty of Physical Education & Sport Science
National & Kapodistrian University of Athens
Integrated theory of intrinsic
and extrinsic motivation
(Vallerand & Losier, 1999)

https://images.app.goo.gl/AZRtG71qmbJPrWw27
Integrated theory of intrinsic – extrinsic
motivation
The integration of theoretical approaches in the study,
investigation, justification and interpretation of the
behavior and psychological state of athletes is critical and
particularly important.

Central point to motivation are the long-term and

continuous motivation.
Integrated theory of intrinsic – extrinsic
motivation
 Hierarchical model of internal-external motivation
 Global level
 Contextual level
 Situational level
1. Social factors
2. Levels of motivation
3. Consequences
The theory of self-determination is a central point of
theory (Vallerand, 1997)
Integrated theory of intrinsic – extrinsic
motivation

https://images.app.goo.gl/wRpqBfRzRX5y3Jej7
 Integrated theory of intrinsic – extrinsic
motivation
Social Psychological Types of Consequences
factors mediators/needs motivation
Perceptions of Intrinsic motivation • Affect
• Success/failure • competence External motivation • Persistence
• Competition/ • autonomy • identified regulation • etc
cooperation • relatedness • introjected regulation
• Trainee’s behavior • external regulation
Amotivation
Social factors: Success/failure
 The Successful experience leads to the experience that
exercise participant is competence and efficacious
relative to skills being learned and performed.
 Failure feedback leads to a reduction in the belief that
the person is competent resulting to reduced motivation
Social factors: Competition/cooperation
 Emphasis upon defeating someone is an ego goal
orientation that is associated with loss in intrinsic
motivation. Competition reduces feeling of autonomy,
as the focus is external and not internal.
 Cooperation relates to a task or mastery goal
orientation.
Social factors: Trainee behavior
 The trainee should be democratic in nature and he/she
must willing to share the perception of control with
exercise participants. The controlling trainee risks
destroying the intrinsic motivation of the athlete.
Self-determination theory
(Deci & Ryan, 1985; Ryan & Deci, 2000)
Self-determination definition
“To be self-determined is to endorse one’s actions at the
highest level of reflection. When self-determined, people
experience a sense of freedom to do what is interesting,
personally important and vitalizing.”
Edward Deci and Richard Ryan
www.selfdeterminationtheory.org

“One’s ability to define and achieve goals based on a

foundation of knowing and valuing oneself” (Field & Hoffman,
1994)
Self-determination definition
“Self-determination is a combination of skills, knowledge,
and beliefs that enable a person to engage in goal-
directed, self-regulated, autonomous behavior. An
understanding of one’s strengths and limitations together
with a belief in oneself as capable and effective are
essential to self-determination. When acting on the basis
of these skills and attitudes, individuals have greater
ability to take control of their lives and assume the role of
successful adults in our society.” (Field, Martin, Miller, Ward &
Wehmeyer, 1998, p. 2)
Self-determination theory (SDT)
… is a theory of human motivation and personality that
concerns people's inherent growth tendencies and
innate psychological needs. It is concerned with the
motivation behind choices people make without external
influence and interference.

Self-determination …
refers to the degree of autonomy a person has in his or
her decisions and actions, in the sense of personal
influence on his or her behavior and decision-making.
 Controlled - autonomous / self-determined action
Self-determination theory
 The
Self-determination theory

self-determination continuum
https://images.app.goo.gl/LjwVXdYiN9ZUoJEY7
 Psychological mediators/needs

Failure to meet or Internal motivation is

fulfill psychological increased when
needs will lead to these needs are
reduced motivation satisfied (Ryan & Deci, 1999)
(Deci, 1999)
https://images.app.goo.gl/N9757cRzPo8crmkq9
Psychological mediators: Competence
 Competence is related to exercise participant’s
confidence which leads to intrinsic motivation.
 Competence is critical to the development of intrinsic
motivation, but without autonomy there is no self-
determination, which negatively affects intrinsic
motivation.
 Competence without autonomy gives rise to the
efficacious pawn. In the efficacious pawn you have an
individual who is confident that he can successfully
perform a task, but for external reason.
Psychological mediators: Autonomy
 The concept of autonomy is
central to self-determination
theory.
 There is no self-
determination in exercise
participation without
autonomy.
 increased intrinsic motivation
 greater resiliency
 increased hapiness
https://images.app.goo.gl/mz7nL868TGki7cgNA
Psychological mediators: Autonomy
… refers to a person's belief that has control over his fate,
actions and choices.
 Persons who are involved in setting goals are more
successful in achieving those goals (Ryan & Deci, 2000).
 Incorporating choice-making opportunities in
interventions to reduce problem behaviors results in
improved behavioral outcomes (Shogren, Faggella-Luby, Bae, &
Wehmeyer, 2004).
 Promoting choice-making opportunities in vocational
tasks increased engagement in the activities (Watanbe &
Sturmey, 2003).
Psychological mediators: Relatedness
Relatedness refers to the
 … basic need to relate to other people, to care for
others and have others to care for you.
 … interaction with other people, supporting and being
supported by other exercise participants (social animal).
 ... exercise participant’s enjoyment is associated with
he/she related to other exercise participants,
teammates and support personel.
SDT: Basic psychological needs

https://images.app.goo.gl/N9757cRzPo8crmkq9 https://images.app.goo.gl/NyT14upwCi7XeNda8
Self-determination theory: Critical model
Self-determination theory
Self-determination theory
Self-determination theory
Self-determination theory
Motivation:

https://images.app.goo.gl/TLevboBEo3nT85Zm8
SDT: Types of intrinsic motivation
 Intrinsic motivation: High level of self-determination
 Intrinsic motivation to know
 Intrinsic motivation to accomplishment
 Intrinsic motivation to experience stimulation
Motivation: Social factors
 Success / failure
 Competition / cooperation
 Trainee behavior

Social factors facilitate or not the intensity and

functioning of one's psychological characteristics.
Motivation: Success/failure
 Success creates the belief that one is sufficient and
effective and failure is the opposite (Harter & Bandura
theories).
 Success and failure experiences formulate a person's
sense of autonomy in their relationships.
Motivation: Competition / cooperation
 Competition (e.g., overcoming performance of others -
ego orientation) reduces exercise participant's sense of
autonomy because the control is external.
 Cooperation (task orientation) does not adversely
affect the athlete's sense of autonomy and relationships,
as the locus of control is internal.
Motivation: Trainee behavior
 The trainee's behavior can negatively or positively
affect the athlete's sense of autonomy, competence, and
relationships.
SDT: Intrinsic – Extrinsic Motivation Types

https://images.app.goo.gl/AZRtG71qmbJPrWw27
SDT: Amotivation
 A state of lacking any motivation to engage in an
activity, characterized by a lack of perceived competence
and/or a failure to value the activity or its outcomes.
 The absence of motivation is the least self-determining
form of motivation.
 Amotivation or lack of motivation refers to behaviors
that are neither based on internal nor external
motivated.
SDT: The meaning of regulation
Regulation refers to the perception that a behavior can
be regulated either internally or externally.
The behavior of the individual moves within a
continuum, where the degree and type of self-
determination varies according to the individual's
position.

Internalization refers to the process by which the

reward is distinguished from less external features and
more internal elements.
SDT: Extrinsic motivation
1. External regulation

2. Introjected regulation

3. Identified regulation

4. Integrated regulation
SDT: External regulation
 … is a controlled (non-
self-regulating) form of
motivation.
 … aims at earning
external reward or
avoiding punishment.

https://images.app.goo.gl/Ta75XAwHk7ZCEANo6
SDT: Introjected regulation
First step in the self-determination continuum, becoming
a motive from external to internal
 External motives are partially internalized.
 Greater sense of self-determination by the person,
but not fully assimilated/internalized motives.
 Critical element the attribute or cause by the person
 Why am I doing what I am doing? For an external
factor or because of an internal disposition?
SDT: Identified regulation
 Identification / acceptance of an external motivation
to the extent that it begins to internalize, become a
personal motivation
 Exercise participants can internalize part of the
motivation because it can help accomplish a goal (e.g.,
performing or learning an exercise that the exercise
participant does not want, but which will help his overall
mental and physical health)
SDT: Integrated regulation
The process by which external motivations are
incorporated into exercise participant's internal
motivation system
 Integration, assimilation of external regulatory
mechanisms as identical to internal mechanisms.
 Modify the feeling of control from external to internal
factors.
 Integration of external motives, which can't be
separated from internal ones.
SDT: Intrinsic motivation
... refers to the behavior and the motives that are driven
by internal rewards. In other words, the motivation to
engage in a behavior arises from within the individual
because it is naturally satisfying to you.
 Individually motivated people engage in exercise
activities that are personally interest to them, with full
will and personal control.
 Internal motivation reflect the exercise participant's
desire and interest.
SDT: Extrinsic – intrinsic motivation

https://images.app.goo.gl/Jrqv2C5bkLNve2gd8
SDT: Extrinsic – intrinsic motivation

https://images.app.goo.
gl/wMi7HtcSPExqh8c76
Practical implications for trainees
 Involvement in physical activities should be motivated
internally as this lasts longer. Parents and educators
must promote autonomy, be supportive and positive.
The programs and activities should vary in order to be
suitable for each individual. It is useful to provide
positive feedback and avoid comparing people with
mental illness with others.
Practical implications for trainees
 Involvement in physical activity programs has both internal
and external sources of motivation. Internalization is
achieved by fulfilling the three basic needs (autonomy,
competence, relatedness). Internal forms of motivation lead
to greater mental well-being, vitality, psychological
satisfaction, and encouragement (Ryan, Williams, Patrick, & Deci,
2009).
 Exercise, in combination with psychological behavior
modification techniques, contributes in improvement of
quality of life and manages depression in patients with heart
problems (Gary et al., 2010).
Practical implications for trainees
 When the instructors show flexibility in their programs,
they give the practitioners the choice of individual
exercises and alternatives, then they better satisfy the
need for autonomy.
 Parents, trainees, and friends can contribute
 positively to the quality and the intensity of the
motivation process,
 to adherence to exercise programs, and
 increase exercise satisfaction and mental well-being
(Biddle et al., 2007).
Self-motivation & exercise participation

https://images.app.goo.gl/3tDDiPVFKpDTevEu9
Self-motivation: Exercise participation

Self-motivation is
important to exercise
participation,
commitment and
persistence
 Self-motivation is
having the initiative to
do a task or activity
without being
supervised or being told
to do it.

https://images.app.goo.gl/GZgWV9xNqhmwCFVg7
Self-motivation
Motivation is a useful thing. Motivation drives our
behaviours. There are many types of motivation.

The two main types of motivation are external and

internal.

With external motivation, you’re doing something

because the activity will bring some reward or benefit at
the end of it.
Self-motivation - Intrinsic motivation
With internal motivation, you do something purely
because you enjoy the activity itself.

• The more internally motivated an exercise is, the more enjoyable

it usually is. So from the point of view of happiness, it makes
sense to have more internally motivated physical activities.
Exercise participants who are internally motivated show more
interest and excitement over what they do, and have more
confidence.
• You are usually better at internally motivated actions too. You
show more persistence and creativity, and because of that you’ll
have increased happiness and self-esteem.
Self-motivation: Intrinsic vs extrinsic
motivation
If you want to do more of something, you can try to
change your motivation to something closer to internal
motivation.
If you do so, your performance will likely improve, and
you’ll generally be happier.
"The early bird gets the worm"

"He/she is a night owl”

Self-motivation: Why does timing matter?
When you do things can affect your motivation. Three
signs you are doing things at the wrong time:
 you can not focus
 total lack of motivation
 no matter how much or how long you try, you don't get
anything done
Motivate your self!!!!

https://images.app.goo.gl/RW5yPMthT4t2nXxk9 https://images.app.goo.gl/BFnux9piVHmS2KG98
Developing your internal motivation
 There are many things that we have to do, and we can’t
expect everything to be internally motivated. So how do
we stay motivated to do non internally motivating
things?
 Internal motivation is developed and maintained when
we are autonomous, competent and supported.
 We feel autonomous when we can make our own
choices and decisions.
 We feel competent when we can do things.
 We feel supported when we are connected to others.
Competent
 Practice. The more competent you are at a certain
activity, the more motivated you’ll be to do it. If you’re
trying to learn a new skill and losing motivation because
it’s difficult, at least take heart in the knowledge that the
better you get, the more motivated you’ll typically get.
 Look for positive feedback. Your motivation will
become stronger if you can find some way of getting
positive feedback on your progress. Avoid negative
feedback – Negative feedback will stand in the way of
your confidence and block your internal motivation.
Competent
 Break down your tasks and goals. If a task is
very complex and challenging, breaking it down can
help you stay motivated.
 Make sure the difficulty level matches your
ability. You want your goals and activities to be
reasonable, not so easy that you become bored, but
not so difficult that you become frustrated. If an
exercise or goal is too easy or hard, find some way
to adjust accordingly.
Self-motivation: How can I
motivate my self
Using creative visualization
 When you use creative visualization,
you literally visualize or picture
yourself accomplishing your tasks or
goals.
 Try doing this when you are falling
asleep at night
 Creative visualization works best
when you are in a quite and calm
environment away from your
everyday activities.
Writing down your goals
… will help you to stay organized and will make setting a
course of action easier.
… and you begin to achieve them, your self-confidence
will soar and your motivation will increase.
You should make yearly, monthly, weekly, and daily
goals.
Set aside a time every day, to review your goals, and see
which ones you have met and which ones you need to
work on.
Writing down your goals

https://images.app.goo.gl/dg5oKwBxoQnBsJ5i7
Break down tasks
 Break down your goal or task into
smaller goals or tasks.
 The task or goal will be smaller and
easily accomplished.
 This will help prevent you from
becoming stressed or frustrated as
you work towards completing your
task or achieving your goal.

https://images.app.goo.gl/97m9CzgkLMbKVz2i9
Positive speaking and language
 Once you know what the
goal or task is, use positive
language to promote your
success.
By verbally speaking or
writing the opposite of the
negative words you believe,
you are motivating yourself
and giving yourself a better
chance of success.
https://images.app.goo.gl/XLHUKF5RXStRHonc6
How to strength motivation
1. Set a goal.
2. Understand that finishing what you start is important.
3. Socialize with achievers and people with similar interests or
goals, since motivation and positive attitude are contagious.
4. Never procrastinate anything.
5. Persistence, patience and not giving up, despite failure and
difficulties, keep the flame of motivation burning.
6. Read about the subjects of your interest.
7. Constantly, affirm to yourself that you can, and will succeed.
8. Look at photos of things you want to get, achieve or do.
9. Visualize your goals as achieved, adding a feeling of happiness
and joy.
Self-motivation

https://images.app.goo.gl/nhtZdckioL7Uwyhf7
Conclusively, …
 Exercise is gradually becoming part of the treatment or
rehabilitation process of many different types of clinical
populations. The number of published research papers
is constantly increasing. This means that in the coming
years knowledge of the subject will be extremely rich.
All categories of patients can benefit from exercise
programs.
Conclusively, …
 Also the information about adherence of clinical populations to
exercise or the psychological effects of exercise on clinical
populations has started being well established. In addition,
research finds have supported the most appropriate forms of
exercise for clinical populations and the possible physiological
mechanisms of enhancement.
Review Questions
1) Which are the psychological needs in exercise
participation based on self-determination theory?
2) Indicate the sequence of the internalization of exercise
participation motives (extrinsic – intrinsic motivation)
Identified regulation, integrated regulation, external
regulation, introjected regulation
Video - Links
• Self-determination theory: https://www.youtube.com/watch?v=
rOKP0wgDftQ
• Self-determination theory: https://www.youtube.com/watch?v
=VgSMxY6asoE
• Intrinsic motivation and self-determiantion theory: https://www.
coursera.org/lecture/self-determination-theory/3-intrinsic-motivation-
sR9P5
• Rewards and intrinsic motivation: https://www.coursera.org/lecture/
self-determination-theory/4-rewards-intrinsic-motivation-cnuP9
• Promoting motivation, health, and excellence: https://www.
youtube.com/watch?v=VGrcets0E6I
• The psychology of self-motivation: https://www.youtube.com/
watch?v=7sxpKhIbr0E
“
Unit 4 – Social Benefits in Sport and PA:
Socialization & Other Benefits

”
Learning Objectives
• Know some general aspects of the social benefits of participation in
sport and physical activity
• Know how sports can contribute to the development of soft skills
• Know the soft skills that athletes develop through sports
• Know the socialization aspects of sport, including the social skills
developed
• Know the socio-moral background of sport
• Know how sport can contribute to social inclusion
• Know other social aspects of sport, such as active citizenship, crime
reduction and volunteering in sport
Social Benefits in Sport and PA:
Socialization and Other Benefits

Eleni Sakellariou
“EDRA” – Social Cooperative Activities for Vulnerable Groups
Social benefits of participation in sport and physical activity -
Introduction
“Sport means all forms of physical activity which, through casual and organised participation, aim at
expressing or improving physical fitness and mental well-being, forming social relationships or
obtaining results in competition at all levels.”
Council of Europe (2001)
http://www.sportni.net/sportni/wp-
content/uploads/2013/03/the_social_benefits_of_sport_an_overview_to_inform_the_community_planning_process.pdf

• Physical inactivity is the fourth leading risk factor for global mortality (WHO).
• Sport & physical activity provide all people with a wide range of physical, social and mental health
benefits.
• Sport improves:
• physical and mental health
• social life, active citizenship and social inclusion.
• Sport brings people together from different ethnic, cultural, religious, linguistic and socio-economic
backgrounds.
• Improves social skills.
Social benefits of participation in sport and physical activity -
Introduction

• Emphasising the social nature of most sporting activities leads to continued

participation.
• Social aspects of spot can make a more diffuse contribution to health improvement,
including to mental health.

“...opportunities afforded by exercise might also lead to wider social networks and
social cohesion…. People with good social networks live longer, are at reduced risk of
coronary heart disease, are less likely to report being depressed or to suffer a
recurrence of cancer, and are less susceptible to infectious illness than those with
poor networks.” (Acheson Report on inequalities and health, 1999)

http://www.sportni.net/sportni/wp-
content/uploads/2013/03/the_social_benefits_of_sport_an_overview_to_inform_the_community_planning_p
rocess.pdf
Sports & soft skills
Soft skills are personal attributes that allow people to build positive social
relationships. Especially team sports are an excellent source of soft skills
development, as they allow athletes to function within a supportive
environment.

Teamwork
• Joint effort to achieve a positive result.
• It requires cooperation, coordination, and accountability.
• Athletes become adaptable, persistent, and patient.
• Active participation of all team members on improving team performance.
• Helps develop the mind and solve problems in real time.

https://www.workinsports.com/blog/social-and-emotional-benefits-of-playing-sports/
https://www.edutopia.org/discussion/social-and-academic-benefits-team-sports
Sports & soft skills

Communication Skills
• Sports take a lot of communication
• Spoken and unspoken communication
• Important skills in maintaining a functioning sports team

https://www.edutopia.org/discussion/social-and-academic-benefits-team-sports
Sports & soft skills

Decisive Action
• Athletes develop the skills to make effective snap decisions.
• Athletes learn critical decision-making skills that will benefit them both during
and after game time.
• In sports athletes learn to conquer their natural “fight or flight” instinct to make
consistent and difficult decisions under high pressure situations.
• Athletes are better at making deadlines and working in stressful situations in
the future.
https://www.edutopia.org/discussion/social-and-academic-benefits-team-sports
Sports & soft skills

Competition Skills
Skills you develop by competing in sports that translate directly to your career:
• Communication
• Organization
• Rules and Structure
• Goals and Expectations
• Stamina
• Attitude
• Problem-solving
https://www.workinsports.com/blog/social-and-emotional-benefits-of-playing-sports/
 Sports & soft skills

Conflict resolution
• Conflicts are present in sports.
• Well managed conflict can have many positive outcomes in sports.
• Conflict resolution also essential outside of sports, including work and family
relationships.

https://www.workinsports.com/blog/social-and-emotional-benefits-of-playing-sports/
 Sports & soft skills

Fair Play
• Fair play is the main rule in any sport.
• Fraudulent actions won’t result in a happy ending.
• Unfair acts are punished and disapproved.
• Sport encourages fair and rightful behavior.
• Honesty and fairness are respected and recognized qualities in life.
https://www.workinsports.com/blog/social-and-emotional-benefits-of-playing-sports/
 Sports & soft skills

Leadership Skills
• Every sports team has a leader, either a coach or a veteran player.
• Leaders are powerful guides, motivating athletes to perform beyond their
current capabilities.
• This happens both in group and individual sports.
• Leaders can have a positive effect on everyone and teach through action.
https://www.workinsports.com/blog/social-and-emotional-benefits-of-playing-sports/
 Sports & soft skills

Respect Skills
• Sports teach us to respect people and institutions above us (e.g. courts, laws,
boss, parents).
• Respecting others is very important.
• Respecting opponents is a central part of every game.
• Respect others the way you want to be respected – this can be applied in all
aspects of life.
https://www.workinsports.com/blog/social-and-emotional-benefits-of-playing-sports/
 Sports & soft skills

Empathy
• Empathy means that we care about each other.
• In sports, teammates work as one.
• They support each other, they motivate each other, and they care about each
other.
• A healthy and stable team has a higher chance of success.
• When you have empathy you are better able to translate the world through
someone else’s viewpoint.
https://www.workinsports.com/blog/social-and-emotional-benefits-of-playing-sports/
 Sports & soft skills

Build Self-Esteem and a Sense of Community

• Team sports are said to bolster the five C’s:
competence, confidence, connections, character, and caring.
• Team sports provide athletes with a natural community.
• Playing sports means higher levels of social support and also associates with
critical self-esteem development.
https://www.edutopia.org/discussion/social-and-academic-benefits-team-sports
 Sports & soft skills

Time Management
• The time commitment required by athletes can be comparable to that of a full-
time job.
• Team athletes know that every second counts.
• This helps athletes focus on reaching their goals sooner than non-athletes.
https://www.edutopia.org/discussion/social-and-academic-benefits-team-sports
Sport, socialization & other benefits - Introduction

• Socialization goals are considered to be one of the factors that

encourage individuals to engage in sport.
• Sports clubs, fitness centers, and the areas/halls allocated for sportive
activities in residential areas pave the way for social interaction.
• Individuals using such areas have more active participation in social life.
• In this respect, it is considered that sports and social skills are closely
related, particularly the sports that involve sharing the same
environment with other people.
https://files.eric.ed.gov/fulltext/EJ1182762.pdf
Sport, socialization & other benefits - Introduction

• Social skills are the verbal or non-verbal behavioral

communication skills of an individual in line with the social norms
to sustain his/her life in agreement with the social circle.
• These skills are effective in sustaining participation in sporting
activities.
• Social skills enable the individual to establish proper
communications with other people and contribute to having a
positive impact on them.
https://files.eric.ed.gov/fulltext/EJ1182762.pdf
Sport, socialization & other benefits - Introduction
• Sport has an effect on acquiring and developing social skills.
• Regular sports participation during childhood and adolescence contributes to the
social skill acquisition such as cooperation, seeking rights, awareness of
responsibilities, establishing empathy, self-control, and leadership.
• The aggressiveness level is decreased and positive peer relations are
maintained in this respect.
• Also, socializing through sports activities in old age period contributes to social
skills such as empathy and control of impulses.
• Old-aged people dealing with sports show more participation in social life.
https://files.eric.ed.gov/fulltext/EJ1182762.pdf
Sport, socialization & other benefits - Introduction
• Those who have the opportunity to participate in a community or to establish
individual relationships through social skills training programs in sportive
contexts have been able to generalize their skills to the other areas of their
social lives and have adopted a more positive attitude in their interpersonal
relationships.
• There has been an increase in self-efficacy and self-esteem levels of individuals
depending on the sport and the feedback they received from the people around.
• Regular sports participation enables people to become more active and more
successful in their social environments such as school and workplace.

https://files.eric.ed.gov/fulltext/EJ1182762.pdf
 Socio-moral background of sport

• Sport can contribute to building social cohesion and reducing crime

and antisocial behavior.
• Sport provides the appropriate framework to cultivate social skills,
improve relationships among people, leading to moral development.
• “Sport activities have significant potential in promoting health,
education (formal or non-formal), training, intercultural dialogue,
peace and development, including the development of social skills
and competences related to citizenship” – European Council (2000)
Declaration of Nice.
http://sucre.auth.gr/sites/default/files/media/attachments/SUCRE-IO4-
Sports_&_Games_additional_theoretical_background.pdf
 Socio-moral background of sport

• Not all have the same opportunities to access and participate in

sports, physical activities and games.
• Exclusion and discrimination against individuals and groups such as
people with disabilities, ethnic and religious minorities, etc. in the
sports world are widespread nowadays.
• Therefore, the mere participation in sport does not guarantee moral
and social development.
http://sucre.auth.gr/sites/default/files/media/attachments/SUCRE-IO4-
Sports_&_Games_additional_theoretical_background.pdf
 Sport & Social Inclusion

• The social, moral and unifying role of sport is enhanced,

when environments promoting equality, interconnection,
mutual acceptance and pursuance of common goals
among members of a group or community are
established.
• Sport can play a key role in facilitating the integration of
vulnerable and minority groups, such as migrants and
refugees.
http://sucre.auth.gr/sites/default/files/media/attachments/SUCRE-IO4-
Sports_&_Games_additional_theoretical_background.pdf
 Sport & Social Inclusion

• Sport programs using sport and physical activities and movement games
are being implemented throughout the world as means of promoting conflict
resolution, acceptance of diversity, and social adaptation and integration.
• Sport, physical activities, and movement games can create a strong sense
of coherence and cohesion in the community.
• Therefore, it is a powerful tool for improving the quality of life and the
facilitation of minorities’ social inclusion.
http://sucre.auth.gr/sites/default/files/media/attachments/SUCRE-IO4-
Sports_&_Games_additional_theoretical_background.pdf
 Active Citizenship

• Sport can lead to increased social connectedness and are associated with
various benefits of active citizenship.
• Volunteering and community benefits, such as the construction and
maintenance of local community life, identity, and pride.
• Inclusion or (re-)integration of special groups including individuals with
physical and/or mental disabilities, young people with autism, disengaged
youths, youth at risk, elderly, often at risk of social isolation.
https://www.mdpi.com/1660-4601/16/6/937/htm
 Crime Reduction and (Anti-)Social Behavior

• Sports can be used to increase pro-social behavior, reduce smoking, alcohol

and substance misuse, or prevent youth delinquency.
• They can help to improve the behavior and habits of adults with drug
addiction or other social exclusion factors.
• Outdoor sport programs implemented for children and young people in
foster care institutions as well as for disaffected youths and pupils showing
anti-social behavioral traits resulted in a decrease in the number of
behavioral referrals.
https://www.mdpi.com/1660-4601/16/6/937/htm
 Volunteering in Sport

• According to Special Eurobarometer 472: Sport and physical activity

(2018), in total, 6% of EU citizens engage in volunteering to support
sporting activities.
• People who volunteer in sport do a range of different activities:
• Organising or helping to run a sporting event (33%)
• Coaching or training (27%).
• Being a member of a board or committee (21%), supporting day-to-day
club activities (20%) and doing administrative tasks (18%).
http://data.europa.eu/euodp/en/data/dataset/S2164_88_4_472_ENG
“ Unit 5 – Benefits of Exercise and PA
Participation: Mental Illness Consequences to
Social Well-being & Stigma

”
Learning Objectives
• Know the social benefits of team / club sport participation
• Know the social health outcomes of team sport participation, in relation to team
sport versus individual sport benefits
• Know the social health outcomes of team sport participation, in relation to
competitive versus non-competitive structure
• Know the social health outcomes of team sport participation, in relation to
commitment and continuation.
• Know the consequences of mental illness to social well-being
• Understand stigma in mental health and the problems relate to it
• Know how to counter stigmatization
• Know the psychosocial benefits of sport for individuals with severe mental
illness
Benefits of Exercise and PA Participation:
Mental Illness Consequences to Social Well-
being & Stigma
Eleni Sakellariou
“EDRA” – Social Cooperative Activities for Vulnerable Groups
Benefits of team/ club sport participation

• Sports club participants have improved health related quality of life and life
satisfaction given the social nature of their participation, compared to more
individual PA activities such as walking and going to the gymnasium.
• Even after adjusting for differences in levels of PA, club participants have
better physical role functioning, vitality, social functioning, mental health and
life satisfaction than gymnasium and walking participants.
• Participation in a socially engaged manner can contribute to mental health
and life satisfaction.
• The improved health benefits in the sport club group compared to individual
based PA may result from enhanced social connectedness, social support,
peer bonding and self-esteem which may be provided by club support.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4028858/pdf/1479-5868-10-135.pdf
Benefits of team/ club sport participation

• Participation in team sport and athlete identify were associated with

lower depression scores.
• Specifically, athletic identify mediated the relationship between sport
participation and depression.

• Club-based and team-based sport participation, when compared to other

individual forms of PA, is associated with better psychological and social
health outcomes, because:
• Of the social nature of this participation
• When people play a sport of their choice, it is fun and enjoyable in the social
context and they are often intrinsically motivated to participate.
• Each individual should choose the sport that it suits their preferences.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4028858/pdf/1479-5868-10-135.pdf
Benefits of team/ club sport participation

• A wide range of different positive social, psychological, and

psychosocial health outcomes associated with participation in
team sport (M. H. Andersen et al., 2018)
• In total, 25 psychological health benefits, 19 social health
benefits, and 8 psychosocial health benefits were identified in 17
studies.
https://journals.sagepub.com/doi/abs/10.1177/1403494818791405
 Benefits of team/ club sport participation
Overview of the positive social and psychosocial health outcomes associated with team sport participation in adults (M. H. Andersen et al.,
2018)
Social benefits Psychosocial benefits
1 Camaraderie Psychosocial health
2 Collective solidarity Psychosocial well-being
3 Collectivity Reduced feelings of loneliness
4 Communicative skills Reduced social isolation
5 Cooperation Sense of community
6 Friendships Emotional social support
7 Friendship network Trust
8 Reduced social exclusion Psychosocial health
9 Relationships; interpersonal, social, and positive peer relationships Psychosocial well-being
10 Social bonds and bonding Reduced feelings of loneliness
11 Social capital Reduced social isolation
12 Social connections and social connectedness
13 Social engagement
14 Social inclusion
15 Social interaction
16 Social network
17 Social skills
18 Social well-being
19 Teamwork
Benefits of team/ club sport participation

M. H. Andersen et al. (2018) identified three key issues influencing the

psychological and social health outcomes of team sport participation as a
health-promoting activity.
• 1. Team sport versus individual sport
• 2. Competitive versus non-competitive structure, and
• 3. Commitment and continuation
https://journals.sagepub.com/doi/abs/10.1177/1403494818791405
Benefits of team/ club sport participation
1. Team sport versus individual sport
• Study on the development of social capital among physically inactive, healthy
premenopausal women age 19–47 years who participated in (recreational) football
and running as part of a 16-week health intervention project.
• Team sport (i.e. football) had a significant advantage over individual sport (i.e.
running) in the development of social capital, resulting in better social health
outcomes.
• The participants in the football group developed social bonds, internal bonding, and
network formation to greater degree than the participants in the running group.
• A majority of young male Australian rule football players felt that it was easier for
them to partake in physical exercise to improve health in a team sport environment
due to the peer support and camaraderie.
• Among university students with high perceived stress, participating in ball sports
and dancing was associated with decreased depressive symptoms, whereas no
stress-moderating effects were found for aerobic exercise.

https://journals.sagepub.com/doi/abs/10.1177/1403494818791405
Benefits of team/ club sport participation

1. Team sport versus individual sport

• There are significant positive social and mental health benefits of
participation in team sport compared with participation in type of sports
that are more individualistic in nature.
• The type of sport is a crucial feature in order to increase and facilitate
these psychological and social health benefits.
• The social nature of team sport facilitates participation in PA.

https://journals.sagepub.com/doi/abs/10.1177/1403494818791405
Benefits of team/ club sport participation

2. Competitive versus non-competitive structure

• Negative consequences and limitations of using team sport with regard to the
competitive nature of team sport.
• In a study, it was found that football not only had the capacity to stimulate mental
health recovery, but the competitive nature of the football activities could also
potentially have negative and reverse impacts on the mental health clients’
selfesteem, resulting in stress and performance anxiety particularly for the low-
skilled football players, thereby exacerbating mental illness.
• Over-aggression and violence were also negative side effects of the football
activities.
https://journals.sagepub.com/doi/abs/10.1177/1403494818791405
Benefits of team/ club sport participation
2. Competitive versus non-competitive structure
• Study about Lifeball participants to assess changes in PA, social isolation, and
loneliness.
• Lifeball was intentionally created as a non-competitive team game that
targeted older individuals leading a sedentary lifestyle.
• Findings indicated that the non-competitive structure functioned as an entry
point into PA.
• Significant improvements in psychosocial health, well-being, and emotional
social support, along with reduced feelings of loneliness and social isolation.
• A need for shifting focus from competition to participation in health promotion
interventions, defined as “inclusive competition.”
• Inclusive competition promotes elements of fun, enjoyment, safety,
cooperation, and collaboration and team spirit. These values facilitate
participation and positive involvement, social interactions, caring relationships,
and a supportive atmosphere.

https://journals.sagepub.com/doi/abs/10.1177/1403494818791405
Benefits of team/ club sport participation

2. Competitive versus non-competitive structure

• Critical aspects of using team sport in health contexts.
• These are associated with the inherent competitive nature of team sport in
supporting the adoption of a structure of inclusive competition that
facilitates participation and promotes health.
• However, for certain target groups, the competitive element of team sport
participation is of crucial importance in the promotion of social and mental
health benefits.
https://journals.sagepub.com/doi/abs/10.1177/1403494818791405
Benefits of team/ club sport participation
3. Commitment and continuation
The social context of team sport
• Τeam sport (volleyball) fostered a sense of community for the participants that
encouraged long-term commitment to sport and PA.
• Female participants, through the camaraderie, support, bond, and loyalty of the volleyball
team, were encouraged and determined to continue volleyball practice each week for
more than 2 years.
• Football players expressed a sense of commitment to the football team in the health
intervention and a dependence on other people’s participation, in contrast to the runners,
who valued the flexibility and interdependence.
• The football players were committed to the activity itself and not letting down their
teammates, whereas the commitment of the runners was related to a health discourse
and to fulfilling obligations made to the project.
• One year after the intervention, only the football players continued to play football as a
team in a local football club.
• Sense of obligation toward the team members, team spirit, sense of positive mutual
interdependency and feeling of collectivity, sense of responsibility of being part of a team.

https://journals.sagepub.com/doi/abs/10.1177/1403494818791405
Benefits of team/ club sport participation
3. Commitment and continuation
Team sport as an enjoyable and meaningful activity
• Footballers ranked their enjoyment of the football activity high and ranked “having fun” as
second highest on the list of important aspects regarding their participation in football
compared with runners.
• The significance team members attributed to team participation and their desire for
commencement or continued involvement in football could be ascribed to experiences of
pleasure and enjoyment.
• Participation in team sport is a meaningful activity with particular regard to individuals with
mental health problems, as it gives participants as sense of meaning, purpose, and
stability.
• E.g. involvement in team sport (Australian rules football) provided unemployed men with a
sense of occupational identity, offering them a sense of meaning and satisfaction.
• Thus, the social, enjoyable, and meaningful nature of team sport is an important aspect of
keeping people engaged in, participating in, and committed to PA also in the long run.

https://journals.sagepub.com/doi/abs/10.1177/1403494818791405
The consequences of mental illness to social well-being

• The consequences of mental illness often affect the person’s social and
economic well-being and all aspects of life.
• People with mental illness remain one of the most marginalised groups in
society.
• They are often isolated from family and friends.
• They may experience family instability, poverty, unemployment, stigma
and exclusion.
• These problems result in high rates of death and earlier death.
• Also, people with mental illness are more likely to have never married, to
live alone, to be unemployed and to have not completed secondary
school.

http://www.aph.gov.au/DocumentStore.ashx?id=4b08cc9f-e5c0-4402-9951-91e730d2c020
The consequences of mental illness to social well-being

• People with mental illness who are unable to maintain employment or

study roles lose common life roles linked to self esteem, meaning and
social connectedness.
• Isolation can lead to loss of skills and confidence to engage socially with
others.
• Poor family relations experienced by many people with a mental illness
further contribute to the isolation.
• 84% of those with mental illness are separated, divorced, widowed or
single;
• 85% are reliant on welfare benefits;
• 72% do not have a regular occupation;
• and 45% live in hostels, supported housing or crisis shelters, or are
homeless.
http://www.aph.gov.au/DocumentStore.ashx?id=4b08cc9f-e5c0-4402-9951-91e730d2c020
Stigma in mental health
• People with mental illness often have to struggle with the negative
attitudes and behaviors that society, and they themselves, hold
regarding mental illness, one of which is stigma.
• Byrne (2000) defines stigma as a sign of disgrace or discredit, which
sets a person apart from others.
• The stigma of mental illness, although more often related to context
than to a person’s appearance, remains a powerful negative attribute in
all social relations.
• Stigma is a complex, multifaceted social process that consists of
labelling, stereotyping, separation, status loss, and discrimination that
co-occur in a power differential.

https://www.ncbi.nlm.nih.gov/pubmed/21357643
https://www.cambridge.org/core/journals/advances-in-psychiatric-treatment/article/stigma-of-mental-
illness-and-ways-of-diminishing-it/EF630432A797A5296D131EC0D4D5D7AD
Understanding stigma

• 1 in 4 living in the EU can expect to experience a mental health

problem during his or her lifetime
• People affected by mental health problems are being stigmatised in
almost all areas of their daily life.
• They are socially and structurally excluded and hindered from realising
their abilities, coping with the normal stresses of life, working
productively and fruitfully, and being able to make a contribution to
their community.
(Burfeind, 2010)

https://ec.europa.eu/health//sites/health/files/mental_health/docs/ev_20101108_bgdocs_en.pdf
Understanding stigma – the problems

• People with mental health problems are being stigmatised

in all areas of their life
• People with mental health problems are confronted with
prejudice
• Frequent stigmatisation leads to anticipated stigmatisation
• People with mental health problems also stigmatise
themselves (self-stigmatisation)
• Stigmatisation leads to exclusion with even more negative
consequences

https://ec.europa.eu/health//sites/health/files/mental_health/docs/ev_20101108_bgdocs_en.pdf
Understanding stigma – the problems

• Lack of treatment in primary and psychiatric care

• Social inclusion still needs to be promoted
• The individual’s and the economic costs of stigmatisation
are high
• People in contact with mentally ill people also experience
stigmatisation
• Due to stigmatisation mental health issues have low
priority in policies

https://ec.europa.eu/health//sites/health/files/mental_health/docs/ev_20101108_bgdocs_en.pdf
How to counter stigmatization?
There are many efforts to counter stigmatisation and social exclusion, but there is lack of
evaluated interventions (Burfeind, 2010)

• Social distance as indicator for stigmatising attitude and behaviour

• Pupils, students and health professionals seem to be a good target
• Public protest campaigns risk an attitude rebound
• Contact to people with mental disorder is the most effective way to overcome social distance
• Including mentally ill people in the conception and realisation of action fosters empowerment
• Education and information – combined with contact – is most effective
• A combination of methods is effective
• Addressing different levels, individuals, groups and society, helps sustain the effect
• All in all the most successful interventions include:
• The provision of information about the stigmatised group, the opportunity for personal
contact or other elements that facilitate perspective-taking, the change of methods and
media, and the promotion of new social norms (e.g., through a role-model, legislative
changes or non-stigmatizing depiction in the media).
https://ec.europa.eu/health//sites/health/files/mental_health/docs/ev_20101108_bgdocs_en.pdf
Psychosocial benefits of sport for individuals with severe
mental illness
The Social Meaning of Sport in the Lives of Patients
• The sporting activities seemed to generate enthusiasm among the
patients before and after the activity.
• Sport meant being part of a group and receiving an identity from that,
having a social interest which gave meaning.
• Sport required individuals to undertake a social learning experience,
which extended and enhanced their social network.
• Increases in social confidence, greater social skills, and a decrease in
social withdrawal from experiencing a new social world
• Individuals became more autonomous and had developed or enhanced
their ability for social engagement.

https://www.hindawi.com/journals/apsy/2015/261642/
Psychosocial benefits of sport for individuals with severe
mental illness
The Direct Benefits of Sport
• Sport provided individuals with somewhere to go and something to do.
• Sport provided an opportunity to be someone within a positive group and
a positive sense of identity.
• Interactions within the sporting environment were not often focusing on
their mental illness or problems.
• Sport was often associated with a normal trip with excitement and
pleasure or getting back to what was perceived as normal for the
patient.
• It represented a social learning opportunity as it could help break down
perceptual biases.
• Sport served as a distraction from individuals’ typical worries, anxieties,
or mental health symptoms.
• Sport was associated with the accomplishment of a task.

https://www.hindawi.com/journals/apsy/2015/261642/
“ Unit 6 – Barriers Toward Exercise & PA
Interventions for Physical Activity
Participation Improvement

”
Learning Objectives
 Know the theoretical approaches explaining barriers of MI patients’
PA/exercise participation

 Recognise and understand the barriers towards exercise in mental ill patients.

 Recommend and apply interventions to overcome barriers

Barriers Toward Exercise & PA Interventions
for Physical Activity Participation
Improvement

Maria Psychountaki & Nektarios Stavrou

Faculty of Physical Education & Sport Science
National & Kapodistrian University of Athens
 Introduction
1
Psychological disorders & mental illness affect an individual’s …
• Ability to work,
• Engage in relationships and
• Live independently in community

It constitutes a significant risk factor for

• Morbidity and
• Mortality
Mueser et al., 2001; Evans et al., 2007

…
Psychological disorders & Mental illness represent:
a significant health problem
• The life expectancy is 20-25 years less than that of the general population

Dixon et al., 1999; McGrath et al., 2008

• 33,5 to 70% of individuals with schizophrenia have an additional morbidity

Casey & Hansen, 2009

…
Mental illness is a serious public health issue
Severe mental illnesses (schizophrenia, bipolar disorder, major depression)

cause 10.5%
of the burden of disease and injury worldwide.
WHO, 2000
account for the 3 of the top 30 leading causes of years
with disability.

Murray & Lopez, 1997

…
 Individuals with Severe Mental Illness are …
• less active Lindamer et al., 2008

• Lethargy
Depression associate with
• lack of motivation
Increase
• low self- sedentary behavior
is confidence
• low self-esteem
… one of the most threatening health issues. Grace et al., 2005; Lin et al., 2010

“Approximately 30% of the European population

has a long-term condition. People with a long-term
condition that is comorbid with a mental health
problem have worse health outcomes than do
people with either of these alone” (p. 141).
Clow & Edmunds (2014) …
Researches have concluded that …
Physical Activity & Exercise
• Reduce depression (in the same level with Psychotherapy or pharmacotherapy)
• Improve general health – without the negative side effects of drugs (Landers,
2007)
• Are an important component of the quality of life of any participant

• Can improve the physical & Mental Health

• … and health related quality of life of mentally ill population
(Josefsson et al., 2014; Rosenbaum et al., 2014; Vancampfort et al., 2015)

…
Researches have concluded that …
Physical Activity & Exercise
• Can positively affect a various range of mental health conditions (e.g.,
schizophrenia, Alzheimer’s disease, depression)
• Can positively affect well-being
(Clow & Edmunds, 2014)

Physical Inactivity
• Is a major cause of morbidity & mortality as other risk factors
for cardiovascular disease (e.g., Wei et al., 1999)

…
Follow-ups examinations ...
Although it is well documented that PA & Exercise have
multiple benefits for physical & mental health …

• Most of the participants had not maintained their activity

level (Andersen et al., 1998)
• Adult PA levels have declined over the past two decades
(Haskel et al., 2007)

…
Follow-ups examinations ...
Indicatively,
• the majority of American adults are considered non-active (Haskel et al., 2007)
• the 47.2% of young Cypriots do not perform any type of exercise at all
(Kyriakou & Pavlakis, 2011)
• the 25% of the Greek population do not participate in PA beyond the necessary
daily tasks (Valanou, Bamia, Chloptsios, Koliva, & Trichopoulou, 2006).
• Only a minority of individuals with depression and bipolar disorder engage in PA
& Exercise (Wielopolski et al., 2014; Janney et al., 2014)

…
Follow-ups examinations ...
Prevalence of INACTIVITY,
• Is great among clinical population:

• 96% of the sample did not meet PA guidelines of at least 150 min/week
of moderate-to-vigorous-intensity PA (Jerome et al., 2009)

Generally, research evidence (nonclinical & clinical populations)

• Physical inactivity has crucial implications for morbidity and

mortality
• Physical activity interventions can be effective and
• … have a meaningful impact on health parameters.
…
Overall,
These reasons led researchers to
• find ways to increase the level of exercise & PA in mentally ill people’s everyday
lives.
• PA programmes for mentally ill individuals should be integrated into mental
health services (Richardson et al., 2005).

Because of the importance of PA and exercise in terms of health

improvement, it is essential to identify
• the causes of the low levels of exercise participation and
• the difficulty of adhering to an exercise routine .
 Theories explaining barriers of mental ill patients’
2
exercise participation
Severe Mental Ill (SMI) individuals face several barriers,
obstacles or difficulties in their PA & Exercise participation.

Having this in mind,

• meta-syntheses of the qualitative literature
• systematic reviews
• meta-analyses
Have examined the factors that may encourage or prevent exercise
participation among SMI individuals

(Firth, Rosenbaum, Stubbs, Corczynski, Yung, & Vancampfort, 2016; Mason & Holt, 2012;
Soundy, Freeman, Stubbs, Probst, Coffee, & Vancampfort, 2014b).
…
 People may be turned off by the exercise because:
• they never done exercise,
• they were not good at sports at school,
• they would feel silly,
• they have thoughts that other people would make fun of him/her,
Royal
• exercise could not help unless it hurts,
College of
• during exercise they are sweaty and uncomfortable,
Psychiatrists
• they are too tired,
(Taylor, 2014) • they would rather do something else,
• they believe that it is expensive,
• they think exercise will make them feel worse,
• they don’t have anyone to do exercise with,
• they don’t know where, when or how to start.
…
 The reason …
Individuals with mental health problems engage in significantly
• Less vigorous exercise, and
• Greater amounts of sedentary behaviour than health controls
(Stubbs et al., 2016a,b; Vancampfort et al., 2016a)

is predictive of a range of adverse health

outcomes including: It is also associated with
• obesity, • more severe negative symptoms &
• Diabetes, & • poor socio-occupational
functioning
• medical co-morbidity
among individuals with mental health issues (Vancampfort, Knapen, Probst, Scheewe, Remans,
& De Hert, 2012; Suetani et al., 2016)
(Vancampfort et al., 2013a,b; Suetani et al., 2016)
Common Barriers toward exercise
Personal barriers Socio-ecological barriers
Physical • Support
• Physical illness & Poor health  • Time
barrier for 25% of patients.
• Cost
• Tiredness / Low energy  it was
reported by 45% of patients • Access to facilities
Psychological • Insufficient information
• Experienced Stress / Depression  a
more significant barrier to exercise
for 61% of patients
• Disinterest in exercise (motivation) =
barrier for 32% of patients.
(Firth, Rosenbaum, Stubbs et al.,
• Self-confidence 2016)
• Safety
Theoretical models explaining barriers of mental ill patients’
exercise participation

Case Management - Person Centered Treatment plan

• Features
o Holistic approach to individual needs
o Process of facilitation allows for referral, not just direct service
o Collaborative outcomes: Individualized support combined with
individual’s effort

• Case management is a collaborative process of assessment,

planning, facilitation and advocacy for options and services to meet an
individual’s needs
Person Centered Treatment plan
Case Management

Client’s
Support
CLIENT System
(e.g., family,
friends)

Healthcare & Service Providers

(e.g. clinicians, representatives …
Individualized Case Management approaches
• Strengths Based Clinical Formulation
• Recovery Life Goal
• Treatment Goal
• Clinical and Systemic Discharge Criteria
• Focus of Treatment
• 1st Objective: Within the next X days (patient’s name) will …
• Discipline Specific Interventions
• 2nd Objective: Within the next X days (patient’s name) will …
• Discipline Specific Interventions
Adams & Grieder, 2005, 2013; Faulkner et al., 2007a
Transtheoretical Enter Precontemplation
Μodel
Stages of change
model
Maintenance Contemplation

Relapse Determination

Action

DiClemente & Prochaska, 1982 Exit and re-enter at any …

Transtheoretical Model (TM) DiClemente & Prochaska, 1982

TM is used to inform an individualized approach:

• TM can help identify the person’s readiness to engage in PA
• TM provides processes to help the person move from a stage of
not considering exercise to thinking about potential types of
physical activity ...

…
The process of TM includes: DiClemente & Prochaska, 1982
• provide information on how exercise may help,
• address perceived barriers to exercise,
• use positive aspects of exercise to counter fears and anxieties about future
health
• and once engaged in exercise includes processes designed to continue
engagement.

• Motivational interviewing (MI)

is one of the processes used in applying the TM which may help people
• to identify the barriers to exercise and
• to promote engagement with physical activity programmes .

Brodie & Inoue, 2005

People with SMI (severe mental illness)
need more exercise … unfortunately, they engage in significantly
• less vigorous exercise
• greater amounts of sedentary behaviour than health individuals
(control group) (Stubbs et al., 2016a,b; Vancampfort et al., 2016a)

Research evidence  Exercise interventions can:

- Improve physical health
- Reduce psychiatric symptoms (Rosenbaum et al., 2014; Firth et al., 2015)
- Reduce negative symptoms
- Reduce cognitive deficits (Firth et al., 2015; Kimhy et al., 2015)

…
People with SMI (severe mental illness)
• Meta-analysis suggests (Firth et al., 2015):
Various exercise modalities can be effective for improving outcomes in
SMI
Important: sufficient total volume of activity is needed

• Clinical trials found that:

significant benefits for depressive and psychotic symptoms only occur
among participants who achieve sufficient amounts of exercise
(Hoffman et al. 2011; Scheewe et al. 2013).

Therefore,
training programmes which can maximize adherence to exercise
in SMI may be the most effective.
1
Common Barriers toward exercise
Personal barriers Socio-ecological barriers
Physical
• Support
• Physical illness & Poor health 
barrier for 25% of patients.
• Time
• Tiredness / Low energy  it was • Cost
reported by 45% of patients • Access to facilities
Psychological • Insufficient information
• Experienced Stress / Depression  a
more significant barrier to exercise
for 61% of patients
• Disinterest in exercise (motivation) =
barrier for 32% of patients.
• Self-confidence (Firth, Rosenbaum, Stubbs et al.,
2016)
• Safety
Personal Barriers
• Insufficient time to exercise
• Inconvenience of exercise
• Lack of self-motivation
The top-3 barriers are
• Non-enjoyment of exercise • Time
• Boredom with exercise • Energy
• Low self-efficacy • motivation

• Fear of being injured

• Lack of self-management skills (set goals)
Manaf, 2013; Sallis & Hovel,
• Lack of support 1990; Sallis, Hovell, & Hofstetter,
1992
…
Socio-ecological barrier
• Lack of support = the most frequently experienced practical
barrier  it was reported by 50% of patients.
• Lack of time  it was reported by 19% of patients.
• Non-availability of suitable places
• Accessibility of PA places
• Traffic to and from places
• Availability of public transportation

Social environment
• Support from family or friends
Manaf, 2013; Sallis & Hovel, 1990; Sallis,
• Community spirit Hovell, & Hofstetter, 1992
…
2
Overcoming barriers toward physical activity

Know the barriers in order to break them!

Recognizing and understanding barriers is the first step in
overcoming them …

We can find many interesting ideas in the bibliography …

Centers for Disease Control and Prevention (2007).

Overcoming Barriers to Physical Activity. Physical Activity …
for Everyone.
Know the barriers in order to break them! www.exerciseright.com.au

Lack of time
• Monitor your daily activities for one week.
• Identify at least 3 30-minute time slots you could use for PA
• Add PA to your daily routine.
• Walk or ride your bike to work or shopping,
• Organise school activities around PA
• Walk the dog
• Exercise while you watch TV
• Park farther away from your destination etc.
• Select activities requiring minimal time.
• e.g. walking, jogging or stair climbing
Know the barriers in order to break them! www.exerciseright.com.au

Lack of energy
• Plan exercise into your schedule.
• Schedule PA for times in the day or week when you feel energetic.
• Start small and build gradually.
• Even something as simple as a brisk walk can be beneficial.
• It’s a long race so by starting small, you avoid gassing at the start
• Give it a go.
• Convince yourself that if you give it a chance, PA will increase your energy
level; then, try it.
Know the barriers in order to break them! www.exerciseright.com.au
Lack of motivation
• Plan ahead.
• Make PA a regular part of your daily or weekly schedule and write it on your
calendar.
• Set SMART goals.
• Setting SMART goals (Specific, Measurable, Attainable, Relevant and Timed) gives
you the freedom to choose a goal that is both relative to your current situation and
also achievable.
• Start small.
• The key is to be honest with yourself and start small.
• It’s a long race so by starting small, you avoid gassing at the start.
• Use technology.
• Apps can help give you the motivation to get outside and move.
• Rally support.
• Invite a friend to exercise with you on a regular basis and write it on both your
calendars.
Know the barriers in order to break them! www.exerciseright.com.au

Lack of support
• Ask for help.
• Explain you interest in PA to friends and family
• Ask them to support your efforts
• Exercise with friends.
• Invite friends and family members to exercise with you
• Plan social activities involving exercise
• Develop new friendships with PA people.
• Join a group with physically active people
Know the barriers in order to break them! www.exerciseright.com.au
Fear of injury
• Warm up and cool down.
• Learn how to warm up and cool down to prevent injury
• Exercise appropriately for yourself.
• Learn how to exercise appropriately considering your age, fitness
level, skill level, and health status.
• Minimise your risk.
• Choose activities involving minimum risk.
• Consult a professional.
• Exercise with the help of an accredited exercise professional who can
show you how to exercise safely and at a level suitable to your
unique needs.
Know the barriers in order to break them! www.exerciseright.com.au

Lack of Skill
• Select well-known activities .
• Choose activities requiring no new skills; walking, climbing
stairs, or jogging
• Take a class to develop new skills.
Know the barriers in order to break them! www.exerciseright.com.au

Lack of resources
• Select activities that require minimal facilities or
equipment.
• e.g. walking, jogging, jumping rope etc.
• Identify inexpensive program.
• Inexpensive, convenient resources available in your community
• e.g. community education programs
• Park and recreation programs
• Work-site programs etc.
Know the barriers in order to break them! www.exerciseright.com.au

Weather conditions
• Develop a set of regular activities that are always
available regardless of weather.
• e.g. indoor cycling, aerobic dance, indoor swimming, stair
climbing, rope skipping, walking dancing, gymnasium games
etc.
Know the barriers in order to break them! www.exerciseright.com.au

Travel
• Put a jump rope in your suitcase.
• Walk the halls and climb the stairs in hotels.
• Stay in places with swimming pools or exercise facilities.
Know the barriers in order to break them! www.exerciseright.com.au

Family obligations
• Share babysitting time.
• Share babysitting time with a friend, neighbour, or family member
who also have children
• Exercise with the kids.
• Go for a walk together, play running games, do aerobic dance and
exercise together
• Use home exercise equipment.
• Jump rope, ride a stationary bicycle while the kids are busy playing
or sleeping.
• Exercise when the kids are not around.
• e.g. during school hours or their nap time
Know the barriers in order to break them! www.exerciseright.com.au

Retirement years
• Retirement as an opportunity to become more
active.
• Spend more time gardening, walking the dog, and playing with
grandchildren
• Learn new skills.
• e.g. ballroom dancing, swimming etc.
• Make regular PA a part of every day.
• Go for a walk every morning or every evening before dinner.
5
Conclusions
Interventions for people with SMI …
Exercise training programmes should be designed
• to improve exercise capacities and cardiorespiratory fitness
• to provide the necessary levels of supervision or assistance for
each patient to overcome personal or socio-ecological barriers and
achieve their goals .

(Firth, Rosenbaum, Stubbs et al.,

2016)
5
Conclusions
• There are implications of poor physical health in SMI
• Need to monitor the physical health of this clinical population and
• Need to provide advice on how to increase levels of physical activity.
• PA programmes that include professional and peer support may be more likely
to facilitate physical activity uptake and adherence (Faulkner et al., 2007a).
• Need for a structured day programme - available 5 days/week
• It will run by a multidisciplinary team and
• It includes individual and group activities

 Support to each patient may need not only to engage with, but also to
maintain regular physical activity.
Conclusions with regard the barriers toward PA
(Firth, Rosenbaum, Stubbs et al.,
2016)
People with SMI However,
Value exercise for its ability • Many barriers arise for their
• to improve physical health participation in PA:
• to improve their appearance - Mental health symptoms
• And the psychological benefits. - Tiredness
- Insufficient support
Valued outcome - Meta-syntheses present substantial barriers for
of qualitative literature: the majority of patients.
• Improving self-identity
• Improving body
(Mason & Holt, 2012; Soundy et al., 2014a)

…
COORDINATOR PARTNERS

COOSS Marche Fundación Intras Fokus ČR Praha

Italy Spain Czech Republic

KSDEO Edra
Greece

National and Capodistrian Panellinios ENALMH

University of Athens Athletics Club Belgium
Greece Greece
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