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State anxiety, psychological stress and positive

well-being responses to yoga and aerobic
exercise in people with schizophrenia: A pilot
study
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Disability and Rehabilitation, 2011; 33(8): 684689

RESEARCH PAPER

State anxiety, psychological stress and positive well-being responses to

yoga and aerobic exercise in people with schizophrenia: a pilot study

DAVY VANCAMPFORT1, MARC DE HERT2, JAN KNAPEN1,2, MARTIEN WAMPERS2,

HELLA DEMUNTER2, SEPPE DECKX1,2, KATRIEN MAURISSEN1,2 & MICHEL PROBST1,2

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Faculty of Kinesiology and Rehabilitation Sciences, and 2University Psychiatric Centre, Catholic University Leuven, Leuven,
Belgium

Accepted July 2010

Abstract
Purpose. Worsening of schizophrenia symptoms is related to stress and anxiety. People with schizophrenia often experience
difficulties in coping with stress and possess a limited repertoire of coping strategies. A randomised comparative trial was
undertaken in patients with schizophrenia to evaluate changes in state anxiety, psychological stress and subjective well-being
after single sessions of yoga and aerobic exercise compared with a control condition.
Method. Forty participants performed a single 30-min yoga session, 20-min of aerobic exercise on a bicycle ergometre at
self-selected intensity and a 20-min no exercise control condition in random order.
Results. After single sessions of yoga and aerobic exercise individuals with schizophrenia or schizoaffective disorder showed
significantly decreased state anxiety ( p 5 0.0001), decreased psychological stress ( p 5 0.0001) and increased subjective
well-being ( p 5 0.0001) compared to a no exercise control condition. Effect sizes ranged from 0.82 for psychological stress
after aerobic exercise to 1.01 for state anxiety after yoga. The magnitude of the changes did not differ significantly between
yoga and aerobic exercise.
Conclusion. People with schizophrenia and physiotherapists can choose either yoga or aerobic exercise in reducing acute
stress and anxiety taking into account the personal preference of each individual.

Keywords: Schizophrenia, exercise, yoga

Introduction
Schizophrenia is one of the most debilitating
psychiatric disorders [1]. The Diagnostic Statistical
Manual of Mental Disorders-IV (DSM-IV) criteria
for schizophrenia include positive and negative
symptomatology severe enough to cause social and
occupational dysfunction [2]. Positive symptomatology reflects an excess or distortion of normal
functions and manifests itself in symptoms such as
delusions, hallucinations and disorganised speech
and behaviour. Negative symptoms reflect a reduction or loss of normal functions consisting of
symptoms such as affective flattening, apathy, avolition, social withdrawal and cognitive impairments.
The lifetime prevalence and incidence range from

0.30 to 0.66% and from 10.2 to 22.0 per 100,000

person-years, respectively [3]. According to the
Global Burden of Disease Study, schizophrenia
accounts for 1.1% of the total DALYs (disabilityadjusted life years) and 2.8% for men and 2.6% for
women of YLDs (years lived with disability).
Schizophrenia is listed as the fifth leading cause of
DALYs worldwide in the age group of 1544 years
[4]. Moreover, people with schizophrenia have a
20- to 25-year reduced life expectancy compared to
the general population [59].
Worsening of schizophrenia symptoms is related to
stress and anxiety. People with schizophrenia often
experience difficulties in coping with stress and
possess a relatively limited repertoire of coping
strategies [10,11]. In schizophrenia, an increase in

Correspondence: Davy Vancampfort, University Psychiatric Centre, Catholic University Leuven, Campus Kortenberg, Kortenberg, Belgium.
E-mail: davy.vancampfort@uc-kortenberg.be
ISSN 0963-8288 print/ISSN 1464-5165 online 2011 Informa UK, Ltd.
DOI: 10.3109/09638288.2010.509458

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Schizophrenia
subjective stress results in an increase in negative
affect and a decrease in positive well-being [12].
Clinical rehabilitation strategies that aim to enhance coping with feelings of stress and anxiety
should therefore be key.
Yoga [13] and aerobic exercise [14] as an add-on
treatment are known to be beneficial in schizophrenia. This benefit is seen across several dimensions of
the schizophrenia outcome. It remains to be established whether the benefits extend to stress and
anxiety symptoms. In other populations, yoga has
shown promise in improving these symptoms
[15,16]. In persons with psychiatric disability,
improvements can be observed already after a single
session [17]. Also varying amount and types of
physical activities are associated with reductions in
stress and anxiety scores. A narrative review of 24
studies evaluated the effects of single exercise
sessions on state anxiety in both clinical and
non-clinical populations [18]. In 21 (87%) of the
studies, acute exercise resulted in a significant
reduction in state anxiety. Individuals with highstate anxiety and unfit people showed the greatest
improvement post-exercise.
The aim of this study is to evaluate the changes in
state anxiety, psychological stress and subjective
well-being responses after a single yoga session and
after an acute bout of aerobic exercise at self-selected
intensity, and compare these with a no exercise
control group in a sample group of people with
schizophrenia or schizoaffective disorder.
The second aim is to investigate if differences in
responses can be observed between yoga and
aerobic exercise. The single-session format will be
utilised to facilitate evaluation of acute changes in
state anxiety, psychological stress and subjective
well-being.

Material and methods

Participants
Over an 8-month period, all individuals with schizophrenia or schizoaffective disorder of an acute
inpatient care unit of the University Psychiatric
Centre of Kortenberg were invited to participate.
Only patients with a clinical global impression
severity (CGIS) scale [19] score of 4 or more assessed
by a trained psychiatrist during a semi-structured
interview, and who were cooperative for the yoga
and aerobic exercise, were included. People with
schizophrenia were excluded if they had psychiatric
co-morbidity (anxiety disorders and/or depressive
disorders, substance dependence). The somatic
exclusion criteria included evidence of significant
cardiovascular, neuromuscular and endocrine

685

disorders that might prevent safe participation in the

study.

Procedure
The effects of a single 30-min yoga session and a
20-min bout of aerobic exercise were compared with
a no exercise control condition. The first week
participants undertook a habituation yoga and
aerobic exercise session to get used to the environment and the protocol. Questionnaires were filled
out the second week. The test condition order was
randomly assigned to control for the influence of
previous test(s). An independent statistician generated a randomisation list using a research randomiser
(http://www.randomizer.org). Tests were performed
on a one-to-one basis on consecutive days at the
same hour. In between the test conditions medication intake remained unchanged. A physiotherapist
trained to teach both yoga therapy and exercise
therapy delivered the interventions.
The yoga session was based on the principles of
hatha yoga [20]. It included breath awareness,
focussing on the present as well as relaxation.
Accompanying this were bodily postures, coordination, strength, flexibility and balance. Session routines varied to some degree based on the needs and
abilities of the individual. In general, routines were
similar to that described in Table I and included an
average of five poses per session.
The aerobic exercise session was performed on an
electronically braked bicycle ergometre (Ergo 2000,
Ergo-Fit, The Netherlands) and consisted of cycling
for 20 min at a self-selected intensity with heart rate
feedback. The heart rate was displayed in real time
on a monitor to provide feedback during the aerobic
exercise. The physiotherapist was present in the
room and only left during completion of the
questionnaires.
During the no exercise control condition, participants sat quietly in a room for 20 min and were told
that they could read. Reading material was provided

Table I. Yoga routine.

Duration: approximately 30 min
(1) Cardiovascular warming-up exercises 5 min
(2) Abdominal breathing exercises 5 min
(3) Asanas
a. Tadasana (mountain posture) 3 min
b. Vrikshasana (tree posture) 3 min
c. Bidalasana (cat posture) 3 min
d. Bhujangasana (cobra posture) 3 min
e. Apanasana (knees to chest posture) 3 min
(4) Relaxation technique 5 min. This involves adopting
Shavasana

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D. Vancampfort et al.

for participants who did not bring their own material.

The same physiotherapist was also here present in
the room and only left during completion of the
questionnaires.
The study procedure was approved by the Ethical
Committee of the University Psychiatric Centre,
Catholic University of Leuven, campus Kortenberg
in accordance with the principles of the Declaration
of Helsinki. All participants gave their informed
consent.

no exercise condition and SDdiff is the standard

deviation of the difference between the two conditions. As a general guideline, an ES of 0.200.50 is
considered to be a small effect, 0.500.80 medium,
and a value of more than 0.80 large [24]. The
significance level was set at 0.05.

Results
Participants

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Questionnaires
State anxiety was assessed by the State Anxiety
Inventory (SAI) [21]. The range of possible total
scores is 2080, and higher scores indicate higher
levels of anxiety. The SAI has been extensively
validated and is the most widely used measure of
anxiety in exercise research [22].
Psychological stress and positive well-being were
measured using the Subjective Exercise Experiences
Scale (SEES) [22]. The SEES consists of three
subscales: psychological stress, positive well-being
and fatigue. Each subscale contains four items,
which are scored on a scale from 0 (not at all) to 7
(entirely). Higher scores on a subscale indicate a
higher perception for this factor. The SEES represents one of the most reliable and valid instruments
for assessing subjective well-being in exercise settings [23].
The SAI and the SEES were assessed 5 min before
the yoga, aerobic exercise and no exercise control
condition and immediately after the completion of
the sessions.

Statistical analysis
A within-participants repeated-measures ANOVA
with Scheffe post-hoc analysis was conducted using
Statistica 8 (StatSoft, Tulsa, OK) to test the
significance of the pre-post differences between the
means and the differences between the three interventions.
Effect sizes (ES) were measured via Cohens d
statistic. Cohens d is the standardised difference
between the post-test means of the experimental
condition (yoga or aerobic exercise) and the comparison control condition divided by a standard
deviation of the difference between the two conditions, conceptually expressed as:

A total of 57 individuals with schizophrenia or

schizoaffective disorder were initially recruited. Five
individuals with co-morbid substance dependence
and one patient with co-morbid anxiety disorder were
excluded. Two patients were excluded as a consequence of a neuromuscular disorder. From the 49
included individuals, five persons did not agree to
participate (three were not interested, two not
motivated). Two individuals did not complete all
the test conditions. Reasons for additional drop-out
were not being motivated to fill in the questionnaires
after the yoga session (n 1) and not being motivated
to continue the aerobic exercise condition (n 1).
Two persons were excluded due to incomplete data.
Consequently, 40 participants were included in the
final analysis. All included participants were able to
complete the questionnaires within 510 min without
difficulties and with minimal instructions.
The gender distribution of the final sample was 22
male (31.8 + 8.7 years; body weight: 86.91 + 16.63
kg; body mass index: 26.22 + 3.62) and 18 female
persons with schizophrenia (32.74 + 8.93 years;
body weight: 65.93 + 19.34 kg; body mass index:
25.91 + 4.22). All individuals were Caucasian
and Belgian natives and all were treated with
antipsychotic drugs. On average, individuals received
2.11 + 1.10 different antipsychotics. Mean CGISscore in this study was 5.33 + 0.82. Acute symptoms
were at least partially remitted in all patients.

Internal consistency
The internal consistency assessed by Cronbachs
alpha coefficients was 0.94 for the SAI, and 0.91 and
0.92 for respectively the subscales psychological
stress and positive well-being on the SEES.

Changes in state anxiety, psychological stress and

subjective well-being

d x1  x2 =SDdiff
where d is the effect size, x1 is the mean value for
yoga or aerobic exercise, x2 is the mean value for the

The means before and after yoga, aerobic exercise

and the no exercise condition are presented in
Table II.

687

Schizophrenia

Table II. Means and standard deviations of state anxiety, psychological stress and subjective well-being before and after the three conditions.
Yoga (n 40)

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State anxiety
Psychological stress
Subjective well-being

Aerobic exercise (n 40)

No exercise (n 40)

Before

After

Before

After

Before

After

44.17 + 12.82
10.25 + 5.82
16.07 + 5.12

33.30 + 9.92
6.95 + 4.01
20.42 + 5.05

42.97 + 12.43
10.07 + 5.48
16.35 + 5.31

33.75 + 9.82
7.10 + 4.09
19.55 + 5.10

41.77 + 13.42
10.20 + 5.46
16.62 + 5.60

41.85 + 13.59
10.30 + 5.63
16.57 + 5.45

State anxiety. A within-participants repeated-measures ANOVA revealed a significant time main

effect, with decreased scores over time after yoga
and aerobic exercise (F5,195 30.95, p 5 0.0001).
State anxiety reduced significantly after yoga
(ES 0.87, p 5 0.0001) and after aerobic exercise
(ES 1.01, p 5 0.0001) compared to the no exercise
control condition. There were no significant differences between yoga and aerobic exercise.
Psychological stress. The repeated-measures ANOVA
showed a significant time main effect (F5,195 22.13,
p 5 0.0001). In both yoga (ES 0.83, p 5 0.0001)
and aerobic exercise (ES 0.82, p 5 0.0001), postscores were significantly lower than in the no-exercise
control condition. There were no significant differences in response between the two experimental
conditions.
Subjective well-being. The repeated-measures ANOVA demonstrated a significant time main effect
(F5,195 28.37, p 5 0.0001). Positive well-being
scores after yoga (ES 0.86, p 5 0.0001) and after
aerobic exercise (ES 0.83, p 5 0.0001) were significantly higher than after the no exercise control
condition. There were again no significant differences in response between the yoga and aerobic
exercise conditions.

Discussion
Main findings
To the best of our knowledge, this is the first study
demonstrating large effect sizes (varying from 0.82 to
1.01) on state anxiety, psychological stress and
well-being after single sessions of yoga and aerobic
exercise in people with schizophrenia. The scores
after yoga did not differ significantly with those after
a single aerobic exercise session.
This study adds to current knowledge that yoga
and acute bouts of aerobic exercise provide a
transient elevation of subjective well-being and a
transient reduction in psychological stress and state
anxiety in this clinical sample.
Transient reductions in psychological stress and
state anxiety may have relevant health benefits.

The use of alcohol, nicotine or illegal drugs is a

common practice among individuals with schizophrenia [2527]. Although numerous motivations
exist to use these substances, it has been suggested
that the mentioned unhealthy behaviours may partly
be attempts to alleviate or to cope with unpleasant
affective states and feelings of anxiety [28,29]. The
limited benefit of such efforts supports the need to
provide other more healthy methods to regulate the
variability of subjective well-being. This study
indicates that both yoga and aerobic exercise could
be such an alternative. More research is however
needed.

Limitations of the study

The findings of this study need to be interpreted
cautiously due to some methodological limitations.
First, as a consequence of the high drop-out rate,
selection bias may be a limiting factor because
patients who participated may have had already a
keen interest in the areas of physical activity and/or
yoga, and therefore may be more aware of the
benefits.
Second, also the limited sample size and the
single-centre nature of the study limits the generalisability of our findings.
This study did also not examine potential physiological (e.g. increased nor epinephrine, serotonin
and beta-endorphins, increased parasympathetic
activity) and/or psychological mechanisms (e.g.
increased self-efficacy, distraction) that could be
responsible for the reduced state anxiety, psychological stress and improved subjective well-being [30].
Although we tried to minimise the interactions
between the physiotherapist and patient during the
yoga, aerobic exercise and reading control condition,
improvements after yoga and aerobic exercise might
be related to an increased interaction in these
sessions compared to the reading control condition,
rather than to the interventions per se. Another
control condition (e.g. discussing the news paper
together) could have ruled out this therapistpatient
interaction.
A fourth limitation was the lack of repeated
measures post-yoga and post-aerobic exercise.
Although state anxiety and psychological stress

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688

D. Vancampfort et al.

reductions are expected to last for 24 h after

cessation of activity [18], only the response immediately after the completion of the session was
assessed.
Lastly, no baseline measures concerning psychopathology were assessed. Also motivation and
interest for physical activity and yoga were not
evaluated. Consequently, we did not investigate if
the reductions in state anxiety and psychological
stress and the improvement in subjective well-being
are affected by the presence of specific psychotic
symptoms. In the same way, it is not completely
clear in which way the level of motivation towards
or interest in a specific condition may have affected
the beneficial yoga and aerobic exercise responses.
It is known that motivational factors are indeed
implicated in the stress coping mechanism of
physical exercises [31].

Implications for future research

Future research on acute changes in state anxiety,
stress and well-being after yoga and aerobic exercise
in schizophrenia needs to address several salient
issues.
It would be interesting to investigate more in detail
if there are differences in putative underlying
mechanisms of the acute changes in state anxiety,
stress and well-being after yoga and aerobic exercise.
Future studies will also need to demonstrate that
any beneficial effects of yoga or aerobic exercise can
be translated into behavioural outcomes. Specifically, future studies need to examine whether a
regular yoga and/or aerobic exercise programme
increases rates of abstinence from alcohol, nicotine
or illegal drugs and whether any effects of yoga or
exercise on abstinence rates are mediated by reductions in psychological stress and state anxiety and
increases in subjective well-being during or following
these activities.

Implications for clinical practice

When offering a clinical rehabilitation programme to
reduce state anxiety and psychological stress and
increase subjective well-being aerobic exercise and
yoga can be equally effective. Physiotherapists should
therefore provide people with schizophrenia with
choices and options about the type and content of
their clinical rehabilitation programme. For example,
the physiotherapist could assess what types of
exercises (e.g. yoga or aerobic exercise) would best
fit with the patients preference. Physiotherapists
should acknowledge individual responses on yoga
and/or exercise. These individual responses should

be taken into consideration when (re)designing and

(re)delivering a clinical rehabilitation programme.

Conclusion
In summary, this is the first study demonstrating that
both yoga and aerobic exercise result in state anxiety
and stress reductions and increases in subjective
well-being.
These findings have implications for add-on
physiotherapy in patients with schizophrenia. Physiotherapists should provide people with schizophrenia with choices and options about the type and
content of their clinical rehabilitation programme.
Future studies will need to examine the putative
underlying mechanisms of the decreases in feelings
of anxiety and stress. Furthermore, studies need to
demonstrate if any beneficial effects of yoga or
aerobic exercise can be translated into behavioural
outcomes, for example through increasing rates of
abstinence from alcohol, nicotine or illegal drugs.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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