Across the globe, there are many treatments available but mainly the most actual and relieving treatments include antidepressant, cognitive-behavioral psychotherapies, relaxation and unstructured therapy techniques (Byrne, Wingero & Dager, 1993).Many researches are conceded to make a comparison between the effectiveness of various techniques in the treatment of anxiety disorder worldly. In Pakistan, there is very little attention has given to this issue. The focus of the present study is an effort to assess the efficacy of two techniques named as progressive muscular relaxation and physical exercise in the treatment of anxiety disorder. These techniques were chosen because Pakistan is listed in under established countries where limited health care resources or facilities are available. These mediations are economically affordable and its effectiveness in the treatment of anxiety disorders are well recognized in other parts of the world (Carek, Laibstain , & Carek, 2011; Nickel et al., 2006 ; Tordeurs, Janne, Appart, Zdanowicz, & Reynaert, 2011). These types of interventions also helps to reduce the issues related to stigma associated with the visit of mental health services, and help to deal with anxiety disorders by self-management programs instead of seeking treatment services on regular basis. Therefore, this study aimed to provide evidence on the effectiveness of a PMR and physical exercise in patients with anxiety disorder in Pakistan.

Everyone feels anxiety from time to time. Optimistically, anxiety is a normal phenomenon which is experienced by every living organism and is essential for survival and adaptation. It is not always harmful or risky, typically short-lived and is also useful in daily performances. Moreover, few people get over a week without some anxious tension or a feeling that something is not going to be well. In general, people may feel anxiety when they are facing an important affair, such as an exam or job interview, or when they perceive some threat or danger, such as awake due to strange sounds in the night etc. However, an important point to remember, such everyday anxiety is generally occasional, mild and brief, while if anxiety felt by the person with an anxiety disorder  frequently then it is more intense, and lasts longer for hours, or even days.

Anxiety is one of the increasing psychological disorder effecting approximately 40 million people around the world (Anxiety Disorders Association of America, 2010; Park, 2011). Anxiety is defined as feeling of discomfort and distress related to future uncertainties and doubts which approaches feelings of nervousness, extreme fear resulting due to specifically disturbing event (Webster, 2001).

Anxiety disorders are one of the major disorder which is rapidly growing as it was projected that lifetime prevalence of anxiety disorder is approximately 30%, 12-month prevalence is approximately 20% for all types of anxiety disorders (Kessler, Chiu, Demler, Merikangas, &  Walters, 2005). Kessler and colleagues (2005) appraised that 18.1% of the general population are effected from anxiety disorder. On the other hand, one systematic review found 28 epidemiological studies found anxiety symptoms or disorders, in older adults: 19 in community samples, and nine in clinical samples. The range of anxiety disorder prevalence estimates in those studies varied markedly, ranging from 1.2% to 15% in public samples and from 1% to 28% in medical settings. The occurrence of clinically significant anxiety symptoms ranges from 15% to 52% in community samples and 15% to 56% in medical settings (Bryant, Jackson, & Ames, 2008).

Anxiety disorders are one of the common occurring in society which have an extensive negative impact on daily functioning and excellence of human life. It is discovered that anxiety disorders effect the cognitive, physical and behavioral response systems simultaneously to humans across the lifetime. For instance, if a person is spending a lot of time suspecting about finances (cognitive), he  possibly feel himself on verge and nervousness (physical) which results disturbing his patterns and he may spend quite a bit of time in checking household budget or investments (behavioural). As far as students are concerned, if a student is preparing for an important exam, he may fear about his performance or result in exams (cognitive), resulting he will feel tension and maybe even have “butterflies in stomach” (physical), to handle with this tension, he may initially avoid studying and then cram at the last minute (behavioural).

These examples clearly emphasizing the deterioration in human functioning and behavioral changes on all levels are related to, or significance of anxiety disorder. Due to its deleterious effect, there is emergent interest to advance knowledge about epidemiology, course and treatment of anxiety disorders. However, in Pakistan, scarce attention has given to different important aspects of anxiety disorders like management and treatment. The current study is design to observe how physical exercise (PE) is effective in reducing physical illness and progressive muscle relaxation (PMR) is effective in decreasing the symptoms of anxiety among patients.

Normal anxiety

Whenever the sympathetic nervous system arouses, fight or flight response is activated by danger, either real or illusory, it leads to changes in three “systems of functioning”: the way one thinks and feels (cognitive), the way one’s body feels and works (physical), and the way one acts (behavioural). These three systems change differ, depending on the person and the context like; (1) cognitive: attention shifts immediately and automatically to the potential threat. The influence on a person’s thinking can range from mild worry to severe terror. (2) physical: effects include heart tremoring or increased heart rate, shallow breathing, trembling or shaking, sweating, dizziness or lightheadedness, feeling “weak in the knees,” freezing, muscle tension, shortness of breath and nausea. (3) behavioral: people engage in certain behaviors and refrain from others as a way to guard themselves from anxiety (e.g., taking self-defense classes or avoiding certain streets after dark).

An anxiety disorder may make people feel apprehensive most of the time or for brief intense episodes, which may occur for no obvious reason. People with anxiety disorders may have anxious feelings that are so uncomfortable that they avoid daily routines and activities that might cause these feelings. Some people experienced occasional anxiety attacks so intense that they are terrified or immobilized. People with anxiety disorders are usually aware of the unfounded and extreme nature of their fears. When they come for treatment, many say, “I know my fears are unreasonable, but I just can’t seem to stop them.”

As demonstrated in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5:  American Psychiatric Association, 2013) excessive fear, anxiety and behavioral problems are collective features of anxiety disorder. Individuals with anxiety disorders anticipate threat in future as a result become fearful with real or perceived threat, experience physical symptoms and want to get escape from anxiety (DSM–5, 2013). It can turn into a serious disorder when it becomes excessive and uncontrollable, when there does not appear to be any purpose behind it.Larson and colleagues (2010) depict anxiety as a foreseen conviction of a psychological distress which is a consequence of viewing a distressing and possibly unsafe occasion. 


Following are the types of anxiety disorder:

Generalized anxiety disorder: It concerns of having excessive, beyond reality and tension that has no possible reason.

Panic disorder: in this you have unexpected, intense fear that carries on a panic attack. The symptoms include chest pain, heart palpitations, and heavy sweating. Sometimes it may feel that you are choking or experiencing a heart attack.

Social anxiety disorder: in this you have excessive worry about daily social situation and an exaggerated worry about self-consciousness. One can have a fear of being judged by the society.

Specific phobias: in this one have intense fear experience about an object or any situation such as heightened areas or flying. This will make you avoid most of the ordinary situations.

Agoraphobia: in this one feel trapped in a situation where they consider it is hard to get escape in emergency situations. It may include having a panic situation on airplane, public conveyance or in crowd.

Separation anxiety: it not only concerns little kids but ones that have feeling of anxiousness and loved ones. Anyone can get separation anxiety disorder. It occurs when any person who lose their loved ones will feel anxious or fearful. It is a constant feeling that something will happen bad to our close ones.

Selective mutism: it includes specific anxiety which occurs who easily talks to their family members but cannot speak in front of public more likely at school.

Medication-induced anxiety disorder: in this there is a use of some specific medications or any drugs that are not legal, having withdrawal symptoms from some drugs, can activate the symptoms of anxiety disorder.


Progressive Muscular Relaxation (PMR)

Relaxation is a state of being free from physical and mental tensions, in other words, it is a homeostatic condition which led to physical and psychological well-being. Currently, number of relaxation techniques has been designed to get escape from anxiety, stress and bring state of ease and mental/physical comfort. PMR is one of the most basic technique developed by Jacobson in 1934. It requires a skill to discriminate between the skeletal muscle tension and relaxation (Jacobson, 1938). The technique is based on the conception that anxiety-provoking thoughts and events produce physiological distress. The technique involves progressively tensing and relaxing muscles in different parts of the body, leading to a reduction in physiological tension, (Davis, Eshelman, & Mckay, 2000). Since its origin, different types of PMR have developed, for instance, in 1973 Bernstein and Brokovec considered modifications to the technique to make it suitable to cognitive behavioral stress management. Today mostly versions are relatively shorter in length than Jacobson’s original program (Bernstein, Carlson, & Schmidt, 2007). There is general consensus that relaxation comprises of three core processes namely: muscular responding, autonomic responding and cognitive responding (Poppen, 1998).

Physical exercise (PE)

Physical excersise is considered an important intervention for the treatment of mental and physical illnesses. Physical exercise is related to bodily movements which involves individual’s muscular exercises and requires more energy than resting and generally bring up to movement that increases health (US Surgeon General, 2008). Health- related physical activity consists of body configuration, cardiovascular fitness, flexibility, muscular endurance and strength (Corbin, Pangrazi, & Frank, 2000). Physical activity or exercise is closely linked with fitness determined by physical activity patterns (Blair, Cheng, & Holder, 2001). Walking, abrupt walk, jogging, dancing, swimming, aerobics, yoga etc are main examples of physical activity. The latest standards for exercise training for encouraging and maintaining health. It is recommended that exercise training includes at least five days a week for 30 to 60 minutes at time, depending of the intensity of the exercise and resistance training for the main muscle groups for two to three times a week, 30 to 40 minutes (Fletcher, Ades, Kligfield, Arena, Balady, Bittner, & Williams, 2013).

Individuals who are fit but they withdraw exercise temporarily are more prone to experience increase anxiety (Morris, Steinberg, Sykes, & Salmon,1990). A physically active and proper lifestyle has also been associated with good psychological health in the elderly, along with intellectual stimulation, avoidance of smoking and healthy eating (Flicker, Lautenschlager, & Almeida, 2006). It is also initiate that aerobic exercise training have anxiolytic like impacts on healthy volunteers (Long, & Satvel 1995). Thirlaway and Benton (1992) found that fitness associated with PE habits to such an extent that the fit subjects who don’t exercise had worse psychological well-being status than the rests.

Cognitive behavioral therapy (CBT):  this therapy can teach you how to get away from negative perceptions, panic situations and behaviors and turn into positive ones. It will give some coping strategies to individuals facing anxiety and help them run their daily functioning. It may include individual and family sessions once in a week.


Anxiety is not a medical condition but it comes naturally and is necessary for survival when any individual is triggered or feel themselves in an emergency situation. There are several types of anxiety disorder like panic, social, agoraphobia, and social anxiety. Treatment includes Progressive muscle relaxation (PMR), Exercises and cognitive behavior therapy (CBT) that is good for maintaining individual conditions.