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Citation: Feldman R, Schreiber S, Pick CG and Been E. Gait, Balance and Posture in Major Mental Illnesses:
Depression, Anxiety and Schizophrenia. Austin Med Sci. 2020; 5(1): 1039.
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Austin Medical Sciences
Open Access
Abstract
Background: Mental disorders are among the most common health issues
worldwide. Changes in psychomotor behavior can be observed in gross motor
skills. Gait is an example of behavior that reects various levels of nervous
system function. In psychiatric conditions, gait disturbances are thought to
reect defective brain function. Patients who suffer from gait disturbances tend
to develop balance disorders as well as impaired body posture.
Objective: The purpose of this review is to examine current knowledge
regarding gait and related physical aspects (balance and posture) in patients
suffering from depression, anxiety or schizophrenia, and to formulate
recommendations for the diagnosis and treatment of these patients.
Data Sources: A cross search was conducted in ve databases, using the
following keywords: body posture, balance, and gait. Each of these keywords
was cross-referenced with specic mental illnesses: schizophrenia, depression
and anxiety. Forty-eight suitable articles complying with criteria were chosen.
Major Finding: Our review indicates that patients suffering from mental
disorders have a unique physical prole that is in keeping with the clinical
diagnosis (schizophrenia, depression and anxiety): the physical prole of
patients with schizophrenia is characterized by a slow gait and decreased stride
length, patients suffering from anxiety disorders are characterized by balance
disorders, and those suffering from depression - by a slow gait and slumped
posture.
Conclusions: We would propose that when seeking to create an evaluation
and treatment program for patients with mental illness, specic elements such
as balance, gait patterns and posture, should also be taken into consideration.
Keywords: Gait; Balance; Depression; Anxiety; Schizophrenia
Introduction
Mental disorders are considered one of the most common health
issues worldwide. National Alliance on Mental Illness (NAMI)
data reveal that in any given year, one in every ve adults (aged 18
plus) experience a mental illness and one in 25 adults experience a
severe mental illness, that limits him in one or more of his major-
life-activities. Anxiety and mood disorders are more common among
women, while substance abuse is more common among men [1]. Gait
and posture disorders are common among psychiatric patients. e
reasons for these disorders are many, and include the illness itself,
medication, and the psychosocial context [2].
Motor behavior is regulated by emotions and is an integral
indicator of mental illness [3]. Motor manifestations are important
criteria in the diagnostic method (DSM-5, ICD-10) applied in mood
disorders and help to predict the course of the disease [4,5]. Changes
in psychomotor behavior are evident in facial expressions, gestures,
ne motor skills and gross motor skills [4].
Gait is an example of behavior that reects various levels of
nervous system function. In psychiatric conditions gait disturbances
are thought to reect impaired cortical and subcortical function [6].
Special Article – Depression
Gait, Balance and Posture in Major Mental Illnesses:
Depression, Anxiety and Schizophrenia
Feldman R1*, Schreiber S2,3,4, Pick CG1,4,5 and Been
E1,6
1Department of Anatomy and Anthropology, Sackler
School of Medicine, Tel-Aviv University, Israel
2Department of Psychiatry, Tel Aviv Sourasky Medical
Center, Israel
3Tel-Aviv University Sackler Faculty of Medicine, Israel
4Sagol School of Neuroscience, Tel Aviv University, Israel
5The Dr. Miriam and Sheldon G. Adelson Chair and
Center for the Biology of Addictive Diseases, Tel-Aviv
University, Israel
6Department of Sports Therapy, Faculty of Health
Professions, Ono Academic College, Israel
*Corresponding author: Ron Feldman, Department of
Anatomy and Anthropology, Sackler Faculty of Medicine,
Tel-Aviv University, Tel-Aviv, 69978, Israel
Received: December 17, 2019; Accepted: January 13,
2020; Published: January 20, 2020
In humans, gait develops simultaneously with the development of
higher-level brain structures and functions (prefrontal cortex, basal
ganglia and cerebellum). Since gait reects the integrity of higher-
level brain systems, it is well able to reect psychiatric conditions
[2]. erefore, analysis of an individual’s gait and posture provides a
great deal of information about the capability of the musculoskeletal
system to adjust to physical stressors [7].
Balance is maintained due to the integration of vestibular,
somatosensory and visual inputs in the central nervous system,
and due to the normal functioning of the motor system which
compensates for postural disorders [8]. Dynamic balance control is
adversely impacted by our mood state, most likely due to impaired
integration of visual, vestibular and proprioceptive systems [9,10].
In general, patients with gait disturbances tend to simultaneously
develop balance dysfunction and therefore, both disorders should
be treated concurrently. Moreover, posture and postural control,
two additional important, interrelated physical characteristics, are a
crucial integral component of normal gait.
Gait and posture are inuenced by body embodiment. Recent
studies have demonstrated the relationship between embodiment
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and mental illness [11-15]. Embodiment addresses the interrelation
between mind and body. In psychological terms, embodiment has a
reciprocal causality in both motor- body and cognitive- emotional
dimensions. Emotional states are embodied in physical movement
and emotion recognition plays an important role in social interactions.
e crucial insight aorded by embodiment is that much of perceptual
inference rests on selecting the correct kind of sensory information.
Indeed the main obstacle is knowing how to react properly using
the right way with our senses. A simple observation is that sadness
is reected by attenuated motor activity [12,14,15]. Consequently, a
disorder in any of the above physical characteristics is able to cause
gait disturbance.
Following the increase in the prevalence of mental disorders [1],
today more than ever before, there is a growing need to investigate
and understand their multiple causes and physical characteristics.
is review focuses on a description of the motor characteristics and
functional manifestations of patients who suer from depression,
anxiety and schizophrenia. e results of this review might provide a
basis for the formulation of an evaluation and intervention program
for these patients.
Methods
Data sources and search method
We performed a Meta search, on ve databases (Google Scholar,
PubMed, Science Direct, PsycINFO and Cochrane) using the following
keywords: body posture, balance, and gait, cross-referencing each
keyword with specic mental illnesses: schizophrenia, depression
and anxiety. e search was conducted in May 2018 and updated in
December 2018. No limiters were applied to the search (Figure 1).
Inclusion criteria: Interventional studies (clinical trials), cross-
sectional studies, prospective cohort studies, literary reviews and
meta-analysis; Studies researching schizophrenia, anxiety and
depression and to gait/balance/posture; Studies published in English;
Access to full-text; Studies conducted between 1997 and 2017.
Exclusion criteria: Case control or case descriptions; Letters to
the editor; Studies published in languages other than English; No
access to full-text.
Data synthesis and analysis
At the end of each search phase, the titles and abstracts of the
articles were read systematically and screened according to the
inclusion and exclusion criteria described above. Articles that
appeared to be relevant to the review were read in their entirety.
Finally, a search of the reference list of each article was conducted in
an attempt to locate other articles relevant to the review (Figure 1).
Results
Forty eight articles, which satised the inclusion criteria of the
study, were chosen. ese articles examine the association between
mental disorders, mental states and physical characteristics (Figure
1).
Depression
Posture and depression: ere is a consensus among researchers
that depression adversely aects posture [7,13,16]. Michalak et
al. [13] recently found that sitting posture has a direct eect on
memory among patients suering from depression, and that a minor
motor change – i.e. adopting an upright sitting posture rather than
slump posture while sitting – has a benecial impact on that aspect.
Wilkes et al. [16] suggested that sitting upright reduces fatigue and
increases positive aect among people exhibiting symptoms of
depression. Canales et al. [7] studied posture and perceived body
image in patients with clinical depression during depressive episodes
and upon receiving drug treatment, compared to a healthy control
group. ey found that during depressive episodes patients with
major depressive disorder (MDD), experience a change in posture
(e.g., marked head exion, scapular protraction, pelvic retroversion,
greater thoracic kyphosis) and moderate dissatisfaction with body
image. Furthermore, the study had demonstrated that recurrence of
depressive episodes has a negative inuence on postural alignment.
is nding is consistent with the fact that both emotional and
physical aspects are negatively inuenced by depression.
Balance and depression: A number of studies have found balance
disorders and depression to be related [17,18]. Doumas et al. [19]
detected a considerable deciency in dynamic balance in dual task
performance among patients with depression compared to healthy
controls. Recent studies stress the importance of various physical
training programs in the treatment and amelioration of balance
disturbances among patients with depression, and in the alleviation
of symptoms of depression among healthy individuals [17,18].
Deschamps et al. [17] found that a walking program (supervised
Figure 1: Results scheme of the review process.
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one hour sessions, three times a week for two months at moderate
intensity) has a direct inuence on the ability of MDD patients to make
ecient postural corrections. e authors emphasize the importance
of including a balance assessment in the clinical screening routine in
order to tailor a walking program for these patients.
Gait and depression: ere is a strong association between
MDD, psychomotor deterioration and gait components [12,20].
Lemke et al. [20] were the rst to study spatiotemporal gait patterns
among MDD patients compared to healthy controls. ey found a
signicant reduce in gait velocity, reduced stride length, increased
gait cycle duration and longer double limb support among depressed
patients. e researches addressed to a link between the basal
ganglia activity as part of the pathophysiological mechanism in gait
disturbance. Michalak et al. [12] found that sadness and depression
are characterized by reduced walking speed, arm swing and vertical
head movements, and by greater lateral swaying movements of the
upper body and a slumped posture. A link has been established
between symptoms of depression, reduced walking speed and
increased risk of falls among the elderly. Evidence shows that reduce
gait speed is one of the symptoms of depression in older people, and
that it directly contributes to increased fall risk. Early detection and
integrated treatment of these elements could lower this risk [21].
Paleacu et al. [22] found that gait and cognitive function improved
in response to the administration of antidepressants. In depression,
the neuro circuit pathway related to gait alternations is controversial.
While some researches state that gait changes associate with changes
in brain structures e.g. basal ganglia and cognitive dysfunction
[20,22], others do not point a specic underlying organic pathology
[12,21].
In conclusion, patients with depression are characterized by
slumped posture, impaired dynamic balance, and reduced gait
velocity [2,12,13,16,20,23]. eir slumped posture is in all likelihood
caused by impaired perceived body image, while reduced walking
speed is apparently the result of impaired spatiotemporal parameters
[20]. Future study should focus on the inuence of intervention
programs involving treatment for posture and gait on physical and
mental characteristics of these patients.
Anxiety
Posture and anxiety: Very little information regarding posture
and anxiety was found in the literature. Lipnicki and Byrne [24] found
that study subjects asked to perform a dicult mental arithmetic task
in standing position experienced anticipatory anxiety, as opposed
to subjects who were required to perform the same assignment in
supine condition. One of the explanations suggested is the dierence
in baroreceptor load when the body is in supine position. e paucity
of information on the subject suggests an immediate need to examine
whether a relationship exists between anxiety and posture.
Balance and anxiety: Researchers concur that anxiety is related
to balance dysfunction [8,25,26]. Bart et al. [25] found a correlation
between balance, anxiety disorders and low self-esteem in children
under the age of 7. ey also demonstrated that treatment targeting
balance problems mitigates the dysfunction, greatly reduces anxiety
and increases self-esteem among these children.
e neurological basis that links anxiety disorders and balance
control has been researched for many years [26]. It has been found
that neural circuits that contain a number of pathways that mediate
autonomic control, vestibulo-autonomic interactions and anxiety
form the basis for this link. e core of this neural circuitry is the
parabrachial nucleus (PBN), located in the medulla oblongata. is
nucleus has an extensive network of relationships with a number of
important brain structures responsible for movement and balance
control, including the central amygdaloid nucleus, infralimbic
cortex and hypothalamus. e PBN is the point of convergence of
vestibular, visual and sensory information processing in pathways
that are involved in anxiety, panic and avoidance situations. is
neurological scheme creates a basis that explains the link between
balance disorders and anxiety [26].
Yardley et al. [27] presented evidence of three psychological
mechanisms that aggravate dizziness and delay recovery from
balance disorders. e rst mechanism is avoidance of performing
the movements and of exposure to the environments that caused
the symptoms. e second is increased anxiety, which intensies the
physical symptoms that accompany balance disorder, and the third is
cognitive load, which can have an eect on the central processing of
information needed to maintain control and perception of physical
orientation.
Gait and anxiety: Gait has hardly been studied in anxiety
disorder. It seems that anxiety requires greater attentional demands
while walking. Anxiety inuences oculo-motor and gaze control [28],
thus linking anxiety to visual disturbances and balance disorders.
Researchers agree that gait changes in anxiety disorders are a
secondary component of the illness, not indicating a dierent or
more severe state [28,29].
In conclusion, people who suer from anxiety disorders are
mainly characterized by deciencies in the balance system [25-27].
is decit in balance is related to increased fear of falling and reduced
gait velocity. Future study should perform a more in depth research
regarding the characteristics of gait and posture in patients suering
from anxiety. ere is also a strong need for research that will explore
the inuence of intervention programs on posture, balance and gait
in this population.
Schizophrenia
Posture and schizophrenia: Referring to body posture, it is
well known that schizophrenic patients suer from alterations in
body perception, body representations and embodiment [11,14,30].
e signicant anity between emotion perception decits in
schizophrenia, suggests that such diculties may be more directly
related to the core features of this disorder [30]. Graham-Schmidt et
al. [11] indicate that body structural description may be altered in
schizophrenia in general, and body image alterations are worsened
in passivity symptoms. Cristiano et al. [31] examined gross – body
postural changes in dierent stages of schizophrenia and their
relationship to pain. ey had found that hyperlordosis and forward
head posture were the most common postural features in both
early and late stages of schizophrenia. ese two postural changes
are indicative of a lordotic or a swayback posture, which is more
common in women. However, as the majority of cases occur in men,
these changes may be attributable to schizophrenia itself as well as to
body mass index (BMI), as overweight tends to lead to a swayback
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posture. Cristiano et al. [31] also found that scoliosis is frequent
amongst schizophrenic patients, characterized by BMI-independent
muscle weakness.
Balance and schizophrenia: ere is a consensus in the literature
that balance in schizophrenia patients is decient compared to
healthy individuals, and that the degree of postural sway increases in
this population. It has been found that there is a correlation between
this increase and the severity of the symptoms of the disease [32-34].
One of the mechanisms suggested as causing balance dysfunction in
schizophrenic patients is the reduced use of vision for balance control
[35]. is nding points to impaired sensorimotor integration in
these patients, where decient vision control is most likely caused
by defective processing of spatial elements of visual information
and may be related to a visual impairment. Schizophrenic patients
rely more on vestibular and proprioceptive information to maintain
balance compared to healthy individuals [35].
Gait and schizophrenia: Much has been written about the
association between gait and schizophrenia. ere is general consensus
among researchers that schizophrenia causes a primary disturbance
in stride length regulation, which is manifested in a reduction in gait
velocity compared to healthy controls [36]. Putzhammer et al. [36]
found that this decit is intensied by conventional antipsychotic
treatment, whereas non-drug treatment does not lead to such
intensication. Moreover, these researchers assessed gait patterns
among schizophrenic patients by testing free gait and walking on
a treadmill at various velocities. When walking freely, gait velocity
of the patient group was found to be lower than that of the control
group, primarily because of reduced stride length. When evaluating
gait on the treadmill, dierences between the patient group and
control group in cadence and stride length were signicant only at
the very slow treadmill speed. When treadmill velocity was increased,
all parameters in the patient group were equal to the corresponding
parameters in the control group. is outcome indicates that gait
disturbances among schizophrenic patients can be normalized by
using external devices, such as a treadmill, which aords control
over gait velocity. An additional option for achieving improvement
in gait parameters among patients with schizophrenia was proposed
by Heggelund et al. [37], who recommend maximal strength training
– four repetitions * four sets – using a leg press machine (1RM – one
rep max at 85%-90%) as a therapeutic tool in normalizing walking
mechanical eciency among patients with schizophrenia.
Schizophrenics also suer from ataxic gait, and a correlation has
been established between increasing age and ataxic gait among these
patients [38,39]. Furthermore, Morgante et al. [40] provide evidence
that older aged chronic schizophrenic patients, might present axial
parkinsonian signs (trunk posture anomaly, reduced degree of facial
expression and short step gait) as an early marker of parkinsonism in
this illness.
Gait function among schizophrenics is in all likelihood aected as
a result of impaired executive function [39]. Lallart et al. [39] examined
the association between executive dysfunction and gait disturbance
in recent-onset schizophrenia patients using the dual task paradigm.
ey established the existence of an inverse relationship between the
complexity and diculty of the task and the performance level, and
concluded that schizophrenia is characterized not only by cognitive
impairment, but by coordination and motor functioning impairment
as well.
ere is a general agreement in the literature, that schizophrenic
patients has primarily alternation in higher-level structures
e.g. reduction in supplementary motor area activity, disturbed
functioning in the basal ganglia and the thalamus and abnormal
functional connectivity between the motor cortex and the cerebellum.
is core illness decit alters motor control and contributes to the
impairments and reduction of gait control [22,28,29,36].
In conclusion, Schizophrenic patients are characterized by
impaired gait, reduced acuity of the body structural description, as
well as deciencies in the balance system. e reduction in walking
speed is most likely due to the fact that this illness involves executive
dysfunction [39] whereas disembodiment and alterations in body
representations contribute to decits in their body posture [11,14].
Poor balance control is apparently linked to defective processing of
spatial elements [32-35].
Future study should explore the inuence of specic exercise
programs on the posture, balance and gait of patients with
schizophrenia.
Discussion
is review examined the link between physical characteristics
(gait, posture and balance) and mental illnesses – depression, anxiety
and schizophrenia. is review emphasizes the growing need for the
creation of a diagnostic, treatment and intervention plan, specically
tailored to patients suering from mental illnesses.
e results of this review show that gait, balance and postural
disturbances are highly prevalent among the mentally ill in
comparison to healthy individuals [2,12,39,20-22,28,29,36-38]. In
light of this observation, we propose including tests for balance, gait,
and posture to the evaluation of patients with psychiatric disorders.
More specically, we have shown that patients with depression
suer from slumped posture, poor dynamic balance, and reduced
gait velocity. erefore we suggest that treatment plan for these
patients might include practicing varying walking speeds and
postural elements [12,13,16,20,23]. We propose the inclusion of a
walking program (one hour sessions, three times a week at moderate
intensity) as an integral component of the treatment program to
improve balance in these patients [17].
Patients who suer from anxiety disorders characterized by
deciencies in the balance system. erefore they might benet from
the inclusion of exercise treatment that targets components of the
balance system in their treatment program [25-27].
With regard to schizophrenic patients, evaluation and treatment
programs might address physical aspects such as gait and balance.
As perceptual elements and executive functions are impaired in this
illness [39], these aspects should be taken into consideration when
planning a treatment program. For the treatment of body posture
representation, body-oriented psychological therapy should be
applied together with specic spatial information exercises, referring
to body parts [11,14,15]. Further, work should be done with patients
on the components of balance control, particularly the visual aspect,
which impacts the degree of postural sway [32]. Emphasis should be
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placed on walking speed, since gait disturbances in schizophrenia
patients can be normalized by using external devices, such as a
treadmill [36].
Despite the extensive research on the eectiveness of systematic
physical activity and exercises interventions for people with mental
illness there is lack of information referring the question: does
improvement in gait and balance eect the psychiatric illness, per se,
or does it transiently aect the sense of well- being? [41-45].
A number of methodological limitations can be noted in the
studies examined. Most of the research published to date was
performed on a relatively small sample (n<30) and no randomized
controlled trials were conducted. Part of the studies were cross-
sectional or consisted of reviews of the literature [14,15,17,18,21,26-
28,36], and no follow-ups were made of a single cohort in the long
term [16,24]. A small number of the studies do not take confounding
factors into account, such as age, gender, cigarette smoking, alcohol
consumption, socioeconomic status, general health condition, etc
[19,24,39]. It is important to point out that some of the studies were
carried out under laboratory conditions, thus aecting their external
validity [7,11,12,24,39,46]. Another limitation is the diculty of
controlling and supervising the use of antipsychotics and their
impact on research results [12,19,31,33]. It is important to note
that although postural dysfunctions as well as motor abnormalities
are oen regarded as consequences of antipsychotic treatments
[47], spontaneous involuntary movements have also been found in
antipsychotic naïve patients [48].
is review did not address the importance of devising physical
training or rehabilitation programs and their inclusion as an integral
component of the rehabilitation process of population groups
suering from mental illness. e physical elements were examined
individually and were not integrated in order to test the ecacy of
their inclusion in treatment programs and their importance to this
population. In other words, we did not, for example, explore the
question as to whether a program that integrates balance and gait
components is preferable to a treatment program that focuses on a
single physical aspect.
Finally, additional, broader clinical research should be carried out
on the association between walking and balance aspects and mental
disorders, and the ecacy of exercise treatment plans. ese physical
elements are an important predictor of falls [21,36] and cognitive
impairment, especially in the elderly population [38,39].
Conclusions
In summary, the clinician treating a patient with a particular
mental disorder should take into consideration the physical aspects
that are characteristic of the patient’s mental condition, as part of the
evaluation/treatment program. e correct identication of these
physical components and appropriate treatment can contribute
greatly to improve function and participation in this complex
population.
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