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9 Typing It All Together 261
in plasma cortisol concentration. On the basis of the results, the authors
posited that the effects of the therapy were due to a change in BT rather
than by reducing perceived stressor stresshormone release[71].That is,the
therapy reduced BT and improved sleep, without altering the experience
of perceived stress or HPA-axis-related stress hormone release. However,
the therapy likely led to a reduction in autonomic arousal via reduced
SNS activity, which in turn led to reduced BT during sleep, although the
latter premise was not examined in the study. Irrespective of the biological
mechanism involved, the results suggest that a psychological therapy on
its own is sufficient to reduce a person’s BT, possibly via a reduction in
autonomic arousal; which is a novel way of viewing the effects of the
psychological therapy.
Thermal exercise has also been shown to effectively treat sleep problems,
including the use of cooling suits and cold baths on the one hand, and hot
baths, footbaths,suits/vests, andambient heating onthe other. Specifically,
body cooling strategies have been shown to correct the sleep problems
experienced by insomniacs and to normalise the circadian rhythm of core
BT [26, 84–86]. For example, body-cooling strategies (e.g. cold thermo-
suits) can assist insomniacs to sleep better (i.e. reduced night-time and
early morning awakening, more Stages 3 and 4 sleep), withthe best clinical
effects seen in insomniacs and the elderly [26]. However, paradoxically,
body heating strategies have been shown to also normalise sleep [87].
Specifically, heated thermo-suits can increase slow-wave sleep and reduce
the tendency to wake at night, especially in insomniacs and the elderly
[87]. Even taking a hot bath in the evening [e.g. 40–41 °C for 30-min, up
to thorax] can increase slow-wave sleep and quicken the perceived onset of
sleep in female insomniacs [85]; with similar results obtained in another
study (i.e. hot bath [40–40.5 °C] over ≥2 consecutive nights at 1.5–2
hours before bedtime), in which older female insomniacs showed better
sleep continuity and longer slow-wave sleep in the early part of sleep [88].
So how can both cold and heat stimulationimprove sleep?Quite simply,
applying heat (e.g. warm [38–39 °C] bath for 1-hour) initially results in
hyperthermia (e.g. 1 °C increase in BT) [86]; but after the person gets out
of the bath, their BT rapidly declines [23, 86]. Importantly, it is the rapid
decline in skin temperature (induced by cold bathing or stepping out of a
hot bath) that is thought to accentuate the natural evening decline in BT;
262 R. Brown and E. Thorsteinsson
when the stimulus is applied about 2-hours before planned sleep [20, 26].
That is to say, simply taking a hot or coldbath(orshowerorfootbath)
about 2-hours before planned sleep may assist a person in reducing their
nocturnal BT sufficiently to effectively treat their sleep problem, even in
the case of insomnia [85, 86].
However, ‘thermal exercise’ has yet to be examined in regards to
other comorbidities, including anxiety, depressed mood, and over-
weight/obesity. Nevertheless, exercise has been suggested to improve a
person’s mood at least in part due to a transient increase in BT [89]. Addi-
tionally, it is suggested that body-cooling strategies should be explored
for their potential utility in facilitating weight loss in overweight/obese
individuals. Hansen, Gilman, Odland [90] observed that first-world indi-
viduals tend to live and work in temperature-controlled environments
that approach core BT (i.e. thermal-neutral point); and they pondered
whether the relative temperature equivalence might contribute to obesity
via reduced physical activity, especially a reduction in spontaneous phys-
ical activity (SPA). As described in Sect. 7.2, SPA involves unplanned,
unconscious, biologically driven behaviour that includes fidgeting, foot-
tapping, restless behaviour, and activities-of-daily-living such as walking,
talking, and the maintenance of posture; which is related to the expendi-
ture of 100–800 kcal/day [91]. SPA and its associated energy expenditure,
non-exercise activity thermogenesis (NEAT), are thought to protect lean
people from putting on weight after a large meal by increasing their activ-
ity levels and decreasing them after underfeeding. However, pertinently,
a dramatic reduction in SPA is observed in obese individuals (i.e. about 2
hours less/day), relative to lean individuals; and low SPA is known to be
a risk factor for weight gain and obesity [92–94]. Thus, SPA contributes
significantly to daily energy expenditure in lean individuals, although the
unconscious activity is clearly deficient in overweight/obese individuals.
The World Health Organisation and International Obesity Task Force
have suggested that strategies that can promote NEAT via an increase
in SPA should be examined for the potential in facilitating weight loss in
overweight/obese people. However, in practice, there are only several ways
of increasing a person’s SPA: losing weight, restricting calories, increasing
volitional physical activity and/or exposure to cold [95–97]. The first
three strategies likely represent the ver y pathway/s via which the person
9 Typing It All Together 263
gained weight in the first place (i.e. high caloric intake, weight gain, and
a sedentary lifestyle); thus, there may be little to be gained by trying to
increase SPA in this way. However, body-cooling strategies (e.g. cooling
vests) might be useful in increasing SPA and NEAT in overweight people,
as an adjunct to involvement in a formal exercise program. Unfortunately,
the therapeutic potential of SPA has so far been overlooked, despite the
significant potential of this biological process to be manipulated by ambi-
ent factors (e.g. cold ambient temperature) [98]. However, there appears
to be some utility in exploring the effects of body-cooling strategies on
weight in overweight/obese individuals to determine if weight loss can
be facilitated by an increase in SPA and NEAT; perhaps as an adjunct to
involvement in a formal exercise program, which might also increase the
person’s SPA.
In contrast, and as detailed in Chapter 5, body-warming strategies are
already being used to treat eating disorder patients, and in part, the ther-
apy is thought to result in clinical improvement via the reduced propen-
sity towards hyperactivity. That is, anorexia nervosa patients are typically
hypothermic, and as a result, they may compensate by increasing SPA and
NEAT; which transiently increases their BT, helping them to feel warm,
but it also reduces the potential for weight gain [99]. Several RCTs have
recently evaluated body-warming strategies as a stand-alone therapy or a
component of a therapy package (e.g. mandometer, ambient room warm-
ing, restricted physical activity) in eating disorder patients. In the latter
case, the approach was shown to effectively reduce activity levels, induce
remission (75% of patients), and reducethe relapse rate at 5-years in eating
disorder patients [100]. However, in a small study, Birmingham and col-
leagues [101] found that the therapy (i.e. heating vest set to medium heat
for 3 hours/day for 21 days) was not linked to weight recovery in anorexia
nervosa patients, relative to control patients who wore an unheated vest,
but it was linked to lower anxiety levels and improved treatment compli-
ance. Similarly, ambient heating (i.e. warm environment, intermittent use
of thermal waistcoat or sauna bath in infrared enclosure) reduced hyper-
activity and anxiety and depression levels in anorexia nervosa patients,
which antedated the body weight recovery [102].Inalargerstudy[103],
ambient warming exerted anxiolytic effects on anorexia nervosa patients;
in particular, postprandial anxiety was reduced in patients who rested for
264 R. Brown and E. Thorsteinsson
30 minutes immediately after lunch in a room heated to 32 °C, rela-
tive to higher pre-meal anxiety levels. Together, the results suggest that
body-warming strategies can effectively reduce hyperactivity and affective
distress (e.g. anxiety severity), and as part of a therapy package, it may
also result in significant weight recovery and remission, in eating disorder
patients.
Taken together, the study results presented in this chapter suggest
that body cooling and warming strategies are useful in treating insom-
nia/impaired sleep. In contrast, body-warming strategies can effectively
treat the hyperactivity and affective distress in eating disorder patients;
and as part of a therapy package, it may facilitate weight recovery and
remission in eating disorder patients. However, there is little research on
the effectsof ‘thermal exercise’on othersymptoms anddisorders. Nonethe-
less, it is possible that the therapy may be useful in treating non-eating
disordered individuals with affective distress (e.g. anxiety or depressive
disorder), overweight/obesity and/or sleep-disordered breathing, but so
far, no studies have evaluated the therapies in this regard.
Finally, and more broadly, a variety of therapy approaches have been
examined in this chapter for their potential utility in treating differ-
ent comorbid disorders. These approaches included: altering, tailoring
or repurposing existing psychological and medical therapies; developing
and testing new co-therapy or sequential therapy protocols; using thera-
pies that are already known to improve sleep, circadian rhythm function
and/or reduce BT (e.g. aspirin, bright light therapy); tailoring existing
therapies to the thermal characteristics of individual patients; and novel
therapy approaches (e.g. thermal exercise). Irrespective of the approach
that is used, it is evident that a coordinated and collaborative approach
is required to optimally treat patients with comorbid illnesses, such as is
provided in the multidisciplinary care setting.
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