Case Report: Case report : Mindfulness training led to catharsis and mindfulness-to-meaning   in a patient with social anxiety disorder comorbid with persistent depressive disorder (Dysthymia)

Life history

Ms. A was brought up in luxury. However, her family was strict and included a rugged mother and despotic paternal grandmother, with an elder brother. Her father was almost always working apart from her family. During kindergarten, she had separation anxiety and phobia of people wearing glasses. She reported that she had no intimate schoolmates and felt disliked by classmates and teachers in her elementary school. During high school, she recoiled from being seen by others due to psoriasis which began at age 15.

Ms. A’s mother was an unyielding woman of spirit and an absolute monarch for her. Hence, she was entirely a compliant child. Just after graduation from a woman’s college, she was forced into an arranged marriage with a man who was 9 years older. She could not express her own thoughts and wishes in her marriage. Thereafter, she experienced a stressful marital life with a reckless husband who was a typical mother’s boy and with strict parents-in-law. The mother-in-law was severely controlling. Ms. A reported that she lived only to serve her husband and parents-in-law. However, during these self-sacrificing days, she was blessed with the birth of two sons. However, she could not remember any pleasure during child rearing. She also reported symptoms of severe alexithymia. Later her elder son refused to attend junior school and high school.

Clinical history

In the 2 years before Ms. A’s first intake, she reported she could hardly find words to speak at Parent Teacher Association meetings. Negotiations with the school about the refusal of her son to attend school was a great burden for her. She was intensely concerned about her son. One day at home, she suffered a panic attack that caused great embarrassment in front of her mother-in-law.

Findings, diagnosis and treatment plan (first examination in May 2008)

During the first intake, Ms. A responded slowly and appeared depressed. She stated that she found it painful to talk with school administrators about her son, and ventured out of her home only when necessary due to fear of interacting with people in shops and on the streets or in public transport vehicles. She reported that she completed housework under the scrutiny of her parents-in-law, and that she never enjoyed life, had no appetite and experienced sleep problems.

The following psychological assessment tools and self-report questionnaires were administered during her initial visit: State-Trait Anxiety Inventory, State Anxiety (STAI-S)²¹: 51/80 (cut off point 41); Trait Anxiety (STAI-T)²¹: 57/80 (cut off point 41); Self-rating Depression Scale (SDS)²² 46/80 (moderate), Japanese version of the Liebowitz Social Anxiety Scale (J-LSAS)²³ 104/134 (severe); and Social Anxiety Disorder Scale (SADS)²⁴ 48/150 (moderate). STAI-S and STAI-T test forms were purchased from a licensed company.

Ms. A reported that she experienced a panic attack on only one occasion. Her fear of vehicles was not agoraphobic but rather a result of interpersonal strain. Her primary diagnosis was SAD: She experienced low energy or fatigue, low self-esteem, and feelings of hopelessness continuously over the past two years. Her comorbid psychiatric diagnosis was PDD.

The treatment began with psychoeducation and pharmacological treatment. Fluvoxamine was given in an increment manner from 25 mg to 100 mg per day p.o. Furthermore, clonazepam for anticipatory anxiety and tension was prescribed as needed.

Mindfulness training (MT)

There are two courses for mindfulness training at the Tokyo Mindfulness Center (TMC). One course is the standard Mindfulness-based Stress Reduction Program (MBSR) developed by Jon Kabat-Zinn.²⁵ The other course is optional. Participants can join when they like after an introductory education in mindfulness. Mindfulness Class is open for 3 hours every day except Sunday. The mindfulness class consisted of Hatha yoga for an hour, meditation, mainly calm abiding (Shamata in Sanskrit), for 30 minutes including loving-kindness meditation, and sharing for the remaining time. Participants were encouraged to engage in both formal and informal meditation practices every day. TMC offers one-day meditation retreats every month, and seminars/lectures by internationally renowned guests. The fee of the practice is covered by health insurance for patients having chronic psychiatric disorders. MBSR was delivered by a team consisting of a long-term (15 years) Zen practitioner (HK), a qualified teacher of MBSR (YH), an official instructor of Mindfulness-Based Cognitive Therapy (CK), a yoga instructor (AH) and a clinical psychologist (SN). Ms. A also attended the optional course.

Clinical course

Two months after beginning a selective serotonin reuptake inhibitor (Fluvoxamine), Ms. A’s interpersonal tension decreased and during this time, and her son began to attend school (July 2008). Her reduction in SAD symptoms was 30% (J-LSAS scores dropped from 104 to 72). After 7 years, her SAD symptoms decreased by 60.5% (J-LSAS scores dropped from 104 to 41). J-LSAS scores decreased by 20 after she completed MT. However, her depressive mood did not improve (SDS scores: 36, 46, 38, 31, and 39 points (December 2015) (Figure 1).

Figure 1. Clinical course of Ms. A.

Ms. A began to attend to the mindfulness class, however, she discontinued after attending several classes. After six months (8 years since her first intake, June 2016), she re-engaged in MT, and attended classes several times a week, earnestly. After the 30th sessions, she reported that she experienced a powerful emotional burst and flashback, that is, catharsis, during MT. She felt a release and she gradually began to feel more open and cheerful. She attended more than 160 mindfulness sessions over 25 months including 10 sessions of MBSR. Her social anxiety and depressive symptoms reached a state of almost remission at the end of the treatment: J-LSAS; 104→20, SADS; 48→9, SDS; 46→29, STAI-S; 51→33, Freiburg Mindfulness Scale²⁶; 26→50 (high). Her clinical improvement continued for 3 years after the end of treatment (Figure 1). In addition, she had good relationship with her sons, and her husband was very pleased with the improvement in her condition. However, as her mother-in-law got older, she became short-tempered and communicated with her less.

Treatment course

Ms. A’s social anxiety dramatically improved after MT for 25 months. Ms. A received CBT before MT which should have worked better for her because CBT strengthen cognitive abilities,²⁷ increase positive affective empathy²⁸ and dispute anxious thoughts and feelings via reappraisal in SAD.²⁹ Ms. A’s PDD symptoms fluctuated during pharmacotherapy and CBT. Her depression improved steadily after beginning of the MT and finally arrived at remission. Three years after the end of treatment, Ms. A’s condition remained in complete remission from the two disorders and she was able to maintain a life of mindful well-being (Figure 1).

Experiential avoidance (EA), alexithymia and catharsis

Ms. A had a severe self-sacrificing life with an nearly absent husband and controlling mother in-law for 20 years. Ms. A stated, "Up till now, I had lived my life with the belief that ‘nothing angers me,’ ‘I don’t need anything,’ and ‘I can accept anything.’ I thought that it didn’t matter if I died now or at the age of 80. I strove to convince myself to be happy that I’m fulfilling the mission I’ve been given”【B】 . This statement suggests experiential fusion, an automatic process whereby one becomes absorbed in content of consciousness, leading to a diminished capacity to monitor and/or regulate psychological process. This state is thought to be a target of MT, which is thought to act via enhancing meta-awareness, perspective taking and cognitive reappraisal.³⁰ This also suggest EA, a trait-like tendency to avoid unpleasant internal experiences.³¹ It is reported that dispositional mindfulness has antagonistic effects on EA.^11,12

Ms. A stated, “In other words, my feelings weren’t needed in my life, and I’ve lived by resolutely determining to lock those feelings away deep down in my heart and to never let them out”【C】 . This situation could be called alexithymia. Signs of the resolution of the alexithymia was already stated as following. “As expected, my thoughts settled down as a result of breathing. I felt my pulse with my fingertips, and I noticed a tingling sensation in my face, neck, and arms”【A】 . Namely, it is reported that alexithymia would disappear when a patient is able to feel interoceptive feelings.³² Ms. A’s alexithymia seems to be relieved by MT³³ as shown in the following. “Conversations with my children lasted only as long as necessary, but they began approaching me, and we laughed aloud for the first time in decades.” 【E】

Ms. A’s statement, “But, while sharing yesterday, those stifled emotions suddenly surfaced and I couldn’t stop them from coming out because I didn’t understand what was happening inside me. Afterwards, I had flashbacks and remembered images of past events like they were photos. I was never happy while raising my children and I anguished over whether I was unfit to be a mother, but I fondly recalled my eldest son in flashbacks and I recalled the joy and happiness I felt as our family grew when my second son was born …” 【D】suggests catharsis occurring 4 months after beginning MT. This refers, to the discharge of previously suppressed affect connected to traumatic events that occurs when these events are brought back into consciousness and reexperienced.³⁴ EA might be called suppression in the Freudian sense. Suppression is one of the defense mechanisms of Ego (called repression by Freudian Psychoanalysis) and is a target of therapy using free association. Delmonte³⁵ points out similarities between cathartic release of emotional materials found during mindfulness meditation, and that found in the abreaction of free association. Meditation, like free association in psychoanalysis, could be thought to facilitate the emergence of unconscious (sub-verbal) material and allow for its integration at a higher (more cognitive) level of awareness.³⁶ Furthermore, not only meditations,³⁷ but also free association in psychoanalysis³⁸ affects the operation of default mode network. MT could cause catharsis by alteration of balanced dominance of the hemispheres, which reduces the default dissociation between hemispheres, offering verbal consciousness greater access to normally suppressed emotion.³⁹ In this way, the repressed emotion might be verbalized and catharsis occurs. Recent neuroimaging studies of mindfulness provide findings supporting these hypotheses in which morphometric changes in gray matter asymmetry⁴⁰ and increase in white matter projections^41,42 were shown.

Mindfulness-to-meaning theory (MTM Theory)

It might be meaningful to follow the changes in Ms. A’s psychological conditions after her catharsis. At about 30 sessions of MT (after 4 months), Ms. A experienced catharsis as an initial effect of the heightened awareness that continued to grow during the entire MT period. Shortly after this catharsis, the memories that had been surrounded by negative emotions changed to memories with vivid and joyful emotions. This may be posttraumatic growth, which refers to the psychological growth experienced in the course of challenges to the consequences of trauma and subsequent suffering. Trauma, as used here, is broader and more non-specific than the APA⁴³ definition of trauma.⁴⁴ Ms. A’s catharsis may have changed negative affect to positive one, and this transformation of affect through MT may have been prompted by a cognitive reappraisal that results from sufficiently expanded awareness.²⁰

After about 50 sessions of MT (after 5 months), Ms. A became more stable in the sitting position and began to feel a strong sense of physical and interoceptive sense during MT. At the same time, she had a strange experience and a telepathic experience.³³ I also experienced instances of telepathic communication. 【F】 Her strange and telepathic experience could be a prelude to a mystical experience seen in meditation.

After 60 sessions of MT (after half year), she said to HK, “Recently, I have the feeling that I am living firmly grounded in my daily life. These days, it’s not about me, but more about wanting to help the people around me and wanting everyone to be happy.” MT went beyond the level of completely curing her anxiety and depression to lift her to the level of a well-being.⁴⁵ Furthermore, she became more prosocial and altruistic.

Following about 150 sessions of MT (after 1 year), Ms. A described in the last part of her note as following: “Mindfulness has taught me the meaning of my life. Each person has a unique existence. Mindfulness is a way to truly sense the uniqueness of one’s own existence” 【H】 .

This is just a model of MTM Theory proposed by Garland et al.,²⁰ as a model of mindfulness in the face of adversity to introduce a positive emotion and ultimately allow a durable state having what is pleasant, growth promoting, or meaning in life, a process which motivates values-driven behavior and fosters a deeper sense of purpose and self-actualization, that is to say, eudaimonic well-being, which is not a hedonic approach to happiness depending on obtaining pleasure and avoiding pain.⁴⁵ Garland et al.⁴⁶ studied the chronological evolution of psychological background from the start of MT to MTM in 107 SAD patients. The finding indicated increases in decentering by 3 months (corresponding to Ms. A’s catharsis after 4 months of MT), awareness of interoceptive sense by 6 months (corresponding to Ms. A’s acquisition of the sense after 5 months of MT) and increases in the use of reappraisal by 9 months culminating in greater positive affect at 12 months post-treatment (corresponding to Ms. A’s statement of MTM after 12 months of MT:I had never experienced before, such as being surrounded by warmth and an absence of physical sensation【G】 ).

The consistency of each of these occurring of psychological facts over time between Garland et al. study⁴⁶ and in this case study is noteworthy. Although Ms. A arrived at MTM, it seems that she is on the verge reaching the realm of self-transcendence.⁴⁷ It is believed that Ms. A reached the 5th Level of Engel’s⁴⁸ meditation depth scale (0-7), a state characterized by uplifting experiences (beginning synchronicity and absorption, new experiences of time and space).

In conclusion, the psychological mechanism to arrive at MTM in the present case appears to be the following: Heightened (1) attention or awareness that continues to grow during the entire MT period promotes (2) verbalization of the main theme of suppression, where the stress is (3) reappraised. Then (4) decentering of processing and integrating the painful theme into new adaptive self and world occurs, which appears as (5) catharsis. Furthermore (6) positive appraisal is matured in expanded awareness and finally reaches (7) MTM.

This case report shows exemplary effects of MT. It is the result of Ms. A’s diligent mindfulness efforts, which cannot be applied to all patients with SAD.