Meditation and Psychosis

Bruce Tamlinson

Diksha Malhota

Summary

Background

Traditionally, meditation practice was seen solely as a religious or spiritual practice. However, in recent decades, it has been popular as a healing therapy for many ailments and a way of supporting mental health. Even though it may have many beneficial effects, there is increasing evidence of adverse effects, some of which can be seriously harmful. 

Method

This paper presents a case study of a patient with brief psychotic disorder following intense meditation practice. Appropriate consent has been sought from the patient and relevant ethical guidelines were followed.

Results

There were clear chronological and phenomenological links between meditation and the psychotic symptoms. The patient was diagnosed with brief psychotic disorder. He fully recovered days after discontinuing meditation.

Conclusion

Meditation can induce psychotic symptoms in vulnerable patients. The presentation of such condition may vary between individuals. The prognosis is good on discontinuing meditation.

Background

Meditation encompasses various forms of mental exercises that aim to manage an individual’s emotions and thoughts [1]. Different forms of meditation have evolved often through different religious practices and cultures; for example, the Buddhist meditation school developed in association with Buddhism, which includes Vipassana, Zen and Theraveda; Yogic meditation associated with Hinduism etc. Other forms also exist – transcendental meditation, pranic healing, and Bikram yoga [2].  According to the meditative techniques, there are three major categories of meditation identified: ‘Controlled focus’, ‘Open monitoring’ and ‘Transcendental’ [3]. For example, Zen, Tibetan Buddhism, Qigong, Yoga and Vedanta, and operate with controlled focus techniques. Vipassana and Zazen are mindfulness–type, open monitoring techniques. Meditation techniques which involve repeating mantras silently are called transcendental meditation [3].

A systematic review and meta-analysis about the efficacy of mindfulness-based interventions found them to be superior to no treatment and equivalent to other evidence-based treatments (such as cognitive behavioural therapy and antidepressants) [4]. This supported a previous meta-analysis which found mindfulness-based interventions to be effective for reducing stress, anxiety and depression [5]. The benefits of meditation are often reported in the media and social media. However, the literature on unintended consequences or adverse effects of meditation is limited [6]. A literature review reported adverse effects of meditation to be hallucinations, delusions, derealisation and a distortion of the senses [7]. Though adverse physical health reactions have also been reported, including ulcers, nausea, headaches, gastro-intestinal problems or muscular pain, such symptoms failed to meet the causality criteria [10].

Case Presentation

Here, we present the case of a patient who presented to mental health services in ‘crisis’ in inner city London following practice of meditation. BT was involved in their treatment following presentation to the local Home Treatment Team (HTT), part of a brief and intensive community treatment offer within the crisis pathway as a part of the National Health Service (NHS). DM was part of the multi-disciplinary team offering treatment and RB was involved in the supervision of BT and DM for their clinical work as well as the writing up of this paper.

We encountered 3 patients, in a 12-month period, with psychotic symptoms following meditation. However, we present one of the patients: the clinical presentation, his treatment and outcome as noted whilst he received care with the HTT. The patient consented to the anonymised presentation of his case for the purpose of this article. Trust ethical guidelines were followed. An electronically typed consent was obtained from the patient using BMJ Consent form and a copy was uploaded onto his electronic care records. In addition, audio recording of his verbal consent was obtained since a digital signature was not available.

Case Report

A middle-aged gentleman, with no previous mental health history, presented with anxiety, erratic behaviour and suicidal thoughts to the Emergency Department in psychiatric crisis. This was soon after attending a 10-day Vipassana meditation course.  He described the course as “a torture and like a cult”. He reported during the meditation course, all forms of communication were restricted, including non-verbal: he began to feel strange and confused. He slept only for two hours at night.

On mental state examination, he reported low mood and poor sleep because of the meditation. He also felt a numbness and tingling in his whole body and a sense of something rising inside him. He denied any auditory hallucinations. He described visual experiences such as seeing ghosts, dead people, and random things like Medusa’s head during the meditation. His explanation for what has happened was that he was poisoned by the retreat: he believed they may have put something in his food that was gradually wearing off. He held this belief firmly and it was unshakeable. He believed he was poisoned, as the retreat’s goal was to brainwash people in order to control them. He had considered running out in front of traffic or jumping from his fourth-floor balcony: he was able to stop himself from acting on these thoughts. His cognition was grossly intact, and he was alert and oriented to time, person and place. However, he recalled that a few days earlier during the night he had been disoriented. He had no significant health problems. He was not on any regular medications and did not use any illicit substances.

The psychiatrist felt that he was suffering from acute transient psychosis (International Classification of Disease, 10th Edition or ICD 10 code F.23). He was reported to be perfectly well prior to this presentation with no previous psychiatric or medical history. He had not been on previous medication or used substances and other than the meditation course, no other trigger was identified. Following his presentation to the Emergency Department in the first instance he was prescribed sedative medications: Zopiclone, Promethazine and Diazepam and referred to the Home Treatment Team for monitoring in the community as an alternative to hospital admission. He recovered and gained insight after three days without further pharmacotherapy. He had contact with staff including nursing staff from the Home Treatment Team during this brief period.

Outcome and Follow-up

He recovered from the psychotic symptoms within days after taking sedative medication and discontinuation of meditation. He was discharged from mental health services after a week. It was suggested he explores options for psychological therapy subsequently which he could pursue privately. He completely recovered from the episode and could return to his normal function.

We have come across other case reports on the subject but there were no studies considering its prevalence or attempting to quantify risk. Due to the small number of cases and case series reported, we assume the proportion of patients who experience psychotic symptoms as a result of meditation is small. However, it is also possible there is a degree of under-reporting by those experiencing psychosis, who may not always use a biomedical explanatory model for their experiences and may not consider seeking help through the mental health pathway, unless distressed.

It has been theorised that some patients are more prone to experiencing psychotic symptoms as a result of meditation. For example, it is thought that certain personality types or inherent traits may make individuals more vulnerable to develop psychotic symptoms [8]. Physical health, psychosocial stressors and sleep deprivation may also play a role [11,12]. Conversely, it is not well studied whether the psychosis is a result of malpractice or over-practice of meditation; though, it is difficult to have a consensus on what malpractice and over-practice mean for someone.

It has been proposed that such adverse reactions may occur due to the intrinsic mechanism of such mindfulness-based programmes [10]. It has been hypothesized those practicing meditation achieve a heightened sense of awareness which can be linked to activation of the insular cortex which can potentially cause increased anxiety and flashbacks [9]. Symptoms such as dissociation and blunting have been linked with prefrontal control of the amygdala which is thought to occur in such programmes for those practising ‘decentering’ [9].

This patient did not have any prior psychiatric or relevant family history and developed symptoms immediately following intense meditation. There is no evidence for these symptoms to have been induced by illicit substances. He was fit and well prior to meditation and developed the symptoms relatively acutely. The experience was acutely distressing for him, and he sought emergency help. Taking those points into account, it is more likely that this was a Brief Psychotic Disorder presentation which was induced by meditation. Some literature discusses similar presentations as a possibility of culture bound syndrome [13,14]. For our case, the presentations were not well-recognised illnesses in his culture. The course of the illness was short and the patient made a good prognosis. He recovered completely without any residual symptoms and reported that he was able to return to his normal life.

Intriguingly, all our cases experienced a sense of ‘something rising from the lower back’. This can be considered a visceral hallucination whereby patients can experience abnormal sensations from internal organs. However, in meditative practice, this is known as ‘kundalini awakening’. This effect can be experienced differently in people. However, it has the dominant feature of ‘pressure waves’ that rise above the waist and are normally located around the spine, neck, throat and head. These have been attributed to energy centres or ‘chakras’. Those practising can be predicted to achieve such a sensation because of meditation [15]. Such a visceral hallucination may also be a result of imagination instigated by intense expectation or a hyper-excited state [17,18]. Extreme sensory awareness and mindfulness can also increase sensitivity around internal organs [16], for instance, the rising feeling might be related to interception of the venous blood flow in large veins such as the vena cava.

In conclusion, the patient presented with symptoms which included losing touch with reality and were thought to be psychotic in nature. In our case, there were chronological and phenomenological links between meditation and the psychotic symptoms. Finally, the patient demonstrated significant recovery within a short period of time on discontinuation of meditation.

References

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About the authors

Dr Bruce Tamlinson is a Higher Trainee (ST6), working in Sussex Partnership NHS Foundation Trust.

Diksha Malhotra is an ACP & Pharmacist, working in East London NHS Foundation Trust.