Case

A 27-year-old unmarried male, presented to the psychiatry outpatient department with an acute onset illness of 6 months duration with symptoms of decreased sleep, social withdrawal, decreased self-care, auditory hallucination of both third person discussing and commenting type and made volition with significant socio-occupational dysfunction. During the course of evaluation, it was noted that the patient practiced transcendental meditation in which he would sit still with eyes closed and repeat the ‘mantras’ continuously. Over the last 1 year, he had been practicing the same regularly on a daily basis (2–3 hours), with prolonged duration (4–5 hours) during the 2–3 months before the onset of the current symptoms. He was unable to concentrate on his meditation after onset of auditory hallucinations and around 1 month after onset of illness, stopped meditation. The content of hallucination would be two people discussing among themselves as well as commenting on how useless and bad the patient was. Along with this there would be twisting movement of his right arm against his will and he could not stop even with his active resistance. Considering these symptoms the diagnosis of schizophrenia was entertained according to ICD-10. He was initiated on low dose Amisulpride (200mg) concomitantly. Along with this psycho-education to the patients and family members was given about the nature of illness and need of medication. Within 2–3 weeks, there was significant improvement in symptoms. The patient was completely symptom free for the subsequent month and was compliant on psychotropic medication. He restarted practicing meditation at that point of time in a regular pattern as earlier. Within 2–3 weeks, his earlier psychotic symptoms initiated once again (though patient was compliant on medication), and within the next few weeks, patient started to report of almost all the previous psychotic symptoms.

A thorough evaluation of the patient revealed no history of substance abuse or past history of psychiatric illness, though a few schizoid traits could be elicited in his premorbid personality. He had completed Masters in engineering and was working in a construction company before the symptoms started. Heterosexual in orientation, staying with friends, he had good interpersonal relationship with friends and family. The patient was advised to continue Amisulpride and not to further practice meditation. In his follow-up assessment, it was observed that his symptoms had reduced significantly. The patient has been in regular follow-up thereafter and has maintained well.

Disscussion

This case report documents the association of clear cut schizophrenic psychotic symptoms with intense meditation. The Naranjo algorithm indicates ‘possible’ association between meditation practice and psychotic symptoms in this case (Naranjo et al. Reference Naranjo, Busto, Sellers, Sandor, Ruiz, Roberts, Janecek, Domecq and Greenblatt1981). Similarly, there is some degree of time pattern correspondence between the meditation and development of symptoms further suggesting association (Kiene et al. Reference Kiene, Hamre and Kienle2013). Our case, along with a handful of similar globally reported cases (Kuijpers et al. Reference Kuijpers, van der Heijden, Tuinier and Verhoeven2007; Lustyk et al. Reference Lustyk, Chawla, Nolan and Marlatt2009; Nakaya & Ohmori, Reference Nakaya and Ohmori2010), lends credence that transcendental meditation could be a precipitating factor for psychosis. The proposed neurobiology for this effect is increase in dopamine release in limbic brain regions and change in serotonin and melatonin (Rubia, Reference Rubia2009). Shapiro (Reference Shapiro1994) described contraindications for meditation in people suffering mental illness such as psychosis. However, there is some evidence of meditation combined with yoga having positive effects on negative psychotic symptoms (Visceglia & Lewis, Reference Visceglia and Lewis2011). A meta-analysis of 13 studies (n=468) have shown mindfulness-based practices to be moderately beneficial in treating the negative symptoms of psychosis (Khoury et al. Reference Khoury, Lecomte, Fortin, Masse, Therien, Bouchard, Chapleau, Paquin and Hofmann2013). Similarly, studies also support that these treatment intervention techniques are helpful in decreasing the anxiety in psychotic disorder (Davis & Hayes, Reference Davis and Hayes2011). These practices involve a passive procedure in which one would accept and anchor his/her concentration in the present moment along with attending to the natural flow of in and out breath (Shonin et al. Reference Shonin, Van Gordon and Griffiths2014). However, meditation per se has not been mentioned by the studies. This is different from the meditation practiced by the index case; where he would be more engrossed in chanting of ‘mantras’ and trying to get in the altered state of mind, indicating that transcendental meditation could be more psychosis prone as compared with mindfulness-based practice. Some of the general guidelines for psychotic patients practicing mindfulness-based meditation include engaging only in brief sessions, avoiding deep concentration, and sessions to be guided by soft voices or audio tapes, involvement of experienced facilitators, small groups with possibility of one to one discussion avoiding explicitly analytical/insight-based (i.e. vipassana) meditation techniques, etc. (Pérez-Álvarez et al. Reference Pérez-Álvarez, García-Montes, Perona-Garcelán and Vallina-Fernández2008; Shonin et al. Reference Shonin, Van Gordon and Griffiths2013). Apart from this there are other non-meditative mindfulness-based techniques that have been seen to be effective in depressive symptoms in case of schizophrenia (Moritz et al. 2015). Further, research is warranted to shed light on this complex and crucial issue of association between meditation practices and psychotic symptoms.