Mindfulness Training led to Catharsis and Mindfulness-To-Meaning in a Patient with Social Anxiety Disorder Comorbid with Persistent Depressive Disorder (Dysthymia) - A Case Report with Patient's Personal Note Hisanobu

Background: The use of mindfulness in the treatment of anxiety and depression is becoming more and more widespread, but there are few reports that it has fundamentally changed patients' sense of life. Case Presentation: This report showed 9 year’s progress of treatment for Social Anxiety Disorder and Persistent Depressive Disorder in a 41year-old female patient experiencing a long-term painful married life with a carefree husband and controlling mother-in-law. During the past 25 months, she received 180 sessions of mindfulness training, resulting in complete remission of the anxiety and depression symptoms. After the 30th session she experienced an episode of the catharsis during the mindfulness training and experienced what can be called Mindfulness-To-Meaning, which is characterized by durable eudaimonic well-being in the face of adversity.

to-Meaning (MTM), a durable form of positive affectivity and sense of meaningfulness in life in the face of adversity [12].
In this paper, we would like to show the trajectory of the psychological effects of MT, which induced not only full remission of the SAD and PDD, but also the state of MTM. We further discuss the psychological mechanisms of MT that may lead to and support MTM.

Case Presentation
Mrs. A is 41year-old Japanese housewife who presented with complaints of anthropophobia and feeling gloomy all day long.

Life history
She 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 for people with glasses. She had no intimate schoolmates and reported feeling 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.
Her mother was an unyielding woman of spirit and an absolute monarch for her. The patient 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 married life with a carefree husband who was a typical mother's boy and a strict parents-in-law. The mother-in-law was severely controlling. The patient lived only to serve her husband and parents-in-law. In these self-sacri cing days, the patient was blessed with the birth of two sons. She could not remember any pleasure during child rearing. She reported pretty severe alexithymia. Later her elder son refused to attend junior school and high school.

Clinical History
In the 2 years before the Mrs. A's rst intake, she could hardly nd the words to speak at Parent Teacher Association meetings. School negotiation about the refusal of her son was a great burden for her. One day at home she suffered a panic attack that caused great embarrassment in front of her mother-in-law. She was intensely concerned about her son.
Findings, diagnosis and treatment plan in the rst examination at May 2008 By rst intake, Mrs. A responded slowly and appeared depressed. She found it painful to talk with school administrators about her son. She ventured out of her home only when necessary due to fear of interacting with people in shops and on the streets or vehicles. She completed housework under the scrutiny of her parents-in-law. She reported that she never enjoyed life, had no appetite and sleep problems.
Psychological assessment tools: The following self-report questionnaires were administered at her initial visit. State-Trait Anxiety Inventory, state anxiety (STAI-S) [13]: 51/80, trait anxiety (STAI-T) [13]: 57/80, Selfrating Depression Scale (SDS) [14] 46/80, Japanese version of the Liebowitz Social Anxiety Scale (J-LSAS) [15] 104/134, Social Anxiety Disorder Scale (SADS)[16] 48/150. The patient experienced a panic attack on only one occasion. Her phobic fear in vehicles was not agoraphobic but rather interpersonal strain. Her primary diagnosis was SAD. The patient was experiencing low energy or fatigue, low self-esteem and feelings of hopelessness continuously over the last two years.
Her comorbid psychiatric diagnosis was PDD.
The patient's treatment began with psychoeducation and pharmacological treatment. Fluvoxamine was given in an increment manner from 25mg to 100mg 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 [17]. The other course is optional. Attendants can join when they like after an introductory education in mindfulness.
Mindfulness class was open for 3 hours every day except Sunday. The mindfulness class was consisted of Hatha yoga for an hour, meditation, mainly calm abiding (Shamata in Sanskrit), for 30 minutes including loving-kindness meditation, then sharing for the remaining time. Participants were encouraged to engage in both formal and informal meditation practices each 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 quali ed teacher of MBSR (YH), an o cial instructor of Mindfulness-Based Cognitive Therapy (CK), a yoga instructor (AH) and a clinical psychologist (SN). The patient also attended the optional course.
The patient began to attend to the mindfulness class, however, she discontinued after several classes. After half of a year (8 years since her rst intake, June 2016), the patient re-engaged in MT. She attended classes several times a week, earnestly. After the 30th sessions, she experienced a powerful emotional burst and ashback, 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 times during 25 months including 10 sessions of MBSR. Her social anxiety and depressive symptoms got to almost remission at the end of the treatment: J-LSAS; 104→20, SADS; 48→9, SDS; 46→29, STAI-S; 51→33, Freiburg Mindfulness Scale [18]; 26→37. Her clinical improvement continued for 3 years after the end of treatment (Fig. 1).

Personal Report of Patient
This report was written at December 26th, 2016 after 69th session of MT.
[Rationale for starting mindfulness] It was suggested by my doctor. I'm in OK condition right now, but something deep down inside was off and I noticed a complete lack of a sense of self-a rmation. I was already in my 40s and thought I'd given things a try one more time. One day after the 30th session of MT when it was my turn to share, I suddenly began to cry uncontrollably for no apparent reason. As I share, "Every day is a struggle because I'm anxious to tell the doctor I'll be better soon. I really want to learn how to practice mindfulness, but I'm going around in circles. Although I'm trying, I'm starting to wonder if that [going around in circles] may just be it." I couldn't stop crying even after that. My emotions were gushing out of me, so I took a walk away from the TMC for 3 hours. While walking, I felt like I would throw up once I reached home, and I started having visions similar to ashbacks. The next morning, I was troubled by the feelings that arose in me, and I talked with Psychologist CK. As I explained, "I sensed something from my sudden outburst of emotion while sharing yesterday. 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 ful lling the mission I've been given. 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. But while sharing yesterday, those sti ed 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 ashbacks 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 un t to be a mother, but I fondly recalled my eldest son in ashbacks and I recalled the joy and happiness I felt as our family grew when my second son was born. Photos from my childhood and school days depicted me striving to sti e an unfathomable anguish. As I continue to practice mindfulness, an energy "to live" has sprung out of my closed self." Psychologist CK informed me that this was a good sign and advised me to continue practicing mindfulness for the time being. Meditating in a seated position provides stability and a keen sense of the body and the inner state of the body (interoceptive awareness). One is also able to see things with the eyes half closed. After the 40th session of MT, I increasingly had unusual experiences with those around me. Up till now, my husband had curtly responded to my questions with just "I got it" or "Yeah," but surprisingly he began responding warmly, "That's right. We'll do that from now on". Conversations with my children lasted only as long as necessary, but they began contacting me, and we laughed aloud for the rst time in decades. I had di culty dealing with my local mothers' group, but I ran into them by chance and effortlessly greeted them with a smile instead of running away. One day, my mom wept with joy at something I said to her. I also experienced instances of communicating without speaking (telepathy experiment). What I was thinking that day is the exact same thing Instructor YH was thinking. I would ask Clinical Psychologist CK about something, only to return home and nd it in a book I was reading. Or Psychiatrist HK would mention a technique to resolve a problem I had out of the blue. My condition is stable, and I'm working sincerely and honestly trying to practice mindfulness each day. I strive to get up early and go to bed early each day, and I sit down at 4:30 AM in the morning. Unbelievably, I start moving around as soon as I wake up.
Recently, I've felt the intense desire to help others and to make everyone happy rather than thinking of myself.
During this period, I've experienced mental states I had never experienced before, such as being surrounded by warmth and an absence of physical sensation.
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. Since I started mindfulness, there has always been another self inside of me. The one who is living in the present as a physical body, and the one who can look down on it and judge things calmly at all times.

Treatment Course
Mrs. A's social anxiety dramatically improved after MT for 25 months. Mrs. A received CBT before MT which should have worked better for her because CBT strengthen cognitive abilities [19], increases positive affective empathy [20] and disputing of anxious thoughts and feelings via reappraisal in SAD [21]. Mrs. A's PDD symptoms uctuated during pharmaco-therapy and CBT. Her depression improved steadily after beginning of the MT and nally arrived at remission. Three years after the end of treatment, Mrs. A's condition remained in complete remission of the two disorders and she was able to maintain a life of mindful well-being. (Fig. 1).

Experiential avoidance (EA) and Catharsis
Mrs. A had a severe self-sacri cing life with an absent husband and controlling mother in-law for 20 years.

Mrs. 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 ful lling the mission I've been given." This statement suggests experiential fusion, an automatic process whereby one becomes absorbed in contents 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 [22]. Another statement of Mrs. A, "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." This also suggest EA, a trait-like tendency to avoid unpleasant internal experiences [23]. It is reported that dispositional mindfulness has antagonistic effects on EA [8,9].
A very limited aspect of this situation could be called alexithymia. Mrs. A's alexithymia seems to have been relieved by the long-term MT as reported by Bornemann & Singer [24]. On the contrary, a brief MT had no signi cant effect on alexithymia [25]. In the present case, alexithymia was almost completely released by long-term MT.
Mrs. A's statement, "while sharing yesterday, those sti ed 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 ashbacks 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 un t to be a mother, but I fondly recalled my eldest son in ashbacks and I recalled the joy and happiness I felt as our family grew when my second son was born." This suggests catharsis occurring 4 months after beginning MT. This refers, to the discharge of previously suppressed affects connected to traumatic events that occurs when these events are brought back into consciousness and reexperienced [26]. EA might be called suppression in the Floydian sense. Suppression is one of the defense mechanisms of Ego and called as repression by Freudian Psychoanalysis, which is a target of therapy using free association. Delmonte [27] pointed 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, would be thought as to facilitate the emergence of unconscious (sub-verbal) material and allow for its integration at a higher (more cognitive) level of awareness [28]. Furthermore, MT would 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 [29]. In this way, the repressed emotion might be verbalized and catharsis occurs. Recent neuroimaging studies of mindfulness provided ndings supporting these hypotheses in which morphometric changes in gray matter asymmetry [30] and increase in white matter projections [31,32] were shown.
Mindfulness-to-Meaning Theory (MTM Theory) It might be meaningful to follow the changes in Mrs. A's psychological conditions after her catharsis. About 30 times of MT (after 4 months), Mrs. A experienced catharsis as an initial effect of the heightened awareness that would continue 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 say as 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-speci c than the APA [33] de nition of trauma [34]. Mrs. A's catharsis changes negative affect to positive one, this transformation of affect through MT requires a cognitive reappraisal that results from su ciently expanded awareness [12].
About 50 times of MT (after 5 months), Mrs. 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. The acquisition of interoceptive sense in MT is said to be closely related to the disappearance of alexithymia [25]. Her strange and telepathic experience could be a prelude to a mystical experience seen in meditation.
After 60 times of MT (after half year), She wrote, "I have the feeling that I am living rmly 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 [35]. Furthermore, she became more prosocial and altruistic.
About 150 times of MT (after 1 year), Mrs. 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". This is just a model of MTM Theory proposed by Garland et al. [12], as a model of mindfulness in the face of adversity to introduce a positive emotion regulation and ultimately allow a durable state having what is pleasant, growth promoting, or meaningful in life, a process which motivates values-driven behavior and engenders a deeper sense of purpose and self-actualization, that is to say, eudaimonic well-being, which is not hedonic approaches to happiness depending on obtaining pleasure and avoiding pain [36]. Garland et al. [37] studied the chronological evolution of psychological background from the start of MT to MTM in 107 SAD patients. The nding indicated increases in decentering by 3 months (corresponding to Mrs. A's catharsis after 4 months of MT), awareness of interoceptive sense by 6 months (corresponding to Mrs. 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 Mrs. A's statement of MTM after 12 months of MT). The consistency of each of these occurring time of psychological facts over time between in their study and in our case is very interesting. Although Mrs. A arrived at MTM, She is one breath away from reaching the realm of self-transcendence [38]. It is considered that Mrs. A reached at the 5th Level of Engel's (1997) meditation depth scale (0-7), which state is shown as being uplifted (beginning synchronicity and absorption, new experiences of time and space).
In conclusion, the psychological mechanism to arrive at MTM in the present case was thought as followed: Heightened (1) attentions or awareness that would continue to grow during the entire MT period promotes (2) verbalizes the core of the main theme of suppression, where the stress is (3) reappraised. Then (4) decentering occurs processing and integrating the painful theme into new adaptive self and world, which appears as (5) catharsis. Furthermore (6) positive appraisal is matured in expanded awareness and nally reach at (7) MTM.
This case report showed exemplary effects of MT. It was the result of Mrs. A's very diligent mindfulness efforts, which cannot be applied to all patients with SAD.

Consent for publication
Written informed consent was obtained from the participant.

Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Figure 1 Clinical course of Mrs. A