Mrs. A is 41year-old Japanese housewife who presented with complaints of anthropophobia and feeling gloomy all day long.
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-sacrificing 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.
In the 2 years before the Mrs. A’s first intake, she could hardly find 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 first examination at May 2008
By first 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): 51/80, trait anxiety (STAI-T): 57/80, Self-rating Depression Scale (SDS) 46/80, Japanese version of the Liebowitz Social Anxiety Scale (J-LSAS) 104/134, Social Anxiety Disorder Scale (SADS) 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 . 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 qualified teacher of MBSR (YH), an official instructor of Mindfulness-Based Cognitive Therapy (CK), a yoga instructor (AH) and a clinical psychologist (SN). The patient also attended the optional course.
Two months after the beginning a selective serotonin reuptake inhibitor (Fluvoxamine), Mrs. A’s interpersonal tensions decreased and her son began to attend school (July 2008). Her SAD symptoms reduction 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 → 41). J-LSAS scores further 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) (Fig.1).
The patient began to attend to the mindfulness class, however, she discontinued after several classes. After half of a year (8 years since her first 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 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 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 ; 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-affirmation. I was already in my 40s and thought I’d given things a try one more time.
[The first change you became aware of]
I stopped being angry.
[Changes after you started mindfulness]
<Times 1–20>2016/ June 13–September 23
During this period, I developed the painless habit of waking up and coming to the TMC. I was extremely nervous about being around people I didn’t know, and I felt really fatigued. When I spoke while sharing, I was nervous, had palpitations, my hands shook, and my voice quivered. I was cognizant of the distance between me and the people next to me, and I was resolute about maintaining my personal space. Once my breathing was controlled, I settled down and regained my composure. I felt my body go limp and instantly felt relaxed. I couldn’t concentrate unless I closed my eyes.
<Times 21–40> 2016/September 24–November 1
I got used to coming to the TMC, and I had a normal daily rhythm. ・・・・・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.
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 flashbacks. 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 fulfilling 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 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. Photos from my childhood and school days depicted me striving to stifle 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. ・・・・・
<Times 41–60> 2016/November 4–December 10
・・・・・ 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 first time in decades. I had difficulty 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 find it in a book I was reading. Or Psychiatrist HK would mention a technique to resolve a problem I had out of the blue.
<Times 61–160> 2016/December 12–2017/October 13
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.