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Mania precipitated by meditation: A case report and literature review
by Graeme A. Yorston
St. Andrew's Hospital, Northampton, UK
Mental Health Religion & Culture, November 2001
NOTICE: THIS WORK MAY BE PROTECTED BY COPYRIGHT
ABSTRACT
Meditation is a popular method of relaxation and dealing with everyday stress. Meditative techniques have been used in the management of a number of psychiatric and physical illnesses. The risk of serious mental illness being precipitated by meditation is less well recognized however. This paper reports a case in which two separate manic episodes arose after meditation using techniques from two different traditions (yoga and zen). Other cases of psychotic illness precipitated by meditation and mystical speculation reported in the literature are discussed.
Introduction
Meditation as a method of relaxation and dealing with everyday stress is becoming increasingly popular in the West with an estimated six million practitioners in the USA alone (Graham, 1986). A variety of techniques are in use but most owe their origins to oriental practices. Meditation has also been used as a therapeutic tool in psychiatry for behaviour modification (de Silva, 1984), as part of a holistic programme for chronic schizophrenia (Lukoff et al., 1986) and as an adjunct to dynamic psychotherapy (Kutz, 1985). A number of recent studies have examined the effects of meditation on physical illness (Kabat-Zinn et al., 1998;Wenneberg et al., 1997)
Meditation is generally considered safe with beneficial effects on mental health rather than as a potential trigger for psychiatric illness but there are reports in the literature of the hazards of meditation: Walsh and Roche (1979) described three cases of psychotic illness precipitated by meditation in subjects already diagnosed as suffering from schizophrenia who had discontinued medication. Garcia-Trujillo et al. (1992) described a further two cases of acute psychosis precipitated by oriental meditation in subjects previously diagnosed as schizotypal personality disorder. Chan-Ob and Boonyanaruthee (1999) report a further three patients who presented with psychotic symptoms after practicing meditation. French et al. (1975) reported a single case of ‘altered reality testing’ after transcendental meditation. The precipitation of psychotic illness by Jewish mystical speculation has also been reported (Greenberg et al., 1992). Krieger and Zussman (1981) reported a case of a brief reactive psychosis in a Thai immigrant to the USA which occurred after confronting a family Buddhist mortuary ritual.
A review of the literature failed to reveal any cases of affective disorder being precipitated by meditative techniques. This paper reports a case in which two separate manic episodes were precipitated by periods of intense meditation using techniques from two different traditions (yoga and zen).
Case report
Miss X, a 25-year old self-employed, university graduate presented with a two week history of increased talkativeness, sleeplessness, over-activity and disinhibited behaviour. The onset followed a weekend yoga course that encouraged psychological release. She telephoned her instructor frequently, often in the middle of the night, offering undying love. She also pushed her hand through a window and sustained minor lacerations. There was no past psychiatric history but she had experienced brief periods of low mood 10 and six years previously which had resolved without psychiatric intervention. There was a family history of depression in her father who had received electro-convulsive therapy, and of late life depression in her paternal grandmother. Her birth and milestones were normal. There was no history of illicit drug use.
She was admitted informally to hospital but was detained when she became irritable and aggressive and insisted on leaving. At interview she shouted and tried to embrace some members of staff, but struck out at others. There was pressure of speech, thought disorder with flight of ideas, her mood was elevated and there were grandiose delusions including the belief that she had some special mission for the world: she had to offer ‘undying, unconditional’ love to everyone. She had no insight. A diagnosis of manic episode was made and she was treated with haloperidol 10mg daily and lorazepam up to 4mg daily and her symptoms were gradually controlled over the next six weeks. She refused mood-stabilizing medication.
At outpatient follow up she was noted to be mildly hypomanic on two occasions (the second after a sesshin or intensive Zen meditation weekend) but these episodes responded to chlorpromazine without admission to hospital. She agreed to a trial of carbamazepine 800mg daily which she took for two years. She also underwent twice weekly psychodynamic psychotherapy for over two years.
Two months after entering a Zen Buddhist retreat that she had been associated with for two years, she re-presented with a five-day history of sleeplessness, decreased appetite and labile affect. At interview she laughed inappropriately and had outbursts of activity – lying on her bed one moment, jumping off the next. She made stereotypical praying movements, was sexually disinhibited, restless, distractible and irritable. She was thought disordered with pressure of speech. Though admitted informally she soon insisted on leaving and attacked a member of staff. She was detained and transferred to an intensive psychiatric care unit for three days where treatment with haloperidol 6mg and lorazepam 3mg was commenced. Her mental state settled over the next eight weeks. She continued to refuse mood stabilizing treatment and re-entered the Buddhist retreat.
Discussion
The precipitation of mania by meditation has not been described before yet descriptions of the altered state of consciousness (ASC) associated with contemplative practice abound in the mystic literature of different religions (Buckley, 1981). Zen is a Japanese school of Buddhism – the word itself derives from Sanskrit dhyana or meditation and it is meditation or mindfulness that forms the essence of the Zen philosophy of life. A euphoric state of enlightenment called satori is sometimes achieved by experienced monks (Humphreys, 1962). Thapa and Murtha (1985) compared the subjective accounts of ASCs in subjects with complex partial seizures, schizophrenia and meditators from ashrams and other religious organizations in India. They found the core experiential characteristics of perceptual distortion were common to all three ASCs but important differences existed such as only the meditative ASC being accompanied by a positive emotional effect. The authors did not include manic patients in their study so were unable to make direct comparisons with the experiences in mania. Lukoff (1988) however reported in a single case study that seven of the eight dimensions of mystical experience described by Stace (1960) were experienced by a manic patient.
There is evidence that mystical experiences have a neuro-biological basis possibly in the right temporal lobe (Fenwick, 1996) and contemplative meditation which can lead to such experiences can be studied in experimental conditions (Deikman, 1963, 1964). Lou et al. (1999) have shown a differential cerebral blood flow distribution in meditative states and normal consciousness.
Students practise Zen to develop concentration without thinking (Watts, 1962) but this can be difficult and novices are often bombarded by distracting stimuli – both external and intrapsychic which can continue after the meditation session leading to insomnia. There is evidence to suggest sleep deprivation may act as a final common pathway in the onset of mania (Kasper & Wehr, 1992; Wehr, 1991; Wright, 1993) and it is possible that it was the pressure of thought stirred up by meditation that disrupted the patient’s sleep and precipitated the manic episode in this case and in two of the cases reported by Chan-Ob and Boonyanaruthee (1999). Interestingly the patient herself likened both episodes of mania to a release of tension and blocked energy from years of not dealing with emotions in a helpful way.
Other evidence for psychological precipitants for mania comes from life events (Sclare & Creed, 1990) and expressed emotion (Miklowitz et al., 1986) research. These factors appear to be most important in the first episode of illness, the effects lessening with each subsequent episode. These observations have been suggested as evidence in support of the kindling hypothesis (Silverstone & Romans-Clarkson, 1989). The move to the retreat and adoption of a different lifestyle in this case must have been a significant stressor. Indeed, religious change in itself can be associated with psychiatric illness: Witztum et al. (1990) showed high rates of serious mental illness in converts to ultra-orthodox Judaism in Jerusalem and speculated that, for some, the conversion may have been an attempt to control emerging signs of psychiatric illness.
Other more established risk factors for mania in this case are the positive family history of affective disorder and the discontinuation of carbamazepine (Scull & Trimble, 1995).
The orthodox psychiatric diagnosis in this case was bipolar affective disorder. Grof and Grof (1986) have argued however that traditional psychiatric thinking fails to recognize the difference between mystical and psychotic experiences, tending to underestimate the potential for a healing and positive transformation of what the authors term a transpersonal crisis. It is important to remember that other cultures have and do classify what we now call psychoses in different ways and that, as Carey (1997) has advocated, knowledge drawn from different approaches should be respected and allowed to contribute to the scientific study of mental illness. The absence of previous reports of mania precipitated by meditation despite its apparent potency at inducing euphoric states of consciousness suggests that adequate practice and supervision may enable the subject to learn to control the emergence of intrapsychic material. If this is so, then it could have implications for reducing the risk of relapse in this patient and potentially in others. Thus, although our understanding of the psychology and neurobiology of meditation is growing (see West, 1987) for a comprehensive review) it deserves more study.
_______________
References
BUCKLEY, P. (1981). Mystical experience and schizophrenia. Schizophrenia Bulletin, 7, 516–521.
CAREY, G. (1997). Towards wholeness: transcending the barriers between religion and psychiatry. British Journal of Psychiatry, 170, 396–397.
CHAN-OB, T. & BOONYANARUTHEE, V. (1999). Meditation in association with psychosis. Journal of the Medical Association of Thailand, 82(9), 925–930.
DE SILVA, P. (1984). Buddhism and behaviour modification. Behavioural Research and Therapy, 22, 661–678.
DEIKMAN, A.J. (1963). Experimental meditation. Journal of Nervous and Mental Disease, 136, 329–343.
DEIKMAN, A.J. (1966). Implications of experimentally induced contemplative meditation. Journal of Nervous and Mental Disease, 142, 101–116.
FENWICK, P. (1996) The neurophysiology of religious experience. In D. BHUGRA (Ed.) Psychiatry and Religion (pp. 167–177). London: Routledge.
FRENCH, A.P., SCHMID, A.C. & INGALLS, E. (1975). Transcendental meditation, altered reality testing and behavioral change. Journal of Nervous and Mental Disease, 161, 55–58.
GARCIA-TRUJILLO, R., MONTERREY, A.L. & GONZALEZ DE RIVIERA, J.L. (1992). Meditacion y psicosis. Psiquis Revista de Psiquiatria Psicologia y Psicosomatica, 13(2), 39–43.
GRAHAM, H. (1986) The human face of psychology: humanistic psychology in its social and cultural context. Milton Keynes: Open University Press.
GREENBERG, D., WITZTUM, E. & BUCHBINDER, J (1992). Mysticism and psychosis: the fate of Ben Zoma. British Journal of Medical Psychology, 65(3), 223–235.
GROF, C. & GROF, S. (1986). Spiritual emergency: The understanding and treatment of transpersonal crises. Special Issue: The psychotic experience: disease or evolutionary crisis? ReVision, 8(2), 7–20.
HUMPHREYS, C. (1962). Teach Yourself Zen. Aylesbury: English Universities Press.
KABAT-ZIN, J., WHEELER, E., LIGHT, T., SKILLINGS, A., SCHARF, M.J., CROPLEY, T.G., HOSMER, D. & BERNHARD, J.D. (1998). In uence of mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy. Psychosomatic Medicine, 60 (5), 625–632.
KASPER, S. & WEHR, T.A. (1992). The role of sleep and wakefulness in the genesis of depression and mania. Encephale, 18 Spec No 1, 45–50.
KRIEGER, M.J. & ZUSSMAN, M. (1981). The importance of cultural factors in a brief reactive psychosis. Journal of Clinical Psychiatry, 42(6), 248–249.
KUTZ, I. (1985) Meditation as an adjunct to psychotherapy: an outcome study. Psychotherapy and Psychosomatics, 43(4), 209–218.
LOU, H.C., KJAER, T.W., FRIBERG, L., WILDSCHIODTZ, G., HOLM, S. & NOWAK, M. (1999). A 150-H2O PET study of meditation and the resting state of normal consciousness. Human Brain Mapping, 7(2), 98–105.
LUKOFF, D. (1988). Transpersonal perspectives on manic psychosis: creative, visionary and mystical states. Journal of Transpersonal Psychology, 20, 111–140.
LUKOFF, D., WALLACE, C.J., LIBERMAN, R.P., & BURKE, K. (1986) A holistic program for chronic schizophrenic patients. Schizophrenia Bulletin, 12, 274–282.
MIKLOWITZ, D.J., GOLDSTEIN, M.J. & NUECHTERLEIN, K.H. (1986). Expressed emotion, affective style, lithium compliance and relapse in recent onset mania. Psychopharmacology Bulletin, 22, 628–632.
SCLARE, P. & CREED, F. (1990). Life events and the onset of mania. British Journal of Psychiatry, 156, 508–516.
SCULL, D.A. & TRIMBLE, M.R. (1995). Mania precipitated by carbamazepine withdrawal. British Journal of Psychiatry, 167, 698.
SILVERSTONE, T. & ROMANS-CLARKSON, S. (1989). Bipolar affective disorder: Causes and prevention of relapse. British Journal of Psychiatry, 154, 321–335.
STACE, W. (1960). The teachings of the mystics. New York: Mentor.
THAPA, K., & MURTHY, V.N. (1985). Experiential characteristics of certain altered states of consciousness. Journal of Transpersonal Psychology, 17, 77–86.
WALSH, R. & ROCHE, L. (1979) Precipitation of acute psychotic episodes by intensive meditation in individuals with a history of schizophrenia. American Journal of Psychiatry, 136 (8), 1085–1086.
WATTS, A.W. (1962) The way of zen. Harmondsworth: Penguin Books.
WEHR, T.A. (1991) Sleep loss as a possible mediator of diverse causes of mania. British Journal of Psychiatry, 159, 576–578.
WENNEBERG, S.R., SCHNEIDER, R.H., WALTON, K.G., MACLEAN, C.R., LEVITSKY, D.K., SALERNO, J.W., WALLACE, R.K., MANDARINO, J.V., RAINFORTH, M.V. & WAZIRI, R. (1997) A controlled study of the effects of the transcendental meditation program on cardiovascular reactivity and ambulatory blood pressure. International Journal of Neuroscience, (89) 15–28.
WEST, M.A. (1987) The psychology of meditation. Oxford: Clarendon Press.
WITZTUM, E., GREENBERG, D. & DASBERG, H. (1990) Mental illness and religious change. British Journal of Medical Psychology, 63, 33–41.
WRIGHT, J.B. (1993) Mania following sleep deprivation. British Journal of Psychiatry, 163, 679–680.
by Graeme A. Yorston
St. Andrew's Hospital, Northampton, UK
Mental Health Religion & Culture, November 2001
NOTICE: THIS WORK MAY BE PROTECTED BY COPYRIGHT
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ABSTRACT
Meditation is a popular method of relaxation and dealing with everyday stress. Meditative techniques have been used in the management of a number of psychiatric and physical illnesses. The risk of serious mental illness being precipitated by meditation is less well recognized however. This paper reports a case in which two separate manic episodes arose after meditation using techniques from two different traditions (yoga and zen). Other cases of psychotic illness precipitated by meditation and mystical speculation reported in the literature are discussed.
Introduction
Meditation as a method of relaxation and dealing with everyday stress is becoming increasingly popular in the West with an estimated six million practitioners in the USA alone (Graham, 1986). A variety of techniques are in use but most owe their origins to oriental practices. Meditation has also been used as a therapeutic tool in psychiatry for behaviour modification (de Silva, 1984), as part of a holistic programme for chronic schizophrenia (Lukoff et al., 1986) and as an adjunct to dynamic psychotherapy (Kutz, 1985). A number of recent studies have examined the effects of meditation on physical illness (Kabat-Zinn et al., 1998;Wenneberg et al., 1997)
Meditation is generally considered safe with beneficial effects on mental health rather than as a potential trigger for psychiatric illness but there are reports in the literature of the hazards of meditation: Walsh and Roche (1979) described three cases of psychotic illness precipitated by meditation in subjects already diagnosed as suffering from schizophrenia who had discontinued medication. Garcia-Trujillo et al. (1992) described a further two cases of acute psychosis precipitated by oriental meditation in subjects previously diagnosed as schizotypal personality disorder. Chan-Ob and Boonyanaruthee (1999) report a further three patients who presented with psychotic symptoms after practicing meditation. French et al. (1975) reported a single case of ‘altered reality testing’ after transcendental meditation. The precipitation of psychotic illness by Jewish mystical speculation has also been reported (Greenberg et al., 1992). Krieger and Zussman (1981) reported a case of a brief reactive psychosis in a Thai immigrant to the USA which occurred after confronting a family Buddhist mortuary ritual.
A review of the literature failed to reveal any cases of affective disorder being precipitated by meditative techniques. This paper reports a case in which two separate manic episodes were precipitated by periods of intense meditation using techniques from two different traditions (yoga and zen).
Case report
Miss X, a 25-year old self-employed, university graduate presented with a two week history of increased talkativeness, sleeplessness, over-activity and disinhibited behaviour. The onset followed a weekend yoga course that encouraged psychological release. She telephoned her instructor frequently, often in the middle of the night, offering undying love. She also pushed her hand through a window and sustained minor lacerations. There was no past psychiatric history but she had experienced brief periods of low mood 10 and six years previously which had resolved without psychiatric intervention. There was a family history of depression in her father who had received electro-convulsive therapy, and of late life depression in her paternal grandmother. Her birth and milestones were normal. There was no history of illicit drug use.
She was admitted informally to hospital but was detained when she became irritable and aggressive and insisted on leaving. At interview she shouted and tried to embrace some members of staff, but struck out at others. There was pressure of speech, thought disorder with flight of ideas, her mood was elevated and there were grandiose delusions including the belief that she had some special mission for the world: she had to offer ‘undying, unconditional’ love to everyone. She had no insight. A diagnosis of manic episode was made and she was treated with haloperidol 10mg daily and lorazepam up to 4mg daily and her symptoms were gradually controlled over the next six weeks. She refused mood-stabilizing medication.
At outpatient follow up she was noted to be mildly hypomanic on two occasions (the second after a sesshin or intensive Zen meditation weekend) but these episodes responded to chlorpromazine without admission to hospital. She agreed to a trial of carbamazepine 800mg daily which she took for two years. She also underwent twice weekly psychodynamic psychotherapy for over two years.
Two months after entering a Zen Buddhist retreat that she had been associated with for two years, she re-presented with a five-day history of sleeplessness, decreased appetite and labile affect. At interview she laughed inappropriately and had outbursts of activity – lying on her bed one moment, jumping off the next. She made stereotypical praying movements, was sexually disinhibited, restless, distractible and irritable. She was thought disordered with pressure of speech. Though admitted informally she soon insisted on leaving and attacked a member of staff. She was detained and transferred to an intensive psychiatric care unit for three days where treatment with haloperidol 6mg and lorazepam 3mg was commenced. Her mental state settled over the next eight weeks. She continued to refuse mood stabilizing treatment and re-entered the Buddhist retreat.
Discussion
The precipitation of mania by meditation has not been described before yet descriptions of the altered state of consciousness (ASC) associated with contemplative practice abound in the mystic literature of different religions (Buckley, 1981). Zen is a Japanese school of Buddhism – the word itself derives from Sanskrit dhyana or meditation and it is meditation or mindfulness that forms the essence of the Zen philosophy of life. A euphoric state of enlightenment called satori is sometimes achieved by experienced monks (Humphreys, 1962). Thapa and Murtha (1985) compared the subjective accounts of ASCs in subjects with complex partial seizures, schizophrenia and meditators from ashrams and other religious organizations in India. They found the core experiential characteristics of perceptual distortion were common to all three ASCs but important differences existed such as only the meditative ASC being accompanied by a positive emotional effect. The authors did not include manic patients in their study so were unable to make direct comparisons with the experiences in mania. Lukoff (1988) however reported in a single case study that seven of the eight dimensions of mystical experience described by Stace (1960) were experienced by a manic patient.
There is evidence that mystical experiences have a neuro-biological basis possibly in the right temporal lobe (Fenwick, 1996) and contemplative meditation which can lead to such experiences can be studied in experimental conditions (Deikman, 1963, 1964). Lou et al. (1999) have shown a differential cerebral blood flow distribution in meditative states and normal consciousness.
Students practise Zen to develop concentration without thinking (Watts, 1962) but this can be difficult and novices are often bombarded by distracting stimuli – both external and intrapsychic which can continue after the meditation session leading to insomnia. There is evidence to suggest sleep deprivation may act as a final common pathway in the onset of mania (Kasper & Wehr, 1992; Wehr, 1991; Wright, 1993) and it is possible that it was the pressure of thought stirred up by meditation that disrupted the patient’s sleep and precipitated the manic episode in this case and in two of the cases reported by Chan-Ob and Boonyanaruthee (1999). Interestingly the patient herself likened both episodes of mania to a release of tension and blocked energy from years of not dealing with emotions in a helpful way.
Other evidence for psychological precipitants for mania comes from life events (Sclare & Creed, 1990) and expressed emotion (Miklowitz et al., 1986) research. These factors appear to be most important in the first episode of illness, the effects lessening with each subsequent episode. These observations have been suggested as evidence in support of the kindling hypothesis (Silverstone & Romans-Clarkson, 1989). The move to the retreat and adoption of a different lifestyle in this case must have been a significant stressor. Indeed, religious change in itself can be associated with psychiatric illness: Witztum et al. (1990) showed high rates of serious mental illness in converts to ultra-orthodox Judaism in Jerusalem and speculated that, for some, the conversion may have been an attempt to control emerging signs of psychiatric illness.
Other more established risk factors for mania in this case are the positive family history of affective disorder and the discontinuation of carbamazepine (Scull & Trimble, 1995).
The orthodox psychiatric diagnosis in this case was bipolar affective disorder. Grof and Grof (1986) have argued however that traditional psychiatric thinking fails to recognize the difference between mystical and psychotic experiences, tending to underestimate the potential for a healing and positive transformation of what the authors term a transpersonal crisis. It is important to remember that other cultures have and do classify what we now call psychoses in different ways and that, as Carey (1997) has advocated, knowledge drawn from different approaches should be respected and allowed to contribute to the scientific study of mental illness. The absence of previous reports of mania precipitated by meditation despite its apparent potency at inducing euphoric states of consciousness suggests that adequate practice and supervision may enable the subject to learn to control the emergence of intrapsychic material. If this is so, then it could have implications for reducing the risk of relapse in this patient and potentially in others. Thus, although our understanding of the psychology and neurobiology of meditation is growing (see West, 1987) for a comprehensive review) it deserves more study.
_______________
References
BUCKLEY, P. (1981). Mystical experience and schizophrenia. Schizophrenia Bulletin, 7, 516–521.
CAREY, G. (1997). Towards wholeness: transcending the barriers between religion and psychiatry. British Journal of Psychiatry, 170, 396–397.
CHAN-OB, T. & BOONYANARUTHEE, V. (1999). Meditation in association with psychosis. Journal of the Medical Association of Thailand, 82(9), 925–930.
DE SILVA, P. (1984). Buddhism and behaviour modification. Behavioural Research and Therapy, 22, 661–678.
DEIKMAN, A.J. (1963). Experimental meditation. Journal of Nervous and Mental Disease, 136, 329–343.
DEIKMAN, A.J. (1966). Implications of experimentally induced contemplative meditation. Journal of Nervous and Mental Disease, 142, 101–116.
FENWICK, P. (1996) The neurophysiology of religious experience. In D. BHUGRA (Ed.) Psychiatry and Religion (pp. 167–177). London: Routledge.
FRENCH, A.P., SCHMID, A.C. & INGALLS, E. (1975). Transcendental meditation, altered reality testing and behavioral change. Journal of Nervous and Mental Disease, 161, 55–58.
GARCIA-TRUJILLO, R., MONTERREY, A.L. & GONZALEZ DE RIVIERA, J.L. (1992). Meditacion y psicosis. Psiquis Revista de Psiquiatria Psicologia y Psicosomatica, 13(2), 39–43.
GRAHAM, H. (1986) The human face of psychology: humanistic psychology in its social and cultural context. Milton Keynes: Open University Press.
GREENBERG, D., WITZTUM, E. & BUCHBINDER, J (1992). Mysticism and psychosis: the fate of Ben Zoma. British Journal of Medical Psychology, 65(3), 223–235.
GROF, C. & GROF, S. (1986). Spiritual emergency: The understanding and treatment of transpersonal crises. Special Issue: The psychotic experience: disease or evolutionary crisis? ReVision, 8(2), 7–20.
HUMPHREYS, C. (1962). Teach Yourself Zen. Aylesbury: English Universities Press.
KABAT-ZIN, J., WHEELER, E., LIGHT, T., SKILLINGS, A., SCHARF, M.J., CROPLEY, T.G., HOSMER, D. & BERNHARD, J.D. (1998). In uence of mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy. Psychosomatic Medicine, 60 (5), 625–632.
KASPER, S. & WEHR, T.A. (1992). The role of sleep and wakefulness in the genesis of depression and mania. Encephale, 18 Spec No 1, 45–50.
KRIEGER, M.J. & ZUSSMAN, M. (1981). The importance of cultural factors in a brief reactive psychosis. Journal of Clinical Psychiatry, 42(6), 248–249.
KUTZ, I. (1985) Meditation as an adjunct to psychotherapy: an outcome study. Psychotherapy and Psychosomatics, 43(4), 209–218.
LOU, H.C., KJAER, T.W., FRIBERG, L., WILDSCHIODTZ, G., HOLM, S. & NOWAK, M. (1999). A 150-H2O PET study of meditation and the resting state of normal consciousness. Human Brain Mapping, 7(2), 98–105.
LUKOFF, D. (1988). Transpersonal perspectives on manic psychosis: creative, visionary and mystical states. Journal of Transpersonal Psychology, 20, 111–140.
LUKOFF, D., WALLACE, C.J., LIBERMAN, R.P., & BURKE, K. (1986) A holistic program for chronic schizophrenic patients. Schizophrenia Bulletin, 12, 274–282.
MIKLOWITZ, D.J., GOLDSTEIN, M.J. & NUECHTERLEIN, K.H. (1986). Expressed emotion, affective style, lithium compliance and relapse in recent onset mania. Psychopharmacology Bulletin, 22, 628–632.
SCLARE, P. & CREED, F. (1990). Life events and the onset of mania. British Journal of Psychiatry, 156, 508–516.
SCULL, D.A. & TRIMBLE, M.R. (1995). Mania precipitated by carbamazepine withdrawal. British Journal of Psychiatry, 167, 698.
SILVERSTONE, T. & ROMANS-CLARKSON, S. (1989). Bipolar affective disorder: Causes and prevention of relapse. British Journal of Psychiatry, 154, 321–335.
STACE, W. (1960). The teachings of the mystics. New York: Mentor.
THAPA, K., & MURTHY, V.N. (1985). Experiential characteristics of certain altered states of consciousness. Journal of Transpersonal Psychology, 17, 77–86.
WALSH, R. & ROCHE, L. (1979) Precipitation of acute psychotic episodes by intensive meditation in individuals with a history of schizophrenia. American Journal of Psychiatry, 136 (8), 1085–1086.
WATTS, A.W. (1962) The way of zen. Harmondsworth: Penguin Books.
WEHR, T.A. (1991) Sleep loss as a possible mediator of diverse causes of mania. British Journal of Psychiatry, 159, 576–578.
WENNEBERG, S.R., SCHNEIDER, R.H., WALTON, K.G., MACLEAN, C.R., LEVITSKY, D.K., SALERNO, J.W., WALLACE, R.K., MANDARINO, J.V., RAINFORTH, M.V. & WAZIRI, R. (1997) A controlled study of the effects of the transcendental meditation program on cardiovascular reactivity and ambulatory blood pressure. International Journal of Neuroscience, (89) 15–28.
WEST, M.A. (1987) The psychology of meditation. Oxford: Clarendon Press.
WITZTUM, E., GREENBERG, D. & DASBERG, H. (1990) Mental illness and religious change. British Journal of Medical Psychology, 63, 33–41.
WRIGHT, J.B. (1993) Mania following sleep deprivation. British Journal of Psychiatry, 163, 679–680.