Abstract
Objective:
One of the most prevalent psychiatric conditions that affect a person's quality of life, ability to function and productivity, and consequently the loss of national income, are anxiety disorders. Rajyoga meditation (RM) is a form of meditation that is performed without rituals or mantras and can be practiced anywhere at any time. In this study, we attempted to evaluate the modulation of psycho-physiological parameters in panic disorder patients by a technique of short-term on RM.
Methods:
In this prospective randomized control study, 110 patients with panic disorder were randomized into two groups, Group A (standard treatment + RM) and Group B (Standard treatment). The participants of both group participants were subjected to sleep quality score, Physical Health Questionnaire-9 score, Panic Disorder Severity Scale (PDSS), and Hamilton Anxiety Rating Scale (HAM-A) questionnaires before starting the study (baseline) and at the end of the 8th week. Study groups were compared at baseline and at the end of 8 weeks.
Results:
We found that the PDSS/HAM-A was not statistically different among the study groups at baseline (P > 0.05); however, there was a statistically significant difference in mean z-scores of PDSS and post-HAM-A scores among the study groups at 8 weeks (P < 0.001). The composite score was created by adding the z-scores of pre- and post-PDSS and HAM-A. We found a statistically significant difference in postcomposite scores between the study groups (P < 0.001). Analysis of co-variance for PDSS and HAM-A among study groups showed statistical significance (P < 0.001).
Conclusion:
When used in conjunction with pharmaceutical treatments for the treatment of panic disorder, RM is a successful therapy. The key factors are adherence and motivation while being supervised by a licensed therapist.
Keywords: Composite score, Hamilton Anxiety Rating Scale, panic anxiety syndrome, Panic Disorder Severity Scale, Rajyoga meditation, z-score
Introduction
One of the most prevalent psychiatric conditions that affects a person's quality of life, ability to function and productivity, and consequently, the loss of national income, are anxiety disorders (ADs). According to the World Mental Health Survey, the lifetime prevalence of ADs varies between 3% and 19% among nations.[1] According to the Global Burden of Disease 2015 report, ADs contributed to the sixth-highest number of years with a disability.[2] Despite the enormous disease burden, ADs are generally underdiagnosed and undertreated, which results in significant health damage and financial loss.
Panic disorder (with or without agoraphobia), agoraphobia without panic, social phobia (social AD), specific phobia, generalized AD (GAD), acute stress disorder, posttraumatic stress disorder, obsessive–compulsive disorder, and AD not otherwise specified are the major categories of ADs listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-IV) (American Psychiatric Association).[3]
Panic attacks happen frequently and without warning in people with panic disorder. Even when there is no obvious threat or trigger, these attacks are distinguished by a rapid wave of panic, discomfort, or a sense of losing control. Not everybody who has a panic episode goes on to have a panic disorder.
One of the most prevalent ADs is panic disorder, with lifetime prevalence rates in the general population estimated to range between 2.1% and 4.7%.[4,5] Since panic disorder is frequently accompanied by a chronic progression that causes financial hardship and a loss of quality of life, it is crucial to properly prevent and treat panic disorder.
Psychological and pharmaceutical therapies are two of the main strategies for treating panic disorder. Cognitive-behavioral therapy is a type of psychological intervention. There are elements of their therapy regimens that may additionally improve their corresponding medical illnesses in patients with a panic disorder and concurrent comorbid medical ailments.
Meditation is usually defined as a form of mental training that aims to improve an individual's psychological capacities. Meditation encompasses a family of complex practices that include yoga meditation, mindfulness meditation, mantra meditation, and tai chi.[6] Rajyoga meditation (RM) is a form of meditation that is performed without rituals or mantras and can be practiced anywhere at any time. Rajyoga word has been derived from Raja, meaning king, and yoga, meaning union between soul (spiritual energy) and supreme soul (ocean of spiritual energy).[7]
The objective of this study was to evaluate the modulation of psycho-physiological parameters in panic disorder patients by a technique of short term on RM.
Methods
In this prospective randomized control Study, 110 patients with panic disorder, as defined by the DSM-5 criteria,[8] were selected by consecutive sampling from the Psychiatry Department at the All India Institute of Medical Sciences, Patna. The same control group design was applied.
All the participants were subjected to the preapproved demographic questionnaire and Physical Health Questionnaire-9 (PHQ 9), which were used for screening purpose.
Patients in the age group of 18–60 years of either gender diagnosed according to the DSM-5 criteria for Panic AD with comorbid depression and PHQ 9 score <20 were included in the study. Patients with a history of comorbid psychiatric syndrome, subjects with a history of neurological trauma, vascular disease, and organic brain disorder, and patients with alcohol addiction were excluded from the study.
All the study subjects have been explained about the study protocol in their language of communication and were asked to sign the informed consent before beginning of the study. Prior ethical approval has been taken from the Institute Ethical Committee vide letter number AIIMS/Pat/IEC/2019/411 dated November 30, 2019. The study has also been registered on the trial registry portal of Government of India vide Registration Number CTRI/2020/12/029462 before starting the study.
The study participants were randomized into two groups using computer-generated block randomization tables. The two groups were defined as follows:
Group A: Experiment (standard treatment + RM) group: n = 55
Group B: Control (standard treatment) group: n = 55.
Standard treatment
Selective serotonin re-uptake inhibitor (SSRI) as well as cognitive behaviour therapies (CBT) as per psychiatric advice and clinical psychologist supervision was given as standard treatment.
Rajyoga meditation
The RM technique from the Brahma Kumaris school of thought, which emphasizes the cultivation of positive thoughts for oneself and others through guided technique, was used in the RM practice in the current study. With a focus on the idea of the ultimate soul, a hypothetical primary source of energy for each and every person, particularly emphasizes the intentional transfer of cognitive process from a body-conscious to the soul-conscious state.
The intervention arm of the study population has been subjected to supervised RM sessions tailored specifically for the purpose of anxiety spectrum disorder by a team of long-term (>10 years) Rajyoga meditators. The RM session protocol (6 domains) was practiced sequentially by all the intervention group participants 25–30 min each morning and evening daily for 5 days or more every week for 8 weeks.
Meditation quality was assessed by subjective and objective feedback.
Subjective feedback
Each fortnight, the six components of the meditation practice were assessed for the self-reported effectiveness by the participants on 0–10 scale with a score of 0 if the participants could not attain any focus for the meditation practice most of the time during the fortnight and a score of 10 if he could attain desired focus most of the time during the fortnight. The maximum possible score could be 60 for the fortnight and the maximum possible total score for the complete duration would be 240.
Objective feedback
Each fortnight, the six domains were scored between 0 and 4 for the level of understanding of the concept of meditation by the participants. A score of 0 was given if a participant could not understand the domain and 4 if the participant could be able to make a very good understanding of it. The maximum score could be 28 for the fortnight, and 140 for the total period [Table 1].
Table 1.
The quantitative scores for the individual components of meditation based upon subjective feedback of the participants
| Domains | Score |
||||
|---|---|---|---|---|---|
| 0 | 1 | 2 | 3 | 4 | |
| I. Knowledge of self | No understanding | Little understanding | Reasonable understanding | Good understanding | Very good understanding |
| II. Knowledge of supreme | No understanding | Little understanding | Reasonable understanding | Good understanding | Very good understanding |
| III. Knowledge of universal flow of energy | No understanding | Little understanding | Reasonable understanding | Good understanding | Very good understanding |
| IV. Yoga | |||||
| Morning (30 min) | Felt nothing | Felt somewhat | Felt reasonably | Good feeling | Very good feeling |
| Evening (30 min) | Felt nothing | Felt somewhat | Felt reasonably | Good feeling | Very good feeling |
| V. Dharana (quality of traffic control) | Felt nothing | Felt somewhat | Felt reasonably | Good feeling | Very good feeling |
| VI. Service/good wishes and gratitude (quality of practice) | Felt nothing | Felt somewhat | Felt reasonably | Good feeling | Very good feeling |
The participants of both the group participants were subjected to the following before starting the study (baseline) and at the end of 8th week.
Preapproved demographic and clinical questionnaire
Sleep quality score: Subjective feedback: 0-Complete loss of sleep to 10-Perfectly sound sleep
PHQ-9 score
Panic Disorder Severity Scale (PDSS) questionnaire
Hamilton Anxiety Rating Scale (HAM-A) questionnaire.
Data analysis
The data have been compiled using Microsoft Excel [Internet] (Microsoft Corporation, 2010). The data have been further analyzed using SPSS version 27.0 (IBM Corp. (2020). IBM SPSS Statistics for Windows). All the normally distributed continuous variables have been compared, computing mean and standard deviation with a 95% confidence interval. Nonparametric tests have been used for nonnormally distributed variables; the outcome is presented as proportions. Pearson's correlation has been used for assessing the associations. A value of P < 0.05 has been taken as the level of significance.
Results
Sociodemographic characteristics
The sociodemographic data of the participants of the two groups are presented in Table 2. The two study groups were comparable in terms of sociodemographic variables (P > 0.05).
Table 2.
Sociodemographic variables among study groups
| Group A (Rajyoga), n (%) | Group B (control), n (%) | P | |
|---|---|---|---|
| Age (years), mean±SD | 34.49±8.3 | 34.36±11.1 | 0.946* |
| Gender | |||
| Males | 38 (69.1) | 27 (49.1) | 0.052# |
| Females | 17 (30.9) | 28 (50.9) | |
| Type of family | |||
| Nuclear | 22 (40) | 22 (40) | 1# |
| Joint | 33 (60) | 33 (60) | |
| Education | |||
| Uneducated | 2 (3.6) | 5 (9.1) | 0.215# |
| Elementary school | 4 (7.3) | 1 (1.8) | |
| High school | 17 (30.9) | 25 (45.5) | |
| Graduation | 24 (43.6) | 19 (34.5) | |
| Postgraduation | 7 (12.7) | 3 (5.5) | |
| Higher qualification | 1 (1.8) | 2 (3.6) | |
| Occupation | |||
| Unemployed | 13 (23.6) | 6 (10.9) | 0.344# |
| Housewife | 12 (21.8) | 17 (30.9) | |
| Self employed | 9 (16.4) | 8 (14.5) | |
| Government job | 6 (10.9) | 5 (9.1) | |
| Student | 2 (3.6) | 0 | |
| Agriculture | 6 (10.9) | 10 (18.2) | |
| Others | 7 (12.7) | 9 (16.4) | |
| SES | |||
| Upper | 4 (7.3) | 3 (5.5) | 1# |
| Upper middle | 4 (7.3) | 4 (7.3) | |
| Lower middle | 28 (50.9) | 29 (52.7) | |
| Upper lower | 19 (34.5) | 19 (34.5) | |
| Dietary pattern | |||
| Vegetarian | 12 (21.8) | 13 (23.6) | 1# |
| Nonvegetarian | 43 (78.2) | 42 (76.4) | |
| Tobacco use | 5 (9.1) | 5 (9.1) | 1# |
| Alcohol use | 0 | 1 (1.8) | 0.315# |
*t-test, #Chi-square test. SD: Standard deviation, SES: Socioeconomic status
Table 3 shows the comparison of comorbidities among study groups. The two study groups were comparable in terms of mean sleep hours, diagnosis, mean duration of untreated period, family history, and comorbidities (P > 0.05). Figure 1 shows panic disorder and panic attacks with anxiety was distributed equally among study groups (P > 0.05).
Table 3.
Comparison of panic anxiety syndrome among study groups
| Group A (Rajyoga), n (%) | Group B (control), n (%) | P | |
|---|---|---|---|
| Mean hours of sleep | 7.4±1.1 | 7.3±2.1 | 0.714* |
| Diagnosis | |||
| Panic disorder | 13 (23.6) | 22 (40) | 0.101# |
| Anxiety + panic attacks | 42 (76.4) | 33 (60) | |
| Mean duration of untreated period from onset of illness (months) | 18.65±13.9 | 17.3±15.9 | 0.629* |
| Family history | |||
| Yes | 6 (10.9) | 5 (9.1) | 1# |
| No | 49 (89.1) | 50 (90.9) | |
| Co-morbidities | |||
| Nil | 45 (83.3) | 43 (78.2) | 0.647# |
| Anxiety | 1 (1.9) | 4 (7.3) | |
| Depression | 2 (3.7) | 2 (3.6) | |
| Agoraphobia | 6 (11.1) | 5 (9.1) | |
| Dissociative symptoms | 1 (1.8 | 1 (1.8) | |
*t-test, #Chi-square test
Figure 1.
Bar graph showing diagnosis of study groups
We calculated individual z-score for pre- and post-PDSS/HAM-A. We found that the pre-PDSS/HAM-A were not statistically different among the study groups (P > 0.05); however, there was a statistically significant difference in mean z-scores of post-PDSS and post-HAM-A scores among the study groups (P < 0.001).
The composite score was created by adding the z-scores of pre- and post-PDSS and HAM-A. We found a statistically significant difference in postcomposite scores between the study groups (P < 0.001) [Table 4].
Table 4.
Z-score and composite score for Panic Disorder Severity Scale and Hamilton Anxiety Rating Scale among study groups
| Clinical scores | Mean±SD |
Effect size | P | |
|---|---|---|---|---|
| Group A | Group B | |||
| PDSS (z-score) | ||||
| Pre | −0.136±1.02 | 0.136±0.96 | 0.27 | 0.155* |
| Post | −0.72±0.68 | 0.72±0.71 | 2.07 | <0.001* |
| HAM-A (z-score) | ||||
| Pre | −0.64±0.98 | 0.064±1.02 | 0.704 | 0.503* |
| Post | −0.73±0.56 | 0.73±0.79 | 2.13 | <0.001* |
| Composite score PDSS and HAM-A | ||||
| Pre | −0.1±8.75 | 0.1±0.88 | 0.032 | 0.234* |
| Post | −0.72±0.52 | 0.72±0.63 | 2.49 | <0.001* |
*t-test. PDSS: Panic Disorder Severity Scale, HAM-A: Hamilton Anxiety Rating Scale, SD: Standard deviation
We used preintervention PDSS/HAM-A as a covariate when comparing the postintervention PDSS/HAM-A between Group A and Group B. Therefore, we ran a one-way ANCOVA with: (a) Postintervention PDSS/HAM-A as the dependent variable; (b) The control and two intervention groups as levels of the independent variable, and (c) The preintervention PDSS/HAM-A as the covariate.
Tables 5 and 6 show whether there was an overall statistically significant difference in postintervention PDSS/HAM-A between the study groups once their means had been adjusted for preintervention PDSS/HAM-A.
Table 5.
Analysis of co-variance for Panic Disorder Severity Scale and Hamilton Anxiety Rating Scale among study groups
| ANCOVA | Group A | Group B | F | P |
|---|---|---|---|---|
| PDSS | 11.53±3.5 | 4.38±3.4 | 145.84 | <0.001* |
| HAM-A | 17.4±5.44 | 7.33±3.89 | 161.64 | <0.001* |
*Statistically Significant. PDSS: Panic Disorder Severity Scale, HAM-A: Hamilton Anxiety Rating Scale, ANCOVA: Analysis of co-variance
Table 6.
Repeated measures ANOVA for Panic Disorder Severity Scale and Hamilton Anxiety Rating Scale among study groups
| Variable | Group, mean±SD |
Partial eta square | P | |
|---|---|---|---|---|
| Control | Experimental | |||
| ZD | ||||
| Pre | 0.068±0.50 | −0.067±0.79 | 0.016 | 0.192 |
| Post | −0.038±0.58 | 0.038±0.74 | ||
| PDSS | ||||
| Pre | 15.31±4.96 | 13.91±5.92 | 0.322 | <0.001 |
| Post | 11.53±3.53 | 4.38±3.40 | ||
| HAMA | ||||
| Pre | 26.35±6.64 | 25.51±6.40 | 0.406 | <0.001 |
| Post | 17.40±5.44 | 7.33±3.90 | ||
Two-way RMANOVA. PDSS: Panic Disorder Severity Scale, HAM-A: Hamilton Anxiety Rating Scale, SD: Standard deviation, ZD: Z-score for difference in scores
The data have further been evaluated for the possible correlation between the difference in clinical scores of the severity of the condition before and after intervention and the total meditation quality scores among study participants using Pearson's correlation after testing for Levine's test for the equality of variance. There was a positive correlation between clinical score and meditation quality; however, it was not statistically significant (P > 0.05) [Table 7].
Table 7.
Correlation between meditation quality and clinical improvement
| Clinical scores | Meditation quality score from baseline (n=300) |
Meditation quality score from 1st fortnight (n=240) |
|||
|---|---|---|---|---|---|
| Correlation co-efficient (r) | P | Correlation co-efficient (r) | P | ||
| D1: (Pre-HAM-Post-HAM) | 0.090 | 0.513 | 0.011 | 0.917 | |
| D2: (Pre-PDSS-Post-PDSS) | 0.150 | 0.273 | 0.038 | 0.713 | |
| Composite PDSS and HAM | 0.135 | 0.325 | 0.031 | 0.760 | |
PDSS: Panic Disorder Severity Scale, HAM-A: Hamilton Anxiety Rating Scale
Discussion
To improve a patient's total health and well-being, complementary treatments or alternative medicines are utilized in conjunction with traditional medical management.[9] Yoga, massage therapy, progressive muscle relaxation, acupuncture, acupressure, reflexology, aromatherapy, music therapy, guided imagery, and meditation are a few examples of these treatments. Normally, medications are used to treat anxiety before and after surgery, but mounting research supports the value of complementary therapies in the healing process. These treatments are used to lessen stress, headaches, the length of hospital stays, and the need for sedatives, and to improve patients' relaxation, sleep, satisfaction, and overall health.[10,11]
Our study found that the z-scores of PDSS and HAM-A were not statistically different among the study groups (P > 0.05) during preintervention period; however, there was a statistically significant difference in mean z-scores of PDSS and post-HAM-A scores after intervention among the study groups (P < 0.001). Our study also found a statistically significant difference in postcomposite scores between the study groups (P < 0.001). We also found that there was an overall statistically significant difference in postintervention PDSS/HAM-A between the study groups once their means had been adjusted for preintervention PDSS/HAM-A.
According to neuroimaging studies, meditation causes the prefrontal cortex, thalamus, and inhibitory thalamic reticular nucleus to become more active, as well as the functional differentiation of the parietal lobe.[12] Anxiolytic effects may result from neurochemical changes brought on by meditation, enhanced parasympathetic activity, decreased locus ceruleus firing with decreased noradrenaline, enhanced GABAergic drive, increased serotonin, and lower levels of the stress hormone cortisol are the elements that reduce anxiety during meditation. The anti-anxiety effects of meditation are also influenced by the elevated levels of endorphins and arginine-vasopressin.[12]
According to a study by Parmentier et al.,[13] mindfulness meditation lessens anxiety and depressive symptoms by regulating emotions, reducing concern, and decreasing thinking rumination.
Another study, a randomized clinical trial by Hoge et al. (2013) on a subset of participants with GAD, found that although both the intervention group had shown a significant reduction in the HAM-A score after an 8-week intervention of mindfulness-based stress reduction (MBSR) and stress management education, the group that had received the MBSR intervention had a significantly lower stress score and better tolerability.[14]
The prefrontal cortex and amygdala are crucial for controlling emotions and the stress response. The prefrontal cortex is known to focus more on the positive handling of similar inputs, whereas the amygdala is known to attribute meaning to unpleasant emotional stimuli. The cortical brain region's inverse relationship to a person's behavior in a stressful circumstance appears to be modulated by meditation. According to studies, during meditation, prefrontal activity surpasses amygdala reaction.[15,16]
RM is a term that is frequently used in relation to meditation and has references in numerous traditional Indian literary works, such as the Bhagwadgeeta and Patanjali's Yoga Sutras. According to some recent studies, RM boosts happiness through neuroplasticity. In one study, it was found that RM practices were linked to a significant increase in the grey matter volume in the brain regions related to emotion regulation, happiness, and reward centers, the right insular cortex, and the left inferior orbitofrontal cortex.[17] It is widely established that the etiology of panic disorder is directly related to both the orbitofrontal cortex and the insular cortex.[18] The neural plasticity brought on by the guided meditation practice of the intervention group members may have contributed to the short-term meditation intervention's success in reducing anxiety symptoms and the severity of the condition in the current study.
According to a study by Kiran et al.,[19] patients who practiced Rajyoga also had elevated blood cortisol levels on the 2nd postoperative day, but the increase was markedly less than in the control group. On the 5th postoperative day, the Rajyoga group's cortisol levels generally returned to normal range as the stress was resolved. In addition, Creswell et al. discovered that practicing mindfulness meditation for a brief amount of time changes how the brain and body react to stress.[10] Similarly to this, Turakitwanakan et al. have found that practicing mindfulness meditation lowers blood cortisol levels, which suggests that it can reduce stress.[20] Gainey et al. found that in diabetic patients, meditation decreased glycated hemoglobin and cortisol levels.[21]
Conclusion
When used in conjunction with pharmaceutical treatments for the treatment of panic disorder, RM is a successful therapy. The key factors are adherence and motivation while being supervised by a licensed therapist. The results of the current study indicate that RM techniques can improve sleep quality and lower clinical panic AD scores. We conclude that irrespective of the quality of meditation, mere meditation practice for the long term would help alleviate the anxiety and panic disorder symptoms.
Ethical approval
The work has been approved by the Institutional Ethical Committee of AIIMS, Patna, in which it was performed and that subjects gave informed consent to the work. The study has also been registered on the trial registry portal of the Government of India vide registration number CTRI/2020/12/029462. Name of the ethics committee: IEC, AIIMS Patna. Approval number and date: AIIMS/Pat/IEC/2019/411 dated November 30, 2019.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
The authors acknowledge Department of Science and Technology, Government of India for the funding support for the study under DST-SATYAM initiative (research grant no DST/SATYAM/255/18). The authors express their gratitude toward the patients, facilities, scientific and technical assistance provided by Department of Physiology and Psychiatry in completing this work.
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