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Introduction
Meditation is a "mindfulness" technique, where an individual trains their mind to focus on the present moment. This focus may be tailored to the individual's breath, surrounding environment, or artificial audio. Meditation can be practiced as an act of worship, mindfulness, or stress relief. On the left, Figure 1 displays a morning exercise group participating in meditation in Singapore.

History
The word "meditate" comes from the Latin word meditatum ("to ponder"). The French monk Guigo II was the first one to use the term "meditatum" in the 12th century AD.

The art of meditation has been practiced for centuries but was originally established in India. It is believed that the followers of Vedanta, a school of Hindu philosophy, were the first documented case of worshippers practicing meditation in about 1500 BCE. Towards the end of the BCE era, meditation was found in various Indian Buddhist & Chinese Taoist philosophies. Siddhartha Gautama, a spiritual leader born in modern-day Nepal, preached Buddhism, a philosophy encouraging several prominent elements of "enlightenment" through meditation. The Tao Te Ching, a Taoist philosophical text authored by Laozi around 400 BC, commands its readers to "become totally empty", "quiet the restlessness of the mind", and "be still". Laozi affirms that such a practice would "bring[s] enlightenment".

Through the Silk Road, Western cultures were exposed to the concept of meditation. Records indicate that meditation was integrated in the Jewish religion, but not so much in Christianity. The Sefer Yetzirah, one of the earliest Kabbalist texts in Judaism, mentions meditation as a way of "consciously building up a deep sense of your place in relation to the dimensions". As time went on, meditation continued to be incorporated in the daily lives of various cultures throughout the Asian continent. Meditation was introduced in the United States through two prominent Hindu monks, Swami Vivekananda (depicted in Figure 2) & Paramahansa Yogananda. Both monks performed country-wide tours across the US, preaching to the Americans about the teachings of Hinduism.

The shift in belief that meditation was solely a spiritual practice to a practice that has scientific backing began in the mid-1900s. Starting with clinical studies, meditation opened up the scientific field of neuroscience. In 2004, a study conducted on Tibetan meditators revealed that meditation had positive effects on neural plasticity.

In today's world, meditation is widely known and is practiced by people all around the world.

Forms of Meditation
According to a WebMD.com article (proof-checked by Dan Brennan, MD), the practice of meditation can be broken down into the following: guided meditation, mindfulness meditation, focused meditation, heart-centered meditation & movement meditation.

Guided meditation is where the meditator follows a step-by-step guide led by a teacher or instructor.

Mindfulness meditation is when the meditator focuses solely on their breath. According to New York Times writer David Gelles, the purpose of mindfulness meditation is to center one's focus on the "present moment" and not necessarily to "empty" one's mind. Figure 3 illustrates a man focusing on his breath as mindfulness meditation entails. Focused meditation, also known as "focused attention meditation" (FAM), centers one's focus on an external element. An example of an external element may be a candle flame or a chant. An example of a focused meditation is a "body scan meditation", where meditators "visualize" parts of their body (starting from the toes to the head). This is preferable for meditators who have trouble focusing on their breath during mindfulness meditation. According to a 2012 study conducted by Wendy Hasenkamp, FAM can improve one's stamina in focusing on one object - though it is not clear if this is specific to FAM or meditation itself. The opposite of focused meditation is open-minded meditation (OM), where the meditator opens his awareness to his surroundings. The "focus" in OM meditation is "awareness itself".

Heart-centered motivation or loving-kindness meditation (LKM ) is a form of meditation that is tailored to one's emotions rather than one's mind. One focuses on developing feelings of "self-love". Once the meditator achieves "self-love", they may engage their love to things that the meditator disfavors.

Movement meditation is a great way of meditation for those who have trouble remaining still for elongated periods. Some excerises mentioned in the WebMD.com article include yoga, tai chi and even everyday activities - such as gardening and cooking.

Meditation in Sports
Mindfulness has proven to positively affect athletic performances as it can reduce stress (through reduced salivary cortisol levels ), increase concentration levels, and further advance cognitive functions needed to perform (such as the ability to remove distractions). Meditation increases an athlete's chances of entering into a state of flow (or the zone ), the ability to be entirely synchronized with their performance. American golfer Mark Calcavecchia explains that during his state of flow, he "[doesn't] think about the shot, or the wind, or the distance, or the gallery, or anything. [He] just pull[s] a club and swing[s].”.

Kobe Bryant, regarded as one of the greatest American basketball players of all time, said that he "meditate[d] every day... as that prepares me to face whatever comes next". Bryant felt as if he was "constantly chasing the day" if he skipped out on his habitual meditation practice.

A study conducted by Baltzell et al., (2014) assigned 7 Division 1 female footballers through a "mindfulness meditation training session" (MMTS) program. The program lasted 6 weeks and totaled 12 overall sessions. After the MMTS program, the D1 athletes were interviewed on the impact meditation had on their performance. All athletes reported that the MMTS program was the reason for their "positive [..] mental shift" on the field. Similar results were found in a 2016 study, where 10 basketball players were evenly separated into two groups: a group that meditates and a group that does not meditate. The basketball players that meditated found that they became stress-free and less prone to anger or fear during performance.

Effects of Meditation
The psychological and physiological effects of meditation have been studied. In recent years, studies of meditation have increasingly involved the use of modern instruments, such as fMRI and EEG, which are able to observe brain physiology and neural activity in living subjects, either during the act of meditation itself or before and after meditation. Correlations can thus be established between meditative practices and brain structure or function.

Since the 1950s hundreds of studies on meditation have been conducted, but many of the early studies were flawed and thus yielded unreliable results. Contemporary studies have attempted to address many of these flaws with the hope of guiding current research into a more fruitful path. In 2013, researchers found moderate evidence that meditation can reduce anxiety, depression, and pain, but no evidence that it is more effective than active treatments such as drugs or exercise. Another major review article also cautioned about possible misinformation and misinterpretation of data related to the subject.

Positive Effects
An original research paper conducted in 2019 reports that "hundreds" of scientific literature assert the positive effects on medical conditions and the physiological well-being. According to a 2015 study done by Hari Sharma from the College of Medicine of Ohio State University, meditation is proven to reduce stress, increase memory and reduce depression. Alongside the psychological benefits, the physiological benefits include an increased blood flow to the brain and decreased blood pressure.

In a 2019 case study completed by scientists in China, 40 healthy individuals were placed in two, 8-week "mindfulness training program(s)". The two programs taught two different types of meditation: FAM meditation and OM meditation. 4 individuals failed to complete the training. The 36 individuals who completed the training exhibited positive changes in regulating mood and depression.

Mograbi GJ, a professor of Philosophy of Science at Federal University of Mato Grosso, concluded in his 2011 study, Meditation and the Brain: Attention, Control and Emotion, that meditation is a form of "self-control" & very well can contribute to a "better quality of life".

Negative Effects
Although meditation is a realistic psychological treatment to mood problems & depression levels, it is not recommended for people who suffer with psychiatric issues as it may heighten psychosis.

This was suggested from a 1975 case study where a 39-year-old woman experienced "altered reality testing and behavior" after an extended period of time practicing transcendental meditation (a form of focused meditation). Associated undesirable effects of meditation include anxiety, hallucinations, emotional stress & general confusion. The lack of clarity on what the adverse effects of meditation actually result in is due to the vagueness of what constitutes as an "adverse" effect. An "adverse" reaction to meditation is "highly subjective", according to a 2021 article from Brown University conducted by Dr. Willoughby Britton. Dr. Britton further explains that "re-living of a previous trauma may be healing for some and destabilizing for others", hence one meditator's "re-living of [sic] previous trauma" may be a beneficial thing as opposed to another meditator who may find it traumatizing. Britton also mentions that the lack of reported, unwanted effects of meditation may be incorrectly interpreted as an absence of adverse effects.

Dr. Britton conducted a study to explore the adverse effects of meditation programs. Out of 96 participants, 58% of the participants experienced "at least one meditation-related adverse effect", which were symptoms largely in relation to "dysregulated arousal". Participants reported re-experiencing past traumas and having nightmares. Dr. Britton remarks that focus should be planted on the "impact" of the effect and not the "valence" of it. Britton states that feeling "emotionally-checked out... can provide some relief, especially for a person suffering from intense anxiety". 6% of participants reported "impairments in functioning lasting more than one month", which may serve as a sign that disassociation is harmful in those specific cases. Dr. Britton concludes that her study aims to heighten "harms-monitoring in order to maximize the safety and efficacy of mindfulness-based meditation".

Cebolla et al., 2017
A multilingual 2013 survey was published by a group of researchers from the University of Valencia inviting participants to explore the "unwanted effects" of meditation. The survey was advertised on websites relating to meditation, such as meditation associations. The participants were chosen to be analyzed based on their accurate completion of the survey and their time of meditation practicing (participants who had not meditated for more than two months were not considered in the final analysis). From 914 total people who accessed the survey, n = 509 were excluded due to improper completion of the survey, and n = 57 were excluded due to a lack of meditation experience, leaving only n = 342 participants to assess. The survey was available in Portuguese, Spanish, and English.

Participants were asked about their sociodemographic data (age, race, ethnicity, etc.), medical history (anxiety or depression), type of meditation practice, frequency and time of meditation experience, method of learning (self-taught vs. classes), and mentorship (religious context). Participants were then required to detail if they had any adverse side effects as a result of their meditation experience ("yes" or "no"). If the participant answered "yes", participants detailed the side effect, the context of when said side effect took place, form of meditation practice, and time length (Cebolla et. al., 2017 ).

At the end of the survey, participants completed a "checklist" of 18 possible experiences that may be experienced from meditation (ranging from "less motivation in life" to "feelings of alienation"). The scientists derived this checklist from German psychiatrist Micheal Landen. Responses for this checklist were on a scale of 0-10, "0" being "never" and "10" being "frequently" (Cebolla et. al., 2017 ).

Results
The majority of participants who were accounted for in this study were women (68.4% vs. 31.6% [men]), Spanish (42.9%), married (48.5%), and/or had at least the equivalence to a university-level education (54.4%, with 33.3% being individuals who held a masters or a Ph.D.). Throughout the types of meditation practiced, 46.8% of participants practiced informal practice meditation on a daily basis (integrating thoughtfulness and concentration into daily activities, such as walking).

When participants were asked if they incurred unwanted side effects, 25.4% of the participants selected "yes". 41.3% of these participants answered that unwanted effects occurred during individual meditation (as opposed to a group or a retreat), 8% of the participants were practicing body scan meditation (focusing on sensations that are felt throughout the body) and 10.3% of these meditators practiced 21+ minute sessions. Table 1 below lists the symptoms experienced by meditators who answered "yes" to incurring unwanted side effects whilst practicing meditation.Table 1 39% of these symptoms were transitory (vs. 10.3% who reported side effects to be continuous), 37.9% did not need to discontinue medication (as opposed to the 1.1% who discontinued medication due to side effects), whilst 44.8% did not need assistance from a therapist or medical facility (as opposed to the 5.7% who reported that medical assistance was necessary).

A one-way ANOVA on ranks test was implemented to observe the differences between the side effects vs. frequency/years of practice. The scientists found a significant difference between side effects and body awareness meditation (X 2 = 5.335; p < .05) (Cebolla et. al., 2017 ). Body awareness meditation is a form of focused meditation, where the meditator focuses on their body parts. No significant differences were found for the years of practice.

Further analysis was completed on the checklist of 18 possible side effects from meditation in relation to learning styles. A univariate ANOVA test was conducted on the checklist and found two significant differences. Significant differences were found in feelings of "increased emotional pain" [F(3,227) = 2.908; p <.05; η2 = .037] and "need to prolong meditation" [F(3,225) = 2.793; p <.05; η2 = .036] (Cebolla et. al., 2017 ).

Limitations


The researchers concluded that although there was a decent number of reports for side effects (25.4% of the respondents reported side effects), almost half of the participants that attempted to answer the questionnaire regarding side effects did not fill out the questionnaire adequately - thus losing more data.

The data that was adequate and studied found that the side effects reported were mostly insignificant and didn't cause lasting problems in the meditators. Side effects were found more in individual meditation vs. group meditation and in longer meditation sessions vs. shorter meditation sessions. Focused-attention meditation (FA meditation) was found to bring about more side effects while body-awareness meditation brought out fewer side effects (Cebolla et al., 2017 ). FA meditation was found to be mostly associated with greater "self-criticism", or a belief that time not spent meditating was "wasted". The researchers explained this correlation by detailing the nature of FA meditation, stating that since FA meditation is "heavily structured" towards a "unique" object of meditation, it may go against the meditator's "experience" (Cebolla et. al., 2017 ).

The researchers acknowledge that correlation does not imply causation & although unwanted side effects could be associated with meditation, no definitive evidence has been shown to directly attribute meditation to any unwanted side effects. The researchers highlight various significant limitations the study suffered from, including cultural imbalance (the majority of participants hailing from Spanish or Latina America), obvious bias (biases typically associated with surveys), and the lack of proper responses.

Conclusion
After reviewing the history & religious practices involving meditation, it is evident that meditation has played a significant part in peoples' lives for centuries. With various techniques, those who choose to meditate, despite whatever form of meditation it is, reap several neurological and health benefits. Although meditation has been mostly painted with a positive brush, the idea of meditation bringing out unwanted effects has been researched. Although Dr. Britton's study found over 50% of her participants to have experienced one or more unwanted effects, it seems to be a case-by-case basis and is up to the interpretation of the meditator themselves.

In a 2017 study done by a group of researchers of the University of Valencia, their survey ultimately found that 25.4% of participants suffered unwanted side effects of meditation. These effects ranged from self-criticism to greater emotional pain. A significant difference was found between unwanted side effects and body-awareness meditation. Albeit the study brought greater attention to potential negative experiences of meditation, the study fell to many limitations - including bias and a significant amount of data lost in the process. Nonetheless, the researchers recommended that meditation should not be practiced by those with psychotic issues.

Overall, the literature reviewed has shown that meditation is an ancient practice that has fully merited its praise and longevity. The use of meditation has been positively observed throughout many different fields - from religion to sports.