Psychotic Episode Associated With Bikram Yoga

“Mr. B” was a 33-year-old man with a history of brief hallucinogen-induced psychosis, with full interval remission, 10 years before he became psychotic while participating in a Bikram yoga instructors’ training seminar lasting several days. In the days leading up to the episode, he felt dehydrated, ate poorly, and slept only 2–3 hours per night. He then developed auditory and visual hallucinations (he reported seeing owls speaking to him, “cat-like slits” in people’s eyes, and a cross on his own forehead), paranoia, and a disturbing sense that there was “a battle for control of [his] mind” and that he had “betrayed God.” He endorsed racing thoughts, and after feeling increasingly agitated one day, he recited the Lord’s Prayer loudly in class and became physically aggressive when confronted, which necessitated involuntary hospital admission. On examination, the patient displayed a flat affect, endorsed ideas of reference and delusional thinking, and was uncharacteristically preoccupied with religious ideation, but he was not manic. Laboratory testing revealed no electrolyte abnormalities, urine toxicology screening was negative, and an electroencephalogram and brain magnetic resonance imaging were normal. The patient was treated with aripiprazole 15 mg/day, with robust improvement in psychosis after 1 week and full resolution by 1 month. Aripiprazole was discontinued, and the patient continued to report feeling “normal” at the 4-month follow-up.