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Letters to the Editor   |    
Psychotic Episode Associated With Bikram Yoga
JESSICA S. LU; JOSEPH M. PIERRE
Am J Psychiatry 2007;164:1761-1761. doi:10.1176/appi.ajp.2007.07060960

To The Editor: Yoga is a widely practiced activity thought to benefit various conditions, including psychiatric disorders (1). However, intensive yoga and meditation have been reported in association with altered perceptions and full-blown psychotic episodes (2–4). Bikram yoga, also known as “hot yoga,” is a form of yoga copyrighted in 1979 that is based on 26 postures performed in a room heated to 105° F. We report a case of psychosis precipitated by 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.

This case demonstrates that while yoga may have physical and psychological health benefits, it is not devoid of side effects. Intensive forms of yoga such as Bikram may in particular have a liability for psychotic decompensation among those individuals who are more psychosis-prone because of stress, sleep and sensory deprivation, and dissociative experiences that can arise from meditation. Castillo (5) reported that the meditative trance experiences among Indian yogis are often characterized by dissociation, hallucinations, and beliefs in possessing supernatural powers. While such experiences are typically labeled pathological by Western clinicians, they can be identified as part of spiritual awakening in Eastern meditative traditions (2, 5). Distinguishing between pathological and culturally sanctioned experiences can therefore be a clinical challenge requiring open-mindedness and sensitivity. In our patient, his experiences were recognized as pathological within the cultural framework in which he practiced yoga, and psychiatric hospitalization and antipsychotic treatment resulted in symptomatic improvement. Clinicians should screen patients for alternative therapies, including yoga, caution patients who are prone to either mania or psychosis against stress and sleep deprivation, and consider the cultural contexts of yoga-induced psychosis in order to fully help their patients in healing.

1.Lavey R, Sherman T, Mueser KT, Osborne DD, Currier M, Wolfe R: The effects of yoga on mood in psychiatric inpatients. Psychiatr Rehabil J 2005; 28:399–402
 
2.Walsh R, Roche L: Precipitation of acute psychotic episodes by intensive meditation in individuals with a history of schizophrenia. Am J Psychiatry 1979; 136:1085–1086
 
3.Sethi S, Bhargava S: Relationship of meditation and psychosis: case studies. Aust N Z J Psychiatry 2003; 37:382
 
4.Cahn-Ob T, Boonyanaruthee V: Meditation in association with psychosis. J Med Assoc Thai 1999; 82:925–930
 
5.Castillo R: Trance, functional psychosis and culture. Psychiatry 2003; 66:9–21
 
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References

+Dr. Pierre is on the speaker’s bureaus of Bristol-Myers Squibb, AstraZeneca, and Pfizer. Dr. Lu reports no competing interests.

+This letter (doi: 10.1176/appi.ajp.2007.07060960) was accepted for publication in July 2007.

+Reprints are not available; however, Letters to the Editor can be downloaded at http://ajp.psychiatryonline.org.

+

References

1.Lavey R, Sherman T, Mueser KT, Osborne DD, Currier M, Wolfe R: The effects of yoga on mood in psychiatric inpatients. Psychiatr Rehabil J 2005; 28:399–402
 
2.Walsh R, Roche L: Precipitation of acute psychotic episodes by intensive meditation in individuals with a history of schizophrenia. Am J Psychiatry 1979; 136:1085–1086
 
3.Sethi S, Bhargava S: Relationship of meditation and psychosis: case studies. Aust N Z J Psychiatry 2003; 37:382
 
4.Cahn-Ob T, Boonyanaruthee V: Meditation in association with psychosis. J Med Assoc Thai 1999; 82:925–930
 
5.Castillo R: Trance, functional psychosis and culture. Psychiatry 2003; 66:9–21
 
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