Psychotic Episode Associated With Bikram Yoga -- Am J Psychiatry

This was a letter to the editor in the American Journal of Psychiatry that I came across:

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.

The letter then goes on to criticize the safety of Yoga practice, concluding with:

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.

May I first point out that:

1. We don't all practice Bikram Yoga; and
2. the patient had suffered from hallucinogen-induced psychosis prior to enrolling in the instructor course.

My conclusion from reading the article, and granted I'm not a licensed clinician, is that the patient would have likely undergone the same mental break in any highly-stressful environment where he may have suffered sleep deprivation and malnutrition as part of adjusting to the training. Armed service training, springs to mind, which is both intensely physical and psychological; often more than an unstable individual can withstand. Had the patient enlisted rather than enrolled, would this letter have warned us of the dangers of military practice?
Training to become a Bikram instructor is reportedly intense, but not so overly demanding that its instructors are all psychotic (though practicing in 105 degree rooms...). Reading this blog: Bikram's Teacher Training 2006, I can imagine insomnia and loss of appetite could occur for some individuals as they adjusted. That, plus the intensity of training reported in the aforementioned blog would probably lead me to hallucination (likely from heat-stroke). However, I can assure any reader that may worry about this, that the art of Yoga is not to blame.

Namasté