Bipolar Depression with Secondary Psychosis Triggered by Polysubstance and Hyperhomocysteinemia: A Case Report
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Abstract
The intersection between early-onset mood disorders, substance use, and the development of psychotic conditions in adolescence represents a diagnostic and therapeutic challenge in psychiatric practice. This article presents a case report of a 17-year-old male with a history of persistent depressive disorder, hyperactivity, and multiple suicide attempts, who progressed to severe psychic disorganization ("schizophrenization") associated with cocaine use and severe nicotine dependence. The clinical evolution illustrates the complexity of differentiating between substance-induced psychosis and the prodrome of a primary psychotic disorder, as well as the impact of delirium secondary to nicotine withdrawal on mental disorganization. Therapeutic management required multiple pharmacological approaches, culminating in the consideration of atypical strategies due to refractoriness. We discuss the hypothesis of schizophrenization as an interpretative matrix, expanded by the concepts of self-medication of distress, alexithymia, limbic hypersignification in patients with Bipolar Affective Disorder, and Autism Spectrum Disorder (ASD) traits, offering a model to understand progressive destructuring in adolescents with multiple vulnerabilities.
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References
I. Shaska, E., Mulita, F., Zenelaj, E., Tahiri, A., Durmishi, E., Gishto, T., Begotaraj, E., & Leivaditis, V. (2025). Mental health and the broader consequences of illicit substance abuse beginning in adolescence. Advances in Psychiatry and Neurology, 34(1), 1-12.
II. Starzer, Y. K., Nordentoft, M., & Hjorthøj, C. (2018). Rates and Predictors of Conversion to Schizophrenia or Bipolar Disorder Following Substance-Induced Psychosis. American Journal of Psychiatry, 175(4), 343-350.
III. Roncero, C., Daigre, C., Grau-López, L., Barral, C., Pérez-Pazos, J., Ruiz-Veguilla, M., ... & Casas, M. (2013). An international perspective and review of cocaine-induced psychosis: a call to action. Substance Abuse and Rehabilitation, 4, 11-20.
IV. Hughes, J. R. (2007). Effects of abstinence from tobacco: valid symptoms and time course. Nicotine & Tobacco Research, 9(3), 315-327.
V. Kótyuk, E., Farkas, J., Magi, A., Eisingkóvics, D., Barta, C., & Demetrovics, Z. (2022). Validation of the Reward Deficiency Syndrome Questionnaire (RDSQ-29) in a Hungarian adolescent sample. Journal of Psychopharmacology, 36(5), 589-598.
VI. Hatami Nejad, R., Taremian, F., & Yaghubi, H. (2025). The role of alexithymia and emotion regulation difficulties in predicting substance use disorders among adolescents. Scientific Reports, 15(1), 2341.
VII. Blum, K., Bowirrat, A., Baron, D., Lott, L., Ponce, J. V., Brewer, R., ... & Gold, M. S. (2020). Biogenetic model of severe substance use disorder: Reward Deficiency Syndrome (RDS). Current Psychopharmacology, 9(1), 5-15.
VIII. Hemming, L., Gargan, I., Green, J., Batty, M., & Craig, J. (2023). "I use alcohol and drugs to help me process the world": A qualitative study of self-medication in autistic adults. Autism, 27(4), 1081-1094.
IX. Morie, K. P., Yip, S. W., Nich, C., Hunkele, K., Carroll, K. M., & Potenza, M. N. (2016). Alexithymia and addiction: a review and preliminary data suggesting neurobiological links to reward/loss processing. Current Addiction Reports, 7, 74-84.
X. Schaafsma, S. M., Pfaff, D. W., Spunt, R. P., & Skuse, D. H. (2015). Deconstructing and reconstructing theory of mind. Trends in Cognitive Sciences, 19(2), 65-72.
XI. Andreasen, N. C. (1982). Negative symptoms in schizophrenia: definition and reliability. Archives of General Psychiatry, 39(7), 784-788.
XII. Kim, M., Lee, T. Y., Kim, E., Kwon, J. S., & Kim, M. (2025). Shared and distinct network structures of psychotic symptoms in schizophrenia and bipolar I disorder. Translational Psychiatry, 15(1), 42
XIII. Fusar-Poli, P., & Yung, A. R. (2012). How long is long enough? A meta-analysis of the duration of untreated psychosis. Schizophrenia Bulletin, 38(6), 1152-1160.
XIV. Barch, C. E., & Ceaser, A. (2012). Cognition in schizophrenia: core psychological and neural mechanisms. Trends in Cognitive Sciences, 16(1), 27-34.
XV. Kapur, S. (2003). Psychosis as a state of aberrant salience: a framework linking biology, phenomenology, and pharmacology in schizophrenia. American Journal of Psychiatry, 160(1), 13-23.
XVI. Winton-Brown, T. T., Fusar-Poli, P., Ungless, M. A., & Howes, O. D. (2014). Dopaminergic basis of salience dysregulation in psychosis. Trends in Neurosciences, 18(2), 85-94.
XVII. Murray, R. M., Quigley, H., Quattrone, D., Englund, A., & Di Forti, M. (2016). Traditional marijuana, high-potency cannabis and synthetic cannabinoids: increasing risk for psychosis. World Psychiatry, 15(3), 195-204.
XVIII. Di Forti, M., Quattrone, D., Freeman, T. P., Tripoli, G., Gayer-Anderson, C., Quigley, H., ... & Murray, R. M. (2019). The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study. The Lancet Psychiatry, 6(5), 427-436.
XIX. Chouinard, G., & Jones, B. D. (1980). Neuroleptic-induced supersensitivity psychosis: clinical and pharmacologic characteristics. American Journal of Psychiatry, 137(1), 16-21.
XX. Moncrieff, J. (2006). Does antipsychotic withdrawal provoke psychosis? Review of the literature on rapid onset schizophrenia (supersensitivity psychosis) and withdrawal-related relapse. Acta Psychiatrica Scandinavica, 114(1), 3-13.
XXI. Horowitz, M. A., Jauhar, S., Natesan, S., Murray, R. M., & Taylor, D. (2021). A method for tapering antipsychotic treatment that may minimize the risk of relapse. Schizophrenia Bulletin, 47(4), 1116-1129.
XXII. Levy, B., & Holzman, P. S. (1997). Logical filtering and thought disorder in schizophrenia. Schizophrenia Bulletin, 23(3), 399-411.
XXIII. Levine, J., Rapoport, A., Bracha, H. S., Pakhas, V., & Melamed, Y. (2002). Elevated homocysteine levels in young male patients with schizophrenia. American Journal of Psychiatry, 159(10), 1790-1792.
XXIV. Fan, N., Gao, X., Wang, Y., Zhao, X., Liu, Y., & Zhang, H. (2024). Homocysteine levels in first-episode patients with psychiatric disorders: a systematic review and meta-analysis. Frontiers in Psychiatry, 15, 1380900.
XXV. Levine, J., Sela, B. A., Osher, Y., Belmaker, R. H., & Adlersberg, M. (2002). Homocysteine-reducing strategies improve symptoms in chronic schizophrenic patients with high plasma homocysteine levels. Biological Psychiatry, 52(6), 441-445.
XXVI. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation.
XXVII. Kessler, R. C., Adler, L., Ames, M., Demler, O., Faraone, S., Hiripi, E., Howes, M. J., Jin, R., Secnik, K., Spencer, T., Ustun, T. B., & Walters, E. E. (2005). The World Health Organization Adult ADHD Self-Report Scale (ASRS): A short screening scale for use in the general population. Psychological Medicine, 35(2), 245–256.
XXVIII. Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276.