Marcelo Caixeta

MD, Psychiatrist, Goiânia – Brazil

^*Corresponding Author: Marcelo Caixeta, MD, Psychiatrist, Goiânia – Brazil

Received: 06 June 2025; Accepted: 17 June 2025; Published: 26 June 2025.

Article Information

Citation: Marcelo Caixeta. Schizophrenization Process in a Hyperactive-Bipolar Patient with Substance Use: A Clinical Case with Neologistic Delusions. Journal of Psychiatry and Psychiatric Disorders 9 (2025): 195-198.

DOI: 10.26502/jppd.2572-519X0249

Abstract

Keywords

Schizophrenization, Neologisms, Bipolar Disorder, Substance Use, ADHD, Psychosis, Case Report.

Article Details

1. Introduction

Psychotic symptoms involving neologisms, conceptual fragmentation, and symbolic disruption are traditionally associated with primary schizophrenic syndromes. However, in clinical practice, such phenomena are not exclusive to schizophrenia. Patients with affective disorders, particularly those with bipolar spectrum conditions, may exhibit a progressive deterioration in symbolic integration and ego structure, especially under the influence of chronic stress, substance use, or treatment discontinuity. This symbolic disorganization, which we refer to as a process of schizophrenization, represents a transition from mood-based psychopathology toward a more dissociative and psychotic profile. Rather than an abrupt onset of schizophrenia, such patients demonstrate gradual weakening of ego boundaries, emergence of delusional systems, and creation of neologistic constructs — signs of a symbolic system no longer governed by stable ego function. In this report, we present the case of a highly functional individual — a medical doctor — with a background of childhood hyperactivity and adult-onset bipolar symptoms, whose clinical trajectory evolved toward schizophreniform psychosis. The case is discussed through a structural psychopathology lens, highlighting the symbolic, neurobiological, and sociocultural elements involved in this form of ego disintegration.

2. Case presentation

Patient X is a 35-year-old single male, originally from Goiás, Brazil, with a completed university education and professional training as an orthopedic surgeon.

2.1 First Psychotic Episode

In January 2022, while living alone in Goiânia, the patient experienced a sudden onset of disorganized thinking, persecutory delusions, and agitated behavior. He believed he was being threatened via Instagram and threw his phone out of a window before forcibly entering two neighboring apartments. He was later calmed by the building’s superintendent and returned to his own apartment. Following this episode, his father brought him back to his hometown. Over the next two weeks, the patient escalated his use of alcohol and drugs, and his psychotic symptoms worsened. He became increasingly paranoid, accusing his father of heading a secret organization that was allegedly excluding him. He issued death threats against his father and rejected psychiatric consultation. Due to worsening behavior, an involuntary psychiatric hospitalization was arranged in Goiânia.

2.2 Personal and Academic History

The patient had been affectionate and family-oriented throughout childhood. Although strong-willed, he excelled academically and was accepted into competitive programs. He began using alcohol, tobacco, and cannabis during medical school. After being denied certification by the Brazilian Society of Orthopedic Surgery due to institutional issues, he became depressed, angry, and vengeful, even suggesting retaliation against medical staff. At that time, he rejected psychiatric treatments and pursued only alternative therapies without improvement.

2.3 Medical Exams and Laboratory Workup

The patient underwent routine laboratory tests during his most recent hospitalization, which showed mostly normal values. Noteworthy findings included slightly elevated homocysteine (16.49 µmol/L), high vitamin B12 (1272 pg/mL), and low HDL cholesterol (28 mg/dL).

2.4 Hospitalizations and Clinical Evolution

His first hospitalization lasted from February 11 to 26, 2022, followed by outpatient care until June 2022. He returned briefly to medical work but struggled due to stress intolerance and ongoing substance use. By early 2023, he had moved back in with his parents and remained unemployed and addicted to drugs.

2.5 Psychiatric Treatment Attempts

In 2023, a psychiatrist prescribed oral paliperidone, which the patient refused. An injectable formulation was later attempted but also initially declined. In May 2025, he received two intramuscular doses (100 mg and 150 mg of paliperidone palmitate) after becoming increasingly reclusive and suicidal.

2.6 Current Admission (May 23, 2025)

Upon admission, the patient presented with disorganized speech, elevated mood, psychomotor agitation, and recent suicidal ideation. Hospitalization was indicated, and treatment included lithium, valproate, alprazolam, and oral paliperidone (switched from zuclopenthixol due to akathisia).

2.7 Treatment Response

The patient showed improvement in psychomotor agitation, speech, and coordination, though persistent delusions regarding a criminal organization led by his father remained. He denied further suicidal thoughts and expressed a wish to resume medical practice, possibly as a general practitioner in his hometown.

Discussion

This case illustrates a progressive transformation of affective and hyperactive psychopathology into a schizophreniform psychotic state, triggered and aggravated by substance abuse, family permissiveness, and inconsistent psychiatric management. The patient had early signs of ADHD, characterized by impulsivity and high activity levels, but was also focused and goal-oriented, achieving admission to a competitive medical program and later completing an orthopedic residency. During his university years, his hyperactivity gradually evolved into anxiety, followed by mood instability and substance use. He began experiencing delusional content — notably paranoid ideas and neologisms, such as the term “ADHERAHI”, a fabricated name for a persecutory force he claimed was observing and influencing him. The emergence of neologisms and bizarre delusions marks a qualitative shift in his mental organization, suggesting a fragmentation of symbolic thought. These linguistic disruptions are not random but reflect a deeper collapse in the cohesion of conceptual structures. In this sense, the patient’s psychosis appears as a process of schizophrenization — not primary schizophrenia, but a transition from affective pathology into a more dissociative and disorganized mode of thinking, possibly due to untreated bipolar disorder and prolonged substance use.

From a structural psychopathology perspective, this can be interpreted as the weakening of ego functions under pressure from a hyperactive limbic system. In patients with ADHD, the ego may appear strong due to self-centered behaviors, but this strength is often limited to immediate gratification. Assertive and integrative functions of the ego are weaker. With the addition of bipolar mood fluctuations and chronic cannabis use — possibly contributing to an amotivational syndrome — the ego’s capacity to synthesize and regulate symbolic meaning diminishes further. In our patient, symbolic automatisms begin to dominate thought: a symbol or invented word begins to “think” in place of the self. This suggests the emergence of mental automatism — a classic psychotic symptom where the subject feels invaded by alien thoughts or external forces. These phenomena can be understood in light of Isaías Paim’s description of conceptual fragmentation caused by parallel predatory associations, which attack and destabilize the meaning of symbolic units. When the ego is weak, these symbolic attacks fragment concepts and lead to psychotic constructs. We observe similar symbolic dynamics in aphasic patients who are unable to produce spontaneous speech but can still recite automated phrases or expressions. In such cases, the linguistic system operates independently of conscious volition. Likewise, in psychosis, particularly when mediated by neologisms, we see evidence of a symbolic system that has become detached from ego control — the symbol thinks, speaks, and acts in place of the subject. This patient’s condition, therefore, represents an intermediate state: not congenital schizophrenia, but a progressive schizophrenization of a bipolar mind, driven by trauma, drugs, and symbolic collapse. In our clinical research group, we have observed that affective disorders are more likely to evolve into psychosis when exacerbated by prolonged anxiety (possibly linked to chronic hyperglutamatergia), misdiagnosis, or untreated metabolic deficiencies (e.g., low folate, high homocysteine, or deficiencies in B vitamins, zinc, magnesium, and S-adenosylmethionine). The patient’s prognosis remains guarded. His father is passive, enabling continued drug use and social withdrawal. Without a structured therapeutic plan — combining mood stabilization, antipsychotic treatment, and environmental containment — this trajectory may lead to what we call psychiatric vegetabilization, a chronic and irreversible state of psychic passivity and symbolic emptiness.

Conclusion

This case demonstrates how an initially functional and intellectually capable individual with ADHD and bipolar disorder may gradually evolve into a psychotic condition through sustained substance abuse, family permissiveness, and fragmented psychiatric care. The process of schizophrenization observed here is marked by the emergence of neologisms, persecutory delusions, symbolic disintegration, and weakened ego control, forming a borderline state between affective psychosis and schizophrenia.

Understanding such transitional states is essential to prevent misdiagnosis, therapeutic abandonment, or chronic deterioration. Early intervention and sustained pharmacological and psychosocial support are crucial to avoid progression toward symbolic collapse and psychiatric institutionalization.

Declarations

Patient Consent

Written informed consent was obtained from the patient’s legal representative (father) for publication of this case report. Identifying details have been anonymized.

Conflict of Interest

The author declares no conflict of interest.

Funding

This work received no external funding.

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