In literature Leonard introduce, after Wernike (1900) and Kleist (1928), the concept of cycloid psychoses, and he gives again a weight to the mixed forms in affective disorders [1–4]. A lot of different medical conditions cause pychiatric problems, like hyperammonemia, hyponatiremia, thyroid disfunction, urinary infections and still others. The aim of our study is to evaluate the role of a medical condition in perplexity inside psychotic mixed states in bipolar disorder (BD). We propouse three different cases and literature review.

Three patients with perplexity in BD were assessed with: the SCID-P for axis I diagnosis, HRSD, YMRS, internistical examination, blood test exams and urinanalysis, and first level brain imagin (CT and/or MRI). We conducted a systematic review of the literature (PubMed, Embase, PsychInfo), using the terms “bipolar disorder”, “mixed states”, “perplexity” and “medical condition”.

All our patients present: hyperammonemia, reduction of TSH and presence of infection at the urinanalysis, and a resolution of perplexity with the normalization of the blood test and urinanalysis.

To our knowledge there are not studies that confirm the relationship between thyroid and epatic dysfunction, and urinary infection with perplexity in psychotic mixed states in BD, and the resolution with the normalization of blood and urinary exams. Further research is warranted to replicate our clinical observations and to confirm our results.

The authors have not supplied their declaration of competing interest.