IntroductionHyperthyroidism may lead to high anxiety status, emotional lability, irritability, overactivity, exaggerated sensitivity to noise, and fluctuating mood, insomnia and hyporexia. in extreme cases, they may appear delusions and hallucinations as psychiatric symptoms.Case reportwe report the case of a 53-year-old female who was diagnosed of hyperthyroidism and generalized anxiety disorder. The patient went to emergency department because of high levels of anxiety, with heart palpitations, trembling, shortness of breath and nausea. She was presenting auditory hallucinations and delusions as psychiatric symptoms. an urgent thyroid profile was made and it was observed the next results: TSH < 0.005; T4:4; T3:21. Due to a severe thyroid malfunction, the patient was admitted and treated with antithyroid agent, improving the psychiatric and somatic symptoms.Discussionin this case, a patient diagnosed of hyperthyroidism and generalized anxiety disorder presented very severe psychiatric symptoms, with hallucinations and delusions. These symptoms may be produced by primary psychiatric disorders, but is very important to look for thyroid alterations, because if they are the cause, the acute treatment of thyroid malfunction is the correct management of the patient.ConclusionsHyperthyroidism is very common in general population, being infradiagnosed most of times. in patient with anxiety or other psychiatric symptoms, it is very important to make a thyroid function tests before the diagnosis of a psychiatric disorder. in extreme cases, hyperthyroidism status may lead to severe psychiatric and somatic complications.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Background: There is rising awareness about the need of multidisciplinary approaches integrating psychological treatments for schizophrenia, but a comprehensive evidence base on their relative efficacy is lacking. Conventional pairwise meta-analyses cannot provide a hierarchy based on the randomised evidence. We aimed to integrate the available evidence to create hierarchies of the comparative efficacy, acceptability and tolerability of psychological interventions for schizophrenia. Methods: We performed a network meta-analysis (which uses both direct and indirect comparisons) of randomized controlled trials on psychological treatments aimed at positive symptoms in the acute treatment of schizophrenia, compared with another psychological intervention or with a no treatment condition (waiting list, treatment as usual). We excluded trials done in patients with predominant negative symptoms, concomitant psychiatric disorders or medical illnesses, and those done in first episode or stable patients. Published and unpublished studies were sought through database searches, trial registries and websites. Study selection and data extraction were conducted by at least two independent reviewers. Our primary outcome is the change in positive symptoms on a validated rating scale. Secondary outcomes include number of dropouts, overall and negative symptoms of schizophrenia, response, relapse, adherence, depression, quality of life, functioning and adverse events. Analyses were conducted in R within a frequentist framework. The risk of bias in studies has been evaluated using the Cochrane Risk of Bias tool and the credibility of the evidence will be evaluated using an adaptation of the GRADE framework to NMA, recommended by the Cochrane guidance. Subgroup and sensitivity analyses will be conducted to assess the robustness of the findings. The protocol of this review has been registered in Prospero (registration number: CRD42017067795). Results: After screening 20196 references for title and abstract and 2555 full text articles, we identified 58 suitable trials, for a total of 3956 participants. Regarding primary outcome positive symptoms, only Cognitive Behavioural Therapy was significantly more effective than treatment as usual, with a standardised mean difference of-0.59 [95% credible interval-1.03;-0.16].