Anxiety disorders in the joint hypermobility syndrome

A narrative review of the literature on illness uncertainty in hypermobile ehlers-danlos syndrome: implications for research and clinical practice

BACKGROUND

Hypermobile Ehlers-Danlos syndrome (hEDS) is characterized by joint and skin laxity, and often accompanied by chronic pain, dysautonomia, increased distress and, functional limitations. The journey to accurate diagnosis is often prolonged due to unclear etiology of symptoms. This manuscript is a narrative review of the literature on illness uncertainty (IU) in hEDS, highlighting the unique facets of IU in this population, as compared to the broader chronic pain population (given symptom overlap between these two disease groups), that warrant additional investigation. Additionally, we considered the unique challenges associated with IU in the context of the developmental nuances of pediatric populations. Specifically, we aimed to (1) map the extant literature of the IU experience in chronic pain conditions broadly including the pediatric and adult research to identify key concepts related to IU and incorporate potential developmental considerations in IU; (2) delineate and describe the IU experience specifically in patients with hEDS, with the goal of identifying gaps in the literature based on aspects of presentation in hEDS that do and do not differ from the broader chronic pain population; and (3) elucidate the potential areas of adverse impact of IU in both general chronic pain populations, and those with hEDS specifically, to provide actionable areas for future research and clinical care of individuals with hEDS. Results of this review indicate that IU has been well-studied in chronic pain generally, but inadequately evaluated in hEDS specifically. Specific features of hEDS (complexity of the disorder, involvement of multiple bodily systems, contribution of organic pathology) may uniquely contribute to IU in this population. This review suggests that ambiguities surrounding the diagnosis of hEDS, symptom course, and treatment recommendations, along with misdiagnosis, perceived dismissal of symptoms, or attribution of symptoms to mental health concerns might increase risk for IU and related distress in patients.

CONCLUSION

Findings from the present review suggest that distinct features of hEDS yield a set of driving factors for IU that may be somewhat different than those faced by patients with chronic pain or other medical conditions. The development of a validated measure of IU to appropriately assess this construct in patients with hEDS is a research priority. In the clinical setting, providers should be attentive to the potentially aversive diagnostic and treatment experiences reported by patients and attempt to provide clear explanations based on the extant knowledge of hEDS, and implement best-practice recommendations for multidisciplinary treatment.

Characterization of Migraine in Children and Adolescents With Generalized Joint Hypermobility: A Case-Control Study

Background and Objectives

The prevalence of generalized joint hypermobility (GJH) is 5-65% in children and adolescents. The hypothesis of this study was to see whether there is an association between headache characteristics and GJH in children and adolescents with migraine.

Methods

We performed a primary retrospective case-control analysis of an established database of patients with headache aged 5-17 years.

Results

We included 5435 participants. Approximately 31.6% of participants (1,719/5,435) were diagnosed with GJH (Beighton score ≥ 6). Nausea (73.1% vs 67.5%, χ2 with 1 degree of freedom = 17.0, p < 0.0001), phonophobia (87.3% vs 78.8%, χ2 with 1 degree of freedom = 18.0, p < 0.0001), and the PedMIDAS score (48.2 ± 52.5, 95% CI 45.7-50.6 vs 41.6 ± 51.2, 95% CI 40.0-43.3, effect size = 0.13, p < 0.0001) were noted to be more severe in participants with GJH than those without GJH.

Discussion

Youths with GJH and migraine were noted to have more severe migraine characteristics.

Hypermobile spectrum disorders symptoms in patients with functional neurological disorders and autism spectrum disorders: A preliminary study

Autism spectrum disorders (ASDs) and functional neurological disorders (FNDs) share some clinical characteristics such as alexithymia, sensory sensitivity and interoceptive issues. Recent evidence shows that both the disorders present symptoms compatible with a diagnosis of hypermobile Ehlers-Danlos Syndrome and hypermobile spectrum disorders (hEDS/HSD), a heterogeneous group of heritable connective tissue disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. Here we compared the prevalence of hEDS/HSD-related symptoms in a group of patients with FNDs, of people with ASDs without intellectual disabilities, and a non-clinical comparison group (NC). Twenty patients with FNDs, 27 individuals with ASDs without intellectual disabilities and 26 NC were recruited and completed the Self-reported screening questionnaire for the assessment of hEDS/HSD-related symptoms (SQ-CH). We found that 55% of the patients with FNDs, 44.4% of the individuals with ASDs and 30.8% of NC scored above the cut-off at the SQ-CH; SQ-CH scores of both FNDs and ASDs group were significantly higher than the NC group's ones. In conclusion, both ASDs and FNDs individuals present hEDS/HSD-related symptoms in a higher number than the general population. Imputable mechanisms include (i) overwhelming of executive functions with consequent motor competence impairment for ASDs individuals, and (ii) exacerbation of FNDs symptoms by physical injury and chronic pain due to abnormal range of joint mobility. Moreover, we speculated that the amygdala and the anterior cingulate cortex circuitry might be responsible for the imbalances at the proprioceptive, interoceptive, and emotional levels.

Advances in assessment of hypermobility-related disorders

There has been increasing recognition in recent years of the prevalence and impact of symptoms which extend beyond the musculoskeletal system on the lives of people with hypermobility-related disorders. This has led researchers to develop more comprehensive assessment tools to help direct and monitor treatment. This article presents some of the latest assessment and diagnostic developments and their implications for practice from a physical therapy perspective.

Functional somatic syndromes and joint hypermobility: A systematic review and meta-analysis

OBJECTIVE

There have been multiple reports of increased joint hypermobility (JH) in functional somatic syndromes (FSS). We sought to evaluate the evidence for an association.

METHODS

A systematic search of the databases Medline and PsycINFO was conducted to identify all controlled studies from inception to February 2020 measuring the association of an FSS and JH. Records were identified and screened, and full-text articles assessed for eligibility by two independent authors. Meta-analysis was performed using random-effects modelling with the DerSimonian and Laird method.

RESULTS

We found 220 studies initially, which yielded 11 studies for inclusion in the qualitative review and 10 in the quantitative analysis - 5 studies on fibromyalgia, 3 on chronic fatigue syndrome and 3 on functional gastrointestinal disorder. Nine of the 11 studies found increased rates of JH in FSS compared to controls, though most studies were fair to poor in quality. Meta-analysis showed a weighted summary effect odds ratio of 3.27 (95% CI: 1.83, 5.84; p < 0.001) of JH in FSS, suggesting greater odds of FSS in individuals with JH than in those without.

CONCLUSIONS

There is some evidence for an association between FSS and JH, but this is limited by the generally poor quality of studies and the narrow range of FSS studied. Better research is needed to confirm these findings as well as evaluate causation using prospective cohort studies.

Management of shoulder instability in hypermobility-type Ehlers-Danlos syndrome

Shoulder instability in hypermobile Ehlers-Danlos syndrome can result in lifelong pain and functional disability. Treatment in this population is complicated by the severe degree of instability as well as the underlying abnormalities of the joint connective tissue. Appropriate care for these patients requires a thorough understanding of the natural history of their disease, knowledge of the available treatment options, and certain special considerations. This article reviews the pathoanatomy, recognition, and management of shoulder instability in the patient with hypermobile Ehlers-Danlos syndrome.

Hypermobile Ehlers-Danlos syndromes: Complex phenotypes, challenging diagnoses, and poorly understood causes

The Ehlers-Danlos syndromes (EDS) are a group of heritable, connective tissue disorders characterized by joint hypermobility, skin hyperextensibility, and tissue fragility. There is phenotypic and genetic variation among the 13 subtypes. The initial genetic findings on EDS were related to alterations in fibrillar collagen, but the elucidation of the molecular basis of many of the subtypes revealed several genes not involved in collagen biosynthesis or structure. However, the genetic basis of the hypermobile type of EDS (hEDS) is still unknown. hEDS is the most common type of EDS and involves generalized joint hypermobility, musculoskeletal manifestations, and mild skin involvement along with the presence of several comorbid conditions. Variability in the spectrum and severity of symptoms and progression of patient phenotype likely depend on age, gender, lifestyle, and expression domains of the EDS genes during development and postnatal life. In this review, we summarize the current molecular, genetic, epidemiologic, and pathogenetic findings related to EDS with a focus on the hypermobile type.

The ALPIM (Anxiety, Laxity, Pain, Immune, and Mood) Syndrome in Adolescents and Young Adults: A Cohort Study

OBJECTIVE

ALPIM (anxiety, laxity, pain, immune, and mood) syndrome has been previously described in adults. The authors aimed to identify its occurrence in adolescents and confirm its existence in adults. Given the association of the disorder with somatic symptoms, separation anxiety disorder (SAD) was explored as an ALPIM comorbidity.

METHODS

Medical records of patients aged 11-34 with a diagnosis of depression or anxiety (panic disorder, SAD, social anxiety or generalized anxiety disorder) seen during a 1-year period were reviewed. Data were collected on the presence of ALPIM comorbidities. Analyses were conducted to detect their co-occurrence and evaluate possible predictors of the ALPIM syndrome.

RESULTS

Inclusion criteria were met by 185 patient charts. A significant association was observed between the ALPIM comorbidities with 20 study subjects (10.8%) meeting criteria for ALPIM syndrome (patients with one or more diagnoses from each ALPIM domain). Patients with SAD had increased odds of being diagnosed with ALPIM (odds ratio=7.14, 95% CI=2.48-20.54, p<0.001). Neither major depression nor generalized anxiety disorder was found to be predictive of ALPIM syndrome. There was no difference in the prevalence of ALPIM-related comorbidities between study subjects <18 years old compared with those ≥18 years old.

CONCLUSIONS

These findings reestablish the association of distinct psychiatric and nonpsychiatric conditions described as the ALPIM syndrome. Furthermore, the syndrome may present during adolescence. SAD may be an independent predictive factor for the occurrence of ALPIM syndrome. Patients with individual ALPIM comorbidities should be assessed for the syndrome, especially if they have a history of SAD.

Ethnic differences in the diagnosis of schizophrenia and mood disorders during admission to an academic safety-net psychiatric hospital

U.S. Hispanics, now the single largest minority group in the country, face unique mental health disparities. The current study utilizes Andersen's Behavioral Model of Health Service Use to examine ethnic disparities in receiving a schizophrenia or mood disorder diagnosis at psychiatric hospital admission. Our retrospective cohort study examined electronic health record data at an academic safety-net psychiatric hospital for adult patients (n = 5571) admitted between 2010 and 2013. Logistic regression with block-wise entry of predisposing, enabling and need variables was used to examine ethnic disparities in receiving a schizophrenia diagnosis at admission. The block of need factors was the strongest predictor of receiving a schizophrenia diagnosis compared to predisposing and enabling factors. Compared to non-Hispanic whites, Hispanics and African Americans had a greater likelihood of receiving a schizophrenia diagnosis at admission. Additionally, patients diagnosed with schizophrenia had elevated positive and negative symptoms and were more likely to be male, single/unmarried, homeless, high inpatient service utilizers, involuntarily hospitalized, and to exhibit functional impairment at psychiatric hospital admission. To address elevated positive and negative symptoms of schizophrenia, functional impairment, social withdrawal, and high inpatient service utilization, promising psychosocial interventions should be adapted for racial and ethnic minority populations and utilized as an adjuvant to antipsychotic medication.

Joint hypermobility is also associated with anxiety disorders in the elderly population

BACKGROUND

Anxiety disorders (AD) are very prevalent in the elderly, tend to compromise quality of life, and generate substantial costs. Considering that the prevention and early detection of anxiety may be relevant to increase health gains in older adults, it would be of great interest to identify whether the joint hypermobility syndrome (JHS) is also related to anxiety disorders in this age range.

METHODS

Cross-sectional data was collected in a sample of 108 subjects in a rural town in Spain. Instruments included Spielberger STAI, a modified Wolpe Fear Survey Schedule, General health Questionnaire (GHQ)-28, and the anxiety and mood disorders section of the SCID, to assess past year prevalence of anxiety disorders. JHS was evaluated by trained examiners using the "Hospital del Mar criteria".

RESULTS

Among the 108 subjects (55% women, 45% men) over 60 years old, 21.3% meet criteria for JHS. These subjects scored significantly higher in both State (F = 5.53; p = 0.02) and Trait (F = 4.68; p = 0.03) anxiety and the GHQ 28 (F = 6.29; p = 0.01). Compared with non JHS subjects, they had more AD (34.8% vs. 11.8%; x²  = 6.90; p = 0.02) and mood disorders (30.4% vs. 10.6%; x²  = 5.65; p = 0.041) in the past year prevalence. A multiple logistic regression analysis showed that both JHS (β = 0.196; p = 0.04) and fears (β = 0.34; p = 0.001) are predictors of AD (r²  = 188; p = 0.001) in this population.

CONCLUSIONS

Joint hypermobility syndrome is associated with anxiety in the elderly population, and it may be used as a physical marker for AD among subjects within this age range. Copyright © 2017 John Wiley & Sons, Ltd.

Gastrointestinal disorders in joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type: A review for the gastroenterologist

BACKGROUND

Joint hypermobility syndrome (JHS)/Ehlers-Danlos syndrome hypermobility type (EDS-HT) is the most common hereditary non-inflammatory disorder of connective tissue, characterized by a wide range of symptoms, mainly joint hyperextensibility and musculoskeletal symptoms. A majority of patients also experiences gastrointestinal (GI) symptoms. Furthermore, JHS/EDS-HT has specifically been shown to be highly prevalent in patients with functional GI disorders, such as functional dyspepsia and irritable bowel syndrome.

PURPOSE

The aim of this review was to examine the nature of GI symptoms and their underlying pathophysiology in JHS/EDS-HT. In addition, we consider the clinical implications of the diagnosis and treatment of JHS/EDS-HT for practicing clinicians in gastroenterology. Observations summarized in this review may furthermore represent the first step toward the identification of a new pathophysiological basis for a substantial subgroup of patients with functional GI disorders.

Psychiatric and psychological aspects in the Ehlers-Danlos syndromes

There is increasing amount of evidence pointing toward a high prevalence of psychiatric conditions among individuals with hypermobile type of Ehlers-Danlos syndrome (JHS/hEDS). A literature review confirms a strong association between anxiety disorders and JHSh/hEDS, and there is also limited but growing evidence that JHSh/hEDS is also associated with depression, eating, and neuro-developmental disorders as well as alcohol and tobacco misuse. The underlying mechanisms behind this association include genetic risks, autonomic nervous system dysfunction, increased exteroceptive and interoceptive mechanisms and decreased proprioception. Recent neuroimaging studies have also shown an increase response in emotion processing brain areas which could explain the high affective reactivity seen in JHS/hEDS. Management of these patients should include psychiatric and psychological approaches, not only to relieve the clinical conditions but also to improve abilities to cope through proper drug treatment, psychotherapy, and psychological rehabilitation adequately coupled with modern physiotherapy. A multidimensional approach to this "neuroconnective phenotype" should be implemented to ensure proper assessment and to guide for more specific treatments. Future lines of research should further explore the full dimension of the psychopathology associated with JHS/hEDS to define the nature of the relationship. © 2017 Wiley Periodicals, Inc.

Ehlers-Danlos Syndrome-Hypermobility Type: A Much Neglected Multisystemic Disorder

Ehlers-Danlos syndrome (EDS)-hypermobility type (HT) is considered to be the most common subtype of EDS and the least severe one; EDS-HT is considered to be identical to the joint hypermobility syndrome and manifests with musculoskeletal complaints, joint instability, and soft tissue overuse injury. Musculoskeletal complaints manifest with joint pain of non-inflammatory origin and/or spinal pain. Joint instability leads to dislocation or subluxation and involves peripheral joints as well as central joints, including the temporomandibular joints, sacroiliac joints, and hip joints. Soft tissue overuse injury may lead to tendonitis and bursitis without joint inflammation in most cases. Ehlers-Danlos syndrome-HT carries a high potential for disability due to recurrent dislocations and subluxations and chronic pain. Throughout the years, extra-articular manifestations have been described, including cardiovascular, autonomic nervous system, gastrointestinal, hematologic, ocular, gynecologic, neurologic, and psychiatric manifestations, emphasizing the multisystemic nature of EDS-HT. Unfortunately, EDS-HT is under-recognized and inadequately managed, leading to neglect of these patients, which may lead to severe disability that almost certainly could have been avoided. In this review article we will describe the known manifestations of the extra-articular systems.

Nationwide population-based cohort study of psychiatric disorders in individuals with Ehlers-Danlos syndrome or hypermobility syndrome and their siblings

BACKGROUND

To assess the risk of psychiatric disorders in Ehlers-Danlos syndrome (EDS) and hypermobility syndrome.

METHODS

Nationwide population-based matched cohort study. EDS, hypermobility syndrome and psychiatric disorders were identified through Swedish national registries. Individuals with EDS (n = 1,771) were matched with comparison individuals (n = 17,710). Further, siblings to individuals with EDS who did not have an EDS diagnosis themselves were compared with matched comparison siblings. Using conditional logistic regression, risk of autism spectrum disorder (ASD), bipolar disorder, attention deficit hyperactivity disorder (ADHD), depression, attempted suicide, suicide and schizophrenia were estimated. The same analyses were conducted in individuals with hypermobility syndrome (n = 10,019) and their siblings.

RESULTS

EDS was associated with ASD: risk ratio (RR) 7.4, 95 % confidence interval (95 % CI) 5.2-10.7; bipolar disorder: RR 2.7, CI 1.5-4.7; ADHD: RR 5.6, CI 4.2-7.4; depression: RR 3.4, 95 % CI 2.9-4.1; and attempted suicide: RR 2.1, 95 % CI 1.7-2.7, but not with suicide or schizophrenia. EDS siblings were at increased risk of ADHD: RR 2.1, 95 % CI 1.4-3.3; depression: RR 1.5, 95 % CI 1.1-1.8; and suicide attempt: RR 1.8, 95 % CI 1.4-2.3. Similar results were observed for individuals with hypermobility syndrome and their siblings.

CONCLUSIONS

Individuals with EDS and hypermobility syndrome are at increased risks of being diagnosed with psychiatric disorders. These risk increases may have a genetic and/or early environmental background as suggested by evidence showing that siblings to patients have elevated risks of certain psychiatric disorders.

Neurovisceral phenotypes in the expression of psychiatric symptoms

This review explores the proposal that vulnerability to psychological symptoms, particularly anxiety, originates in constitutional differences in the control of bodily state, exemplified by a set of conditions that include Joint Hypermobility, Postural Tachycardia Syndrome and Vasovagal Syncope. Research is revealing how brain-body mechanisms underlie individual differences in psychophysiological reactivity that can be important for predicting, stratifying and treating individuals with anxiety disorders and related conditions. One common constitutional difference is Joint Hypermobility, in which there is an increased range of joint movement as a result of a variant of collagen. Joint hypermobility is over-represented in people with anxiety, mood and neurodevelopmental disorders. It is also linked to stress-sensitive medical conditions such as irritable bowel syndrome, chronic fatigue syndrome and fibromyalgia. Structural differences in “emotional” brain regions are reported in hypermobile individuals, and many people with joint hypermobility manifest autonomic abnormalities, typically Postural Tachycardia Syndrome. Enhanced heart rate reactivity during postural change and as recently recognized factors causing vasodilatation (as noted post-prandially, post-exertion and with heat) is characteristic of Postural Tachycardia Syndrome, and there is a phenomenological overlap with anxiety disorders, which may be partially accounted for by exaggerated neural reactivity within ventromedial prefrontal cortex. People who experience Vasovagal Syncope, a heritable tendency to fainting induced by emotional challenges (and needle/blood phobia), are also more vulnerable to anxiety disorders. Neuroimaging implicates brainstem differences in vulnerability to faints, yet the structural integrity of the caudate nucleus appears important for the control of fainting frequency in relation to parasympathetic tone and anxiety. Together there is clinical and neuroanatomical evidence to show that common constitutional differences affecting autonomic responsivity are linked to psychiatric symptoms, notably anxiety.

Joint hypermobility and the heritable disorders of connective tissue: clinical and empirical evidence of links with psychiatry

OBJECTIVE

The heritable disorders of connective tissue (HDCTs) are a group of genetic disorders affecting connective tissue matrix proteins. Fragility, laxity of tissues and joint hypermobility (JH) are commons features of HDCT for which the prognosis may range from benign to life threatening. JH and HDCTs, especially joint hypermobility syndrome, Ehlers-Danlos syndromes and Marfan syndrome, have been associated with psychiatric symptomatology. We explored the existing knowledge concerning this association in order to provide an overview of mental disorders linked to JH/HDCT, as well as the hypotheses proposed to explain such association.

METHOD

A comprehensive search of scientific online databases and references lists was conducted, encompassing publications based on quantitative and qualitative research, including case reports.

RESULTS

Psychiatric conditions in which there is some evidence of an association with JH/HDCT are anxiety disorders, depression, schizophrenia, neurodevelopmental disorders (autism, attention deficit/hyperactivity disorder, and developmental coordination disorder), eating disorders, personality disorders and substance use/misuse.

CONCLUSION

Despite the need of more research, the available data highlight the importance of examining psychiatric symptoms in those affected by JH/HDCT and the importance of providing interventions with a multidisciplinary approach. The relationship between JH/HDCT and mental disorders merits further attention in order to improve current knowledge and clarify a possible common etiology.

Association between joint hypermobility and anxiety in Brazilian university students: gender-related differences

INTRODUCTION

Anxiety disorders may be associated with several non-psychiatric disorders. Current literature has been investigating the association between anxiety and joint hypermobility (JHM), with special interest in non-articular symptoms that may be related to autonomic dysfunction. This study investigated the association between anxiety and JHM in a sample of Brazilian university students.

METHODS

Data were cross-sectionally collected in two Brazilian universities (N=2600). Participants completed three validated self-rating anxiety scales: Beck Anxiety Inventory (BAI), Social Phobia Inventory (SPIN) and the brief-version of SPIN (Mini-SPIN). They also answered the self-rating screening questionnaire for JHM: the Five-part Questionnaire for Identifying Hypermobility.

RESULTS

Hypermobile women showed significantly higher scores in all the anxiety scales, when compared with men: BAI total score (t=3.77; p<0.001), its four subscales, SPIN score (t=2.71; p<0.007) and Mini-SPIN (t=2.58; p<0.01). Among BAI subscales, the autonomic subscale was shown to be more significantly (t=3.89; p<0.001) associated with joint hypermobility in women.

CONCLUSIONS

The results of the present study support earlier evidence on the relationship between anxiety and JHM in women, showing specific gender-related features in this field. It also directs attention to non-articular symptoms that may be enrolled in this association.

Ectomorphic somatotype and joint hypermobility are linked in panic and agoraphobic patients: a case-control study

OBJECTIVE

To test whether there is an association between somatotype measures, joint hypermobility (JH), and panic and/or agoraphobia (PA).

METHOD

Sociodemographic characteristics, somatotype, and JH status were assessed in 60 patients (30 men and 30 women) with PA and 60 non-clinical controls, matched by age and gender.

RESULTS

Patients and controls categorized by gender did not differ in terms of age, educational degree, marital status, or labour situation. There were significant differences between mean somatotype groups both in men and women. Men and women somatotype patients were significantly less endomorphic and more ectomorphic than controls. Hypermobility was significantly more frequent in both male and female patients. In the entire sample, 38.3% of patients and 13.3% of controls were categorized as ectomorphic (χ(2) = 8.5, p = 0.004). After adjusting for age and sex, ectomorphic somatotype was independently related to JH status [OR = 3.25, 95% CI 1.35-7.8, p = 0.008].

CONCLUSIONS

Since PA may be associated with JH, it is suggested that the relationship found between panic and ectomorphic somatotype might be mediated through JH.

A cross-sectional survey assessing sources of movement-related fear among people with fibromyalgia syndrome

Fear of movement may contribute to functional limitations and loss of well-being among individuals with fibromyalgia (FM). The objectives of this study were to assess factors contributing to movement-related fear and to explore relationships among these factors, function and wellness, in a widespread population of people with FM. This was an internet survey of individuals with FM. Respondents completed a battery of surveys including the Fibromyalgia Impact Questionnaire--Revised (FIQR), Tampa Scale of Kinesiophobia (TSK), Activities-Specific Balance Confidence Scale (ABC), Primary Care Posttraumatic Stress Disorder screen (PC-PTSD), Vertigo Symptom Scale (VSS-SF), a joint hypermobility syndrome screen (JHS), and screening questions related to obsessive-compulsive personality disorder (OCPD), physical activity, work status, and demographics. Analysis included descriptive statistics, Pearson product-moment correlations, and linear regression. Over a 2-year period, 1,125 people (97.6 % female) completed the survey battery. Kinesiophobia was present in 72.9 % of the respondents, balance confidence was compromised in 74.8 %, PTSD likely in 60.4 %, joint hypermobility syndrome likely in 46.6 %, and OCPD tendencies in 26.8 %. The total FIQR and FIQR perceived function subscores were highly correlated (p < 0.0005, r > 0.4) with pain, kinesiophobia, balance confidence, and vertigo. Reported activity level had poor correlation (r < 0.25) with all measured variables. Pain, ABC, VSS, and TSK predicted FIQR and FIQR-pf, explaining 65 and 48 % of the variance, respectively. Kinesiophobia, balance complaints, vertigo, PTSD, and joint hypermobility were common in this population of people with FM. Sources of movement-related fear correlated to overall wellness and perceived function as measured by the FIQR and FIQR-pf.

Joint hypermobility: emerging disease or illness behaviour?

Joint hypermobility syndrome is a common clinical entity which is much misunderstood, overlooked, misdiagnosed and mistreated. It was first described in the 1960s as a purely musculoskeletal condition due to joint laxity and hypermobility occurring in otherwise healthy individuals. Some four decades later it is now perceived to be a multi-systemic heritable disorder of connective tissue with manifestations occurring far beyond the confines of the locomotor system and with ramifications potentially affecting most, if not all, of the bodily systems in one way or another. Most authorities in the field find it clinically indistinguishable from the Ehlers-Danlos syndrome--hypermobility type (formerly, EDS type III). In >50% of patients the diagnosis is delayed for ≥10 years. Failure to diagnose and treat the condition correctly results in needless pain and suffering and in many patients to a progressive decline in their quality of life and in some to a loss of independence.

Arachnodactyly--a key to diagnosing heritable disorders of connective tissue

Arachnodactyly literally means spidery fingers, and describes the long, slender fingers typical of patients with Marfan syndrome (MFS). Many clinicians regard arachnodactyly as pathognomonic of MFS; however, this view is misleading as arachnodactyly is a key element of the marfanoid habitus, which is present in several heritable disorders of connective tissue (HDCTs). Other features of the marfanoid habitus include long hands and feet, increased skin stretch, joint hypermobility and characteristic changes in the physiology of the pectum. Here, we focus on the differential diagnosis of diseases with features of the marfanoid habitus. Ectopia lentis (lens dislocation) and aortic root dilation or dissection are cardinal features of MFS. Distinguishing MFS from other HCDTs has important implications for treatment, as cardiovascular and ocular complications commonly seen in patients with MFS are not seen in all HDCTs. Joint hypermobility syndrome and Ehlers-Danlos syndrome are also HDCTs, neither of which is associated with ectopia lentis or aortic changes. Some of the rarer forms of Ehlers-Danlos syndrome are associated with severe vascular, dental and skin pathologies. This Review serves as a guide for correctly diagnosing members of the HDCT family.

Anxiety and joint hypermobility association: a systematic review

BACKGROUND

Anxiety disorders are often associated with several non-psychiatric medical conditions. Among the clinical conditions found in association with anxiety stands out the joint hypermobility (JH).

OBJECTIVES

To carry out a systematic review of the clinical association between anxiety disorders and JH.

METHOD

A survey was conducted in MEDLINE, PsychINFO, LILACS e SciELO databases up to December 2011. We searched for articles using the keywords 'anxiety', 'joint' and 'hypermobility' and Boolean operators. The review included articles describing empirical studies on the association between JH and anxiety. The reference lists of selected articles were systematically hand-searched for other publications relevant to the review.

RESULTS

Seventeen articles were included in the analysis and classified to better extract data. We found heterogeneity between the studies relate to the methodology used. Most of the studies found an association between anxiety features and JH. Panic disorder/agoraphobia was the anxiety disorder associated with JH in several studies. Etiological explanation of the relationship between anxiety and JH is still controversial.

CONCLUSION

Future research in large samples from the community and clinical setting and longitudinal studies of the association between anxiety and HA and the underlying biological mechanisms involved in this association are welcome.

Clinical profile of benign joint hypermobility syndrome from a tertiary care military hospital in India

BACKGROUND AND AIMS

Joint hypermobility when associated with symptoms in the absence of systemic rheumatologic disease is termed as benign joint hypermobility syndrome (BJHS). BJHS is often an under-recognised and a poorly managed entity. Indian studies on BJHS are very few and none have been carried out in any of the service rheumatology centres. Hence this retrospective study was carried out at a tertiary medical institute of the Indian Army to assess the varied clinical profile of BJHS.

METHODS

All patients consecutively diagnosed as BJHS at the rheumatology clinic of the Army Hospital (Research and Referral) Delhi from May 2010 to May 2011 were included in the study. Their age, sex, presenting features, clinical profile, laboratory and radiological parameters were studied.

RESULTS

The mean age of these patients was 30 ± 5.71 years with a median duration of symptoms of 42 (06-120) months. There were 45 males and 39 females (male : female = 1.15 : 1.00). The median Beighton's score in these patients was 6/9 (range 4-9). Most of our patients were military personnel (43/84), and all had knee joint pain with evidence of degenerative changes in 19 and synovitis in two patients. Eleven patients including nine military personnel had evidence of soft tissue rheumatism with associated fibromyalgia in four and anxiety disorder in one. Out of 18 patients with a Beighton's score of ≥ 7, nine had incidental findings of lateral head tilt on frontal observation. There was evidence of carpal tunnel syndrome in a patient with wrist synovitis and one patient had associated skin laxity without features of Ehlers-Danlos syndrome.

CONCLUSION

BJHS is often under-recognized in clinical practice and is usually missed because of a lack of awareness. A high index of clinical suspicion to diagnose this entity is essential due to its associated morbidities, especially among those exposed to strenuous physical activities.

Are there anxious genes?

Anxiety comprises many clinical descriptions and phenotypes. A genetic predisposition to anxiety is undoubted; however, the nature and extent of that contribution is still unclear. Methods for the genetic analysis of such complex disorders is briefly reviewed, followed by a discussion of the comorbidity of anxiety with other psychiatric disorders and their possible common genetic etiology. Extensive genetic studies of the serotonin (5-hydroxytryptamine, 5-HT) transporter (5-HTT) gene have revealed how variation in gene expression can be correlated with anxiety phenotypes. Complete genome-wide linkage scans for panic disorder (PD) susceptibility genes have suggested a locus on chromosome arm 7p, and association studies have highlighted many candidate genes. A highly significant association between phobias, panic disorder, and a duplication at chromosomal region 15q24-26 is one of the most exciting findings to date. Emerging molecular genetic technologies and the use of increasingly sophisticated animal models of anxiety provide great promise for the future of the field.

Joint hypermobility, fears, and chocolate consumption

Our purpose was to evaluate joint hypermobility, an inherited disorder of the connective tissue significantly associated with anxiety disorders, in a sample of nonclinical students in relation to the frequency of severe fears and consumption of chocolate, coffee, cigarettes, and alcohol. One hundred fifty students completed the Hakim and Grahame Simple Questionnaire to detect hypermobility and the self-administered modified Wolpe Fear Scale (100 items). Severe fears and daily consumption of cigarettes, alcohol, coffee, and chocolate were compared with the hypermobility scores. We found significant differences when comparing severe fears between the groups with and without hypermobility (7.6 vs. 11; p = 0.001), reinforcing the hypothesis that the intensity of fears is greater in subjects with hypermobility. Only the frequency of chocolate intake was significantly higher among subjects with hypermobility (31.2% vs. 51.2%; p = 0.038) and may correspond to attempts of self-treatment of the collagen condition.

Does the association between mitral valve prolapse and panic disorder really exist?

OBJECTIVE

Although the possible relationship between panic disorder and mitral valve prolapse (MVP) attracted considerable research interest in the 1980s and 1990s, the reported prevalence of MVP in these patients has been inconsistent and widely variable. Clinical and epidemiologic studies have produced controversial data on possible association or definite causal relationship between these 2 entities. The primary objective of the present review was to summarize the current state of knowledge on the association between panic disorder and MVP, including the influence of diagnostic criteria for MVP on the controversial results.

DATA SOURCES

We searched MEDLINE, LILACS, and EMBASE databases using the keywords panic and mitral. Inclusion criteria were articles concerning the reciprocal association of MVP and panic disorder, published from the earliest dates available through December 2006.

STUDY SELECTION

All relevant articles published in English, Spanish, or Portuguese and reporting original data related to the association of MVP and panic disorder were included. Forty articles fulfilling the criteria for inclusion in this review were identified.

DATA SYNTHESIS

Even though the reported prevalence of MVP in panic disorder varied from 0% to 57%, a significant association between the 2 disorders was documented in 17 of the 40 studies. Such inconsistent results were due to sampling biases in case or control groups, widely different diagnostic criteria for MVP, and lack of reliability of MVP diagnosis. None of the reviewed studies used the current state-of-the-art diagnostic criteria for MVP to evaluate the volunteers. Apparently, the more elaborate the study methodology, the lower the chance to observe a significant relationship between these 2 conditions.

CONCLUSIONS

Published results are insufficient to definitely establish or to exclude an association between MVP and panic disorder. If any relationship does actually exist, it could be said to be infrequent and mainly occur in subjects with minor variants of MVP. To clarify this intriguing issue, future studies should mainly focus on the observed methodological biases and particularly should use the current criteria for MVP as the standard for evaluation.

Joint hypermobility syndrome is a risk factor trait for anxiety disorders: a 15-year follow-up cohort study

OBJECTIVE

The objective of the study was to assess whether joint hypermobility syndrome (JHS) is a risk factor for developing anxiety disorders using a 15-year prospective cohort study.

METHOD

The initial cohort recruited 158 subjects aged 16 to 20 years from the general population in a Spanish rural town. The cohort was studied at baseline and at a 15-year follow-up. Joint hypermobility syndrome was assessed using Beighton's criteria, and the psychiatric disorders were assessed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Disorders. Subjects with anxiety disorders at baseline were excluded from the follow-up.

RESULTS

Joint hypermobility syndrome at baseline was found in 29 of 158 subjects (21.1%). Cumulative incidence of panic/agoraphobia disorder at follow-up, as main diagnosis, was significantly higher for the JHS group (41.4%) than for the control group (1.9%), with a relative risk of 22.3 [95% confidence interval (CI) 4.6-108.7, P<.0001] (Number Needed to Treat [NNT] 3, 95% CI 2.9-2.3). Incidence of social phobia and simple phobia was also significantly higher for the JHS group [relative risk (RR)=6.52, 95% CI 1.7-24.2, P<.001 and RR=3.31, 95% CI 1.1-9.6, P=.02, respectively]. Moreover, anxiolytic drug use was nearly fourfold higher among JHS compared to non-JHS subjects.

CONCLUSION

Joint hypermobility syndrome was associated with higher risk of developing anxiety disorders. If replicated, these findings may give enhanced value to JHS assessment in clinical and general population studies.

Joint hypermobility and anxiety: the state of the art

Joint hypermobility (JH) is considered a common benign, hereditary, overlap, connective tissue disorder with a prevalence in the general population of about 10% in European populations and 25% in other ethnic groups. JH shows an association with mitral valve prolapse and fibromyalgia. However, the most significant and important association between joint hypermobility syndrome (JHS) and any other disorder from a clinical point of view is with panic disorder. This article summarizes all published studies on JHS and anxiety, analyzing the main results and limitations. An overview of the etiologic explanation of the association between JH and anxiety, with special focus on genetic findings, is also included. The most relevant conclusions are the following: JHS is more prevalent in individuals with panic disorder/agoraphobia, and patients with JHS present with greater prevalence of panic disorder/agoraphobia. In addition, there is an association between JHS severity and severity of anxiety, and mitral valve prolapse plays a secondary role in the association between JHS and anxiety. New fields of research based on these data are suggested.

Body shape and psychiatric diagnosis revisited

Abstract Introduction. Body shape has been aim of study by Medicine throughout centuries to find connections between shapes and illnesses. Methods. The objective of this systematic review was to understand the origin, as well as update empirical research, of body constitution. Results. The study of body constitution and of some other groups of physical signs (such as minor physical anomalies or joint hypermobility) provides insights into the biology of mental disorders that may result in a greater understanding of its aetiology, treatment, and prevention. Discussion. We discuss the role of body constitution in order to support psychiatric nosology, especially in differential diagnosis, through an overall or holistic "body and mind" perception.

Do hypermobile subjects without pain have alteration to the feedback mechanisms controlling the shoulder girdle?

OBJECTIVES

It has been reported that hypermobile subjects have proprioceptive deficits. However, it remains unclear whether pain-free subjects with hypermobility also have deficits.

METHODS

Ten subjects with hypermobility and nine without hypermobility were recruited following ethical approval and informed consent. Shoulder mobility, joint position sense (JPS) and a reflex of trapezius evoked from arm afferents were compared.

RESULTS

There was greater shoulder mobility in the hypermobile group (p = 0.004). There were no differences in shoulder JPS between the groups (p = 0.27), although, the hypermobile group displayed a larger degree of variability (p = 0.014). Finally, there were no differences in the latency of upper and lower trapezius reflexes evoked from arm afferents (p = 0.86 and 0.98, respectively).

CONCLUSIONS

In a group of people with hypermobility without shoulder problems, there was no difference in either shoulder JPS or reflex latency when compared with a non- hypermobile group. The relevance of pain to proprioceptive deficits is discussed.

Benign Joint Hypermobility Syndrome: Psychological Features and Psychopathological Symptoms in a Sample Pain-Free at Evaluation

30 subjects with BJHS (Hypermobile) ( M age = 32.3 yr., SD = 10.4) and two control groups, 25 healthy subjects (Healthy) ( M age = 33.9 yr., SD = 93) and 30 fibromyalgic patients (Fibromyalgic) ( M age = 32.2 yr., SD = 9.4), were given the Symptom Checklist-90-R, the Illness Behavior Questionnaire, the Female Functional Symptoms Frequency (FFF) and the Male Functional Symptoms Frequency (MFF), derived from the DSM-III–R, evaluating functional somatic disturbances and their intensity, and the Symptom Questionnaire. The mean scores for the Hypermobile group showed significant psychological distress and increased frequency and intensity of somatic symptoms. Scores on Anxiety and Somatic Symptoms, General Hypochondriasis, Disease Conviction, Affective Disturbance, Denial, and Irritability were significantly higher in the Hypermobile than in the Healthy group. Elevated scores were found for the Fibromyalgic group on the Illness Behavior Questionnaire subscales for Psychological vs Somatic Focus, Disease Affirmation, and Discriminating Factors when compared with the Hypermobile group. Considerable emotional symptoms were detected which should not be underestimated by physicians when establishing an integrated biopsychosocial therapy.

Hypermobility and the hypermobility syndrome

Hypermobile joints by definition display a range of movement that is considered excessive, taking into consideration the age, gender and ethnic background of the individual. Joint hypermobility, when associated with symptoms is termed the joint hypermobility syndrome or hypermobility syndrome (JHS). JHS is an under recognised and poorly managed multi-systemic, hereditary connective tissue disorder, often resulting in a great deal of pain and suffering. The condition is more prevalent in females, with symptoms frequently commencing in childhood and continuing on into adult life. This paper provides an overview of JHS and suggested clinical guidelines for both the identification and management of the condition, based on research evidence and clinical experience. The Brighton Criteria and a simple 5-point questionnaire developed by Hakim and Grahame, are both valid tools that can be used clinically and for research to identify the condition. Management of JHS frequently includes; education and lifestyle advice, behaviour modification, manual therapy, taping and bracing, electrotherapy, exercise prescription, functional rehabilitation and collaborative working with a range of medical, health and fitness professionals. Progress is often slow and hampered by physical and emotional setbacks. However with a carefully considered management strategy, amelioration of symptoms and independent functional fitness can be achieved.

Rhizarthrose juvénile bilatérale dans une laxité constitutionnelle

We report a rare case of major trapezometacarpal instability observed in a 31-year-old woman with congenital hyperlaxity. The patient presented major functional impotency of both thumbs, closure of the first commissure, and absence of effective opposition except between the lateral borders of the long fingers due to severe pain in the trapezometacarpal joint attributed to osteoarthritis. The patient underwent bilateral trapezectomy with ligamentoplasty. The gross examination of the trapezeal specimens revealed major cartilage destruction on the medial portion of the trapezeal joint surface. Three months after surgery, the patient was able to resume occupational and recreational activities. At one year, she was pain free with normal function. No other similar case could be identified in the literature and search for a pathological condition which could have contributed to the altered collagen was negative. It was observed that since stabilization was achieved by ligamentoplasty, recurrence should not be expected in congenital hyperlaxity if the tendons are unaffected.

Joint hypermobility and skin elasticity: the hereditary disorders of connective tissue

The hereditary disorders of connective tissues (HDCTs) encompass a spectrum of conditions linked pathophysiologically by abnormalities of collagen, fibrillin, and matrix proteins. The clinical picture ranges from morbidity because of musculoskeletal, skin, ocular and visceral pathologies to mortality from acute vascular collapse. For many of the conditions, there is a considerable overlap in clinical features, although severity varies; appreciating the subtle differences in presentation is vital to the clinician in determining the diagnosis. Though conditions associated with severe vascular pathology are rare, other hereditary disorders of connective tissues such as the joint hypermobility syndrome and Stickler's disease are common and probably underrecognized. Abnormal skin elasticity and scaring, joint hypermobility, and chronic arthralgia are important clues that should trigger the clinician to search for underlying hereditary disorders of connective tissues. In this article, we discuss the spectrum of clinical findings, management, and genetic screening of the more common hereditary disorders of connective tissues, highlighting their diagnostic criteria and their differences.

The relationship between frequency and intensity of fears and a collagen condition

Encouraged by the positive relationship between joint laxity and panic anxiety, our objective in this study was to compare widespread cultural fears in subjects with and without joint hypermobility syndrome and to assess whether this relationship is sustained for common fears as well. A sample consisting of 1,305 subjects from a rural town were assessed for joint hypermobility syndrome using Beighton's criteria. We assessed fear intensity and frequency using a modified version of the Fear Survey Schedule (FSS-III). Intense fears, defined with a score of 3-4, were compared between hypermobile and nonhypermobile subjects. The analysis was carried out separately for men and women. Nonparametric analysis was applied throughout. Joint hypermobility syndrome was found in 19.9% (141) of women and 6.9% (41) of men. Concerning the fear survey, when we compared the groups with and without joint hypermobility, the mean total scores for both genders were significantly higher for the hypermobile group. When we analyzed each item individually, 43 out of the 44 most severe fears in women and 36 out of the 39 in men, scores were significantly higher in the hypermobile group. We found significant differences between subjects with and without joint hypermobility when assessing specific fears, reinforcing the hypothesis that intensity of fears is greater in subjects with joint hypermobility syndrome. These results show that the association of joint laxity and phobic anxiety is sustained for intense fears and might represent a susceptibility factor for these anxiety conditions.

Anxiety and medical disorders

Anxiety symptoms and disorders are associated with a range of general medical disorders. This association may be a physiologic consequence of the general medical disorder, a psychologic reaction to the experience of having a medical illness, a side effect of treatment, or a chance occurrence. This article briefly reviews the associations of panic disorder with seizure disorder, Klüver-Bucy syndrome, mitral valve prolapse, and respiratory disorders; of generalized anxiety disorder with chronic obstructive airway disease and cardiovascular and endocrine disorders; of social anxiety disorder with Parkinson's disease; of obsessive-compulsive disorder with striatal disorders; and of posttraumatic stress disorder with head injury and pain. Such associations provide important clues for understanding the neurobiology of anxiety disorders.