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Bulbena A, Rosado S, Cabaleiro M, Martinez M, Baeza-Velasco C, Martin LM, Batlle S, Bulbena-Cabré A. Validation of the neuroconnective endophenotype questionnaire (NEQ): a new clinical tool for medicine and psychiatry resulting from the contribution of Ehlers-Danlos syndrome. Front Med (Lausanne) 2023; 10:1039223. [PMID: 37234249 PMCID: PMC10206165 DOI: 10.3389/fmed.2023.1039223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 03/22/2023] [Indexed: 05/27/2023] Open
Abstract
Introduction The link between anxiety disorders and joint hypermobility syndrome (now under hypermobility spectrum disorders, which include hypermobile Ehlers-Danlos syndrome) has been widely replicated over the past 30 years and has grown beyond the initial nosological limits. To integrate clinical and research progress in this field, a new neuroconnective endophenotype (NE) and its corresponding instrument, the Neuroconnective Endophenotype Questionnaire (NEQ), have been developed. This new clinical construct, created with the active participation of patients, includes both somatic and psychological dimensions and symptoms and resilience items. Methods The NE includes five dimensions: (1) sensorial sensitivity, (2) body signs and symptoms, (3) somatic conditions, (4) polar behavioral strategies, and (5) psychological and psychopathological dimensions. The NEQ information is collected through four self-administered questionnaires (sensorial sensitivity, body signs and symptoms, polar behavioral strategies, and psychological characteristics) and a structured diagnostic part that should be completed by a trained observer. This hetero-administered part incorporates (a) psychiatric diagnoses (using structured criteria, e.g., MINI), (b) somatic disorders diagnosis, using structured criteria, and (c) assessment of joint hypermobility criteria. Results In a sample of 36 anxiety cases with 36 matched controls, the NEQ obtained high scores for test-retest, inter-rater reliability, and internal consistency. As for predictive validity, cases and controls significantly differed in all five dimensions and hypermobility measurements. Discussion We can conclude that the NEQ has achieved acceptable reliability and validity values and, therefore, is ready to be used and tested in different samples. This original and consistent construct including somatic and mental items may improve clinical specificity, the search for more comprehensive therapies, and their genetic and neuroimaging bases.
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Affiliation(s)
- Antonio Bulbena
- Department of Psychiatry and Forensic Medicine, Universitat Autonoma Barcelona, Barcelona, Spain
- Anxiety Unit, Hospital del Mar, Institute Neuropsychiatry and Addictions (INAD) CIBERSAM, Barcelona, Spain
| | - Silvia Rosado
- Anxiety Unit, Hospital del Mar, Institute Neuropsychiatry and Addictions (INAD) CIBERSAM, Barcelona, Spain
- Doctorate Program in Psychiatry, Department of Psychiatry and Forensic Medicine, Universitat Autonoma Barcelona, Barcelona, Spain
| | - Marina Cabaleiro
- Department of Psychiatry and Forensic Medicine, Universitat Autonoma Barcelona, Barcelona, Spain
- Anxiety Unit, Hospital del Mar, Institute Neuropsychiatry and Addictions (INAD) CIBERSAM, Barcelona, Spain
| | - María Martinez
- Department of Psychiatry and Forensic Medicine, Universitat Autonoma Barcelona, Barcelona, Spain
- Anxiety Unit, Hospital del Mar, Institute Neuropsychiatry and Addictions (INAD) CIBERSAM, Barcelona, Spain
| | - Carolina Baeza-Velasco
- Laboratoire de Psychopathologie et Processus de Santé, Université Paris Cité, Paris, France
- Department of Emergency Psychiatry and Acute Care, CHU Montpellier, Montpellier, France
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Luis-Miguel Martin
- Anxiety Unit, Hospital del Mar, Institute Neuropsychiatry and Addictions (INAD) CIBERSAM, Barcelona, Spain
| | - Santiago Batlle
- Anxiety Unit, Hospital del Mar, Institute Neuropsychiatry and Addictions (INAD) CIBERSAM, Barcelona, Spain
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ARİFOĞLU KARAMAN Ç, ZEREN E, MARAL F, PARLAK M, KİRAZLI Ö, BORACI H, ZEREN M, ARİFOĞLU Y. The Effect of Hypermobility on Pain and Quality of Life in Young Adults. BEZMIALEM SCIENCE 2022. [DOI: 10.14235/bas.galenos.2022.55707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Carvalho HC, Machado NCSS, Yáñez-Silva A, Rocabado M, Júnior ARDP, Alves LP, Ribeiro W, Lazo-Osório RA. Autonomic nerve regulation in joint hypermobility patients with myofascial trigger points by Musculoskeletal Interfiber Counterirritant Stimulation (MICS). Med Eng Phys 2022; 109:103903. [DOI: 10.1016/j.medengphy.2022.103903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 09/14/2022] [Accepted: 10/04/2022] [Indexed: 11/11/2022]
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Kennedy M, Loomba K, Ghani H, Riley B. The psychological burden associated with Ehlers-Danlos syndromes: a systematic review. J Osteopath Med 2022; 122:381-392. [PMID: 35420002 DOI: 10.1515/jom-2021-0267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 03/16/2022] [Indexed: 11/15/2022]
Abstract
CONTEXT Ehlers-Danlos syndromes (EDS) are disorders of connective tissue that lead to a wide range of clinical presentations. While we are beginning to understand the association between EDS and psychological manifestations, it is critical that we further elucidate the relationship between the two. Understanding the correlation between EDS and mental health will better ensure swift diagnosis and effective treatment for patients. OBJECTIVES This study aims to systematically examine and report the prevalence of psychiatric disorders in the EDS population. METHODS The PubMed database was searched on June 14, 2021 for articles published from January 2011 to June 2021. We included original, evidence-based, peer-reviewed journal articles in English that reported information on psychiatric disorders among EDS patients. Psychiatric disorders and psychological conditions were limited to those included in the "psychology" and "mental disorders" Medical Subject Headings (MeSH) search terms defined by the National Library of Medicine. Publications identified utilizing this search strategy by M.K. were imported into the Covidence system, where they first underwent a title and abstract screening process by three independent reviewers (M.K., K.L., H.G.). During the full-text review, two independent reviewers read the full text of the questionable articles to assess their eligibility for inclusion. Studies were excluded if they did not meet our target objective or if they were not in English or if they were opinion pieces, conference abstracts, or review articles. Data were extracted from the shortlisted studies by reviewers. During the data extraction phase, the quality and risk of publication bias were assessed by two independent reviewers utilizing the National Institutes of Health (NIH) Study Quality Assessment Tools. Any disagreements in study selection, data extraction, or quality assessment were adjudicated via discussion between the two reviewers, utilizing a third reviewer as a decider if necessary. RESULTS Out of 73 articles identified, there were no duplicates. A total of 73 records were screened, but only 40 articles were assessed in full text for eligibility. A total of 23 articles were ultimately included, which collectively discussed 12,298 participants. Ten (43.5%) of the included studies were cross-sectional in design, three (13.0%) were case reports, and three (13.0%) were retrospective chart reviews. The remaining seven (30.4%) articles were either case-control, cohort, qualitative, controlled observational, or validation studies. Twelve (52.2%) of the studies reported data on depression disorders, six of which reported prevalence data. Nine (39.1%) of the studies reported data on anxiety disorders, five of which reported prevalence data. Studies that reported nonprevalence data presented odds-ratio, mean scores on psychiatric evaluations, and other correlation statistics. Psychiatric disorders that were most reported in these articles were mood disorders (n=11), anxiety disorders (n=9), and neurodevelopmental disorders (n=7). Although the reports varied, the highest psychiatric prevalence reports in EDS patients involved language disorders (63.2%), attention-deficit/hyperactivity disorder (ADHD) (52.4%), anxiety (51.2%), learning disabilities (42.4%), and depression (30.2%). CONCLUSIONS Although mood disorders were cited in more articles, the highest reported prevalence was for language disorders and ADHD. This discrepancy highlights the importance of performing more research to better understand the relationship between EDS and psychiatric disorders.
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Affiliation(s)
- Matthew Kennedy
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | - Katherine Loomba
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | - Hira Ghani
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | - Bernadette Riley
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
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Pandey S, Chouksey A, Pitakpatapee Y, Srivanitchapoom P. Movement Disorders and Musculoskeletal System: A Reciprocal Relationship. Mov Disord Clin Pract 2021; 9:156-169. [DOI: 10.1002/mdc3.13390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/28/2021] [Accepted: 12/01/2021] [Indexed: 11/09/2022] Open
Affiliation(s)
- Sanjay Pandey
- Department of Neurology Govind Ballabh Pant Postgraduate Institute of Medical Education and Research New Delhi India
| | - Anjali Chouksey
- Department of Neurology Christian Medical College Vellore India
| | - Yuvadee Pitakpatapee
- Department of Medicine, Division of Neurology, Faculty of Medicine, Siriraj Hospital Mahidol University Bangkok Thailand
| | - Prachaya Srivanitchapoom
- Department of Medicine, Division of Neurology, Faculty of Medicine, Siriraj Hospital Mahidol University Bangkok Thailand
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Davies G, Csecs JLL, Ball H, Dare J, Bremner S, Hosking R, Critchley HD, Grey N, Eccles JA. Altering Dynamics of Autonomic Processing Therapy (ADAPT) trial: a novel, targeted treatment for reducing anxiety in joint hypermobility. Trials 2021; 22:645. [PMID: 34548065 PMCID: PMC8453027 DOI: 10.1186/s13063-021-05555-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/18/2021] [Indexed: 11/15/2022] Open
Abstract
Background Hypermobility is a poorly recognised and understood musculoskeletal disorder thought to affect around 20% of the population. Hypermobility is associated with reduced physiological and psychological functioning and quality of life and is a known risk factor for the development of an anxiety disorder. To date, no evidence-based, targeted treatment for anxiety in the context of hypermobility exists. The present intervention (ADAPT—Altering Dynamics of Autonomic Processing Therapy) is a novel therapy combining bio-behavioural training with cognitive approaches from clinical health psychology targeting the catastrophisation of internal sensations, with aim to improve autonomic trait prediction error. Method Eighty individuals with diagnosed hypermobility will be recruited and the efficacy of ADAPT to treat anxiety will be compared to an Emotion-Focused Supportive Therapy (EFST) comparator therapy in a randomised controlled trial. The primary treatment target will be post therapy score on the Beck Anxiety Inventory, and secondary outcomes will also be considered in relation to interoception, depression, alexithymia, social and work adjustment, panic symptoms and dissociation. Due to COVID restrictions, the intervention will be moved to online delivery and qualitative assessment of treatment tolerance to online therapy will also be assessed. Discussion Online delivery of an intervention targeting anxiety would improve the quality of life for those experiencing anxiety disorder and help to reduce the £11.7 billion that anxiety disorders cost the UK economy annually. Trial registration World Health Organization ISRCTN17018615. Registered on 20th February 2019; trial protocol version 2
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Affiliation(s)
- Geoff Davies
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Falmer, UK.,Sussex Partnership NHS Foundation Trust, Worthing, UK
| | - Jenny L L Csecs
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Falmer, UK.,Sussex Partnership NHS Foundation Trust, Worthing, UK
| | - Heather Ball
- Sussex Partnership NHS Foundation Trust, Worthing, UK
| | - Jess Dare
- Sussex Community NHS Foundation Trust, Brighton, UK
| | - Stephen Bremner
- Brighton and Sussex Clinical Trials Unit, Brighton & Sussex Medical School, Falmer, UK
| | - Robin Hosking
- Sussex Partnership NHS Foundation Trust, Worthing, UK
| | - Hugo D Critchley
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Falmer, UK.,Sussex Partnership NHS Foundation Trust, Worthing, UK
| | - Nick Grey
- Sussex Partnership NHS Foundation Trust, Worthing, UK.,School of Psychology, University of Sussex, Falmer, UK
| | - Jessica A Eccles
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Falmer, UK. .,Sussex Partnership NHS Foundation Trust, Worthing, UK. .,Trafford Centre for Medical Research, University of Sussex, Falmer, BN1 9RY, UK.
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Broida SE, Sweeney AP, Gottschalk MB, Wagner ER. Management of shoulder instability in hypermobility-type Ehlers-Danlos syndrome. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:155-164. [PMID: 37588970 PMCID: PMC10426500 DOI: 10.1016/j.xrrt.2021.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
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.
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Affiliation(s)
- Samuel E. Broida
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Aidan P. Sweeney
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | | | - Eric R. Wagner
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
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The Prevalence of Mitral Valve Prolapse in Panic Disorder: A Meta-Analysis. PSYCHOSOMATICS 2019; 60:393-401. [DOI: 10.1016/j.psym.2018.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 10/24/2018] [Accepted: 10/24/2018] [Indexed: 01/04/2023]
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Bulbena-Cabre A, Duñó L, Almeda S, Batlle S, Camprodon-Rosanas E, Martín-Lopez LM, Bulbena A. Joint hypermobility is a marker for anxiety in children. REVISTA DE PSIQUIATRIA Y SALUD MENTAL 2019; 12:68-76. [PMID: 30926372 DOI: 10.1016/j.rpsm.2019.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/12/2018] [Accepted: 01/09/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Joint hypermobility syndrome (JHS) has been found to be associated with anxiety disorders in clinical and nonclinical populations, but to date no studies have evaluated this association in children. The main goal of this study is to evaluate JHS along with anxiety, somatic and behavioral measures in children to clarify if JHS is associated with any of these variables in this age range. METHODS A sample of 160 children (74 girls and 86 boys) ranging from 5 to 17 o were recruited from a Child-Adolescent Mental Health clinic to participate in the study. All children underwent a diagnostic interview using the Mini International Neuropsychiatric Interview for Children and Adolescents. Instruments used include the Child Behavior Checklist (CBCL), the Screening Questionnaire to detect Hypermobility (SQ-CH) and the Children Manifested Anxiety Scale (CMAS-R). RESULTS The prevalence of JHS in this sample was 22%, and this was significantly higher in girls (31%) than in boys (14%) (χ2=6.83; P=.001). The JHS group scored significantly higher in the CMAS-R total anxiety (F=4.51; P=.035), CMAS-R Physiological anxiety (F=7.19; P=.008) and the CBCL somatic complaints (F=8.46; 0.004) and regression analyses showed that these 3 variables were predictors of JHS (χ2=36.77; P<.001; r2=0.22). The JHS group also scored higher in some behavioral measures. CONCLUSION Children with JHS have higher frequency of anxiety disorders and higher intensity of physiological anxiety, somatic complaints, and therefore, JHS might be used as marker for this anxiety phenotype in youngsters.
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Affiliation(s)
- Andrea Bulbena-Cabre
- Universidad Autónoma de Barcelona, Departamento de Psiquiatría y Medicina Forense (UAB), España; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, EE. UU.; Department of Psychiatry, New York Medical College, Nueva York, EE. UU.
| | - Lourdes Duñó
- Mar Health Park, Instituto de Neuropsiquiatría y Adicciones (INAD), Barcelona, España
| | - Sara Almeda
- Mar Health Park, Instituto de Neuropsiquiatría y Adicciones (INAD), Barcelona, España
| | - Santiago Batlle
- Mar Health Park, Instituto de Neuropsiquiatría y Adicciones (INAD), Barcelona, España
| | - Ester Camprodon-Rosanas
- Children and Adolescent Mental Health Research Group. Institut de Recerca Sant Joan de Déu Child and Adolescent Psychiatry and Psychology Department of Hospital Sant Joan de Déu of Barcelona, Spain
| | - Luis Miguel Martín-Lopez
- Universidad Autónoma de Barcelona, Departamento de Psiquiatría y Medicina Forense (UAB), España; Mar Health Park, Instituto de Neuropsiquiatría y Adicciones (INAD), Barcelona, España; Centro de Investigación en red de Salud Mental (CIBERSAM), España
| | - Antonio Bulbena
- Universidad Autónoma de Barcelona, Departamento de Psiquiatría y Medicina Forense (UAB), España; Mar Health Park, Instituto de Neuropsiquiatría y Adicciones (INAD), Barcelona, España; Centro de Investigación en red de Salud Mental (CIBERSAM), España
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Both anxiety and joint laxity determine the olfactory features in panic disorder. Psychiatry Res 2018; 262:420-426. [PMID: 28923431 DOI: 10.1016/j.psychres.2017.09.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 07/26/2017] [Accepted: 09/08/2017] [Indexed: 12/23/2022]
Abstract
Previous research showed a high sensitivity in sensorial modalities in panic disorder (PD). This disorder has been consistently associated to the joint hypermobility syndrome (JHS). In non-clinical samples, this collagen alteration has been also related to an enhanced sensitivity in some sensorial modalities. The main aim of this study is to explore the olfactory functioning in PD in relation to JHS. Sixty patients with PD and sixty healthy controls performed the Sniffin' Sticks Test (SST) (threshold subtest), and completed the Affective Impact of Odors scale (AIO), the Relational Scale of Olfaction (EROL), and the Odor Awareness Scale (OAS). Clinical symptom rating scales and JHS assessment were also obtained. PD patients showed enhanced odor acuity, greater reactivity to smells and also increased odor awareness compared to the healthy controls. Within the patients group, those suffering from JHS displayed higher functioning in all olfactory domains compared to the non-JHS ones. The JHS and anxiety measures emerged as predictor variables of the olfactory function. The present findings highlight the importance of the olfactory function in PD and underline that both, JHS and anxiety, determine the olfactory characteristics in this disorder.
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Baeza-Velasco C, Bulbena A, Polanco-Carrasco R, Jaussaud R. Cognitive, emotional, and behavioral considerations for chronic pain management in the Ehlers–Danlos syndrome hypermobility-type: a narrative review. Disabil Rehabil 2018; 41:1110-1118. [DOI: 10.1080/09638288.2017.1419294] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Carolina Baeza-Velasco
- Laboratory of Psychopathology and Health Processes, University Paris Descartes - Sorbonne Paris Cité, Boulogne Billancourt, France
- Inserm U1061, La Colombière Hospital, Montpellier, France
| | - Antonio Bulbena
- Department of Psychiatry, Autonoma University of Barcelona, Barcelona, Spain
| | | | - Roland Jaussaud
- Department of Internal Medicine and Clinical Immunology, Medicine School, University of Lorraine, CHRU Nancy, Nancy, France
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Bulbena-Cabré A, Rojo C, Pailhez G, Buron Maso E, Martín-Lopez LM, Bulbena A. Joint hypermobility is also associated with anxiety disorders in the elderly population. Int J Geriatr Psychiatry 2018; 33:e113-e119. [PMID: 28543732 DOI: 10.1002/gps.4733] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 04/05/2017] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Andrea Bulbena-Cabré
- Department of Psychiatry and Forensic Medicine (UAB), Autonomous University of Barcelona, Barcelona, Spain.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,VA Bronx Health Care System, Mental Illness Research Education and Clinical Centers, New York, NY, USA.,Doctorate Program, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Conxita Rojo
- Department of Psychiatry and Forensic Medicine (UAB), Autonomous University of Barcelona, Barcelona, Spain
| | - Guillem Pailhez
- Department of Psychiatry and Forensic Medicine (UAB), Autonomous University of Barcelona, Barcelona, Spain.,Mar Health Park, Neuropsychiatry and Drug Addiction Institute (INAD), Barcelona, Spain
| | - Emma Buron Maso
- Department of Psychiatry and Forensic Medicine (UAB), Autonomous University of Barcelona, Barcelona, Spain.,Doctorate Program, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Luis Miguel Martín-Lopez
- Department of Psychiatry and Forensic Medicine (UAB), Autonomous University of Barcelona, Barcelona, Spain.,Mar Health Park, Neuropsychiatry and Drug Addiction Institute (INAD), Barcelona, Spain.,Centro de Investigación en red de Salud Mental, (CIBERSAM), Spain
| | - Antonio Bulbena
- Department of Psychiatry and Forensic Medicine (UAB), Autonomous University of Barcelona, Barcelona, Spain.,Mar Health Park, Neuropsychiatry and Drug Addiction Institute (INAD), Barcelona, Spain.,Centro de Investigación en red de Salud Mental, (CIBERSAM), Spain
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Bulbena A, Baeza-Velasco C, Bulbena-Cabré A, Pailhez G, Critchley H, Chopra P, Mallorquí-Bagué N, Frank C, Porges S. Psychiatric and psychological aspects in the Ehlers-Danlos syndromes. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2017; 175:237-245. [PMID: 28186381 DOI: 10.1002/ajmg.c.31544] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
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.
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Cederlöf M, Larsson H, Lichtenstein P, Almqvist C, Serlachius E, Ludvigsson JF. Nationwide population-based cohort study of psychiatric disorders in individuals with Ehlers-Danlos syndrome or hypermobility syndrome and their siblings. BMC Psychiatry 2016; 16:207. [PMID: 27377649 PMCID: PMC4932739 DOI: 10.1186/s12888-016-0922-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 06/14/2016] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Martin Cederlöf
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, 17177, Sweden.
| | - Henrik Larsson
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, 17177 Sweden
| | - Paul Lichtenstein
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, 17177 Sweden
| | - Catarina Almqvist
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, 17177 Sweden ,Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Serlachius
- Department of Clinical Neuroscience, Karolinska Institutet, Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Jonas F. Ludvigsson
- Department Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, 17177 Sweden ,Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden ,Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK ,Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY USA
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15
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Abstract
Anxiety and somatic symptoms have a high prevalence in the general population. A mechanistic understanding of how different factors contribute to the development and maintenance of these symptoms, which are highly associated with anxiety disorders, is crucial to optimize treatments. In this article, we review recent literature on this topic and present a redefined model of mind-body interaction in anxiety and somatic symptoms, with an emphasis on both bottom-up and top-down processes. Consideration is given to the role played in this interaction by predisposing physiological and psychological traits (e.g., interoception, anxiety sensitivity, and trait anxiety) and to the levels at which mindfulness approaches may exert a therapeutic benefit. The proposed model of mind-body interaction in anxiety and somatic symptoms is appraised in the context of joint hypermobility syndrome, a constitutional variant associated with autonomic abnormalities and vulnerability to anxiety disorders.
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Knight I. The role of narrative medicine in the management of joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2015; 169C:123-9. [PMID: 25821096 DOI: 10.1002/ajmg.c.31428] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type (JHS/EDS-HT) is a hereditary connective tissue disorder affecting every bodily system. It is largely underdiagnosed by many practitioners, with the result of a considerable delay in diagnosis and, consequently, in the onset of adequate management schedule and treatment. Patients may also experience to be misbelieved, erroneously considered affected by a psychiatric or psychosomatic disorders, and rejected by the medical profession, which can lead to feelings of anger and resentment. Patient journeys are often long and complicated, but if doctors allowed the patient time to tell the full story, and were more prepared to think holistically, there may be a far more positive outcome. Here, the patients' perspective is presented with a narrative medicine approach, illustrating the tri-dimensional experience of a JHS/EDS-HT patient, who is also a Bowen Practitioner and a medical writer/educator. Narrative medicine would be invaluable in working with JHS/EDS-HT so that the patient can tell the story, and offer the practitioner a whole picture of her/his suffering and, often, the key for understanding the cause(s). Once this has been achieved, it might be possible to build upon a more positive and therapeutic dialogue which would result in better treatment and more effective management. It is also important for doctors to communicate with JHS/EDS-HT experts who will ultimately improve the patient journey and treatment outcomes of such a complex connective tissue disorder.
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Sinibaldi L, Ursini G, Castori M. Psychopathological manifestations of joint hypermobility and joint hypermobility syndrome/ Ehlers-Danlos syndrome, hypermobility type:The link between connective tissue and psychological distress revised. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2015; 169C:97-106. [DOI: 10.1002/ajmg.c.31430] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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18
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Eccles JA, Owens AP, Mathias CJ, Umeda S, Critchley HD. Neurovisceral phenotypes in the expression of psychiatric symptoms. Front Neurosci 2015; 9:4. [PMID: 25713509 PMCID: PMC4322642 DOI: 10.3389/fnins.2015.00004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 01/05/2015] [Indexed: 12/01/2022] Open
Abstract
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.
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Affiliation(s)
- Jessica A Eccles
- Psychiatry, Brighton and Sussex Medical School Brighton, UK ; Sussex Partnership National Health Service Foundation Trust Brighton, UK
| | - Andrew P Owens
- National Hospital Neurology and Neurosurgery, UCL National Health Service Trust London, UK ; Institute of Neurology, University College London London, UK
| | - Christopher J Mathias
- National Hospital Neurology and Neurosurgery, UCL National Health Service Trust London, UK ; Institute of Neurology, University College London London, UK
| | - Satoshi Umeda
- National Hospital Neurology and Neurosurgery, UCL National Health Service Trust London, UK ; Department of Psychology, Keio University Tokyo, Japan
| | - Hugo D Critchley
- Psychiatry, Brighton and Sussex Medical School Brighton, UK ; Sussex Partnership National Health Service Foundation Trust Brighton, UK ; Sackler Centre for Consciousness Science, University of Sussex Falmer, UK
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Baeza-Velasco C, Pailhez G, Bulbena A, Baghdadli A. Joint hypermobility and the heritable disorders of connective tissue: clinical and empirical evidence of links with psychiatry. Gen Hosp Psychiatry 2015; 37:24-30. [PMID: 25459977 DOI: 10.1016/j.genhosppsych.2014.10.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 09/14/2014] [Accepted: 10/07/2014] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Carolina Baeza-Velasco
- Department of Child and Adolescent Psychiatry, CHU Montpellier, France; Institut de Psychologie, Université Paris Descartes, Sorbonne Paris Cité, France.
| | - Guillem Pailhez
- Anxiety Unit-Institut de Neuropsiquiatria i Addicions (INAD), Hospital del Mar, Barcelona, Spain; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Antonio Bulbena
- Anxiety Unit-Institut de Neuropsiquiatria i Addicions (INAD), Hospital del Mar, Barcelona, Spain; Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Amaria Baghdadli
- Department of Child and Adolescent Psychiatry, CHU Montpellier, France; Laboratory Epsylon (EA 4556), University of Montpellier, France
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Sanches SB, Osório FL, Louzada-Junior P, Moraes D, Crippa JAS, Martín-Santos R. Association between joint hypermobility and anxiety in Brazilian university students: gender-related differences. J Psychosom Res 2014; 77:558-61. [PMID: 25219975 DOI: 10.1016/j.jpsychores.2014.08.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 08/23/2014] [Accepted: 08/26/2014] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- S B Sanches
- Neuroscience and Behavior Department, Faculty of Medicine of Ribeirão Preto - University of São Paulo, Brazil; Departments of Psychiatry and Psychology, Hospital Clínic, University of Barcelona, Institut d'Investigació Biomèdiques August Pi I Sunyer (IDIBAPS), CIBERSAM, Barcelona, Catalonia, Spain.
| | - F L Osório
- Neuroscience and Behavior Department, Faculty of Medicine of Ribeirão Preto - University of São Paulo, Brazil
| | - P Louzada-Junior
- Division of Clinical Immunology, Center for Research in Inflammatory Disease, Faculty of Medicine of Ribeirão Preto - University of São Paulo, Brazil
| | - D Moraes
- Division of Clinical Immunology, Center for Research in Inflammatory Disease, Faculty of Medicine of Ribeirão Preto - University of São Paulo, Brazil
| | - J A S Crippa
- Neuroscience and Behavior Department, Faculty of Medicine of Ribeirão Preto - University of São Paulo, Brazil
| | - R Martín-Santos
- Departments of Psychiatry and Psychology, Hospital Clínic, University of Barcelona, Institut d'Investigació Biomèdiques August Pi I Sunyer (IDIBAPS), CIBERSAM, Barcelona, Catalonia, Spain
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Sanches SB, Oliveira GM, Osório FL, Crippa JAS, Martín-Santos R. Hypermobility and joint hypermobility syndrome in Brazilian students and teachers of ballet dance. Rheumatol Int 2014; 35:741-7. [PMID: 25218649 DOI: 10.1007/s00296-014-3127-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 09/03/2014] [Indexed: 11/29/2022]
Abstract
The current literature has been discussing the risks and benefits of joint hypermobility (JHM) for careers in ballet This study aimed to evaluate the prevalence of JHM and joint hypermobility syndrome (JHS) in a group of ballet teachers and students, looking both at aspects related to the flexibility required to dance, as at the risk of injuries when hypermobility is associated with other symptoms, in the case of JHS. We evaluated ballet teachers and ballet students, with age ranging from 18 to 40 years. All participants completed identification and sociodemographic questionnaires and underwent a physical examination. JHM was assessed using the Beighton score with goniometry. Symptoms of JHS were evaluated according to the Brighton criteria. Final sample consisted of 77 participants, being 44 ballet students and 33 ballet teachers. The prevalence of JHM in the sample as a whole was 58 %. Teachers and students had no significant differences regarding the prevalence of JHM (p = 0.74) (OR 1.21; 95 % CI 0.48-3.07). However, the prevalence of JHS was significantly different (p = 0.04) between students (16 %) and teachers (36 %). Teachers were three times more likely than student to have JHS (OR 3.02; 95 % CI 1.03-8.85). Teachers and students also presented differences in the frequency of specific items of Beighton score and Brighton criteria. These data provide elements to discuss the relationship between hypermobility, ballet technique and selection for dance, suggesting that dancers with JHS could find in ballet teaching an alternative to maintain professional activity with dance, while remaining protected from the higher risk of injury that professional dancers may be exposed to.
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Affiliation(s)
- S B Sanches
- Department of Neuroscience and Behavior, Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo, Terceiro Andar, Av. Bandeirantes, 3900, Ribeirão Preto, São Paulo, 14049-800, Brazil,
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Pailhez G, Rosado S, Baeza-Velasco C, Bulbena A. Ectomorphic somatotype and joint hypermobility are linked in panic and agoraphobic patients: a case-control study. Int J Psychiatry Clin Pract 2014; 18:112-7. [PMID: 24527884 DOI: 10.3109/13651501.2014.894074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Guillem Pailhez
- Anxiety Unit - Institut de Neuropsiquiatria i Addicions (INAD), Hospital del Mar , Barcelona , Spain
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23
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Is pain the only symptom in patients with benign joint hypermobility syndrome? Clin Rheumatol 2014; 34:1613-9. [DOI: 10.1007/s10067-014-2610-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 03/30/2014] [Accepted: 04/02/2014] [Indexed: 12/22/2022]
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Abstract
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.
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Pasquini M, Celletti C, Berardelli I, Roselli V, Mastroeni S, Castori M, Biondi M, Camerota F. Unexpected association between joint hypermobility syndrome/Ehlers–Danlos syndrome hypermobility type and obsessive–compulsive personality disorder. Rheumatol Int 2013; 34:631-6. [DOI: 10.1007/s00296-013-2901-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Accepted: 11/06/2013] [Indexed: 12/20/2022]
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26
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Smith TO, Easton V, Bacon H, Jerman E, Armon K, Poland F, Macgregor AJ. The relationship between benign joint hypermobility syndrome and psychological distress: a systematic review and meta-analysis. Rheumatology (Oxford) 2013; 53:114-22. [DOI: 10.1093/rheumatology/ket317] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Bulbena-Cabré A, Pailhez G, Bulbena A. Joint hypermobility links with anxiety: history and present. ACTA ACUST UNITED AC 2013. [DOI: 10.1179/175361511x13153160075017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Rietveld ABM, Macfarlane JD, de Haas GJF. Some thoughts on the prevention of complaints in musicians and dancers. Clin Rheumatol 2013; 32:449-52. [DOI: 10.1007/s10067-013-2195-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Accepted: 01/25/2013] [Indexed: 11/30/2022]
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Hypermobility in dance: asset, not liability. Clin Rheumatol 2013; 32:455-61. [DOI: 10.1007/s10067-013-2191-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Accepted: 01/25/2013] [Indexed: 11/25/2022]
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Sanches SHB, Osório FDL, Udina M, Martín-Santos R, Crippa JAS. Anxiety and joint hypermobility association: a systematic review. REVISTA BRASILEIRA DE PSIQUIATRIA (SAO PAULO, BRAZIL : 1999) 2013; 34 Suppl 1:S53-60. [PMID: 22729449 DOI: 10.1590/s1516-44462012000500005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- Simone H Bianchi Sanches
- Neurosciences and Behavior Department, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Brazil.
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31
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Abstract
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.
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Bianchi Sanches SH, Osório FDL, Udina M, Martín-Santos R, Crippa JAS. Anxiety and joint hypermobility association: a systematic review. BRAZILIAN JOURNAL OF PSYCHIATRY 2012. [DOI: 10.1016/s1516-4446(12)70054-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Kassavetis P, Batla A, Pareés I, Saifee TA, Schrag A, Cordivari C, Bhatia KP, Edwards MJ. Joint hypermobility syndrome: A risk factor for fixed dystonia? Mov Disord 2012; 27:1070. [DOI: 10.1002/mds.25004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2012] [Revised: 03/02/2012] [Accepted: 03/14/2012] [Indexed: 11/08/2022] Open
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Abstract
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.
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Filho AS, Maciel BC, Martín-Santos R, Romano MMD, Crippa JA. Does the association between mitral valve prolapse and panic disorder really exist? PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2011; 10:38-47. [PMID: 18311420 DOI: 10.4088/pcc.v10n0107] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2007] [Accepted: 06/13/2007] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Alaor Santos Filho
- Department of Neuropsychiatry and Medical Psychology, School of Medicine of Ribeirão Preto, São Paulo University, Brazil
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Baeza-Velasco C, Gely-Nargeot MC, Vilarrasa AB, Fenetrier C, Bravo JF. Association between psychopathological factors and joint hypermobility syndrome in a group of undergraduates from a French university. Int J Psychiatry Med 2011; 41:187-201. [PMID: 21675349 DOI: 10.2190/pm.41.2.g] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To explore the frequency of Joint Hypermobility Syndrome (JHS) among university students and assess whether a relationship exists between this collagen condition and certain psychological variables. METHOD A cross-sectional sample of 365 undergraduates at a French university was assessed with the Brighton's criteria for JHS, Somatosensory Amplification Scale (SSAS), Liebowitz Social Anxiety Scale (LSAS), and Hospital Anxiety and Depression Scale (HADS). RESULTS 39.5% of the participants met Brighton's criteria for JHS. Scores of somatosensory amplification were higher among participants with JHS (t = -2.98; p = 0.03) independent of gender. Female participants with JHS had higher scores in depression (t = -2.01; p = 0.04) and general anxiety (t = -2.35; p = 0.01) than women without JHS. The percentage of males with a medium/high level of social anxiety was greater among participants with JHS (78.6% vs. 41.7%; chi2 = 6.18;p = 0.01). Logistic regression demonstrated that male sex and low level of somatosensory amplification are variables contrary to the presence of JHS. CONCLUSION JHS is a frequent condition among young people evaluated. JHS is associated with psychological distress and higher levels of somatosensory amplification.
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Joint hypermobility syndrome is a risk factor trait for anxiety disorders: a 15-year follow-up cohort study. Gen Hosp Psychiatry 2011; 33:363-70. [PMID: 21762833 DOI: 10.1016/j.genhosppsych.2011.03.004] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 03/04/2011] [Accepted: 03/07/2011] [Indexed: 11/21/2022]
Abstract
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.
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Baeza-Velasco C, Gély-Nargeot MC, Bulbena Vilarrasa A, Bravo JF. Joint hypermobility syndrome: problems that require psychological intervention. Rheumatol Int 2011; 31:1131-6. [DOI: 10.1007/s00296-011-1839-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Accepted: 02/18/2011] [Indexed: 11/29/2022]
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Abstract
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.
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Bendik EM, Tinkle BT, Al-shuik E, Levin L, Martin A, Thaler R, Atzinger CL, Rueger J, Martin VT. Joint hypermobility syndrome: A common clinical disorder associated with migraine in women. Cephalalgia 2011; 31:603-13. [DOI: 10.1177/0333102410392606] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Preliminary studies suggested that headache disorders are more common in patients with joint hypermobility syndrome (JHS). The objectives of this study were to determine if the prevalence, frequency, and disability of migraine differ between female patients with JHS and a control population. Twenty-eight patients with JHS and 232 controls participated in the case-cohort study. Participants underwent a structured verbal interview and were assigned a diagnosis of migraine based on criteria of the International Classification of Headache Disorders, 2nd Edition. The primary outcome measures were the prevalence, frequency, and headache-related disability of migraine. Logistic regression was used for the prevalence analysis and Poisson regression for the frequency and disability analyses. Results indicated that the prevalence of migraine was 75% in JHS patients and 43% in controls. The adjusted odds ratio for the prevalence of migraine was 3.19 (95% CI 1.24, 8.21] in JHS patients. The rate ratios for migraine frequency and headache-related disability were 1.67 (95% CI 1.01, 2.76) and 2.99 (95% CI 1.66, 5.38), respectively, for JHS patients. Our study suggests that JHS is a clinical disorder strongly associated with an increased prevalence, frequency, and disability of migraine in females.
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Affiliation(s)
| | - Brad T Tinkle
- University of Cincinnati College of Medicine, USA
- Cincinnati Children’s, Hospital, USA
| | | | - Linda Levin
- University of Cincinnati College of Medicine, USA
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Abstract
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.
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Association entre anxiété et hyperlaxité articulaire : revue de la littérature. ANNALES MEDICO-PSYCHOLOGIQUES 2010. [DOI: 10.1016/j.amp.2009.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Zarate N, Farmer AD, Grahame R, Mohammed SD, Knowles CH, Scott SM, Aziz Q. Unexplained gastrointestinal symptoms and joint hypermobility: is connective tissue the missing link? Neurogastroenterol Motil 2010; 22:252-e78. [PMID: 19840271 DOI: 10.1111/j.1365-2982.2009.01421.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Unexplained gastrointestinal (GI) symptoms and joint hypermobility (JHM) are common in the general population, the latter described as benign joint hypermobility syndrome (BJHS) when associated with musculo-skeletal symptoms. Despite overlapping clinical features, the prevalence of JHM or BJHS in patients with functional gastrointestinal disorders has not been examined. METHODS The incidence of JHM was evaluated in 129 new unselected tertiary referrals (97 female, age range 16-78 years) to a neurogastroenterology clinic using a validated 5-point questionnaire. A rheumatologist further evaluated 25 patients with JHM to determine the presence of BJHS. Groups with or without JHM were compared for presentation, symptoms and outcomes of relevant functional GI tests. KEY RESULTS Sixty-three (49%) patients had evidence of generalized JHM. An unknown aetiology for GI symptoms was significantly more frequent in patients with JHM than in those without (P < 0.0001). The rheumatologist confirmed the clinical impression of JHM in 23 of 25 patients, 17 (68%) of whom were diagnosed with BJHS. Patients with co-existent BJHS and GI symptoms experienced abdominal pain (81%), bloating (57%), nausea (57%), reflux symptoms (48%), vomiting (43%), constipation (38%) and diarrhoea (14%). Twelve of 17 patients presenting with upper GI symptoms had delayed gastric emptying. One case is described in detail. CONCLUSIONS & INFERENCES In a preliminary retrospective study, we have found a high incidence of JHM in patients referred to tertiary neurogastroenterology care with unexplained GI symptoms and in a proportion of these a diagnosis of BJHS is made. Symptoms and functional tests suggest GI dysmotility in a number of these patients. The possibility that a proportion of patients with unexplained GI symptoms and JHM may share a common pathophysiological disorder of connective tissue warrants further investigation.
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Affiliation(s)
- N Zarate
- Neurogastroenterology Group, Centre for Digestive Diseases, Blizzard Institute of Cell and Molecular Science, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, UK
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Abstract
Joint hypermobility syndrome (JHS) was initially defined as the occurrence of musculoskeletal symptoms in the presence of joint laxity and hypermobility in otherwise healthy individuals. It is now perceived as a commonly overlooked, underdiagnosed, multifaceted, and multisystemic heritable disorder of connective tissue (HDCT), which shares many of the phenotypic features of other HDCTs such as Marfan syndrome and Ehlers-Danlos syndrome. Whereas the additional flexibility can confer benefits in terms of mobility and agility, adverse effects of tissue laxity and fragility can give rise to clinical consequences that resonate far beyond the confines of the musculoskeletal system. There is hardly a clinical specialty to be found that is not touched in one way or another by JHS. Over the past decade, it has become evident that of all the complications that may arise in JHS, chronic pain is arguably the most menacing and difficult to treat.
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García Campayo J, Asso E, Alda M, Andres EM, Sobradiel N. Association Between Joint Hypermobility Syndrome and Panic Disorder: A Case–Control Study. PSYCHOSOMATICS 2010. [DOI: 10.1016/s0033-3182(10)70659-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Anxiety disorders and joint hypermobility syndrome: the role of collagen tissue. Gen Hosp Psychiatry 2009; 31:299. [PMID: 19410113 DOI: 10.1016/j.genhosppsych.2008.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Revised: 08/13/2008] [Accepted: 08/21/2008] [Indexed: 11/20/2022]
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Grahame R. Hypermobility: an important but often neglected area within rheumatology. ACTA ACUST UNITED AC 2008; 4:522-4. [DOI: 10.1038/ncprheum0907] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2008] [Accepted: 08/08/2008] [Indexed: 11/09/2022]
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Ercolani M, Galvani M, Franchini C, Baracchini F, Chattat R. Benign Joint Hypermobility Syndrome: Psychological Features and Psychopathological Symptoms in a Sample Pain-Free at Evaluation. Percept Mot Skills 2008; 107:246-56. [DOI: 10.2466/pms.107.1.246-256] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Carlos Pascual J, Castaño J, Espluga N, Díaz B, García-Ribera C, Bulbena A. Enfermedades somáticas en pacientes con trastornos de ansiedad. Med Clin (Barc) 2008; 130:281-5. [DOI: 10.1157/13116589] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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ERCOLANI MAURO. BENIGN JOINT HYPERMOBILITY SYNDROME: PSYCHOLOGICAL FEATURES AND PSYCHOPATHOLOGICAL SYMPTOMS IN A SAMPLE PAIN-FREE AT EVALUATION. Percept Mot Skills 2008. [DOI: 10.2466/pms.107.5.246-256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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