Evidence-Based Reviews

Anxiety and joint hypermobility: An unexpected association

Current Psychiatry. 2018 April;17(4):15-21

References

1. Tinkle BT, Bird HA, Grahame R, et al. The lack of clinical distinction between the hypermobility type of Ehlers-Danlos syndrome and the joint hypermobility syndrome (a.k.a. hypermobility syndrome). Am J Med Genet A. 2009;149A(11):2368-2370.
2. Hakim A, Grahame R. Joint hypermobility. Best Pract Res Clin Rheumatol. 2003;17(6):989-1004.
3. Hakim AJ, Grahame R. Non-musculoskeletal symptoms in joint hypermobility syndrome. Indirect evidence for autonomic dysfunction? Rheumatology (Oxford). 2004;43(9):1194-1195.
4. Grahame R, Hakim AJ. Hypermobility. Curr Opin Rheumatol. 2008;20(1):106-110.
5. Castori M. Ehlers-Danlos syndrome, hypermobility type: an underdiagnosed hereditary connective tissue disorder with mucocutaneous, articular, and systemic manifestations. ISRN Dermatol. 2012;2012:751768. doi: 10.5402/2012/751768.
6. Bulbena A, Baeza-Velasco C, Bulbena-Cabré A, et al. Psychiatric and psychological aspects in the Ehlers-Danlos syndromes. Am J Med Genet C Semin Med Genet. 2017;175(1):237-245.
7. Bulbena A, Duro JC, Mateo A, et al. Joint hypermobility syndrome and anxiety disorders. Lancet. 1988;332(8612):694.
8. Bulbena-Cabré A, Pailhez G, Cabrera A, et al. Body perception in a sample of nonclinical youngsters with joint hypermobility. Ansiedad y Estrés. 2017;23(2-3):99-103.
9. Martín-Santos R, Bulbena A, Porta M, et al. Association between joint hypermobility syndrome and panic disorder. Am J Psychiatry. 1998;155(11):1578-1583.
10. Bulbena A, Agulló A, Pailhez G, et al. Is joint hypermobility related to anxiety in a nonclinical population also? Psychosomatics. 2004;45(5):432-437.
11. Bulbena-Cabré A, Baeza-Velasco C, Pailhez G, et al. Psicopatología de la hiperlaxitud articular [in Spanish]. Cuadernos de Neuropsicología/Panamerican Journal of Neuropsychology 2016;10(3):61-70.
12. Bulbena‐Cabré A, Rojo C, Pailhez G, et al. Joint hypermobility is also associated with anxiety disorders in the elderly population. Int J Geriatr Psychiatry. 2018;33(1):e113-e119.
13. Bulbena A, Pailhez G, Bulbena-Cabré A, et al. Joint hypermobility, anxiety and psychosomatics: two and a half decades of progress toward a new phenotype. Adv Psychosom Med. 2015;34:143-157.
14. Smith TO, Easton V, Bacon H, et al. The relationship between benign joint hypermobility syndrome and psychological distress: a systematic review and meta-analysis. Rheumatology (Oxford). 2014;53(1):114-122.
15. Cederlöf M, Larsson H, Lichtenstein P, et al. Nationwide population-based cohort study of psychiatric disorders in individuals with Ehlers-Danlos syndrome or hypermobility syndrome and their siblings. BMC Psychiatry. 2016;16(1):207.
16. Gratacòs M, Nadal M, Martín-Santos R, et al. A polymorphic genomic duplication on human chromosome 15 is a susceptibility factor for panic and phobic disorders. Cell. 2001;106(3):367-379.
17. Tabiner M, Youings S, Dennis N, A et al. Failure to find DUP25 in patients with anxiety disorders, in control individuals, or in previously reported positive control cell lines. Am J Hum Genet. 2003;72(3):535-538.
18. Henrichsen CN, Delorme R, Boucherie M, et al. No association between DUP25 and anxiety disorders. Am J Med Genet B Neuropsychiatr Genet. 2004;128B(1):80-83.
19. Eccles JA, Owens AP, Mathias CJ, et al. Neurovisceral phenotypes in the expression of psychiatric symptoms. Front Neurosci. 2015;9:4. doi: 10.3389/fnins.2015.00004.
20. Mallorqui-Bagué N, Garfinkel SN, Engels M, et al. Neuroimaging and psychophysiological investigation of the link between anxiety, enhanced affective reactivity and interoception in people with joint hypermobility. Front Psychol. 2014;5:1162. doi: 10.3389/fpsyg.2014.01162.
21. Critchley HD, Harrison NA. Visceral influences on brain and behavior. Neuron. 2013;77(4):624-638.
22. Porges SW. The polyvagal theory: phylogenetic substrates of a social nervous system. Int J Psychophysiol. 2001;42(2):123-146.
23. Cameron OG. Interoception: the inside story—a model for psychosomatic processes. Psychosom Med. 2001;63(5):697-710.
24. Domschke K, Stevens S, Pfleiderer B, et al. Interoceptive sensitivity in anxiety and anxiety disorders: an overview and integration of neurobiological findings. Clin Psychol Rev. 2010;30(1):1-11.
25. Wiebking C, Bauer A, de Greck M, et al. Abnormal body perception and neural activity in the insula in depression: an fMRI study of the depressed “material me.” World J Biol Psychiatry. 2010;11(3):538-549.
26. Baeza-Velasco C, Gely-Nargeot MC, Vilarrasa AB, et al. Association between psychopathological factors and joint hypermobility syndrome in a group of undergraduates from a French university. Int J Psychiatry Med. 2011;41(2):187-201.
27. Smith TO, Jerman E, Easton V, et al. Do people with benign joint hypermobility syndrome (BJHS) have reduced joint proprioception? A systematic review and meta-analysis. Rheumatol Int. 2013;33(11):2709-2716.
28. Eccles JA, Beacher FD, Gray MA, et al. Brain structure and joint hypermobility: relevance to the expression of psychiatric symptoms. Br J Psychiatry. 2012;200(6):508-509.
29. Beighton P, Horan F. Orthopaedic aspects of the Ehlers-Danlos syndrome. J Bone Joint Surg Br. 1969;51(3):444-453.
30. Grahame R, Bird HA, Child A. The revised (Brighton 1998) criteria for the diagnosis of benign joint hypermobility syndrome (BJHS). J Rheumatol. 2000;27(7):1777-1779.
31. Bulbena A, Duró JC, Porta M, et al. Clinical assessment of hypermobility of joints: assembling criteria. J Rheumatol. 1992;19(1):115-122.
32. Hakim AJ, Grahame R. A simple questionnaire to detect hypermobility: an adjunct to the assessment of patients with diffuse musculoskeletal pain. Int J Clin Pract. 2003;57(3):163-166.
33. Bulbena A, Mallorquí-Bagué N, Pailhez G, et al. Self-reported screening questionnaire for the assessment of Joint Hypermobility Syndrome (SQ-CH), a collagen condition, in Spanish population. Eur J Psychiat. 2014;28(1):17-26.
34. Malfait F, Francomano C, Byers P, et al. The 2017 international classification of the Ehlers-Danlos syndromes. Am J Med Genet C Semin Med Genet. 2017;175(1):8-26.
35. Baxter AJ, Vos T, Scott KM, et al. The global burden of anxiety disorders in 2010. Psychol Med. 2014;44(11):2363-2374.
36. Bystritsky A. Treatment-resistant anxiety disorders. Mol Psychiatry. 2006;11(9):805-814.
37. Bulbena A, Gago J, Pailhez G, et al. Joint hypermobility syndrome is a risk factor trait for anxiety disorders: a 15-year follow-up cohort study. Gen Hosp Psychiatry. 2011;33(4):363-370.
38. Baeza-Velasco C, Gély-Nargeot MC, Bulbena Vilarrasa A, et al. Joint hypermobility syndrome: problems that require psychological intervention. Rheumatol Int. 2011;31(9):1131-1136.
39. Bathen T, Hangmann AB, Hoff M, et al. Multidisciplinary treatment of disability in ehlers-danlos syndrome hypermobility type/hypermobility syndrome: A pilot study using a combination of physical and cognitive-behavioral therapy on 12 women. Am J Med Genet A. 2013;161A(12): 3005-3011.
40. Chen KW, Berger CC, Manheimer E, et al. Meditative therapies for reducing anxiety: a systematic review and meta-analysis of randomized controlled trials. Depress Anxiety. 2012;29(7):545-562.
41. Krisanaprakornkit T, Sriraj W, Piyavhatkul N, et al. Meditation therapy for anxiety disorders. Cochrane Database Syst Rev. 2006;(1):CD004998.

Current nosology of anxiety disorders neglects the somatic aspects and physical manifestations of anxiety, and in general, therapeutic interventions focus only cognitive/psychological aspects of anxiety. Cognitive-behavioral therapy (CBT) may be effective in treating the cognitive distortions associated with the chronicity of the illness and negative emotions. Baeza-Velasco et al³⁸ found that patients with JHS/hEDS have a tendency toward dysfunctional coping strategies, and CBT may be useful to address those symptoms. Moreover, these individuals often suffer from kinesiophobia and hyperalgesia. Some pilot CBT strategies have been developed, and research suggests that along with exercise, CBT can be a valuable pain management tool in patients with JHS/hEDS.³⁹

Nonetheless, these patients often suffer from several somatic complaints and bodily manifestations (eg, somatosensory amplification, dysautonomia) that require treatment. Thus, interventions that address mind and body connections should be implemented. Some research found meditative therapies for anxiety disorders can be effective,^40,41although further randomized controlled trials are needed.

Based on our proposed “Neuroconnective phenotype,” we suggest a new therapeutic approach to address the 5 dimensions of this phenotype.

Somatic symptoms, such as blue sclera, dislocations, scars, easy bruising, and leptosomatic somatotype, do not require specific intervention, but they provide information about the physical phenotype of JHS/hEDS and can facilitate the diagnosis.

Somatic illnesses. Treatment must address often-found comorbid medical conditions, such as irritable bowel syndrome, other gastrointestinal conditions, temporomandibular dysfunction, fatigue, fibromyalgia, and dysautonomia. Obviously specific attention must be paid to JHS/hEDS, which responds relatively well to physical treatments, including aerobic exercise, and particularly well to expert physiotherapy. Relaxation and meditation techniques also are effective.

Continue to: Psychopathology

Anxiety and joint hypermobility: An unexpected association

References

Pages

Recommended Reading