Intended for healthcare professionals

Rapid response to:

Practice Easily Missed?

Joint hypermobility syndrome

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.c7167 (Published 20 January 2011) Cite this as: BMJ 2011;342:c7167

Rapid Response:

Psychiatric manifestations of Joint Hypermobility Syndrome

Ross and Grahame have highlighted that hypermobility is just one
visible feature of joint hypermobility syndrome. They have detailed the
breadth of physical complications including dysautonomia, premature
osteoarthritis and intestinal dysmotility suggesting a broader multi-
system phenotype. We would like to draw readers' attention to the frequent
psychiatric co-morbidity associated with joint hypermobility. In
particular, individuals with joint hypermobility syndrome are over-
represented in panic and anxiety populations presenting to psychiatrists
(1). This excess is suggested to be a large as a 16 times greater risk in
patients with joint hypermobility compared to non-hypermobile controls(2).
Joint hypermobility is more frequent in panic-disorder, where the degree
of hypermobility predicts the severity of anxiety(3). Joint hypermobility
is also linked to a number of psychosomatic disorders including Irritable
Bowel Syndrome(4), Chronic Fatigue Syndrome (5) and fibromyalgia.

Individuals with joint hypermobility exhibit similar autonomic
cardiovascular abnormalities to those with Postural Tachycardia Syndrome
(PoTS) (6, 7). A defining characteristic of PoTS, regardless of its
association with joint hypermobility, is an abnormally reactive autonomic
nervous system, in particular a sharp increase in heart rate on standing.
A phenomenological overlap, if not direct association, is also recognized
between PoTS and anxiety disorders (8).

These findings suggest that constitutionally determined brain-body
interactions may underlie this psychosomatic vulnerability and that joint
hypermobility may represent a subphenotype of anxiety disorder.

1. Garcia-Campayo J, Asso E, Alda M. Joint Hypermobility and Anxiety:
The State of the Art. Curr Psychiatry Rep. 2010 Oct 21.

2. Martin-Santos R, Bulbena A, Porta M, Gago J, Molina L, Duro JC.
Association between joint hypermobility syndrome and panic disorder. Am J
Psychiatry. 1998 Nov;155(11):1578-83.

3. Garcia Campayo J, Asso E, Alda M, Andres EM, Sobradiel N.
Association between joint hypermobility syndrome and panic disorder: a
case-control study. Psychosomatics. 2010 Jan;51(1):55-61.

4. Zarate N, Farmer AD, Grahame R, Mohammed SD, Knowles CH, Scott SM,
et al. Unexplained gastrointestinal symptoms and joint hypermobility: is
connective tissue the missing link? Neurogastroenterol Motil. 2010
Mar;22(3):252-e78.

5. Nijs J, Aerts A, De Meirleir K. Generalized joint hypermobility is
more common in chronic fatigue syndrome than in healthy control subjects.
J Manipulative Physiol Ther. 2006 Jan;29(1):32-9.

6. Gazit Y, Nahir AM, Grahame R, Jacob G. Dysautonomia in the joint
hypermobility syndrome. Am J Med. 2003 Jul;115(1):33-40.

7. Kanjwal K, Saeed B, Karabin B, Kanjwal Y, Grubb BP. Comparative
clinical profile of postural orthostatic tachycardia patients with and
without joint hypermobility syndrome. Indian Pacing Electrophysiol J.
2010;10(4):173-8.

8. Esler M, Alvarenga M, Pier C, Richards J, El-Osta A, Barton D, et
al. The neuronal noradrenaline transporter, anxiety and cardiovascular
disease. J Psychopharmacol. 2006 Jul;20(4 Suppl):60-6.

Competing interests: No competing interests

08 February 2011
Jessica A Eccles
ST2 Academic Clinical Fellow
Neil A Harrison, Hugo D Critchley
Sussex Partnership NHS Foundation Trust, Sussex Education Centre, Millview Hospital, Hove BN3 7HZ, U