Connecting brain and body: Transdiagnostic relevance of connective tissue variants to neuropsychiatric symptom expression

Table 1 Indications prompting screening for hypermobility spectrum disorders/hypermobile Ehlers-Danlos syndrome amongst patients presenting to mental health services (adapted from Ross and Grahame 2011[102])

	Extra-articular features	Articular features
In children and adolescents	Prolonged fatigue or tiring easily	Joint dislocations/subluxations (including congenital hip dislocation)
	Poor motor coordination or ‘clumsiness’ (such as poor ball catching and poor handwriting)	Recurrent ankle sprains
	Chronic widespread pain or ‘growing pains’
	Delayed walking, with bottom shuffling instead of crawling
In adults	Prolonged unexplained fatigue (including ME/CFS)	Recurrent joint dislocations
	Chronic widespread pain, particularly if unresponsive to analgesia (including fibromyalgia)	Multiple soft tissue injuries/rheumatisms
	Functional gastrointestinal disorders (such as IBS, functional dyspepsia, constipation)	Premature osteoarthritis
	Autonomic dysfunction (such as orthostatic intolerance or PoTS)	Persistent or recurrent joint pains
	Progressive loss of mobility secondary to pain or pain-avoidance strategies
	Laxity in supporting tissues (such as hernias, varicose veins, pelvic floor dysfunction)
	Soft/hyperextensible skin, unexplained striae, easy bruising

ME/CFS: Myelo-encephalomyelitis/chronic fatigue syndrome; IBS: Irritable bowels syndrome; PoTS: Postural tachycardia syndrome.

Table 2 Five-point screening questionnaire for detecting hypermobility (from Hakim and Grahame 2003[1])

1 Can you now (or could you ever) place your hands flat on the floor without bending your knees?

2 Can you now (or could you ever) bend your thumb to touch your forearm?

3 As a child, did you amuse your friends by contorting your body into strange shapes OR could you do the splits?

4 As a child or teenager did your shoulder or kneecap dislocate on more than one occasion?

5 Do you consider yourself ‘double-jointed’?

Answering yes to two or more questions suggests hypermobility with sensitivity 80%-85% and specificity 80%-90%