ORIGINAL RESEARCH published: 12 January 2022 doi: 10.3389/fpsyt.2021.803614 Joint Hypermobility and Clinical Correlates in a Group of Patients With Eating Disorders Carolina Baeza-Velasco 1,2,3*, Maude Seneque 2,3 , Philippe Courtet 2,3 , Émilie Olié 2,3 , Charles Chatenet 2 , Paola Espinoza 4 , Géraldine Dorard 1 and Sébastien Guillaume 2,3 1 Université de Paris, Laboratoire de Psychopathologie et Processus de Santé, Boulogne Billancourt, France, 2 Department of Emergency Psychiatry and Acute Care, CHU Montpellier, Montpellier, France, 3 Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France, 4 Departament de Psicologia, Unitat d’Avaluació i Intervenció en Imatge Corporal, Clínica i de la Salut, Universitat Autònoma de Barcelona, Barcelona, Spain Edited by: Background: The ability to move joints beyond the normal range of motion is called Joint Katrin Giel, Hypermobility (JHM). JHM has been associated with a plethora of physical problems Tübingen University and is a frequent sign of hereditary disorders of connective tissue. Neuropsychiatric Hospital, Germany conditions such as eating disorders (ED) have also been related to JHM. However, little Reviewed by: David Houghton, is known about the clinical profile of people with ED and JHM. The aim of this study University of Texas Medical Branch at was to explore JHM in patients with ED and to compare the clinical characteristics of Galveston, United States Jessica Eccles, hypermobile ED patients with non-hypermobile ED patients. Brighton and Sussex Medical School, Method: Fifty-three outpatients diagnosed with ED were assessed using the Beighton United Kingdom score for JHM, the Eating Disorders Inventory 2, the Eating Disorder Examination, and *Correspondence: Carolina Baeza-Velasco the Detail and Flexibility Questionnaire. Information relating to patients’ psychiatric and carolina.baeza-velasco@u-paris.fr somatic comorbidities/symptoms was also collected. Specialty section: Results: Using the traditional Beighton score’s cutoff of ≥4, 41.5% of the sample This article was submitted to presented with JHM. Our results indicate that compared with non-hypermobile ED Psychosomatic Medicine, patients, those with JHM are significantly younger, suffer at a greater extent from joint pain a section of the journal Frontiers in Psychiatry and easy bruising, have a shorter duration of the ED, and have lower scores for cognitive Received: 28 October 2021 rigidity. In addition, for those with anorexia nervosa, the restricting subtype represents a Accepted: 09 December 2021 significantly lower proportion of hypermobile ED patients compared to non-hypermobile Published: 12 January 2022 ED patients. Multivariate analyses showed that cognitive rigidity, age, and duration of the Citation: Baeza-Velasco C, Seneque M, ED could predict the JHM status in this sample. Courtet P, Olié É, Chatenet C, Conclusion: These results suggest that JHM is frequent in patients with ED and is Espinoza P, Dorard G and Guillaume S (2022) Joint Hypermobility and Clinical accompanied by signs of tissue fragility. Patients with ED and JHM seem to present a Correlates in a Group of Patients With specific profile characterized by less cognitive rigidity and restricting behavior in the case Eating Disorders. of anorexia nervosa. Further research is needed in order to confirm these results. Front. Psychiatry 12:803614. doi: 10.3389/fpsyt.2021.803614 Keywords: eating disorders, joint hypermobility, anorexia nervosa, cognitive rigidity, pain Frontiers in Psychiatry | www.frontiersin.org 1 January 2022 | Volume 12 | Article 803614 Baeza-Velasco et al. Hypermobility and Eating Disorders INTRODUCTION METHODS Joint hypermobility (JHM) is a somatic trait characterized by Participants an increased range of joint motion. According to studies of In this study, the participants were men and women clinically general populations, the prevalence of JHM ranges from 10 to diagnosed with ED at the outpatient ED unit of the University 20% (1, 2). However, JHM is more frequent in females and Hospital of Montpellier (France). In this unit, diagnoses in young people since JHM declines with age (3). When JHM are established by a multidisciplinary team composed of is generalized to many joints, it is supposed to be congenital, psychiatrists, psychologists, and nutritionists. Through this inherited, and related to connective tissue (4). Thus, the presence process, a consensus is reached using the best estimated of JHM often underlies abnormal collagen production. In such a procedure, medical records and information from relatives, context, it is not surprising that JHM has been related to several non-standardized clinical assessments by practitioners, and physical problems of both articular and non-articular nature, standardized measures. with varying severity. The most severe cases are the so-called Patients with different types of ED were enrolled between June hereditary disorders of connective tissue (e.g., Ehlers-Danlos 2019 and March 2021. Exclusion criteria included pregnancy, not syndromes, Marfan syndrome, and osteogenesis imperfecta), of being fluent in French, and refusal to participate in the study. which JHM is a hallmark. JHM has been also related to neuropsychiatric conditions, Instruments especially anxiety disorders [e.g., (5)], neurodevelopmental The Beighton Score for JHM disorders such as autism [e.g., (6)], and attention- The Beighton score (15) is the most widely used and probably the deficit/hyperactivity disorder [e.g., (7)]. Although rare, some most reliable tool to assess JHM (4). It consists of the execution of works highlight a link between JHM and hypermobility- five maneuvers with a maximum score of nine points: (1) passive related disorders and/or eating disorders (ED). To the best dorsiflexion of the fifth metacarpal joint (one point per side), (2) of our knowledge, Goh et al. (8) were the first to report passive thumb opposition to the forearm (one point per side), results from a systematic study, wherein JHM was assessed (3) passive hyperextension of the elbow (one point per side), (4) in 30 patients with anorexia nervosa (AN), their first-degree passive hyperextension of the knee (one point per side), (5) the relatives (n = 29), and heathy controls (n = 16). Results capacity to place both hands flat on the floor in front of the feet showed that JHM was more frequent in patients than in with the knees straight (one point). The traditional cutoff score of relatives and controls (63, 34, and 13%, respectively). The ≥4 out of nine points recommended by Beighton’s original work authors concluded that “JHM is a possible indicator of a was used in this study to identify JHM. familial disorder of connective tissue which potentially plays The Mini International Neuropsychiatric Interview a causal role in the development of ED” (8). In another (MINI 5.0.0) study, Bulbena-Cabr et al. (9) reported that hypermobile The MINI (16) is a structured interview which enables the non-clinical youngsters scored significantly higher than non- positive diagnosis of mental disorders through questions phrased hypermobile individuals on bulimia and anorexia subscales to allow yes/no answers. This tool was used to assess psychiatric of the Spanish version of the Body Perception Questionnaire comorbidities (lifetime anxiety disorders, major depressive (10). Later, the same team explored JHM in a group of disorder, and suicide attempts are reported in this study). Version children affected by ARFID (avoidant/restrictive food intake 5.0.0 of the MINI is based on the Diagnostic and Statistical disorder). They observed that compared to healthy controls, Manual of Mental Disorders, fourth edition [DSM-IV; (17)] a significantly major proportion of these children presented and the International Classification of Diseases, 10th edition— with JHM (11). Recently, our group reported that patients with psychiatric disorders [ICD-10; (37)]. Ehlers-Danlos syndrome (mainly affected by the hypermobile subtype) showed an increased prevalence of ED history, The Eating Disorders Inventory 2 (EDI-2) higher risk of current ED, and lower BMI than healthy The EDI-2 (18, 19) is a self-report diagnostic tool designed to controls (12). evaluate symptoms of ED as well as its relation to personality Although preliminary, these data indicate the potential traits and emotions through 91 items rated on a six-point relationship between collagen conditions and ED. In this Likert scale. It contains 11 subscales: drive for thinness, bulimia, sense, it is possible that gastrointestinal problems that are body dissatisfaction, ineffectiveness, perfectionism, interpersonal frequent in hypermobility conditions (13)—as well as food distrust, interoceptive awareness, maturity fears, asceticism, allergies, fragility of oral mucosa, chemo-sensorial abnormalities, impulse regulation, and social insecurity. The higher the score, and proprioception problems which may impact the body the greater the ED symptoms. In the present study, Cronbach’s α schema and image—constitute a favorable environment for the for the total scale was 0.92. development of ED (14). Thus, more studies are needed in order to confirm previous results and elucidate the clinical profile of The Eating Disorder Examination (EDE-Q) people presenting with such a mixed picture of conditions. The self-questionnaire EDE-Q (20) is a screening tool that The aim of this study was to explore JHM in patients with assesses, through 28 items, the four core clinical dimensions of ED and to compare the clinical characteristics of hypermobile ED ED: eating concern, body shape concern, weight concern, and patients with non-hypermobile ED patients. restraint. The total score is calculated by adding all subscales Frontiers in Psychiatry | www.frontiersin.org 2 January 2022 | Volume 12 | Article 803614 Baeza-Velasco et al. Hypermobility and Eating Disorders TABLE 1 | Comparison of characteristics between ED patients with and without JHM. Variable ED without JHM 58.5% [31] ED with JHM 41.5% [22] OR [95% CI] P-value Sociodemographics % [n]/Mean (SD) % [n]/Mean (SD) Age 31.03 (11.02) 22.77 (2.07) 0.904 [0.839; 974] 0.008 Women 87.1% [27] 100% [22] - 0.080* Years of study 13.68 (2.40) 12.90 (2.07) 0.854 [0.656; 1.113] 0.244 ED characteristics Age at onset 17.60 (5.63) 16.35 (3.16) 0.939 [0.816; 1.080] 0.379 Age first consultation 23.77 (9.53) 18.00 (2.64) 0.871 [0.752;1.010] 0.067 Duration of ED (in years) 12.93 (9.07) 6.25 (6.73) 0.891 [0.811; 0.978] 0.015 Anorexia nervosa 61.2% [19] 77.2% [17] 2.147 [0.627; 7.358] 0.224 Type of anorexia nervosa: 4.66 [1.108; 19.652] 0.036 Restricting type 73.7% [14] 37.5% [6] Bingeing/purging type 26.3% [5] 62.5% [10] Bulimia nervosa 19.3% [6] 18.1% [4] 0.980 [0.240; 4.004] 0.978 Other ED 19.3% [6] 4.5% [1] 0.219 [0.024; 1.978] 0.176 Psychiatric comorbidity (lifetime) Major depressive disorder 75.9% [22] 62.5% [10] 0.530 [0.141;1.98] 0.347 Suicide attempt 30% [9] 14.3% [3] 0.389 [0.091; 1.659] 0.202 Anxiety disorders 58.6% [17] 66.7% [10] 1.412 [0.383; 5.19] 0.604 Substance abuse and/or dependence 10.3% [3] 13.3% [2] 1.33 [0.198; 8.996] 0.768 Somatic/health variables (lifetime) BMI 19.31 (6.2) 20.22 (4.8) 1.029 [0.924; 1.134] 0.564 Age of menarche 13.76 (2.43) 12.67 (.976) 0.689 [0.422; 1.125] 0.136 Somatic comorbidity 25.8% [8] 31.8% [7] 1.342 [0.402; 4.477] 0.633 Fractures 19.4% [6] 4.5% [1] 0.198 [0.022; 1.782] 0.149 Dislocations 10.7% [3] 9.5% [2] 0.877 [0.133; 5.783] 0.892 Easy bruising 57.1% [16] 95.2% [20] 15.0 [1.759; 127.913] 0.013 Moderate and severe fatigue (usual) 80.6% [25] 77.3% [17] 0.816 [0.214; 3.108] 0.766 Moderate and severe pain (usual) 35.5% [11] 61.9 [13] 2.955 [0.938; 9.309] 0.064 Joint pain 25% [7] 57.1% [12] 4.00 [1.186; 13.495] 0.025 Thin skin 17.9% [5] 42.9% [9] 3.45 [0.943; 12.621] 0.061 Varicose veins 14.3% [4] 4.8% [1] 0.300 [0.031; 2.904] 0.299 Stretch marks 50% [14] 61.9% [13] 1.625 [0.514; 5.136] 0.408 Physiotherapy consultation 35.7% [10] 61.9% [13] 2.925 [0.906; 9.442] 0.073 Psychological dimensions Detail and flexibility questionnaire: Cognitive rigidity 51.43 (8.16) 45.15 (12.14) 0.939 [0.884; 998] 0.041 Attention to detail 43.60 (8.66) 39.65 (12.15) 0.962 [907; 1.019] 0.186 Eating disorders examination questionnaire: Restraint 3.50 (2.55) 2.20 (2.16) 0.787 [0.490; 1.265] 0.323 Eating concern 2.43 (1.90) 1.00 (1.41) 0.539 [0.148; 1.958] 0.347 Weight concern 3.20 (1.64) 4.25 (.957) 1.904 [0.621; 5.837] 0.260 Shape concern 4.80 (1.64) 5.25 (.957) 1.366 [0.426; 4.379] 0.600 Eating disorders inventory 2: Drive for thinness 4.46 (3.89) 4.45 (4.74) 0.999 [0.872; 1.145] 0.989 Bulimia 5.43 (4.15) 5.80 (4.37) 1.021 [0.892; 1.170] 0.760 Body dissatisfaction 4.76 (2.97) 3.80 (2.87) 0.885 [7.17; 1.094] 0.259 Ineffectiveness 6.56 (3.74) 7.10 (4.37) 1.035 [0.896; 1.195] 0.639 Perfectionnisme 4.73 (3.59) 6.00 (3.12) 1.118 [0.942; 1.328] 0.202 Interpersonal distrust 4.63 (2.69) 4.25 (2.98) 0.951 [0.772; 1.170] 0.632 Interoceptive awareness 8.66 (4.48) 8.55 (4.75) 0.994 [0.877;1.127] 0.928 Asceticism 7.26 (2.65) 7.05 (2.34) 0.966 [767; 1.216] 0.769 Impulse regulation 12.76 (5.83) 12.15 (5.46) 0.981 [0.885; 1.087] 0.711 Social insecurity 4.60 (2.13) 5.10 (2.53) 1.095 [0.857; 1.400] 0.468 Maturity fears 6.62 (3.02) 6.00 (3.75) 0.943 [0.789; 1.128] 0.522 ED, eating disorder; BMI, body mass index; CI, Confidence Interval; OR, Odds ratio; SD, standard deviation; * , chi-square. Frontiers in Psychiatry | www.frontiersin.org 3 January 2022 | Volume 12 | Article 803614 Baeza-Velasco et al. Hypermobility and Eating Disorders TABLE 2 | Multivariate regression logistic models with JHM status as dependent Twenty-two patients (41.5%) scored ≥ 4 for the Beighton variable. score for JHM (i.e., the hypermobile group). When hypermobile Model 1 OR [95%CI] P-value and non-hypermobile ED patients were compared using sociodemographic data, we observed that those with JHM were Duration of ED 0.847 [0.719; 997] 0.047 significantly younger (22.7 vs. 31; p = 0.008). Anorexia nervosa subtype 7.769 [0.798; 75.634] 0.077 Concerning clinical characteristics (Table 1), the non- Cognitive rigidity 0.878 [0.777; 0.992] 0.037 hypermobile group had a longer duration of the ED in terms Joint pain 0.880 [0.102; 7.62] 0.908 of years (12.9 vs. 6.2; p = 0.015), and those with AN presented Model 2 OR [95%CI] P-value with the restricting subtype to a greater extent compared to Age 0.850 [0.730; 0.990] 0.036 hypermobile ED patients (73.7 vs. 26.3%; p = 0.014). In addition, Anorexia nervosa subtype 9.567 [0.894; 102.43] 0.062 the non-hypermobile ED patients had higher scores for cognitive Cognitive rigidity 0.872 [0.779; 0.975] 0.017 rigidity than hypermobile individuals (51.4 vs. 45.1; p = 0.041). Joint pain 0.723 [0.081; 6.485] 0.772 No other difference was found between the groups on measures of psychological functioning. CI, Confidence Interval; OR, Odds ratios; ED, eating disorders. With respect to somatic aspects, a significantly greater proportion of the hypermobile ED patients presented with easy bruising (95.2 vs. 57.1%; p = 0.013) and joint pain (57.1 vs. 25%; together and then dividing the result by four. Higher scores p = 0.025) compared to the non-hypermobile group. The results indicate a more severe ED symptomatology. Cronbach’s α for the are summarized in Table 1. global score was 0.76. Binary logistic regression using JHM status as a dependent variable and duration of ED (highly correlated with age), AN The Detail and Flexibility Questionnaire (DFlex) subtype, cognitive rigidity, and joint pain as covariates showed The DFlex (21) consists of a 24-item self-report scale assessing that cognitive rigidity and duration of ED can distinguish cognitive rigidity (difficulty with set-shifting/flexibility) and over- between hypermobile and non-hypermobile ED patients. attention to detail (weak coherence). These cognitive styles are A second model using age, AN subtype, cognitive rigidity, and typical of rigid perfectionism in patients with ED. Each item joint pain as covariates showed that the age and cognitive rigidity of the DFlex is presented using a rating Likert scale from could predict JHM status (Table 2). 1 (“strongly disagree”) to 6 (“strongly agree”). Higher scores indicate higher levels of psychopathology. Cronbach’s α for the total scale was 0.88. DISCUSSION Fatigue and Pain The aim of the present study was to explore JHM in patients Perceived levels of fatigue in the final week of the study were with ED as well as their clinical characteristics. As expected, obtained by participants scoring their general level of fatigue in a high proportion of patients with ED (41.5%) were positive that week on a numeric scale ranging from 0 to 10. Scores ≥ 6 for JHM using the Beighton score, which is greater than the were categorized as moderate/severe fatigue. prevalence reported for the general population [10–20%; (1, 2)]. Additional clinical/health information was obtained from the However, we observed a lower frequency of JHM in those with clinical interview (BMI, somatic comorbidity, fractures, and AN than that observed by the only study allowing comparisons. age of menarche) and through an ad hoc self-questionnaire Indeed, Goh et al. (8) reported that 63% of their sample with yes/no questions about somatic problems frequently composed of 30 AN patients presented with JHM, while in observed in hypermobile subjects (i.e., easy bruising, joint our sample, 47.2% of AN patients (n = 36) presented with pain, dislocations, thin skin, varicose veins, stretch marks, and JHM. A possible explanation for this difference is the method physiotherapy consultation). used to assess JHM, which is not specified in the report of Goh et al. In any case, these results confirm previous reports Statistical Analysis suggesting an over-representation of JHM in people affected Statistical treatment included a descriptive analysis of the data, by ED (9, 11, 12, 14). However, it is possible that the link non-parametric tests (Chi-square and Spearman correlation), between JHM and ED varies depending on the ED type. and binary logistic regression. Data analysis was performed with Accordingly, in the present study, no relationship was found the IBM SPSS version 28 software package, and the significance between bulimia nervosa (another type of ED) and JHM. In level was taken as 0.05 for all statistical tests. contrast, although from a purely descriptive point of view, AN appears to be more frequent among hypermobile patients than RESULTS among non-hypermobile patients (77.2 vs. 61.2%). In addition, we observed significant differences between hypermobile and Fifty-three patients with ED were included in this study (AN = non-hypermobile AN patients with respect to AN subtype. The 67.9%; bulimia nervosa = 18.8%; other ED = 13.2%) Most of non-hypermobile group mostly presented with the restricting them were female (92.5%). The sample mean age was 27.6 (SD subtype, while the hypermobile group mostly presented with = 10.4) (Table 1). the binging/purging subtype. Interestingly, this result is in line Frontiers in Psychiatry | www.frontiersin.org 4 January 2022 | Volume 12 | Article 803614 Baeza-Velasco et al. Hypermobility and Eating Disorders with the fact that non-hypermobile patients scored significantly hypermobile subjects as a group particularly vulnerable higher for cognitive rigidity. Indeed, there is evidence that these to ED. According to our results, we can speculate that two AN subtypes differ with respect to cognitive style (22), in the context of JHM, ED is probably secondary to the with the restricting subtype corresponding to more cognitive connective tissue problems rather than attributable to control (23). Plausibly, the younger age of the hypermobile ED the premorbid perfectionism and rigid cognitive style group (22 vs. 31 y/o) could have influenced the results for classically described in AN, and that the presenting cognitive rigidity, since several studies have reported that young symptomatology of these patients is somewhat mixed rather than patients with AN are unaffected by processes compromised by strictly restrictive. cognitive rigidity (e.g., set-shifting). This suggests that these Unsurprisingly, a significantly greater proportion of the cognitive impairments increase as a consequence of illness hypermobile group suffered from easy bruising and joint pain (24). However, from multivariate analysis, cognitive rigidity compared to the non-hypermobile group. These symptoms appears to be a predictor even when age and duration of ED are strongly associated with JHM (35) and reflect the tissue are controlled. Thus, these results suggest that hypermobile fragility underlying collagen defects (e.g., fragility of capillaries ED patients may present a specific profile characterized by and blood vessels surrounding the connective tissue, weakness less cognitive rigidity and restricting behavior. A clue for of ligaments holding the bones of joints, and reduced joint understanding this finding comes from the results of the stability). From a clinical perspective, these signs and symptoms neuroimaging study by Eccles et al. (25), who found structural are of particular interest and should not be overlooked. brain differences between hypermobile and non-hypermobile Indeed, the significant weight loss and consequent poor subjects—for instance, in the dorsal right anterior cingulate nutrition that occur in ED can further weaken patients who cortex, which is an area engaged in cognitive control (26, already have an inherently fragile body. For instance, Kaplan 27). and Katz (34) stated that amenorrhea secondary to weight We observed that the hypermobile ED group was significantly loss may affect bone physiology. Thus, in patients with a younger than the non-hypermobile group (22 vs. 31 y/o), which connective tissue disorder (of which JHM is a hallmark) long- is not surprising. As mentioned before, JHM is more common term amenorrhea and bone mass loss may lead to serious in children and decreases as age increases (3). Accordingly, fractures. In addition, in more severe cases of heritable the duration of ED in terms of years was also lower in the disorders of connective tissue (e.g., Ehlers-Danlos syndromes), hypermobile ED group. there may be a risk of visceral perforation in patients Interestingly, while the age of ED onset was similar in both with significant weight loss combined with intense physical groups, patients from the hypermobile ED group had their exercise (36). first ED consultation during adolescence and at a younger The present study has important limitations, such as the age than non-hypermobile patients; however, this difference use of a small sample of convenience, which compromises did not reach statistical significance (18 vs. 23 y/o; p = the generalization of results. In addition, the cross-sectional 0.067). Since congenital JHM is frequently accompanied by design does not allow any conclusions about the directionality several physical problems, it is possible that hypermobile ED of the relationships between the different variables. Despite patients are more familiar with medical consultation from an these limitations, our results add weight to the scarce but early age. In this sense, our data show that 61% of patients growing evidence about the relationship between ED and JHM. with JHM consulted the physiotherapist vs. 35% of non- Further studies are needed to confirm these findings and hypermobile patients. In addition, symptoms derived from or illustrate a clearer picture of the co-occurrence between these related to collagen-altering conditions are often exacerbated two conditions. with puberty, probably due to estrogen secretion and the fast growth of tissue (e.g., skin, joints, and muscles) during this period (28). Thus, this context constitutes a fertile ground for DATA AVAILABILITY STATEMENT the development of mental pathologies such as ED. Indeed, The data that support the findings of this study are available from among the plethora of physical problems experienced by the corresponding author (CB-V), upon reasonable request. people with hypermobility-related disorders, there are many that affect food intake (14). For instance, functional gastrointestinal problems [e.g., abdominal pain, vomiting, dysphagia, bloating, ETHICS STATEMENT gastro-esophageal reflux; (13)], teeth and temporomandibular problems (29), food allergies (30), oral mucosa fragility The studies involving human participants were reviewed and (31), and chemosensory particularities [e.g., hyperosmia; (32)] approved by CPP Sud Méditerranée IV. Written informed may perturb eating, thereby promoting disordered eating consent to participate in this study was provided by the behavior (14). participants’ legal guardian/next of kin. On the other hand, tissue fragility and proprioception impairment, which are common in people with JHM (33), AUTHOR CONTRIBUTIONS may affect the development of a secure sense of body and an accurate body image, which are core factors of ED CB-V and SG designed the study. SG, MS, and CC (34). Thus, there are reasonable grounds for considering assisted with the assessment of patients and data Frontiers in Psychiatry | www.frontiersin.org 5 January 2022 | Volume 12 | Article 803614 Baeza-Velasco et al. Hypermobility and Eating Disorders collection. CB-V performed the statistical analysis and ACKNOWLEDGMENTS drafted the manuscript. All authors have reviewed the manuscript for intellectual content and have approved the The authors wish to thank all patients who participated in final manuscript. this study. REFERENCES 17. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4a edition. Washington, DC: American Psychiatric Association. 1. 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(1992) 33:105– and do not necessarily represent those of their affiliated organizations, or those of 8. doi: 10.1016/S0033-3182(92)72028-3 the publisher, the editors and the reviewers. Any product that may be evaluated in 35. Malfait F, Hakim AJ, De Paepe A, Grahame R. The genetic basis this article, or claim that may be made by its manufacturer, is not guaranteed or of the joint hypermobility syndromes. Rheumatology. (2006) 45:502- endorsed by the publisher. 7. doi: 10.1093/rheumatology/kei268 36. Miles SC, Robinson PD, Miles JL. Ehlers–Danlos syndrome and anorexia nervosa: a dangerous combination?. Pediatric Dermatol. (2007) 24:E1- Copyright © 2022 Baeza-Velasco, Seneque, Courtet, Olié, Chatenet, Espinoza, 4. doi: 10.1111/j.1525-1470.2007.00382.x Dorard and Guillaume. This is an open-access article distributed under the terms 37. International Classification of Diseases. 10th Revision Psychiatric Disorders. of the Creative Commons Attribution License (CC BY). The use, distribution ICD; World Health Organization (1992). or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in Conflict of Interest: The authors declare that the research was conducted in the this journal is cited, in accordance with accepted academic practice. No use, absence of any commercial or financial relationships that could be construed as a distribution or reproduction is permitted which does not comply with these potential conflict of interest. terms. Frontiers in Psychiatry | www.frontiersin.org 7 January 2022 | Volume 12 | Article 803614