Joint Hypermobility, Fears, and Chocolate Consumption Guillem Pailhez, MD, PhD, Silvia Rosado, RN, Andrea Bulbena Cabre ´, MD, and Antonio Bulbena, MD, PhD Abstract: Our purpose was to evaluate joint hypermobility, an inherited dis- order 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 sig- nificant 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. Key Words: Anxiety disorders, chocolate, fear, joint hypermobility, phobic disorders. (J Nerv Ment Dis 2011;199: 903Y906) J oint hypermobility syndrome is an inherited disorder of the con- nective tissue (Ehlers-Danlos, probably type III) significantly as- sociated with anxiety disorders (particularly panic, agoraphobia, and social phobia) both in the clinical and general population (Bulbena et al., 1993, 2004, 2011; Garcı ´a-Campayo et al., 2010). Studies in rheumatological outpatients have shown that patients with joint hy- permobility are 10 times more likely to develop anxiety (Martı ´n- Santos et al., 1998). Interestingly, both joint hypermobility and anxiety disorders have similar prevalence in the general population, between 10% and 15%, and have similar female predominance (3:1). These results have encouraged an interest in examining how joint hypermobility and anxiety disorders interact with common fears. In 2006, our group found significant differences between subjects with and without hypermobility when assessing specific fears. These results show that the association of hypermobility and phobic anxi- ety is sustained for intense fears and may represent a risk factor for these anxiety conditions (Bulbena et al., 2006). However, this asso- ciation has not yet been tested in younger people. With regard to chocolate intake, some findings in the psychi- atric literature support its anxiolytic effect. Subjects self-identified as chocolate addicts can feel this effect during stress (Dallard et al., 2001), and craving for chocolate co-occurs with anxiety and stress- related situations (Bulbena et al., 1991). Other results showed a re- duction of the levels of stress-related hormones when consuming 40 grams of dark chocolate daily (Martin et al., 2009). Other sub- stances linked to anxiety include caffeine, nicotine, and alcohol. For instance, caffeine consumption could trigger anxiety symptoms and panic attacks in patients with panic disorder (Nardi et al., 2008), many smokers experience anxiety symptoms while smoking and during acute abstinence (Esterlis et al., 2009) and, finally, alcohol consumption produces anxiolysis among other effects (Kumar et al., 2009). The purpose of this study was to evaluate joint hypermobility in a nonclinical sample of students aged between 15 and 18 years in relation to a) the frequency of severe fears and b) the consumption of chocolate, coffee, cigarettes, and alcohol. METHODS This cross-sectional study was carried out in a secondary school in Barcelona, Spain. All subjects (N = 150) were non- clinical students from 15 to 18 years old; there were 66 boys and 84 girls. The participants were invited to take part in the study after consultation with a student representative of the center to improve recruitment. Subjects were given a detailed explanation of the study and asked to sign an informed consent form. No participants fulfilled any of the following exclusion criteria: rheumathological diseases involving the joints, hereditary diseases of the connective tissue (Marfan syndrome and Ehlers-Danlos Syndrome except for type III, among others), or severe somatic illness. Of the 180 eligible subjects, 16.7% refused to participate. All participants filled the self-administered simple question- naire to detect hypermobility by Hakim and Grahame (2003). Anal- ysis showed that a positive answer to any two questions in the five-part questionnaire gave the highest combined sensitivity and specificity (80% to 90%) for detecting hypermobility. After hypermobility ex- amination, the participants were asked to anonymously complete a modified version of the self-reported Fear Survey Schedule (FSS; Spanish version), which is considered the most appropriate scale for assessing common fears in the general population (Bulbena et al., 2006; Kogan and Edelstein, 2004; Tejero et al., 1989). The FSS has been used extensively to identify individuals who may have phobias to assess the severity of their fears and to evaluate outcome after treat- ment (Brown and Crawford, 1988; Costello, 1982). The FSS explores the intensity and frequency of a number of widespread feared objects and situations that the subjects have to mark from 0 (not at all) to 4 (extremely) according to their fear. The items included are related not only to common fears but also to specific phobias, social phobia, and agoraphobic situations. Items scored as very (3 points) or extremely (4 points) intense by more than 10% of the sample were used to evaluate the most severe and prominent fears in the sample. Self-reported daily consumption of cigarettes (Do you smoke every day?), alcohol (Do you drink alcohol more than once a week?), coffee (Do you drink coffee or tea with caffeine every day?), and chocolate (If you feel anxious, do you sometimes take chocolate to calm down?) were gathered as dicothomic variables. Scores for the most prominent and intense fears and these particular patterns of daily consumption were compared with the hypermo- bility scores. Total FSS scores and scores per item were analyzed by sex. Nonparametric statistics (Mann-Whitney U-tests) were used throughout the study to ensure more solid comparisons because BRIEF REPORT The Journal of Nervous and Mental Disease & Volume 199, Number 11, November 2011 www.jonmd.com 903 Anxiety Unit, INADYHospital del Mar, Parc de Salut Mar, Barcelona, Spain. Send reprint requests to Guillem Pailhez, MD, PhD, Hospital del MarYINAD, Passeig Marı ´tim, 25-29. 08003 Barcelona. E-mail: 97590@hospitaldelmar.cat. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 0022-3018/11/19911-0903 DOI: 10.1097/NMD.0b013e318234a022 Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.