Restless Legs Syndrome

Restless Leg Syndrome

Restless Legs Syndrome (RLS), also known as Willis-Ekbom disease (WED), is a sleep disorder that is characterized by uncomfortable sensations in the legs, prompting an urge to move them. One or both legs may be affected; in rare cases, the arms are also affected.

According to the National Institute of Neurological Disorders and Stroke (NINDS), up to 10 percent of the population in the United States may suffer from RLS. RLS symptoms may start in adolescence or even childhood but they are the most prominent in adulthood. Of those diagnosed with RLS, 40% report symptoms before the age of 20 (DSM-V). The prevalence rates of RLS increases with age, with women diagnosed between 1.5 and 2 times more often than men.

The key symptoms of RLS are

  • Discomfort, such as tingling, burning, a feeling of throbbing, or pain, that occurs in the legs accompanied by a strong urge to move the legs.

  • The symptoms are worse when the individual is lying down or sitting.

  • The symptoms are worse in the evening and night time hours than any other time of the day.

  • Movement may relieve the symptoms either totally or partially, but the discomfort typically resumes when the individual returns to a resting position.

Patients with RLS also commonly report

  • Difficulty sleeping
  • Jerking leg movements during sleep, which is known as periodic leg movements of sleep (PLMS) Note: This symptom is common in about 80 percent of those with RLS.
  • Extreme fatigue
  • Daytime sleepiness
  • Itching in the legs, with no apparent cause (such as insect bites or infections)

The diagnostic criteria in the DSM-V indicates that the symptoms of RLS must occur at least three times a week and last a minimum of three months. Furthermore, the symptoms result in significant disruption and distress or cause functional impairment in social, occupational, behavioral, or academic functioning. The symptoms cannot be attributed to a medication side effect or substance use.

RLS often accompanies other conditions

More than half of those with RLS also have another mental health condition. This pairing or clustering of conditions is often referred to as, “dual diagnosis,” or “co-occurring disorders.” Some individuals with RLS may report increased anxiety and depression, as a result of poor quality sleep. These symptoms may be treated in tandem.

What it looks like

Most people with RLS experience symptoms soon after they go to bed. They report feeling uncomfortable aching, burning, crawling, creeping, throbbing, or itching in their legs, at varying levels of severity, resulting in insufficient and poor quality sleep. Eighty percent of those affected with RLS report jerking leg movements during sleep, known as Periodic Leg Movements of Sleep, (PLMS). Over time, RLS symptoms may worsen.

This chronic and profound sleep deficit, caused by RLS, results in disabling distress and decreased functioning across all domains of daily life. Lack of energy, daytime fatigue, and disabling exhaustion can cause problems performing at work or school. Learning and memory are consolidated during the Rapid Eye Movement phase of sleep, so losing this valuable phase can disrupt an individual’s ability to store and remember information.

Sleeping partners frequently complain that their own sleep is interrupted by the constant and often rhythmic movements of the RLS sufferer. Interrupted sleep often leads to relationship problems, inattentiveness to the partner, irritability, and decreased libido. Moreover, inadequate sleep can create or worsen mental health conditions, and profoundly affect mood, increasing symptoms of anxiety, depression, ADHD, and other psychiatric conditions.

The motivation and energy to engage with family and friends may decline causing social withdrawal and strained or ruptured relationships. In addition, physical health and immunity deteriorate, leaving the individual more vulnerable to illness. Inadequate sleep can impact the perception of pain. Some individuals report that their symptoms of physical pain improve when they are able to obtain adequate sleep and, conversely, their pain may increase when their sleep is interrupted by RLS.

Women may develop RLS during pregnancy, especially during the last trimester, but these symptoms tend to be temporary. Individuals with some medical problems, such as diabetes, hypertension, hypothyroidism, cardiovascular disease, multiple sclerosis, neuropathy (nerve damage that causes pain), and Parkinson’s disease have a greater risk of RLS than others.

How is RLS diagnosed?

A detailed history and physical exam is a first step: A diagnosis of RLS is made based on a detailed history of symptoms, a physical examination, lab tests, and family and medical history. Sleep studies, including polysomnography may be recommended. Polysomnography measures heart beat, brain waves, and other dimensions that occur throughout the night.

Having RLS is nobody's fault

Many people with RLS blame themselves for being tired all the time or being “lazy,” thinking that they should be better able to control their sleep. It is important to know that RLS is nobody’s fault, and that lack of sleep can cause very real challenges in day to day life. The disruptive, ripple effects of RLS are not within an individual’s immediate control. However, there are treatment options for RLS.

Consequences of not treating RLS

No one signs up for RLS, nor does anyone want to use their limited time and energy to seek treatment for it. Yet, untreated RLS can lead to the array of problems discussed above, disrupting relationships, and impairing productivity, health, and one’s global quality of life. Individuals suffering with RLS are encouraged to seek diagnostic evaluation and explore the available treatment options.

Outlook

While living with RLS can present unique obstacles, there are encouraging treatment options available. Many people, who are properly diagnosed and treated, have found relief from symptoms of RLS.

In good company

Several prominent people reportedly have RLS, such as celebrity Jon Stewart and talk show host Keith Olbermann.

The current thinking on what causes RLS

In the last two decades, a body of research indicates three hypothetical causes for RLS. These include genetics, and concentrations of iron and dopamine in the brain.

The role of iron

Iron deficiency may be a risk factor for RLS. Symptoms of RLS have shown improvement when iron supplementation is prescribed. It is important to note, although a blood test may show adequate stores of iron in the blood serum, there may be insufficient iron in key brain regions, such as the substantia nigra. When indicated, prescribed oral or intravenous iron may be prescribed, often with therapeutic results.

The role of dopamine

The neurotransmitter, dopamine, also plays an important role in RLS. Medications that stimulate the dopamine system have produced significantly improved symptoms of RLS. There appears to be a relationship between a decrease in the number of dopamine receptors in the brain and symptoms of RLS.

Another brain chemical, glutamate, has been implicated in RLS and is currently being explored for treatment modalities.

The role of genes

RLS tends to run in families. More than half the individuals with RLS have a family member who also has this disorder. There is a complex interaction between one’s genes and environmental factors, such as iron, dopamine, glutamate, and others. It has been hypothesized that a variant of the BTBD9 gene, when paired with other environmental factors, may set the stage for RLS.

Medications

Some medications are known to increase the risk for RLS, such as antidepressants that increase serotonin levels like fluoxetine (Prozac) or sertraline (Zoloft). Anti-nausea drugs such as prochlorperazine (Compro) or metoclopramide (Reglan) may lead to RLS, as may some older antipsychotic drugs such as haloperidol (Haldol). In addition, cold medications that include diphenhydramine also may cause RLS.

The use of common substances, such as caffeine, alcohol, and nicotine have also been shown to increase the risk for RLS.

Conditions like sleep apnea or neuropathy (nerve damage) may increase the risk for RLS. People experiencing kidney failure may develop RLS, as well as individuals receiving dialysis. Hypertension and diabetes are additional risk factors for RLS.

Next: Finding The Right Treatment