Restless Legs Syndrome DSM-5 333.94 (G25.81)

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DSM-5 Category: Sleep-Wake Disorders

Introduction

RLS (Restless Legs Syndrome) is a DSM -5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) neuro-motor, Sleep-Wake Disorder, involving an uncomfortable sensation e.g.- “ creepy-crawlies”, tingling, or burning, and a continuous urge to move the legs (American Psychiatric Association, 2013). It is described as a sensation that starts at the soles of the feet, and creeps up the calves, often starting around bedtime. The person with Rest Legs Syndrome will stomp their feet, shake their legs, stand up, and rub their calves, which will produce only momentary relief, as the sensations will resume as soon as they attempt to rest again. This will produce frustration of the sufferer, which can further disrupt efforts to sleep. The disorder is not related to anxiety, or a medical problem, and will delay the onset of sleep, resulting in poorly maintained and non-restorative sleep, with daytime fatigue.

Symptoms of Restless Legs Syndrome.

According to the DSM-5, there are five diagnostic criteria for RLS, with three sub-symptoms for one Criterion:

  1. While resting, and most frequently and severely at night, there is an urge to move the legs, accompanied by uncomfortable sensations, which are at least partially relieved by movement.
  2. These symptoms occur at least three times a week for at least three months,
  3. Resulting in significant distress or impairment in functioning, and
  4. Are not better accounted for by another medical or mental disorder, or,
  5. Use of prescribed medications, or illicit drugs or alcohol (American Psychiatric Association, 2013).

Onset

According to the DSM-5, the typical age of onset of Restless Legs Syndrome is during one's 20's and 30's, with symptoms worsening with age. RLS may occur in children, but is not readily recognized due to difficulty in accurate self- reporting of symptoms by children (American Psychiatric Association, 2013). However, a study done on n= 10,000 families in the US and UK showed an incidence of 2% in children (National Sleep Foundation, 2013).

Prevalence

The DSM-5 indicates that the prevalence of RLS is 2%- 7%, depending on how the diagnostic criteria are defined. Women are about 1.5 to two times more likely to have Restless Legs Syndrome than men (American Psychiatric Association, 2013).

Risk Factors

The DSM-5 identifies risk factors for RLS as follows: being female, especially if pregnant, aging, and family history of RLS. Problems in the dopaminergic system, specifically the nigrostriatal and mesolimbic pathways, (Rizzo, Tonon, Manners, Testa & Lodi, 2013), and with metabolism of iron are also implicated in RLS (American Psychiatric Association, 2013). The serotonergic and glutamenergic systems may also be involved in RLS (Rizzo, et al 2013).

Comorbidity

The DSM -5 identifies depressive and anxiety disorders, as well as attentional disorders- e.g.- ADD/ADHD ( Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder) as comorbid with Restless Legs Syndrome (American Psychiatric Association, 2013). Migraine headache also appears to be comorbid with Restless Legs Syndrome. In a study of n= 30,000 women who experience migraine headaches, there was a 22% increased risk of Restless Legs Syndrome. A possible causal link is that the aforementioned dopaminergic system and iron metabolism problems are also consistent with migraine headache (Brooks, 2012). Another study found not only a correlation between migraine and Restless Legs Syndrome, but more frequent and severe migraines (Lucchesi, Bonnani, Maestri, Sicilano, Murri. & Gori 2012). A correlation between bruxism ( nocturnal jaw grinding and teeth clenching) may also be comorbid with both migraines and Restless Legs Syndrome. In a study of n=870 subjects with RLS, 63% had migraine headaches, 33% experienced bruxism, and 28% had Restless Legs Syndrome, bruxism and migraines. In 76% of patients with RLS, successful treatment of RLS also relieved bruxism. This association was disputed when causality was considered, as there is the possibility that disturbed sleep may cause the migraines (Helwick, 2013). Bruxism can also result in headaches upon wakening, typically in the temporal regions, (personal communication, Brown, K., DDS, 2011) which can be misinterpreted as migraine without accompanying aura. 80% of people with Restless Legs Syndrome also have PLMD (Periodic Limb Movement Disorder), in which sleep will be disrupted by involuntary twitching or jerking movements. There has been speculation that there is a link between Parkinson’s disease and Restless Legs Syndrome, as both disorders involve the dopaminergic system, and symptoms of both disorders can be relieved by dopamine agonists, but at least one study showed the evidence for a causal link is inconclusive (Peeraully & Tan, 2012).

Treatment for Restless Leg Syndrome

The DSM-5 does not specify treatment options for Restless Legs Syndrome (American Psychiatric Association, 2013). Psychoeducation about Restless Legs Syndrome may help people to cope more effectively, and some people find relief from walking, leg massage, stretching, or applying hot or cold packs to their legs Pharmacological treatments are primarily used for relief of Restless Legs Syndrome, including dopamine agonists which are used for treatment of Parkinson’s disease, and benzodiazepines or opiates to induce sleep (National Sleep Foundation, 2013). The risk of dependence on the latter two classes of medications must be weighed against the benefits of diminishing RLS, and are contraindicated in persons with a history of chemical dependency. Acetylcholine antagonist muscle relaxants such as flexaril are also used. There is anecdotal use of vitamin E supplements, or folate, iron and magnesium supplements, but the efficacy of vitamin and mineral supplements in relieving Restless Legs Syndrome cannot be supported by placebo controlled, double- blind studies (NYU Langone Medical Center, 2014).

Impact on Functioning

According to the DSM-5, Restless Legs Syndrome can result in daytime fatigue, with impaired occupational and educational performance, and in about 50% of people with Restless Legs Syndrome, anergia and depressed mood (American Psychiatric Association, 2013), and general reduction in quality of life (National Sleep Foundation, 2013) If one has a sleeping partner, the RLS sufferer's restlessness and movement may disturb their sleep as well, and put increased stress on a relationship.

Differential Diagnosis:

There are multiple diagnostic rule-outs for the clinician to consider. In the DSM -5, disorders such as arthritis, peripheral neuropathy, and lower extremity edema are noted, as well as anxiety resulting in restlessness, leg cramps, positional ischemia resulting in parathesia and numbness, and awkward positioning of the legs while in bed or sitting (American Psychiatric Association, 2013).

References:

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders. (5th Edition). Washington, DC.

Brooks, M, .(2012). Link between Migraine and Restless legs syndrome. Health 24. Retrieved March 4, 2014, from. http://www.health24.com/Medical/Headache-and-migraine/News/Link-between-migraine-and-restless-legs-20120721

Helwick, C. (October 18, 2013) Medscape Medical News from the: American Neurological Association (ANA) 2013 Annual Meeting . Restless Limbs, Migraine, and Bruxism May Form a 'Triad' Retrieved March 4, 2014 from http://www.medscape.com/viewarticle/812790

Lucchesi, C., Bonnani, E., Maestri, M., Sicilano, G., Murri. L., Gori, S. (2012) Evidence of increased Restless leg syndrome in chronic and disabling migraine. Functional Neurology. 27 (2) 91-94.

National Sleep Foundation. (2013) Restless Legs Syndrome (RLS) and Sleep. National Sleep Foundation. Retrieved March 4, 2014, from http://sleepfoundation.org/stage.sleepfoundation.org/sleep-disorders-problems/restless-legs syndrome-rls-and-sleep

NYU Langon Medical Center. (2014). Restless Legs Syndrome. Principal Proposed Natural Treatments, Other Proposed Natural Treatments. NYU Langone Medical Center. Retrieved March 9, 2014, from: http://www.med.nyu.edu/content?ChunkIID=21806

Peeraully, T. and Tan, E. K. (2102) Linking restless legs syndrome with Parkinson's disease: clinical, imaging and genetic evidence. Translational Neurodegeneration 1:6 doi:10.1186/2047-9158-1-6

Rizzo G., Tonon C, Manners D, Testa C, and Lodi R. (2013). Imaging brain functional and metabolic changes in restless legs syndrome. Current Neurology and Neuroscience report. (Abstract).13 (9):372. doi: 10.1007/s11910-013-0372-1.


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