made little difference and has led to accusations of ‘disease mongering’ (Woloshin and Schwartz 2006). An international population study published in 2004 reported that two thirds of those with weekly RLS symptoms said that they had spoken to a physician about their symptoms and only 8% said that they had received a diagnosis of RLS (Hening et al 2004). A number of myths and misconceptions probably contribute to this dismal situation. Myth 1: RLS is a trivial condition RLS is sometimes regarded as merely an inconvenience to the sufferer or even as an entity with no physiological basis. A number of factors may underlie this myth. The very name of the condition sounds benign if not even slightly funny. Few of us have not experienced the discomfort and urge to move the legs that develops on a long, cramped journey, and RLS may be regarded as a ‘natural’ phenomenon. Clinicians may be sceptical, in particular, of the high prevalence of RLS reported in epidemiological studies. It is important to acknowledge that many people with RLS have relatively mild symptoms, and it is doubtful whether there is any benefit in telling such people that they have a recognized medical condition. Nevertheless, there is a substantial group of patients with symptoms of sufficient severity to warrant intervention. Data from the RLS Epidemiology, Symptoms and Treatment (REST) studies conducted in the general population and in primary care practices in the US and some European countries illuminate this point (Hening et al 2004; Allen et al 2005). RLS of any degree of frequency or severity occurred in 7.2% and 11.1% of these studies respectively; RLS that occurred more than twice a week and that caused significant distress was present in roughly a third of each group (2.7% and 3.4% respectively). Also, even those with mild symptoms may benefit from being given a diagnosis to explain their unusual symptoms. It is also true that RLS does not pose the same threat to health as does heart disease or diabetes, for example. Nevertheless, as will be shown later, it may have a very significant effect on the quality of life of the sufferer, and the chronic insomnia in particular may impact on daytime functioning. Myth 2: RLS is ‘all in the head’ Many sufferers report that they have been told their symptoms are psychogenic. Richard Allen (personal communication) tells of one patient who was referred for Restless leg syndrome five years of psychoanalysis as doctors were convinced that he was kicking his wife at night because he was angry at his mother! The difficulty that RLS patients often experience in describing the nature of their leg sensations, and the sometimes bizarre analogies they draw, may contribute this misconception. Patients may also delay presenting for medical attention because they fear they will not be believed. It is undeniable that RLS is associated with anxiety and depression (Picchietti and Winkelman 2005). In a study from Munich, RLS patients were compared with patients with other chronic disorders (Winkelmann et al 2005). There was a much higher prevalence in the RLS group of panic disorder (odds ratio [OR] of 4.7), of generalized anxiety disorder (OR 3.6) and of major depression (OR 2.7). Also, the RLS patients were more likely to attribute their psychiatric disorders and associated symptoms directly to the impact of their underlying condition on their life. The association with depression also has practical significance for the management of RLS; serotonin reuptake blocking antidepressants and, less often tricyclic antidepressants, can precipitate or exacerbate symptoms of RLS (Dorsey et al 1996). Bupropion, an antidepressant with dopamine agonist activity, may be a useful alternative (Nofzinger et al 2000). Myth 3: RLS is ‘all in the legs’ The notion that RLS is due to a vascular disorder of the legs, especially of the veins, dates back to Ekbom (1945) and persists to some degree today (Kanter 1995). Examination of peripheral arteries and veins is normal in most RLS patients. Procedures to reduce incompetent veins have not been shown to reduce RLS symptoms (Kanter 1995; Bradbury et al 1999). The role of peripheral neuropathy in the pathogenesis of RLS is less clear cut. It has been reported that RLS may be a presenting feature of neuropathy, such as those due to diabetes mellitus, alcohol abuse, Charcot-Marie-Tooth syndrome type 2, and of spinal disease such as radiculopathy (Ondo and Jankovic 1996; Gemignani et al 1999). Also, detailed evaluation of RLS patients with sural nerve or skin biopsies has found a high frequency of clinically undetectable axonal and small-fiber neuropathies (Polydekis et al 2000). However, other studies have suggested that the frequency of RLS in neuropathic patients is similar to that in the general population (Salih et al 1994; Banno et al 2000). Nevertheless, as will be discussed later, most evidence points to a central nervous system abnormality. Therapeutics and Clinical Risk Management 2006:2(4) 467