Sleep Breath (2013) 17:10551061

DOI 10.1007/s11325-013-0800-0

ORIGINAL ARTICLE

Psychosomatic symptom profiles in patients with restless legs

syndrome
Jung Bin Kim & Yong Seo Koo & Mi-Yeon Eun &
Kun-Woo Park & Ki-Young Jung

Received: 22 August 2012 / Revised: 13 November 2012 / Accepted: 3 January 2013 / Published online: 23 January 2013
# Springer-Verlag Berlin Heidelberg 2013

Abstract
Purpose It has been reported that restless legs syndrome
(RLS) might be associated with multiple psychosomatic
symptoms. We aimed to identify which psychosomatic
symptom is the most related in RLS patients compared to
healthy controls. We also attempted to determine the relation
between psychosomatic comorbidity and RLS severity regardless of sleep-related symptoms.
Methods One hundred two newly diagnosed patients with
RLS and 37 healthy control subjects participated in the
present study. The RLS patients were categorized as mild
and severe based on the International RLS Study Group
rating scale. Data on demographics were collected. All
participants completed the Pittsburgh Sleep Quality Index,
Athens Insomnia Scale, and Epworth Sleepiness Scale as
sleep-related questionnaires. All participants completed the
Symptom Checklist-90-Revision (SCL-90-R).
Results RLS patients were found to have pervasive comorbid
psychosomatic symptoms. Somatization was found to be the
most significant contributing factor (OR 1.145, 95 % CI 1.061
1.234, p<0.001) for psychosomatic comorbidity in RLS. Severe RLS patients were found to have poorer sleep quality than
mild RLS patients. Furthermore, severe RLS patients had
higher scores for most psychosomatic symptom domains in
SCL-90-R. Anxiety was found to be the most independent
contributing factor for psychosomatic comorbidity according
to RLS severity (OR 1.145, 95 % CI 1.0431.257, p=0.005).
J. B. Kim : Y. S. Koo : M.-Y. Eun : K.-W. Park : K.-Y. Jung (*)
Department of Neurology, Korea University Medical Center,
Korea University College of Medicine,
#126-1, Anam-Dong 5Ga, Seongbuk-Gu,
Seoul 136-705, South Korea
e-mail: jungky@korea.ac.kr

Conclusions Our study demonstrates that comorbid psychosomatic distress is considerable in patients with RLS. Furthermore, most psychosomatic comorbidity is increased with the
RLS severity in association with poorer sleep quality.
Keywords Restless legs syndrome . Psychosomatic
symptom . SCL-90-R . Severity

Introduction
Restless legs syndrome (RLS) is a sensorimotor neurological
disorder, in which the primary symptom is a compelling urge
to move the legs [1, 2]. RLS is a common cause of sleep
disturbance that can severely disrupt normal life functioning
[36]. In addition to sleep disturbance, RLS patients are
known to exhibit considerably greater anxiety than healthy
controls [710]. Previous studies showed that depression was
also comorbid in RLS patients [9, 11, 12]. It is known that
RLS and depression can accompany in patients with medical
disorders such as end-stage renal disease and affect quality of
life, compliance with treatment, and prognosis [6]. Mood
disturbance has been included in the International Restless
Legs Syndrome Study Group rating scale (IRLS) to evaluate
psychosomatic impairment due to RLS [13]. However, little
attention has been paid to identify which specific psychosomatic symptoms are related to RLS. Furthermore, the specific
domains of psychosomatic symptoms correlated with RLS
severity have not been well determined.
To address this issue, we evaluated psychosomatic symptom profiles using the Symptom Checklist-90-Revised (SCL90-R) in patients with RLS. SCL-90-R has been described as a
sensitive instrument for determining the distress continuum,
which ranges from profound psychiatric disorders to mild

1056

dysphoria and anxiety [14], and is a self-rating questionnaire

that assesses psychopathology and psychological distress. It is
currently used to screen for comorbidity in various disorders
[1520]. To our best knowledge, only one study has been
performed to identify the psychosomatic distress by using the
SCL-90-R in RLS patients [21]. The study showed that untreated RLS patients had psychological distress in multiple
domains including somatization, compulsivity, depression,
and anxiety. Furthermore, treated RLS patients had more
severe psychological distress compared to the untreated
group. In subgroup analysis, loss of efficacy and augmentation were major causes of psychological distress increases in
treated RLS patients. The study provided whole psychosomatic profiles in RLS patients by using the SCL-90-R. However, the study focused on the difference of psychological
impairments between the treated and untreated groups in the
context of severity associated with the development of augmentation. The comparison of the psychosomatic symptom
profiles to healthy controls in RLS patients was not evaluated.
Moreover, the study did not present results for the differences
of psychosomatic profiles according to RLS severity not
affected by medications.
In the present study, we aimed to compare the psychosomatic symptom profiles of RLS patients with those of controls to reveal psychosomatic symptoms associated with
RLS. Additionally, we attempted to identify which psychosomatic symptoms are most related to RLS severity regardless of a causal relationship.

Methods
Subjects
One hundred two newly diagnosed, drug naive patients with
RLS were included in the present study. RLS was diagnosed
following the criteria proposed by the International RLS Study
Group [1, 2]. All patients were asked the diagnostic questions
and clinically examined by a board-certified neurologist (KJ).
Subjects responding affirmatively to all four questions were
considered to have RLS. Patients were excluded if they had
RLS mimics or a secondary cause of RLS, including a history
of taking drugs known to cause RLS (e.g., neuroleptics, antidepressants, or antihistamines), a relevant neurological or
psychiatric disorder, or a history of sleep-related disorders
other than RLS-related insomnia. Hemoglobin, blood glucose,
and serum levels of creatinine, iron/ferritin, and thyroid hormones were checked in all patients. RLS severity was determined using the International RLS rating scale (IRLS).
Patients were classified into two subgroups (mild and severe
RLS) with a cut off of 20 point of IRLS [13].
An age-matched group of 37 healthy volunteers were
recruited by advertising in the local community (mean age,

Sleep Breath (2013) 17:10551061

52.8610.76 years). Each candidate completed a detailed

clinical interview by a physician and a sleep questionnaire.
Subjects with a history of a neurologic, psychiatric, or
systemic illness or a family history of neurodegenerative
disorder were excluded. All participants gave written informed consent prior to study inclusion.
Sleep-related and psychosomatic symptom profiles
A structured sleep questionnaire was administered to all
study subjects. This questionnaire included questions on
sleep habits and medication history, the Pittsburgh Sleep
Quality Index (PSQI) [22], the Epworth Sleepiness Scale
(ESS) [23], and the Athens Insomnia Scale (AIS) [24].
A psychosomatic symptom profile of each subject was
evaluated using the Symptom Checklist-90-Revised (SCL90-R) [25]. The SCL-90-R consists of nine symptom domains,
comprising 90 items with self-rating scale weighted from 0 to
5. The scores are represented as T scores, with a mean of 50
and a standard deviation of 10; higher scores indicate more
severe symptoms. The reliability of the SCL-90-R was demonstrated in that Cronbachs alpha was 0.923. We used the
Korean version of SCL-90-R which was standardized and has
been applied to diseases of various fields [26].
Statistical analysis
Demographic characteristics and sleep questionnaires were
compared among control subjects and mild and severe RLS
patients by one-way analysis of variance (ANOVA). To compare the psychosomatic profiles between the control group and
RLS patient groups, SCL-90-R scores were analyzed by Students t test. The same test was also applied to compare the
psychosomatic profiles between mild RLS and severe RLS
groups. To identify psychosomatic factors independently associated with the RLS, logistic regression analysis was performed
with domains of SCL-90-R as independent variables. To identify the correlation between the psychosomatic factors and RLS
severity, Pearsons correlation analysis was performed.
Domains of SCL-90-R and the results of sleep-related questionnaires were subjected to multiple stepwise regression analysis to determine the contributing extent of psychosomatic
domains with adjustment for the results of sleep questionnaires.
Statistical significance was accepted for p values of <0.05.

Results
Comparison of clinical characteristics and sleep
questionnaires
Forty-seven RLS patients were classified in the mild RLS
group, and 55 patients were classified in the severe RLS

1056

dysphoria and anxiety [14], and is a self-rating questionnaire

that assesses psychopathology and psychological distress. It is
currently used to screen for comorbidity in various disorders
[1520]. To our best knowledge, only one study has been
performed to identify the psychosomatic distress by using the
SCL-90-R in RLS patients [21]. The study showed that untreated RLS patients had psychological distress in multiple
domains including somatization, compulsivity, depression,
and anxiety. Furthermore, treated RLS patients had more
severe psychological distress compared to the untreated
group. In subgroup analysis, loss of efficacy and augmentation were major causes of psychological distress increases in
treated RLS patients. The study provided whole psychosomatic profiles in RLS patients by using the SCL-90-R. However, the study focused on the difference of psychological
impairments between the treated and untreated groups in the
context of severity associated with the development of augmentation. The comparison of the psychosomatic symptom
profiles to healthy controls in RLS patients was not evaluated.
Moreover, the study did not present results for the differences
of psychosomatic profiles according to RLS severity not
affected by medications.
In the present study, we aimed to compare the psychosomatic symptom profiles of RLS patients with those of controls to reveal psychosomatic symptoms associated with
RLS. Additionally, we attempted to identify which psychosomatic symptoms are most related to RLS severity regardless of a causal relationship.

Methods
Subjects
One hundred two newly diagnosed, drug naive patients with
RLS were included in the present study. RLS was diagnosed
following the criteria proposed by the International RLS Study
Group [1, 2]. All patients were asked the diagnostic questions
and clinically examined by a board-certified neurologist (KJ).
Subjects responding affirmatively to all four questions were
considered to have RLS. Patients were excluded if they had
RLS mimics or a secondary cause of RLS, including a history
of taking drugs known to cause RLS (e.g., neuroleptics, antidepressants, or antihistamines), a relevant neurological or
psychiatric disorder, or a history of sleep-related disorders
other than RLS-related insomnia. Hemoglobin, blood glucose,
and serum levels of creatinine, iron/ferritin, and thyroid hormones were checked in all patients. RLS severity was determined using the International RLS rating scale (IRLS).
Patients were classified into two subgroups (mild and severe
RLS) with a cut off of 20 point of IRLS [13].
An age-matched group of 37 healthy volunteers were
recruited by advertising in the local community (mean age,

Sleep Breath (2013) 17:10551061

52.8610.76 years). Each candidate completed a detailed

clinical interview by a physician and a sleep questionnaire.
Subjects with a history of a neurologic, psychiatric, or
systemic illness or a family history of neurodegenerative
disorder were excluded. All participants gave written informed consent prior to study inclusion.
Sleep-related and psychosomatic symptom profiles
A structured sleep questionnaire was administered to all
study subjects. This questionnaire included questions on
sleep habits and medication history, the Pittsburgh Sleep
Quality Index (PSQI) [22], the Epworth Sleepiness Scale
(ESS) [23], and the Athens Insomnia Scale (AIS) [24].
A psychosomatic symptom profile of each subject was
evaluated using the Symptom Checklist-90-Revised (SCL90-R) [25]. The SCL-90-R consists of nine symptom domains,
comprising 90 items with self-rating scale weighted from 0 to
5. The scores are represented as T scores, with a mean of 50
and a standard deviation of 10; higher scores indicate more
severe symptoms. The reliability of the SCL-90-R was demonstrated in that Cronbachs alpha was 0.923. We used the
Korean version of SCL-90-R which was standardized and has
been applied to diseases of various fields [26].
Statistical analysis
Demographic characteristics and sleep questionnaires were
compared among control subjects and mild and severe RLS
patients by one-way analysis of variance (ANOVA). To compare the psychosomatic profiles between the control group and
RLS patient groups, SCL-90-R scores were analyzed by Students t test. The same test was also applied to compare the
psychosomatic profiles between mild RLS and severe RLS
groups. To identify psychosomatic factors independently associated with the RLS, logistic regression analysis was performed
with domains of SCL-90-R as independent variables. To identify the correlation between the psychosomatic factors and RLS
severity, Pearsons correlation analysis was performed.
Domains of SCL-90-R and the results of sleep-related questionnaires were subjected to multiple stepwise regression analysis to determine the contributing extent of psychosomatic
domains with adjustment for the results of sleep questionnaires.
Statistical significance was accepted for p values of <0.05.

Results
Comparison of clinical characteristics and sleep
questionnaires
Forty-seven RLS patients were classified in the mild RLS
group, and 55 patients were classified in the severe RLS

Sleep Breath (2013) 17:10551061

1057

Table 1 Comparison of RLS patients and normal healthy controls in terms of clinical characteristics and sleep-related questionnaire
Control (n =3 7)

RLS patients

p value

Mild RLS (n=47)

Severe RLS (n=55)

Clinical characteristics
Age, years
Male, n (%)
BMI, kg/m2
Sleep questionnaires

52.8610.76
11 (29.73)
22.622.99

54.6613.51
32 (68.09)
24.302.99

52.5614.40
22 (40.00)
23.973.48

0.703
0.001a
0.056

PSQI
AIS
ESS
EDS, n (%)

5.782.92
4.353.40
3.862.92
0 (0.00)

10.434.80
9.625.15
5.834.17
8 (17.02)

13.464.58
14.204.93
6.534.52
7 (12.73)

<0.001
<0.001
0.009
0.037a

Analysis was performed using the analysis of variance (ANOVA)

RLS restless legs syndrome, BMI body mass index, PSQI Pittsburgh Sleep Quality Index, AIS Athens Insomnia Scale, ESS Epworth Sleepiness
Scale, EDS excessive daytime sleepiness (EDS was defined as an ESS score>10)
a

Analysis was performed using the chi-square test

group. Clinical characteristics and sleep-related variables

were summarized in Table 1. Age and BMI were no different among the three groups. However, male subjects were
more common in the mild RLS group than the other groups.
PSQI, AIS, and ESS scores were significantly different
among the three groups, which showed tendency to increase
from normal control to the severe RLS group. Excessive
daytime sleepiness (EDS), defined as a score of >10 in the
ESS [23], was significantly higher in patients than control
subjects.

Analysis of the psychosomatic domains in SCL-90-R

impact on the RLS
Students t test revealed that RLS patients had more psychosomatic distress in most of the SCL-90-R domains except
interpersonal sensitivity and paranoid ideation (Table 2). To
identify the most related psychosomatic domain to RLS,
logistic regression analysis was performed. Logistic regression analysis revealed that somatization (OR 1.145, 95 % CI
1.0611.234, p<0.001) and hostility (OR 1.129, 95 % CI

Table 2 Comparison of SCL-90-R between RLS patients and healthy controls

Controls (n=37)

RLS patients

p value

Mild RLS (n=47)

Severe RLS (n=55)

Somatization
Obsessive-compulsive
Interpersonal sensitivity
Depression
Anxiety

43.926.82
42.168.84
43.7611.61
42.357.83
42.169.51

48.518.69
44.708.99
44.708.35
45.748.68
45.268.47

56.4210.90***
51.4911.71**
50.0012.46*
51.8012.71**
53.7113.97***

<0.001
0.003
0.079
<0.001
<0.001

Hostility
Phobic anxiety
Paranoid ideation
Psychoticism
Global severity index
Positive symptom distress index
Positive symptom total

42.686.00
44.548.05
43.038.08
43.688.82
41.328.99
42.4911.43
39.849.87

45.306.13
47.457.85
43.897.08
47.007.85
45.138.21
46.5311.10
45.7211.44

49.7310.79**
52.6914.91*
46.8411.56
50.4412.56
52.8513.18**
56.8913.16***
49.5610.07

<0.001
0.002
0.176
0.005
<0.001
<0.001
<0.001

Values are mean T scorestandard deviation. Students t test was performed between the control and the entire RLS patient group. Also, the same
analysis was performed within the RLS patients group between mild RLS and severe RLS groups. Statistical significance presented by p value in
the table refers to comparisons of entire RLS patient group with the control group
Statistical significance between the mild RLS and severe RLS groups were represented with asterisk: *p<0.05, **p<0.01, ***p<0.001

1058

Sleep Breath (2013) 17:10551061

1.0121.258, p=0.029) were independent contributing factors

for psychosomatic comorbidity in RLS (Table 3).
Relationship between sleep questionnaires, SCL-90-R,
and the RLS severity
All psychosomatic domains except paranoid ideation were
correlated positively with the IRLS. Also, AIS and PSQI
showed moderate positive correlation with the IRLS. However, ESS showed no significant correlation with IRLS
(Table 4).
Multiple stepwise regression analysis revealed that anxiety
(OR 1.141, 95 % CI 1.0371.255, p=0.007) and psychoticism
(OR 0.855, 95 % CI 0.7720.948, p=0.003) were independent contributing factors for psychosomatic comorbidity
according to RLS severity after adjustment for sleep-related
symptoms that can affect psychosomatic distress (Table 5).
Furthermore, multiple stepwise regression analysis also
showed that AIS (OR 1.148, 95 % CI 1.0341.273, p=
0.009) was contributing to the RLS severity even adjusting
for psychosomatic comorbidity. The comparison of SCL-90-R
data among the groups was presented in Fig. 1 with post hoc
analysis results.

Table 4 The correlation between the psychosomatic domain scores of

SCL-90-R and IRLS score
Correlation coefficient

p value

SCL-90-R
Somatization
Obsessive-compulsive
Interpersonal sensitivity
Depression
Anxiety
Hostility
Phobic anxiety
Paranoid ideation
Psychoticism
Global severity index
Positive symptom distress index
Positive symptom total

0.483
0.365
0.261
0.339
0.385
0.314
0.263
0.169
0.210
0.394
0.431
0.268

<0.001
<0.001
0.006
<0.001
<0.001
0.001
0.006
0.078
0.028
<0.001
<0.001
0.005

Sleep questionnaires
PSQI
AIS
ESS

0.511
0.546
0.075

<0.001
<0.001
0.439

The values are coefficient by Pearsons correlation test

SCL-90-R Symptom Checklist-90-Revised, IRLS International Restless
Legs Syndrome Study Group rating scale, PSQI Pittsburgh Sleep
Quality Index, AIS Athens Insomnia Scale ESS Epworth Sleepiness
Scale

Discussion
We found that RLS patients have more psychosomatic distress in all domains of SCL-90-R except interpersonal sensitivity and paranoid ideation compared to controls. Among
the domains, somatization and hostility were found to be
independent contributing factors to RLS. We also identified
that all psychosomatic domains of SCL-90-R except paranoid ideation were correlated with RLS severity. Poor sleep
quality and insomnia were also correlated with the RLS
severity. Anxiety and insomnia were found as the most
impacting factors on the RLS severity even after adjustment
for sleep-related symptoms and psychosomatic distresses,
respectively.
It has been reported that in RLS patients, psychosomatic
symptoms are associated with sleep problems, such as
Table 3 Contribution made by psychosomatic symptoms to RLS by
logistic regression analysis
Odds ratio

95 % CI

p value

1.0611.234
0.8221.016
1.0121.258
0.8061.012
0.9881.277

<0.001
0.095
0.029
0.081
0.075

insomnia and daytime sleepiness [27]. In the present study,

we reaffirmed that RLS patients suffer from psychosomatic
disturbance in addition to RLS symptom itself. However, of
the psychosomatic symptoms, only somatization and hostility
were found to be independently associated with the RLS after
the adjustment for sleep-related symptoms. These findings
suggest that somatization and hostility are the most common
comorbid psychosomatic symptoms in RLS patients regardless of sleep problems. Of the two domains, we found that
somatization was the most significant contributing factor for
psychosomatic comorbidity in RLS patient. A previous study
showed that the prevalence of RLS was high in patients with
somatoform pain disorder [28]. Another study showed that the
poor responses to treatment of RLS might be caused by
Table 5 Contribution made by psychosomatic symptoms to RLS severity adjusted for the results of sleep-related symptom questionnaires
Odds ratio

Somatization
Interpersonal sensitivity
Hostility
Paranoid ideation
Psychoticism

1.145
0.914
1.129
0.904
1.123

CI confidence interval, RLS restless legs syndrome

Somatization
Anxiety
Psychoticism

1.060
1.141
0.855

95 % CI
0.9981.137
1.0371.255
0.7720.948

Analysis was performed by multiple stepwise regression

CI confidence interval

p value
0.107
0.007
0.003

Sleep Breath (2013) 17:10551061

1059

Fig. 1 The results of SCL-90-R score. Comparison among control,

mild RLS, and severe RLS group was performed by one-way ANOVA
test with post hoc analysis. The scores in all domains of SCL-90-R
except paranoid ideation showed significant difference between control
and severe RLS groups. Also the scores in all domains of SCL-90-R
except phobic anxiety, paranoid ideation, and psychoticism showed
significant difference between mild and severe RLS groups. Somatization (p= 0.016) and phobic anxiety (p =0.025) showed significant

difference between control and mild RLS group. Only positive symptom total score showed different SCL-90-R scores between mild and
severe RLS groups significantly. Dagger, significant difference between control and mild RLS group. Double dagger, significant difference between control and severe RLS group. Section sign, significant
difference between mild and severe RLS groups. RLS restless legs
syndrome. SCL-90-R Symptom Checklist-90-Revised

neuropsychiatric comorbidity. In this study, somatoform disorder was the most common comorbid neuropsychiatric disorder [29]. Our results along with previous findings suggest
that because RLS is diagnosed based on symptomatology,
RLS could be easily diagnosed as a comorbidity in somatization patients. On the other hand, patients with somatization
may seek medical attention more frequently, and the symptoms of RLS itself could contribute to psychosomatic presentations [28, 29].
In the analysis between RLS patient groups, severe RLS
patients were found to have poorer subjective sleep quality
and more severe psychosomatic profiles in most domains.
Of all psychosomatic domains, anxiety was found to be
substantially correlated with RLS severity. Previous studies
have reported that anxiety and other psychiatric symptoms
are common among RLS patients [7, 8, 30]. Early investigators noted that RLS occurs particularly in anxious, tense,
or depressed patients [30], and recent studies have reported
increased symptoms of anxiety and depression among RLS
patients [710]. In the present study, anxiety was found to
be modestly but significantly correlated with the severity of
RLS and to potentially contribute to the severity of RLS.
However, it is also possible that patients with severe RLS
are at more risk of anxiety, as has been previously suggested
[30]. Hornyak et al. studied the effect of cognitive behavioral therapy on RLS severity and psychosomatic symptoms. In their study, the anxiety subscale in SCL-90-R
decreased significantly between baseline and the end of

treatment course (from 6.0 to 5.3 points; p=0.036) in parallel with an improvement according to the RLS severity scale
[31]. Therefore, their study and ours suggest that anxiety
should be considered as a treatment target in RLS when
patients have anxiety, particularly in severe patients.
Previous studies have reported that depression is common among RLS patients [8, 9, 28]. Likewise, in the present
study, depression was found to be more common in RLS.
Although depression was not found to be an independent
contributing factor to the RLS severity, the correlation analysis showed positive relationship with IRLS (Table 4).
In the present study, subjective sleep quality represented by
PSQI and the psychosomatic symptom profiles were found to
be significantly correlated with RLS severity. Insomnia represented by AIS was especially found to be an independent
contributing factor for RLS severity. This suggests that
patients subjective sleep quality could be influenced by psychosomatic comorbidity as well as RLS severity regardless of
causality [32]. However, after the adjustment for sleep-related
symptoms and psychosomatic distresses, it was found that
both are contributing to RLS severity independently.
Some study limitations require consideration in our
study. Unmatched gender could be a confounding factor in
the present study. Psychiatric confirmative diagnosis was
not assessed. Diagnosing psychiatric diseases could clarify
the relationship between psychosomatic symptoms and the
severity of RLS. Because the present study was not conducted longitudinally, causality between psychosomatic

1060

impairment and RLS severity cannot be inferred from our

findings, and further clarification is needed for causal relationship between anxiety and RLS severity.
Despite these limitations, our study yielded information
about psychosomatic comorbidity in RLS by comparison to
healthy controls. Furthermore, to our best knowledge, the
present study may be the first study to identify psychosomatic comorbidity in newly diagnosed RLS patients by
using the SCL-90-R.
In conclusion, our study demonstrates the importance of
psychosomatic symptoms during the evaluation of RLS
patients, especially at the time of making diagnosis. Our
findings also support the notion that recognition of comorbid states and management of comorbid psychosomatic
symptoms in RLS are needed to improve both RLS symptoms and sleep quality [29].
Acknowledgments This research was supported by the National
Research Foundation of Korea (NRF) grant funded by the Korean
government (MEST) (no. 20110029740).
Conflict of interest The authors declare that they have no conflict of
interest.

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