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from peptic ulcer and carcinoma, pulmonary and cardiovascular insuf ciency, prostatism, the restless legs syndrome, and periodic leg movements of sleep Restless Legs, Periodic Leg Movements of Sleep, and Related Disorders The disorder known as the restless legs syndrome (anxietas tibiarum) may regularly delay the onset of sleep or occur in its early stages This disorder is surprisingly prevalent, affecting more than 2 percent of the population The patient complains of unpleasant aching and drawing sensations in the calves and thighs, often associated with creeping or crawling feelings The symptoms are provoked by rest and rapidly but temporarily relieved by moving the legs A compulsion to move the legs can be suppressed voluntarily for a brief period but is ultimately irresistible Moving the limbs alleviates the sensation brie y Excessive fatigue may give rise to abnormal ( drawing ) muscular sensations, but careful questioning will distinguish the latter disorder as well as benign nocturnal cramping of leg muscles from the restless legs syndrome It is interesting to note that a proportion of patients have similar symptoms in the arms; these symptoms are prone to occur in those who have not responded to medical treatment In some cases, the leg restlessness and sensations extend into the daytime; in the most severely affected patients, they are present almost continually Fatigue worsens the symptoms and there is a tendency for them to be worse in warm weather The syndrome is usually benign and idiopathic and may persist for years Occasionally it is a prelude to a peripheral neuropathy, particularly in relation to uremia Iron de ciency anemia and low ferritin levels have been associated with the syndrome in a few instances, as has thyroid disease, pregnancy, cigarette smoking, certain drugs such as antidepressants and antihistamines, and varicose veins Also, reduced levels of iron in the cerebrospinal uid (CSF) have been found with periodic limb movements of sleep The basis for this is not well de ned One hypothesis is that iron depletion in the basal ganglia contributes to a decrement in dopamine agonist binding by dopamine receptors and transporters, as has been reported in studies using PET and single-photon emission tomography (SPECT) scans A closely related if not identical disturbance and one that may result in sleep deprivation and daytime somnolence or in disturbance of a bed partner is periodic leg movements during sleep Originally described as nocturnal myoclonus, periodic leg movements are slower than myoclonic jerks They consist of a series of repetitive movements of the feet and legs occurring every 20 to 90 s for several minutes to an hour; mainly the anterior tibialis is involved, with dorsi exion of the feet and big toes, sometimes followed by exion of the hip and knee The movements are similar to the triple exion (Babinski) response, which can be elicited in normal sleeping persons These movements produce frequent microarousals or, if severe and periodic, full arousals The patient, usually unaware of these sleep-related movements at the time they occur, is told of them by a bedmate or suspects their occurrence from the disarray of the bedclothes This type of periodic leg movement may be associated with restless legs as well as with narcolepsy, sleep apnea, the use of tricyclic and serotonin reuptake inhibiting antidepressants, L-dopa, and withdrawal from anticonvulsants and hypnotic-sedative drugs There are, in addition, a few patients who have true myoclonic jerks in the leg or trunk muscles, often associated with dyskinesias that are dif cult to characterize but may include walking-like movements and arrhythmic abduction-adduction of one or both.

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Like the long call butter y, the long put butter y is designed to work toward expiration, and signi cant gains are not likely until the time value of the short put options is reduced In the model shown in Figure 83, we can see the same pro t window with the underlying price decreasing on the horizontal axis The maximum risk to the spread is established on both ends with the time value decay and market price reduction maximizing at the 90 strike price at expiration The advantage to the butter y spread is the limited risk of trade The maximum risk is established with the purchased premium plus costs of trading, and it is not a trade that needs adjusting unless the trader has suf cient reason to believe that the market has found a direction The spread can be applied with the anticipation of the market moving within a certain range between the present and expiration If market fundamentals change or a technical trend develops that will take the market outside the range of the butter y during the term of the trade, one or more options can be liquidated in order

legs or of an arm, as discussed in a later section In a few patients, mainly older ones with a severe form of the nighttime disorder, these movements and the myoclonus spill over into wakefulness and are accompanied by such movements as abnormal spasms, foot stamping, body rocking, and marching in place that are only partly under voluntary control These daytime phenomena may be responsive to low doses of opiates in some cases Treatment Several medications have proved helpful in the treatment of both the restless legs syndrome and periodic leg movements Most physicians, as a rst choice, favor treatment with dopamine agonists such as bromocriptine (125 or 25 mg introduced slowly and taken at night); pramipexole (15 mg twice daily) or pergolide (015 to 1 mg in divided doses during the day) are equally effective Long-acting combinations of L-dopa/ carbidopa (125/50 or 25/100 dose) taken at bedtime have also been successful, but Ldopa causes some patients to develop the movements earlier, ie, in the daytime, or to have an exaggeration of the movements later in the night as the effect of the drug wears off This augmentation is seen to a lesser extent with dopamine agonists Clonazepam (05 to 20 mg), temazepam (30 mg), propoxyphene (65 mg), or imipramine (25 mg) taken l/2 h before retiring are also useful in diminishing the number of movements, but their main bene t is to reduce the fragmentation of sleep Numerous other drugs seem to be helpful in certain patients: baclofen, opioids, carbamazepine, and gabapentin but they are infrequently required A lengthy list of medications that have been effective is given in the comprehensive review by Earley Curiously, a single infusion of iron is said to suppress the movements for several weeks (Earley et al) When painful paresthesias are prominent, patients may bene t from gabapentin or opiate-derivatives such as propoxyphene Caution is urged with the use of benzodiazepines, as these may worsen coexisting sleep apnea Other Causes of Secondary Insomnia Acroparesthesias, a predominantly nocturnal tingling and numbness of the ngers and palms due to tight carpal ligaments (carpal tunnel syndrome), may awaken the patient at night (see further on, under Sleep Palsies ) Cluster headaches characteristically awaken the patient within 1 to 2 h after falling asleep (page 155) In a few patients the headaches were found to occur during or immediately after the REM period Among the secondary insomnias, those due to some type of psychologic disturbance are particularly common Domestic or business worries may keep the patient s mind in a turmoil (situational insomnia) A strange bed or unfamiliar surroundings may prevent drowsiness and sleep Under these circumstances the main dif culty is in falling asleep, with a tendency to sleep late in the morning These facts emphasize that, to a certain degree, conditioning and environmental factors (social and learned) are normally involved in readying the mind and body for sleep Illnesses in which anxiety and fear are prominent symptoms also result in dif culty in falling asleep and in light, tful, or intermittent sleep Disturbing dreams are frequent in these situations and may awaken the patient Exceptionally, a patient may even try to stay awake in order to avoid them In contrast, the depressive illnesses characteristically produce early-morning waking and inability to return to sleep; the quantity of sleep is reduced, and nocturnal motility is increased; REM sleep, although not always reduced, comes earlier in the night If anxiety is combined with depression, there is a tendency for both the above patterns to be observed Yet another pattern of disturbed sleep can be discerned in individuals who are under great tension and worry or are over-.

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