Case Study: Increased Frequency of Sleep-Onset Myoclonic Jerks in a Patient with GAD and PTSD

Case at a Glance

A 31-year-old male with a history of generalized anxiety disorder, PTSD, and major depressive disorder presented with a six-month history of worsening myoclonic jerks. The jerks occurred exclusively at the onset of sleep, raising concerns for a new neurological issue.

Patient's Story

A 31-year-old male presented with concerns about a noticeable increase in involuntary muscle twitches over the past six months. He reported that these 'jerks' primarily affected his arms and legs and would happen four to five times every time he laid down to rest or sleep. He stated, 'I used to get them very rarely, but now it's a constant part of trying to fall asleep.' He denied any associated pain but was worried about the increased frequency and what it might signify.

Initial Assessment

The patient is a 31-year-old male with a height of 5'11" and weight of 175 lbs. His past medical history is significant for generalized anxiety disorder, post-traumatic stress disorder (PTSD), and severe, recurrent major depressive disorder. His current medication regimen includes Cymbalta (duloxetine), propranolol, and gabapentin, all taken daily. The patient is physically active, engaging in regular biking. He denies any use of alcohol or recreational drugs, citing their negative impact on his mental health.

The Diagnostic Journey

The patient's primary complaint was the increasing frequency of myoclonic jerks localized to the sleep-onset period. Given the timing and nature of the jerks, the leading differential diagnosis was benign hypnagogic jerks (also known as 'sleep starts'). These are extremely common, non-pathological phenomena. The diagnostic process focused on contextual factors. The patient's significant history of anxiety and PTSD was considered a major contributor, as stress and hyperarousal are known to exacerbate the frequency and intensity of hypnagogic jerks. A review of his medications was performed; while CNS-active drugs can have various side effects, the symptoms were highly characteristic of a benign process rather than a drug-induced movement disorder. Given the classic presentation (occurring only at sleep onset, no other neurological signs), further neuroimaging or electroencephalography (EEG) was deemed unnecessary at this stage.

Final Diagnosis

Benign Hypnagogic Jerks, exacerbated by underlying anxiety disorder.

Treatment Plan

The treatment plan focused on reassurance, education, and conservative management.

1. Patient Education: The patient was thoroughly educated on the nature of hypnagogic jerks, emphasizing that they are a normal physiological phenomenon and not indicative of a dangerous underlying neurological disease. The connection between his diagnosed anxiety, stress levels, and the increased jerks was explained.
2. Lifestyle Modifications: He was advised on sleep hygiene and stress-reduction techniques. It was also suggested he ensure his physical activity (biking) was not performed too close to bedtime, as intense evening exercise can sometimes contribute to sleep-onset phenomena.
3. Supplementation: The option of trying an over-the-counter magnesium supplement before bed was discussed as a potential method to promote muscle relaxation and potentially reduce the frequency of the jerks.
4. Medication Management: His current psychiatric medications were continued without change, as they were providing benefit for his primary diagnoses. The plan was to monitor for any new side effects.

Outcome and Follow-up

The patient expressed significant relief upon learning the benign nature of his symptoms. He was receptive to the lifestyle and supplement suggestions. A follow-up appointment was recommended in 3-6 months to monitor the symptom frequency and his overall mental health status. He was instructed to return sooner if he experienced any new neurological symptoms, such as jerks occurring during wakefulness, changes in coordination, or weakness.