Case Report :
A 38-year female fulltime working
Optometrist presented to the Insomnia clinic with a
history of six years of sleep onset insomnia.
A complete history revealed medical conditions of hypertension, hypothyroidism
controlled by prescribed medications.
The patient had a good appetite and BMI of 28. She exercised by walking three afternoons per
week. Her work shift varied in terms of
start times: 9-5pm, 11-7pm or 1-9pm of which she had no control over. Corresponding to this, her bedtime varied
from 11 to 11:45pm and wakeup times from 7-9am.
The patient spends her free time
with in house fixit projects which she enjoyed. An all-night PSG ruled out Restless Legs Syndrome
and Sleep Apnea. During the intake interview the patient
revealed experiencing small body jerks throughout the day particularly near bed
time. At the hour of sleep, this turns
to full body jerks and sometimes lasts (reported at 50% of the time) into the
first few hours of her night of sleep. Two-week sleep log data confirmed a
sleep disturbance with varying sleep onset times, reportings of body jerks 67%
of the time that intruded upon her sleep onset and sleep after wakeup
times. The patient described the full
body jerk as a switchblade opening/closing with her waist as the central fulcrum. She does not feel tingling, numbness or other
sensory stimuli. The motor movement is a
brisk, non-violent movement that she feels little control to stop or
abbreviate. The average number of body
jerks that she was conscious of at pre-sleep was seven as measured in the
two-week sleep log assessment. The hypnic jerks had increases over the last
twenty-two months and were intermittent since adolescence. The patient was asymptomatic for
anxiety/stress-related or depression symptomology.
Sleep starts, or hypnic jerks are
described in the literature as a type of parasomnia. The etiology is unknown although aberrant
physiological components of muscular movements. Some studies have identified
the incomplete action of the nervous system to oppose control on the motor
system thus leaving some hypnic
jerk movements [1]. Fryer (2014) measured
intervertebral discs during sleep and found a gradual lengthening over the
course of the night. It was hypothesized
that as the spinal muscles relax, muscles lengthen thus provoking a stretch
reflex [2]. Oswald (2016) conducted a
series of case studies with all night polysomnography of
patients free of medical conditions except for hypnic jerks. In all cases of this study, Oswald (2016)
reported the occurrence of the hypnic jerks as occurring during stage one
sleep. The patient experiences of the
hypnic jerks were reported to vary to some degree (i.e., feeling a warm
sensation, tightness in limbs, no sensations).
And, in all cases the occurrence of the hypnic jerks were unrelated to
external events. Oswald (2016) concluded that the hypnic jerks occur as a
result of poorly developed EEG K complexes.
Additionally, the frequency and magnitude of the hypnic jerks preclude
them from being considered as epilepsy [3]. The patients medical and sleep
history were not positive for a psychiatric diagnosis
or parasomnia [4]. The patient presented
the hypnic jerks as an annoyance experience that interfered with her sleep but
was not anxious or extremely emotional about the condition. Following two weeks of sleep logging the
patient participated in a six session Cognitive Behavioral
Intervention for Insomnia (CBTi).
Topics such as the basics of sleep, relaxation -mindfulness training and
sleep schedule were discussed during these sessions. In addition, the patient was guided in
mindfulness relaxation posture and some general gentle stretching
exercises. A presleep routine of twenty
minutes mindfulness
relaxation followed by quiet stretching was setup with the patient. The CBTi approach provides the patient with
an active approach to alleviating their discomfort from the sleep
disturbance. The additional skills
applied of mindfulness relaxation provided the patient with some new coping
skills that in turn increased her control of her condition [5]. Sleep log data
indicated changes in
sleep efficiency ranging from 10-38% improvement as compared to intake
values. The incidence of the hypnic
jerks followed consistent course in frequency with reductions in the latency
and intensity. Overall, the patient
reported satisfaction with further understanding her condition and being able
to apply new coping skills. 1.
Sander HW, Geisse H, Quinto C,
Sacheo R and Chokroverty S. Sensory Sleep Starts (2016) J Neurol, Neurosurgery
and Psyi 64: 690. http://dx.doi.org/10.1136/jnnp.64.5.690 2.
Fryer J. Hypnic Reflex: A Spinal Perspective (2014) J Sleep Dis and
Therapy 3. https://doi.org/10.4172/2167-0277.1000177 3.
Oswald I. Sudden Bodily Jerks on
Falling Asleep (2016) Brain 122: 92-103. 4.
Fleetham JA and Fleming J.
Parasomnia (2014) CMAJ 186: E273-E280. https://doi.org/10.1503/cmaj.120808 5.
Galbiati A, Rinaldi F, Giora E,
Ferini-Strambi L and Marelli S. Behavioral and Cognitive-Behavioral Treatments
of Parasomnias (2015) Behavi Neurol 1-8. http://dx.doi.org/10.1155/2015/786928 Kathy Sexton-Radek,
Elmhurst College, Elmhurst, Il Suburban Pulmonary and Sleep Associates,
Westmont, IL, USA, E-mail: ksrsleep@aol.com Sexton-Radek K. Hypnic
jerks associated with insomnia (2018) Edelweiss Psyi Open Access 2: 28 Insomnia, Hypothyroidism, Restless Legs Syndrome,
Sleep Apnea, Depression, Cognitive Behavioral Hypnic Jerks Associated with Insomnia
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