Sexsomnia: an uncommon variety of parasomnia

Understanding Sexual Parasomnias: A Review of the Current Literature on Their Nature, Diagnosis, Impacts, and Management

Sexual behavior during sleep, known as sexual parasomnias, has captured the interest of researchers and clinicians. These parasomnias involve various sexual activities that occur unconsciously during sleep. Although relatively rare, they can profoundly affect well-being and relationships and can carry legal consequences. Understanding their nature, prevalence, and causes is crucial for advancing knowledge in this field. This article revisits the topic of sexsomnia, presenting new data and discussing cases published from 2007 to 2023. By analyzing these cases, we aim to enhance recognition, diagnosis, and management of sexsomnia, reducing stigma and providing better support for affected individuals.

The Clinical Spectrum of the Parasomnias

Parasomnias are defined as abnormal movements or behaviors that occur in sleep or during arousals from sleep. Parasomnias vary in frequency from episodic events that arise from incomplete sleep state transition. The framework by which parasomnias are categorized and diagnosed is based on the International Classification of Sleep Disorders-Third Edition, Text Revision (ICSD-3-TR), published by the American Academy of Sleep Medicine. The recent Third Edition, Text Revision (ICSD-3-TR) of the ICSD provides an expert consensus of the diagnostic requirements for sleep disorders, including parasomnias, based on an extensive review of the current literature.

Sleep-Related Dissociative Disorders

In sleep-related dissociative disorders, phenomena of the psychiatrically defined dissociative disorders emerge during the sleep period. They occur during sustained wakefulness, either in the transition to sleep or following an awakening from sleep. Behaviors during episodes vary widely, and can result in injury to self or others. Daytime dissociative episodes and a background of trauma are almost always present; there is typically major co-existing psychopathology. Diagnosis is based on both clinical history and polysomnography; differential diagnosis primarily involves other parasomnias and nocturnal seizures. Information available about treatment is limited; in a few reported cases, psychological interventions have proven effective.

A case-control study of sexualised behaviour in sleep: A strong association with psychiatric comorbidity and relationship difficulties

Sexualised behaviour in sleep (SBS) is a relatively rare parasomnia consisting of instinctive behaviours of a sexual nature occurring during non-rapid-eye movement (NREM) sleep. Little information exists at present regarding the clinical features and onset of this condition as well as its link to psychiatric comorbidity, other sleep disorders and history of adverse early life experience. Aims were to typify the condition further and compare features of SBS patients to those with other NREM parasomnias.

METHODS

Details of 335 consecutive patients presenting to a single tertiary sleep centre with non-rapid eye movement (NREM)-parasomnias over a 15-year period (2005-2020) were examined. Data were collated by reviewing case-notes for anthropometric data, past medical history, clinical findings, and video polysomnography. SBS patients were compared to a cohort of 270 non-SBS, NREM-sleep disorder patients (case-control) to ascertain whether they had any distinguishing features from other parasomnias classified in this group.

RESULTS

Sixty-five patients with SBS were identified: 58 males, 7 females (comprising 19.4% of the cohort overall). Mean age at presentation was 33(±9.5) years. Onset of behaviours was commoner in adulthood in the SBS cohort, whereas non-SBS, NREM-parasomnia onset (n = 270) was commoner in childhood: 61.1% and 52.9% respectively (p = 0.007). An association was identified between the presence of psychiatric diagnoses and onset of SBS (p = 0.028). Significant triggers for SBS behaviours included alcohol consumption (p < 0.001), intimate relationship difficulties (p = 0.009) and sleep deprivation (p = 0.028). Patients with SBS were significantly more likely to report sleepwalking as an additional NREM behaviour (p < 0.001). Males were more likely to present at clinic together with their bedpartner and females presented alone. A history of SBS appeared to be more common in those working in the armed forces or the police compared to those presenting with non-SBS, NREM-parasomnias (p = 0.004).

CONCLUSIONS

SBS is more common in clinical practice than previously described and presents with some distinguishing features within the NREM disorder category. This study is the first to identify that onset in childhood or lack of amnesia does not preclude the condition and that patterns of presentation differ between men and women. Sleepwalkers particularly should be asked about SBS. Comorbid psychiatric conditions, profession and intimate partner difficulties are strong determinants of the presentation.

Neuroelectric Correlates of Human Sexuality: A Review and Meta-Analysis

Many reviews on sexual arousal in humans focus on different brain imaging methods and behavioral observations. Although neurotransmission in the brain is mainly performed through electrochemical signals, there are no systematic reviews of the electrophysiological correlates of sexual arousal. We performed a systematic search on this subject and reviewed 255 studies including various electrophysiological methods. Our results show how neuroelectric signals have been used to investigate genital somatotopy as well as basic genital physiology during sexual arousal and how cortical electric signals have been recorded during orgasm. Moreover, experiments on the interactions of cognition and sexual arousal in healthy subjects and in individuals with abnormal sexual preferences were analyzed as well as case studies on sexual disturbances associated with diseases of the nervous system. In addition, 25 studies focusing on brain potentials during the interaction of cognition and sexual arousal were eligible for meta-analysis. The results showed significant effect sizes for specific brain potentials during sexual stimulation (P3: Cohen's d = 1.82, N = 300, LPP: Cohen's d = 2.30, N = 510) with high heterogeneity between the combined studies. Taken together, our review shows how neuroelectric methods can consistently differentiate sexual arousal from other emotional states.

The prevalence of sleep loss and sleep disorders in young and old adults

The ability to sleep declines with age. The National Sleep Foundation, USA has recommended a minimum sleep amount for all ages. Individuals who experience sleep lesser than the recommended amount could be sleep-deprived. Several factors like stress, altered circadian cycle, medical conditions, etc. cause sleep deficiency. Almost 50-60 % of elderly population suffer from sleep disorders such as sleep apnea, restless legs syndrome, REM sleep behavior disorder, etc. Chronic sleep deprivation may further lead to the development of diseases such as Alzheimer's and Parkinson's. This paper reviews the prevalence of sleep disorders and consequences of sleep loss in young and old adults.

Parasomnias during trans-meridian and long-distance travel: Critical literature review and clinical practice recommendations

Parasomnias are undesirable events that occur during sleep. They can be classified into rapid eye movement parasomnias and non-rapid eye movement parasomnias. Those who experience parasomnias may be anxious about travel for many reasons, including the occurrence of unwanted events during the trip, increased exposure to environmental trigger factors, and the propensity for harm to occur due to unfamiliar surroundings while travelling. There is a paucity of literature examining this area. This review summarizes the relevant literature and the clinical experience of the authors to compile clinical practice recommendations. The clinical features of parasomnias and how they relate to trans-meridian and long-distance travel are described. Triggers for non-rapid eye movement parasomnias, particularly the use of sedative hypnotic drugs, alcohol, drug withdrawal, sleep deprivation, emotional stress and environmental stimulations, are described. Management of parasomnias whilst travelling is reviewed, with a particular focus on trigger minimalization. The role for clonazepam and melatonin is outlined. At the pre-travel health consultation, the physician is strongly advised to screen the traveller for co-morbid sleep conditions, which exacerbate parasomnias. Areas for further research are explored, including the extent to which these sleep disorders impact on the travel experience.

Parasomnias in patients with addictions-a systematic review

Parasomnias are involuntary behaviors or subjective experiences during sleep. Our objective was to review existing information on the presence of parasomnias in patients with addictions or during treatment for addictions. Information about parasomnias related to rapid-eye-movement (REM) and non-REM sleep in patients with addictions, while using substances or in abstinence, was reviewed. A systematic search of published articles reporting parasomnias as a consequence of drug use or abuse was conducted in the PubMed and SciELO databases. The search for the studies was performed in three phases: (1) by title, (2) by abstract, and (3) by complete text. The search was performed independently by two researchers, who then compared their results from each screening phase. Seventeen articles were found. The consumption of alcohol was reported in association with arousal disorders, such as sexsomnia and sleep-related eating disorder; and REM sleep behavior disorder was reported during alcohol withdrawal. Cocaine abuse was associated with REM sleep behavior disorder with drug consumption dream content. Overall, we found that several types of parasomnias were very frequent in patients with addictions. To avoid accidents in bedroom, legal problems, and improve evolution and prognosis; must be mandatory to include security measures related to sleep period; avoid pharmacological therapy described as potential trigger factor; improve sleep hygiene; and give pharmacological and behavioral treatments for patients with these comorbid sleep disorders.

Resolution of sexsomnia with paroxetine

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Sexsomnia is a parasomnia consisting of sexual behavior during non-rapid eye movement sleep. To date, there have been 116 clinical cases of sexsomnia reported and most were treated with clonazepam. We present a case of an adult male with sexsomnia that started during his college days. He presented to us because of problems in his current marriage arising from sexual behavior during sleep. Polysomnography revealed no significant sleep-disordered breathing, electroencephalography abnormality, or abnormal movement during non-rapid eye movement and rapid eye movement (REM) sleep. Alcohol consumption was reported to worsen his sexsomnia. To avoid the neuro-depressant effects of benzodiazepines, paroxetine was administered and resulted in complete resolution of sexsomnia.

Sexual Behaviors and Sexual Health of Sexsomnia Individuals Aged 18-58

Objective: The objective of this study was to address the relationships between demographics and sexsomnia episodes, and sexual health issues in affected individuals. This study is the first sexsomnia survey conducted in Turkey. Sexsomnia comprises involuntary, unconscious sexual behavior during sleep, observed by a bed partner. Method:To reach people with and without sexsomnia, an online survey method was used. Among 274 participants, 42 of them reported having sexsomnia. Results: Women who do not have sexsomnia have more sexual problems than women who have sexsomnia episodes. The sexsomnia experiences of men and women also differed. Additionally, there were gender differences with difficulties caused by the sexsomnia. Conclusions: There is a need for further studies on sexsomnia that address socio-cultural, gender, and biological factors (including sleep disorders).

Clinical neurophysiology of NREM parasomnias

The nonrapid eye movement (NREM) parasomnias range from age-related developmental phenomena in children to aggressive and injurious motor behaviors in all age groups. These parasomnias are commonly referred to as disorders of arousal and are an important cause of sleep-related injury. Genetic predisposition plays a role in the disorders of arousal, most evident in sleepwalking. Important concepts guiding our current understanding of the pathophysiology of the NREM parasomnias include sleep state instability (a propensity for arousal during NREM sleep), sleep inertia (incomplete awakening from NREM sleep), state dissociation (an ability to simultaneously straddle both NREM sleep and wakefulness), and activation of central pattern generators (permitting expression of subcortically determined motor behaviors without conscious higher cortical input). Management is multifaceted with an emphasis on education and nonpharmacologic measures. The purpose of this chapter is to review wake and NREM neurobiology and update our current understanding of NREM parasomnia pathophysiology, epidemiology, genetics, clinical features, precipitating factors, neurophysiologic evaluation, diagnosis, and clinical management.

Blaming rape on sleep: A psychoanalytic intervention

The governance of sleep sex (or sexsomnia) in the criminal law is a nightmare. Press reports of sleeping, often drunk, men acquitted as automatons of raping adults and children suggest cases are rising. The use of automatism, rather than insanity, in these cases is strong evidence of the immemorial struggle faced by legal psychiatry in appropriately construing unconscious defendants. This paper responds by drawing on well-established psychoanalytic conceptions of unconsciousness to present sexsomnia as dispositional to the defendant. Taking the Freudian concepts of eros and death instinct, it asserts that sexsomniacs are acting on repressed sadistic desires. Accordingly, those on notice of their sexsomnia, who fail to mitigate the risk of further attacks, should be guilty of rape. Reliance on (a reformed) insanity defence - being a denial of responsibility at the time of the offence - undermines the scope of the criminal law to self-responsibilise sexsomniacs against perpetrating unwanted sex.

The Co-Occurrence of Sexsomnia, Sleep Bruxism and Other Sleep Disorders

Background: Sleep sex also known as sexsomnia or somnambulistic sexual behavior is proposed to be classified as NREM (non-rapid eye movement) parasomnia (as a clinical subtype of disorders of arousal from NREM sleep—primarily confusional arousals or less commonly sleepwalking), but it has also been described in relation to REM (rapid eye movement) parasomnias. Methods: The authors searched the PubMed database to identify relevant publications and present the co-occurrence of sexsomnia and other sleep disorders as a non-systematic review with case series. Results: In the available literature the comorbidity of sexsomnia and other sleep disorders were reported mainly in case reports and less in case series. Sexsomnia was reported both with one and with multiple sleep-related disorders, with NREM parasomnias and obstructive sleep apnea (OSA) being the most commonly reported. Furthermore, the authors enrich the article with new findings concerning two novel cases of sleep bruxism triggering recurrent sexsomnia episodes. Conclusions: Sexsomnia has still not been reported in the literature as often as other parasomnias. The coexistence of sexsomnia and other sleep-related disorders should be more thoroughly examined. This could help both in sexsomnia as well as other sleep-related disorders management.

Functions and Mechanisms of Sleep

Sleep is a complex physiological process that is regulated globally, regionally, and locally by both cellular and molecular mechanisms. It occurs to some extent in all animals, although sleep expression in lower animals may be co-extensive with rest. Sleep regulation plays an intrinsic part in many behavioral and physiological functions. Currently, all researchers agree there is no single physiological role sleep serves. Nevertheless, it is quite evident that sleep is essential for many vital functions including development, energy conservation, brain waste clearance, modulation of immune responses, cognition, performance, vigilance, disease, and psychological state. This review details the physiological processes involved in sleep regulation and the possible functions that sleep may serve. This description of the brain circuitry, cell types, and molecules involved in sleep regulation is intended to further the reader's understanding of the functions of sleep.

Sexsomnia: sleep sex research and its legal implications

"Sleep sex," also known as sexsomnia, is a sleep disorder characterized by sexual behaviors committed while asleep. There has recently been increased interest in sexsomnia due to controversies arising in legal trials that have been widely publicized in the social and public media. This article attempts to marshal the current information about sexsomnia from the forensic literature and provides an overview of sexsomnia including common features, precipitating factors, prevalence rates, diagnostic procedures, and treatment. As sexsomnia represents a condition in which sexual acts are committed without awareness or intention, this paper also reviews the development of sexsomnia as a legal defense and summarizes Canadian case law on the topic. It provides an overview of the hurdles presented to defense attorneys attempting to utilize the defense and examines popular public notions surrounding the legitimacy of sexsomnia and the possibility of malingering. We conclude that sexsomnia is a legitimate sleep disorder for which case law now exists to support its use in legal defenses based on automatism. The question of whether it is an example of "sane" or "insane" automatism remains to be determined by the courts. Regardless of whether or not sexsomnia is determined to be a mental disorder by the courts, it is now a recognized and well-described sleep disorder that can be safely treated and managed by knowledgeable clinicians.

Sleep-related violence and sexual behavior in sleep: a systematic review of medical-legal case reports

OBJECTIVE

To review systematically medical-legal cases of sleep-related violence (SRV) and sexual behavior in sleep (SBS).

SEARCH METHODS

We searched Pubmed and PsychINFO (from 1980 to 2012) with pre-specified terms. We also searched reference lists of relevant articles.

SELECTION CRITERIA

Case reports in which a sleep disorder was purported as the defense during a criminal trial and in which information about the forensic evaluation of the defendant was provided.

DATA EXTRACTION AND ANALYSIS

Information about legal issues, defendant and victim characteristics, circumstantial factors, and forensic evaluation was extracted from each case. A qualitative-comparative assessment of cases was performed.

RESULTS

Eighteen cases (9 SRV and 9 SBS) were included. The charge was murder or attempted murder in all SRV cases, while in SBS cases the charge ranged from sexual touching to rape. The defense was based on sleepwalking in 11 of 18 cases. The trial outcome was in favor of the defendant in 14 of 18 cases. Defendants were relatively young males in all cases. Victims were usually adult relatives of the defendants in SRV cases and unrelated young girls or adolescents in SBS cases. In most cases the criminal events occurred 1-2 hours after the defendant's sleep onset, and both proximity and other potential triggering factors were reported. The forensic evaluations widely differed from case to case.

CONCLUSION

SRV and SBS medical-legal cases did not show apparent differences, except for the severity of the charges and the victim characteristics. An international multidisciplinary consensus for the forensic evaluation of SRV and SBS should be developed as an urgent priority.

Sexsomnia: parasomnia associated with sexual behaviour during sleep

INTRODUCTION

The purpose of our study is to describe 4 cases of sexsomnia, a form of parasomnia characterised by sexual behaviour during sleep.

METHODS

Clinical history and video-polysomnography recordings from patients diagnosed with sexsomnia in the Multidisciplinary Sleep Unit at Hospital Clínic in Barcelona.

RESULTS

Three men and one woman between 28 and 43 years of age reported sexual behaviours during sleep with progression times ranging from 9 months to 7 years. Episodes consisted of masturbation without seeking the participation of a sleeping partner (2 cases) and attempts at sexual intercourse with inappropriate and uncharacteristic vocalizations and behaviours (3 cases). The frequency of the episodes ranged from 4 isolated episodes to 2-3 per week. Patients were amnestic of these events and surprised by their partners' accounts of their behaviour. Medical histories revealed that 1 patient was a somnambulist, 2 had confusional arousals, and 1 experienced somniloquy. Video-polysomnography did not disclose sexual behaviours during sleep but revealed sleep apnoea in 2 cases and periodic leg movements in sleep in another. The only patient treated with clonazepam reported decreased frequency of both confusional arousals and sexsomnia episodes.

CONCLUSIONS

Sexsomnia occurs in young adults and is characterised by masturbation and inappropriate attempts at achieving sexual intercourse followed by total amnesia of the events. It can be associated with other parasomnias such as sleepwalking and confusional arousals. Other sleep disorders, including sleep apnoea and periodic leg movement disorder, may trigger episodes of sexsomnia.

Abnormal sexual behavior during sleep in temporal lobe epilepsy: a case report

Herein, we describe a case who presented with abnormal sexual behaviour during sleep. Video-electroencephalography monitoring during sleep revealed an abnormality suggesting an epileptic basis. The patient was successfully treated with carbamazepin. The psychiatric symptoms that were thought to be related to abnormal sexual behaviours were controlled with antipsychotic treatment. Our findings strongly emphasize the fact that efforts should be spent to increase awareness of seizure activity at night, which can be misinterpreted as benign parasomnias. Such a misinterpretation may have serious consequences, such as insufficient seizure control, progressive personality changes, and cognitive impairment.

Diagnostic delay in REM sleep behavior disorder (RBD)

STUDY OBJECTIVES

REM sleep behavior disorder (RBD) is a parasomnia in which normal muscle atonia of REM sleep is lost. The aim of this study was to confirm if diagnostic delay exists in RBD and identify any contributing factors.

METHODS

A database was compiled of 49 patients with RBD seen at a tertiary referral center from 2005 to 2011 by retrospective review of referral letters and polysomnographic (PSG) reports. Patients with comorbid narcolepsy were excluded. A questionnaire was sent to investigate diagnostic delay, management, and comorbidities.

RESULTS

Mean diagnostic delay was 8.7 ± 11 (median 4.5, IQR 1.75-11.75) years in 30 questionnaire responders. Common reasons for diagnostic delay included belief that symptoms were not serious enough to consult a doctor (59%), mild or infrequent occurrence of sleep behavior (56%), belief that symptoms may resolve (47%), and lack of knowledge of treatment options (47%). The bed partner was an important influence, with the decision to seek medical attention being made jointly by the patient and partner in 47%.

CONCLUSIONS

This study has demonstrated the existence of significant diagnostic delay in RBD, mainly due to lack of understanding of the disorder and its treatment by patients and members of the medical profession.