Sexsomnia.

The recently published Second Edition of the International Classification of Sleep Disorders (ICSD) significantly expands the different diagnostic categories from the first ICSD (1997) reflecting the exponential growth in our knowledge base in this past decade. Many unusual sleep disorders are described including sleep related groaning, sleep related hallucinations, sleep related eating disorders, and exploding head syndrome. However, one newly described sleep disorder, which did not make the final cut, is sexsomnia. The ICSD-II dedicates exactly one paragraph on page 138 to this fascinating parasomnia. Initially described as a variant of somnambulism it is now considered a disorder of arousal. Interestingly, the ICSD points out that four basic drive states--sleep, sex, feeding, and aggression--have been documented to emerge in some type of pathological form with the disorder of arousal manifesting itself as episodes of sleep related abnormal sexual behavior, sleep related eating disorders, and sleep violence. Furthermore, it mentions reports of patients who have all four problems, three of which involve appetitive behaviors.

In the author's opinion, this new parasomnia cannot be so "quickie" dismissed and most likely is vastly underreported due to guilt, embarrassment, religion, morals and upbringing on the part of the patient and or partner but more importantly the sleep medicine professionals lack of investigation through a more detailed history regarding automatic behavior during the night including sexual acts. In my own practice I've had three recent cases of sexsomnia.

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The first one was a very polite, well-mannered young man with a history of Tourette's syndrome complaining of hyper-somnolence. During his polysomnogram he proceeded to masturbate the whole night, clearly seen on the videotape. The polysomnograph tracing revealed that the patient fluctuated between Stage Wake and Stage I during this atypical sexual behavior. Noteworthy he had no recollection the next day.

The second case surprisingly was one of our nocturnal polysomnographic technologists who on rare occasions would have sexual relations with his wife while asleep culminating in orgasm with complete amnesia the next day. Workup revealed moderate obstructive sleep apnea, which was subsequently treated with nasal CPAP. After successful treatment of the sleep related respiratory disturbance there were no further episodes of atypical sexual behavior.

Finally the third case was a legal case most likely malingering. A young man presented to the practice accused of allegedly inappropriately touching his teenage daughter. The history was positive for both a personal and family history of extensive sleep talking and somnambulism. Based on the circumstances which included a difficult divorce, separation anxiety, sleep deprivation and stress this one time occurrence seemed to be strongly suggestive of sexsomnia. Unfortunately, during the legal investigation there appeared to be several other alleged victims of inappropriate sexual contact over a several year time span, which obviously did not fit the criteria for sexsomnia. He was convicted of committing sexual crimes and is now serving eight years.

Review of the scant amount of medical literature available reveals that my experience with this new parasomnia is consistent with other practices in the country. Unfortunately most of the reports are small in nature, predominantly case reports with two series of 11 patients each. One reported by Dr. Christian Guilleminault and associates (Psychosomatic Medicine 2002) and the other by Dr. Colin Shapiro (Can J Psychiatry June 2003).

In general the episodes of sexsomnia range from sexual vocalization, sexualized body movements, masturbation, cunnilingus, fellatio, fondling, and sexual intercourse with orgasm. Most of the episodes were associated with complete amnesia and behavior out of character for the individual. In the Guilleminault's series, patients were separated into different categories:

1. Annoying to bed partner but not harmful. For example sexual moaning and sexually related sounds.

2. Annoying to bed partner and at times harmful to index case. Examples of this category include violent masturbation with bruising and soreness of the genital area.

3. Harmful to bed partner or others, where sex was forcibly imposed on the bed partners.

After a comprehensive workup most of these patients were diagnosed with non-REM parasomnia or REM behavior disorder. There were also cases of partial complex seizures and obstructive sleep apnea. Noteworthy most patients responded to clonazepam, other benzodiazepines, antidepressants, stress management, and of course nasal CPAP for the patients with OSA.

Dr. Shapiro and his group took it one step further and elegantly distinguished sexsomnia from the characteristic features of sleepwalking. In general sexsomnia features are the following: Originating in most cases from non-rapid eye movement sleep, occurs any time during sleep, wide spread autonomic activation, sexual arousal frequently present, duration possibly exceeding 30 minutes, exceptional violence or injurious behavior, exceptionally walking out of bed, predominantly in adults.

With the introduction of Viagra and similar products, it seems many in the field of sleep medicine have drifted away from addressing sexual issues in sleep centers. However, it is important that any new patient evaluation include screening questions regarding atypical sexual behaviors if appropriate. Due to the underlying possible causes of sexsomnia documented in the medical literature it is imperative that each patient suspected of suffering from this new parasomnia undergo a thorough evaluation in the sleep center and not be automatically referred to a psychiatrist or a good lawyer.

by Frank Roman MD JD