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Try out PMC Labs and tell us what you think. Learn More. We describe a year-old married woman diagnosed with sexsomnia as a NREM parasomnia, who sought medical assistance motivated by relationship problems with her husband after two sexsomnia episodes.
This is the second case of sexsomnia reported in Brazil, but the first case with comprehensive follow-up. The patient was clinically evaluated, no psychiatric history was found, and she denied using pharmaceutical or recreational drugs. A video-polysomnography documented nine episodes of short- lasting abrupt awakening from N2 and N3, indicating a non-REM parasomnia, some with masturbation characteristics. The findings of this case, including unusual features, are considered in regard to the range of adverse psychosocial consequences of sexsomnia in these patients and the need for specialized interventions that can be provided by sleep specialists.
Parasomnias are classified as undesirable physical events, experiences, and autonomic nervous system activity that occur during any stage of sleep or its transitions from or into wakefulness. Sexsomnia, characterized by sexual behavior during sleep, is within the spectrum of parasomnias occurring predominantly in NREM sleep, as a variant of confusional arousals and sleepwalking, with or without associated obstructive sleep apnea 1.
It can vary from sleep masturbation to sexual moaning and vocalizations, to fondling and full sexual intercourse with a bed partner.
In all reported cases, memory of the sexual event is completely or almost completely impaired 2 - 6. Little information exists regarding the epidemiology of sexsomnia in the general population, probably because most individuals are unaware of sexsomnia as a medical issue and only look for medical assistance when facing negative consequences 7.
Also, embarrassment may prevent many people from seeking help 8. The unconscious sleep-related sexual behavior often le to adverse psychosocial impacts for the subjects and bed partners, and sometimes can lead to physical injuries and sexual assaults 2356. Although the forensic consequences of sexsomnia have been reported 9the psychosocial impact of sexsomnia on patients and bed partners needs to be more fully understood. Here we report a case of a year-old woman, with a history of sleep talking during childhood, who developed sexsomnia during her marriage.
Based on this case, and a focused literature review, we aim to discuss sexsomnia and propose a systematic classification for its psychosocial implications. In Julywe received in our outpatient sleep medicine practice a year-old woman, whose husband complained about her abnormal sexual behavior during sleep.
She had no memory of the episodes and no dreams related to them. This was first noticed in by her husband, and has occurred, since then, in an occasional pattern of up to twice monthly. It took five years for her to believe that she actually engaged in such nocturnal behaviors, so it was only in that she sought medical assistance.
She consulted with a primary care doctor and a neurologist, who could not identify the basis for those symptoms, and after epilepsy was excluded, she was referred to our hospital psychiatry practice. The patient reported sleep talking since she was years-old, but she had no memory about these events, and she claimed to have no other sleep problems during childhood.
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In she remembers two confusional awakenings when she woke up with her own voice. No other unwanted event during the night was reported by the patient during the anamnesis. She presented no psychiatric history, nor any mental disorder at the time of evaluation, and then she was referred to the sleep medicine group. In some episodes she also masturbated. There had been episodes in which she fondled her husband, who then engaged in sexual activity with her. In the middle of it, she woke up feeling somewhat abused, because from her point of view he was forcing sexual intercourse during her sleep without consent.
This was very unpleasant for her and led to many arguments, mistrust and distancing between the couple. The husband was feeling insecure over not satisfying her sexually and sometimes he thought she could be betraying him with other men, since she uttered the names of other men in her sleep while acting in a sexual manner.
The search for professional help was motivated by the mistrust of her husband, after she masturbated in sleep while saying the name of a coworker. Another motivator was an episode witnessed by her 9-year-old son, who heard her moaning sexually out loud. She had a history of two sleep talking episodes without sleepwalking witnessed by her siblings.
At the time of first consultation, she denied the use of pharmaceutical or recreational drugs besides contraceptive pills, and there was no history of alcohol abuse. She worked with information technology and reported considerable stress at work, related to deadlines, and pressure from her boss to complete many tasks on her own in a short period of time. She went to bed around 9 p.
She snored times per week, with no apnea episodes reported by her husband. Her physical examination found obesity, with a body mass index BMI of 31, and a modified Mallampati Class IV this test is based on visual examination of oral cavity Class IV indicates that the space between tongue base and roof of mouth was very small and only the hard palate is visible 1112suggesting a higher chance of obstructive sleep apnea OSA. The rest of her physical exam was within normal parameters.
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A waking electroencephalogram EEG showed instability of cerebral electrical activity in temporal regions, bilaterally, with predominance on the left, mainly during wakefulness, with no clinical ificance. Brain magnetic resonance imaging and routine blood tests were unremarkable.
We performed a one-night time-synchronized video-polysomnographic VPSG study that continuously monitored her EEG F3-M2, C3-M2, O1-M2, F4-M1, C4-M1, O1-M2electrooculogram, electromyography of submentalis and anterior tibial regions, position in bed, snoring, oral and nasal airflow, abdominal and thoracic respiratory effort, peripheral hemoglobin oxygen saturation and one- derivation electrocardiogram.
from VPSG are summarized below:. The VPSG documented nine episodes of short-lasting abrupt awakening from N3 4 and N2 5some of them with quasi-stereotyped motor behavior of the limbs and hips and moaning, compatible with confusional arousals Figure 1. Characteristics that resembled masturbation contraction of thighs and arms moving towards her pelvis together with a mixture of moaning and sighing were observed in two awakening from N2 and two from N3.
These findings indicated a non-REM parasomnia.
A3: awakening from N3. A2: awakening from N2. A video-EEG was then performed for 4 days continuously during sleep and wakefulness. The international system EEG montage was used, with electrocardiogram electrodes in addition. VEEG showed adequate basal brain electric activity, together with instability of cerebral electric activity in temporal regions, predominantly on the left side and during wakefulness, with no clinical ificance.
During approximately 6 hours of sleep each night, she presented 4 to 5 episodes suggestive of confusional arousals with nonsensical movements and discrete masticatory non- stereotyped movements, but no sexual events were observed during that recording period.
EEG showed no epileptiform correlate during the arousal episodes. Treatment with clonazepam up to 0. Around one year after the first consultation, her life situation changed drastically. She had suspended the use of clonazepam on her own because it had no effect on sexsomnia.
She was transferred to another area at her work in which she had almost no stress. Health problems in a family member requiring care reduced the duration of her nocturnal sleep to 4.
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Curiously, the sexsomnia episodes and the daytime somnolence ceased from this period onward. Currently, she sleeps for 6 to 7 hours per night, with no daytime somnolence nor episodes of sexsomnia, according to her husband, up to the latest follow-up in December The patient reports that cessation of her sexsomnia episodes and the explanation to the couple that sexsomnia is a sleep disorder, helped reunite the couple and reestablish their prior level of intimacy. This is the second Brazilian case of sexsomnia published.
Therefore, the Brazilian case involved a male who engaged in sexual intercourse with his wife during sleep, in contrast to our case that involved a woman with sleep masturbation and vocalizations This case report describes a year-old married woman with a prior history of sleep talking but without a history of sleepwalking, who was diagnosed with sexsomnia as a NREM parasomnia with confirmatory vPSG.
There was no comorbid OSA. The search for medical help was motivated by relationship problems between the patient and her husband after two episodes; the first occurred when she masturbated during sleep while saying the name of another man a coworkerand the second episode occurred when her 9-year-old son heard her moaning sexually out loud.
These compelling situations within the familial nucleus of these patients, deserves special attention regarding the distinctly adverse psychosocial impact of sexsomnia.
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As ly described by Dubessy et al. Additionally, one sexsomnia patient in this French series, a year-old married woman, engaged in repeated episodes of sleep masturbation while uttering sexual vocalizations - and calling out the name of a man, Mike, who was not her husband similar to our caseand she denied knowing any man named Mike 6.
This caused great marital stress, and this nocturnal scenario was identical to that of our reported patient. Considering these sexsomnia-related negative scenarios, a systematic therapeutic approach should be used for patients and spouses, and other relatives. Sexsomnia was first described in a case from Singapore, ininvolving nightly sleep masturbation in a married man, which made his wife feel inadequate, especially since they had nightly intercourse before falling asleep In ICSD3 1released init is classified as a subtype of confusional arousals, named sleep related abnormal sexual behavior.
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In Brazil, this is the second female case of sexsomnia reported in the literature to date. The majority of ly reported sexsomnia cases involve middle-aged men, with a history of other NREM parasomnias. In most cases, the events occurred in bed or within the sleep accommodation, but some reports documented events in other rooms, what may be related to sleepwalking. It is not known yet if this male predominance is due to a gender-determined predisposition or due to bias in seek for medical assistance.
Various factors influence the search for professional help. First of all, a bed partner is needed for sexsomnia to be noticed, otherwise the person affected by sexsomnia may never know about this conditionbecause of the inherent amnesia. Moreover, there is often considerable embarrassment involving sexsomnia, which prevents people from talking to a doctor about it 8 Also, some people may not believe it is a medical problem, and for that reason do not seek medical attention.
Most people, including health professionals, are not aware that this is a sleep disorder. Therefore, few patients seek professional help and, when they do, some of them end up with no clinical diagnosis, and are referred to psychotherapy due top d psychological issues promoting the sexsomnia. Conversely, some patients and partners may need psychotherapy to deal with the consequences of sexsomnia. This can result in substantial delays in proper diagnosis and correct treatment, perpetuating suffering for the sexsomniac and for bed partners or people who live in the same house.
Pleasant feelings for bed partners, although rare, have also been described 2. Physical Fpsychological Prelational Rlegal L. When treating sexsomnia it is important to approach all physical Fpsychological Prelational R and sometimes legal L aspects that affect the lives of sexsomniac patients and bed partners.