ArticlePDF Available

Update on Sexsomnia, Sleep Related Sexual Seizures, and Forensic Implications

Authors:

Abstract

The first classification of sleep-related disorders and abnormal sexual behaviors and experiences was published in 2007. Parasomnias (abnormal sleep-related behaviors and experiences) and sleep-related epileptic seizures were the most frequent disorders, after Kleine-Levin syndrome (periodic hypersomnia with abnormal wakeful sexual behaviors). The first two conditions were named sexsomnia (sleepsex) and epileptic (ictal) exsomnia, respectively. Sexsomnia usually emerges during confusional arousals (CAs) from delta non-REM sleep (N3 sleep), either associated or unassociated with obstructive sleep apnea (OSA). We now report an additional 22 cases of sexsomnia and 3 cases of ictal sexsomnia (temporal lobe epilepsy; bupropion-induced seizures) published from 2007-2015, based on a literature search in PubMed and Embase, and also separately for Turkish language publications. Eighteen of the 22 additional cases of sexsomnia had sufficient data provided to allow for comparative analysis. (The 4 other additional cases involved sexsomnia emerging with Parkinson's disease). The demographics of the second group of 18 sexsomnia cases were comparable to those of the first group of 31 cases (published in 2007), in regards to male gender predominance (67% vs. 81%); age at presentation (40 yrs vs. 32 yrs); age of onset (33 yrs vs. 26 yrs); and mean duration of sexsomnia in males (5.6 yrs vs. 8.3 yrs). The female groups were too small to compare. The distribution of sexual behaviors across the groups was generally comparable in regards to sexual vocalizations, masturbation, fondling, and intercourse/attempted intercourse. Amnesia for the sexsomnia by the affected person was 89% vs. 100%. Video-polysomnographic studies wereconducted in nearly all patients in both groups, and provided important diagnostic findings in almost all patients. The mean number of arasomnias per patient was 1.8+1.4 vs. 2.2+1.0, respectively, with the range extending up to 5 parasomnias per patient. In both groups, a non-REM sleep parasomnia (disorder of arousal [DOA]) was the main cause of the sexsomnia (78% vs. 90%). There was a comparable percentage in each group having obstructive sleep apnea (OSA) as the presumed trigger for a DOA with sexsomnia (17% vs. 13%), and there was control of both sexsomnia and OSA with nasal CPAP in 100% (4/4) of treated cases. Overall treatment efficacy was 82% (n=18) in the 22 patients in the combined groups (n=53) for whom treatment was reported. Nine novel findings on sexsomnia were identified. An abstract on 41 consecutive cases of sexsomnia evaluated at a single sleep center in the U.K. was recently published, and the findings are highly congruent with the 53 cumulative cases in the world literature reported herein. Thus, there are now 94 total cases of sexsomnia reported in the world literature. The forensic implications of sexsomnia are discussed.
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
518
Update on Sexsomnia, Sleep Related Sexual
Seizures, and Forensic Implications
Carlos H. Schenck
ABSTRACT
The first classification of sleep-related disorders and abnormal sexual behaviors and experiences was published
in 2007. Parasomnias (abnormal sleep-related behaviors and experiences) and sleep-
related epileptic seizures
were the most frequent disorders, after Kleine-
Levin syndrome (periodic hypersomnia with abnormal wakeful
sexual behaviors). The first two conditions were named sexsomni
a (sleepsex) and epileptic (ictal) sexsomnia,
respectively. Sexsomnia usually emerges during confusional arousals (CAs) from delta non-
REM sleep (N3
sleep), either associated or unassociated with obstructive sleep apnea (OSA). We now report an additional 2
2
cases of sexsomnia and 3 cases of ictal sexsomnia (temporal lobe epilepsy; bupropion-
induced seizures)
published from 2007-
2015, based on a literature search in PubMed and Embase, and also separately for Turkish
language publications. Eighteen of the 22
additional cases of sexsomnia had sufficient data provided to allow for
comparative analysis. (The 4 other additional cases involved sexsomnia emerging with Parkinson's disease).
The
demographics of the second group of 18 sexsomnia cases were comparable to those of the first group of 31 cases
(published in 2007)
, in regards to male gender predominance (67% vs. 81%); age at presentation (40 yrs vs. 32
yrs); age of onset (33 yrs vs. 26 yrs); and mean duration of sexsomnia in males (5.6 yrs vs. 8.3 yrs). The f
emale
groups were too small to compare. The distribution of sexual behaviors across the groups was generally
comparable in regards to sexual vocalizations, masturbation, fondling, and intercourse/attempted intercourse.
Amnesia for the sexsomnia by the affected person was 89% vs. 100%. Video-
polysomnographic studies were
conducted in nearly all patients in both groups, and provided important diagnostic findings in almost all
patients. The mean number of parasomnias per patient was 1.8+1.4 vs. 2.2+1.0, respec
tively, with the range
extending up to 5 parasomnias per patient. In both groups, a non-
REM sleep parasomnia (disorder of arousal
[DOA]) was the main cause of the sexsomnia (78% vs. 90%). There was a comparable percentage in each group
having obstructive s
leep apnea (OSA) as the presumed trigger for a DOA with sexsomnia (17% vs. 13%), and
there was control of both sexsomnia and OSA with nasal CPAP in 100% (4/4) of treated cases.
Overall treatment
efficacy was 82% (n=18) in the 22 patients in the combined groups (n=53) for whom treatment was reported.
Nine novel findings on sexsomnia were identified. An abstract on 41 consecutive cases of sexsomnia evaluated at
a single sleep center in the U.K. was recently published, and the findings are highly congruent with the
53
cumulative
cases in the world literature reported herein. Thus, there are now 94 total cases of sexsomnia
reported in the world literature. The forensic implications of sexsomnia are discussed.
Key Words: sexsomnia, sleepsex, sexual behaviors of sleep, temporal lobe epilepsy, ictal orgasm, epileptic
sexsomnia, polysomnography, non-REM sleep parasomnia, confusional arousals, obstructive sleep apnea, REM
sleep behavior disorder, clonazepam, SSRI, bupropion, shift work, circadian sleep disorder, Parkinson's disease,
forensic sleep medicine
DOI Number: 10.14704/nq.2015.13.4.873
NeuroQuantology 2015; 4:518-541
1
Corresponding author: Carlos H. Schenck
Address: Minnesota Regional Sleep Disorders Center, Department of Psychiatry (R7), Hennepin County Medical Center, 701 Park Ave.,
Minneapolis, MN 55415, USA.
Phone: + 612-873-6288
e-mail schen010@umn.edu
Relevant conflicts of interest/financial disclosures: The author declares that the research was conducted in the absence of any
commercial or financial relationships that could be construed as a potential conflict of interest.
Received: September 1, 2015; Accepted: September 28, 2015
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
519
Introduction
The first classification of sleep-related disorders
and abnormal sexual behaviors and experiences
was published in 2007, and encompassed a broad
range of sleep-related disorders along with a
broad range of associated sexual behaviors and
experiences, involving the affected person and/or
another person (usually the bed partner)
(Schenck et al., 2007). Kleine-Levin syndrome
(periodic hypersomnia with abnormal wakeful
sexual behaviors) and parasomnias (abnormal
behaviors and experiences accompanying sleep)
were the most frequently reported conditions,
followed by sleep-related epileptic seizures. The
latter two conditions were called sexsomnia (i.e.
a sexual parasomnia) and epileptic (ictal)
sexsomnia, respectively, which have overlapping
and divergent clinical features. Sexsomnia most
often emerges during confusional arousals (CAs)
from slow-wave (delta) non-REM sleep (N3
sleep), which could be associated or unassociated
with obstructive sleep apnea (OSA). Episodes of
sexsomnia emerging with CAs take place in the
bed of the sleeping person. Sexsomnia can also
rarely occur during sleepwalking (SW). Both CAs
and SW are classified as Disorders of Arousal
from non-REM sleep, with sexsomnia recognized
as a variant of CAs (American Academy of Sleep
Medicine, 2014). Sleepsex, atypical sexual
behavior during sleep, sexual behaviors during
sleep, and sleep related abnormal sexual
behaviors are other synonymous terms. Adverse
physical and/or psychosocial effects from the
sexsomnia are common, along with their forensic
consequences (Schenck et al., 2007). Video-
polysomnography (vPSG), i.e., the objective,
multichannel, physiological monitoring of sleep,
with time-synchronized audio-visual recording, is
critical for identifying the cause of the sleep-
related sexual behaviors (and for ruling-out other
causes), and for properly directing the initiation
of specific and generally very effective therapy.
An update on this topic will now be
presented, focusing primarily on additional
published cases of sexsomnia and ictal
sexsomnia, and their forensic consequences. The
cumulative literature reflects a growing
international attention to this still under-
recognized and yet clinically and medical-legally
important topic.
Material and Methods
A PubMed and Embase literature search was
conducted from 2007-2015, which identified
peer-reviewed journal articles and published
abstracts related to sleep and sex and sleep
related sexual seizures. A separate literature
search on this topic was conducted for Turkish
language publications by S. Cankardeş, Istanbul.
All identified publications were critically
reviewed and the reported cases were classified.
Case Samples
A total of 22 additional published cases of
parasomnias with abnormal sleep-related sexual
behaviors (i.e. sexsomnia) were identified, along
with three additional cases of ictal sexsomnia,
since the 2007 report by Schenck et al. Therefore,
to date there have been 53 cases of sexsomnia
published and 10 cases of ictal sexsomnia
published in the peer-reviewed medical
literature, for a total of 63 cases. The rate of
publishing on sexsomnia in the peer-reviewed
literature has increased by >50% over the past 7
years compared to the previous 21 years. Table 1
provides a summary of key findings from the
additional cases and compares them with the
previously published cases. Four of the 22
additional cases of sexsomnia did not have sufficient
data provided to allow for comparative analysis;
therefore, 18 of the additional 22 cases were used for
comparative analysis). The demographics of the
second group of 18 cases are similar to the
demographics of the first group of 31 cases, in
regards to male gender predominance, age at
presentation, and age of onset and duration of
sexsomnia in males. The female groups were too
small to compare. The distribution of sexual
behaviors across the groups was generally
comparable. The frequency of sexsomnia
episodes was reported for 9 of the 18 patients,
with the following distribution: nightly, n=2; 2-4
nights weekly, n=2; one night weekly, n=1; 2-3
nights monthly, n=3; "frequently," n=1. The more
recent group of 18 patients had substantially
fewer sexual assaults, sexsomnia with minors,
and legal consequences compared to the original
reported group of 31 patients. Amnesia for the
sexsomnia by the affected person was 88.9% vs.
100%, with two females in the former group
presenting with the complaint of spontaneous
sleep orgasms, which to date is the only form of
sexsomnia with subsequent recall by the affected
person. vPSG studies were conducted in nearly all
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
520
patients in both groups, which provided
important positive and negative diagnostic
findings in virtually all patients. There was a
comparable number of mean parasomnias per
patient, with the range extending up to 5
parasomnias in two patients. For both groups, a
non-REM sleep parasomnia (disorder of arousal
[DOA]) was the predominant diagnosis, including
a comparable percentage in each group having
obstructive sleep apnea (OSA) as the presumed
trigger for a DOA with sexsomnia, which was
strongly supported by the control of both
sexsomnia and OSA in 100% of cases treated with
nasal continuous positive airway pressure
(nCPAP) therapy. Overall treatment efficacy was
82% (n=18) in the 22 patients in the combined
groups (n=53) for whom treatment was reported.
The additional published cases of
sexsomnia since 2007 will now be described in
detail, with pertinent commentary, in order to
highlight novel findings, and to further elucidate
the phenomenology of this still nascent clinical
area that is situated at the intersection of sleep
medicine, sexual medicine, and forensic medicine.
I) Parasomnias with sleep-related sexual
behaviors
Sexsomnia cases reported from 9 countries
(United States, Spain, Holland, Italy, France,
Turkey, Australia, Brazil, United Kingdom)
A) Peer-reviewed journal articles
(publications 1-8)
1) A Case of Sexsomnia with OSA-Associated
Confusional Arousals (Schenck et al., 2008)
A 32 year-old married man experienced the
concurrent emergence of sexsomnia and OSA,
with subsequent control of both sleep disorders
with nCPAP monotherapy. He had presented to
the Minnesota Regional Sleep Disorders Center
with his wife with the chief complaint of sexually
groping and fondling her while asleep during the
previous four years. This sleep related sexual
activity began at the same time as snoring began,
which became progressively louder over time,
and his wife started complaining that “he tried to
hump me while he was asleep.” His wife reported
that he was somewhat insistent with his sleepsex
initiatives with her, but was never aggressive or
violent, and he always responded promptly to her
limit setting. “On some occasions he would be
awakened by his wife in the midst of a sexsomnia
episode, and then he would recall having a sexual
dream involving the two of them.” His sleepsex
repertoire was the same as the sexual repertoire
during their waking lives. Sexsomnia frequency
was four nights per week. He had total amnesia
for these sexsomnia events. They reported a
normal, regular, conventional wakeful sex life. No
trigger for sexsomnia occurrence could be
identified (e.g. stress, sleep-deprivation, sexual
deprivation). There was no prior history of
parasomnia, psychiatric disorder, paraphilia,
alcohol or drug abuse, or family history of sleep
or sexual disorder. He had been employed
continuously since high school. They had been
married for ten years, without any marital
problems, apart from increasing stress related to
the sexsomnia that eventually posed a risk to the
marriage.
Overnight vPSG at an accredited, hospital-
based sleep disorders center documented OSA,
with an Apnea Index of 19/hr, and oxygen
saturation nadir of 78%. nCPAP therapy
completely normalized sleep continuity and
hemoglobin oxygen saturation during the second
half of the single-night vPSG study. No sexsomnia
or other parasomnia behaviors were documented
during the vPSG study.
The diagnoses were both OSA and
Sexsomnia emerging during CAs induced by OSA.
Treatment of these two temporally linked sleep
disorders was initiated with nCPAP therapy, with
the expectation that one therapy could control
both disorders.
At one month and three-month follow-up
visits, the wife reported complete control of her
husband's snoring and sexsomnia with ongoing
nightly nCPAP therapy. However, on nights when
the nCPAP mask came off his face, there would be
some mild sexual groping and fondling during his
sleep. This indicated an ongoing propensity for
sexsomnia emerging with CAs whenever the
patient's OSA therapy was interrupted. Overall,
the wife was very pleased and was optimistic
about the future of their marriage.
A notable feature of this case, apart from
the close association of the emergence of
sexsomnia with snoring/OSA and their
concurrent and enduring response to nCPAP
therapy, is that the patient reported sexual
dreams involving himself and his wife whenever
his wife awakened him during a sexsomnia
episode. Dreaming with sexsomnia has rarely
been reported. This raises the question of
whether for this patient the occasional episodes
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
521
of dreaming with presumed OSA-induced
sexsomnia emerged during arousals from REM
sleep, which is the sleep stage most frequently
associated with dreaming.
This case calls attention to the need to
question patients with snoring and diagnosed
OSA about sexsomnia, and vice versa. Patients
with OSA and other forms of sleep-disordered
breathing may comprise a large and greatly
under-recognized subgroup of sexsomnia
patients. Patients should be told that sexsomnia
is a medical (sleep-related) problem, and not a
primary psychological or psychiatric problem,
although there could be psychological
consequences.
2) A sexsomnia case from Spain was
reported [translated and summarized by the
author, CHS] in which a 33-year-old male
presented to a neurology sleep clinic with the
chief complaint of sexsomnia for one year with
repeated attempts to remove his pajamas and
fondle his bed partner; there was no self-touching
of genitals or masturbation (Penas-Martinez et
al., 2008). These episodes generally occurred in
the first part of the night, and lasted around five
minutes, without orgasm being achieved. The
frequency of these episodes was two nights
monthly, without any identified precipitant, and
with full subsequent amnesia. There was no
personal or family history of parasomnia. Medical
history included hypertension, asthma, and nasal
polyps. He was a former smoker. Neurological
and medical evaluations were unremarkable.
vPSG during two non-consecutive nights
documented various N3 arousals with diffuse
generalized theta activity, consistent with a non-
REM sleep parasomnia. No sexual or other
parasomnia behaviors occurred during the vPSG
study. Sleep architecture (i.e. distribution and
cycling among the sleep stages) was normal.
However, the presence of snoring, apneas, and
hypopneas was mentioned in this report, but
unfortunately no data were provided, including
any presence of oxygen desaturations. The
authors did state that there was a major postural
component to the snoring and sleep disordered
breathing, with attenuation achieved while the
patient lay on his side.
The presumed diagnosis (not stated by the
authors, but inferred from their comments) was
sexsomnia during confusional arousals from N3
sleep. The findings of abrupt arousals from N3
sleep, which is an abnormal PSG finding, suggests
that perhaps the patient had a prior,
unrecognized, and unobserved history of CAs
without clinical consequence, which may have
predisposed the subsequent emergence of
sexsomnia.
Therapy with clonazepam, 1 mg at bedtime
(a standard therapy for non-REM sleep
parasomnias, including sexsomnia) was initiated.
At two-month follow-up, the patient reported a
decreased frequency of sexsomnia episodes,
despite intermittent use of clonazepam. However,
since the baseline sexsomnia frequency was two
nights per month, and since there was only a two-
month follow-up to assess treatment efficicacy,
with intermittent clonazepam use, no firm
conclusion can be drawn about clonazepam
treatment efficacy.
3) A sexsomnia case from Holland was reported
in which a 30-year-old man, without any prior
parasomnia history, developed de novo
sexsomnia on a nightly basis for four weeks upon
starting escitalopram [SSRI] therapy, 10 mg/day
(standard dose), for control of a major depressive
episode (Krol, 2008). His sexsomnia featured full
intercourse with his bed partner, and complete
subsequent amnesia. The sexsomnia ceased six
days after discontinuation of escitalopram,
consistent with the pharmacologic wash-out
period for this drug. (Escitalopram was also not
beneficial for his depression). There was no
recurrence of sexsomnia at five-month follow-up
during subsequent therapy with high-dose
duloxetine, 90 mg/day. In contrast to
escitalopram, duloxetine (a serotonin-
norepinephrine reuptake inhibitor) was notably
effective in controlling his major depressive
episode.
This is the first reported case of
medication-induced de novo sexsomnia, in which
a standard dose of an SSRI (escitalopram)
immediately induced nightly sexsomnia with full
sexual intercourse and subsequent amnesia, and
with prompt resolution of the sexsomnia upon
discontinuation of the escitalopram. For this
patient, it was a specific medication effect, since
subsequent long-term therapy with a different
class of antidepressant (duloxetine) at a high
dose did not induce sexsomnia. The sexsomnia
may have been an idiosyncratic medication
reaction in this male patient, since in another
report to be described below, the same SSRI
escitalopram was therapeutic in controlling
sexsomnia in two female patients.
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
522
A partial translation of this article from
Dutch into English (courtesy of Michael A. Corner,
PhD, Amsterdam) will now be provided:
"He called up three weeks later [after starting
escitalopram therapy], distressed. He told that
he apparently had had nightly sexual
intercourse with his [female] partner,
'apparently' because she had completely
surprised him with this information in the
morning. She had found the timing -
consistently about an hour after falling asleep
somewhat unusual, but further noticed
nothing special about her friend’s [sexual]
behavior. He had caressed her (also genitally)
and undressed her, and they had sex 'like
always,' in which the patient and his girlfriend
sometimes changed position. The patient
reported having no recollection whatsoever of
his nightly amorous approach. He found it
frightening to have exhibited behavior at
night of which he was not conscious and over
which he had no control.
The following week he repeated this
behavior on six of the seven nights. A few
times he had a vague recollection in the
morning, without being certain that it really
had happened. His [girl] friend succeeded
twice in wakening him, upon which,
embarrassed, he deliberately got out of bed
and went back to sleep a little later.
According to the girl friend, he answered “no”
on several occasions when she explicitly
asked him if was sleeping, leading her to
assume that the patient was awake and aware
of their having intercourse. Here too, the
patient was unable to remember any such
thing the next morning.
Furthermore, because the depressive
episode failed to go into remission,
escitalopram treatment was discontinued at
the end of the fourth week. Six days later the
patient had the last of his nighttime ‘episodes’.
In the following five months this behavior
didn’t recur.
A week after stopping escitalopram, the
patient started using duloxetine (60 mg), later
raised to 90 mg. After another eight weeks his
depression was completely in remission.
Upon questioning it became apparent
that the patient had never before any trouble
with parasomnias, also not as a child. A
brother of his as a child had somnambulism,
which disappeared well before puberty.
Standard laboratory investigation
didn’t turn up any deviations. A neurologist
found no indications during a screening
examination of any neurological insults.
Neither were there any indications of a
dissociative disturbance. On the basis of the
clinical picture, a diagnosis of parasomnia as
made."
4) Three sexsomnia cases were reported from
Italy, all involving males aged 32, 42, and 46
years, who had been referred to a sleep disorders
center because of sleep-related sexual episodes
(Della Marca et al., 2009).
A 42-year-old man had a 12-year history of
sexsomnia emerging with OSA, as documented by
vPSG study, with an AHI (apnea-hypopnea index)
of 38.5/hr, but without any parasomnia behavior
occurring during the vPSG study. His sexsomnia
involved initiating sex with his wife that
occasionally led to full intercourse. Treatment
with nCPAP resulted in both control of his OSA
and a marked reduction of his sexsomnia, with
the sexsomnia frequency going from 2-3 nights
weekly to 3-4 nights yearly. Therefore, the
diagnosis of OSA-induced CAs with sexsomnia
was justified, with nCPAP monotherapy
controlling the interlinked OSA and sexsomnia.
A 32-year-old man had a 4-year history of
sexsomnia emerging as a non-REM sleep
parasomnia. His wife reported that he would
initiate sex during sleep that occasionally led to
full intercourse. He had a childhood history of
SW. During his vPSG study, there were three non-
sexual minor motor events emerging from N3
(slow-wave) sleep, which supported the
diagnosis of sexsomnia emerging as a variant of
non-REM sleep parasomnia (CAs, SW). Therapy
was not mentioned.
A 46-year-old man, without any prior
parasomnia history, nor any family history of
parasomnia, presented with a "recent onset"
history of aggressive and violent sleep behaviors
and sexual behaviors during sleep, with full
intercourse, at times associated with sexual
dreams. The wife provided all the details, since
the man had no recall. These events occurred
during the second half of the night and early
morning hours. vPSG documented REM sleep
without atonia, without any associated behaviors
during REM or non-REM sleep. The diagnosis was
REM sleep behavior disorder (RBD) with
sexsomnia. Standard therapy of RBD with
clonazepam, 2 mg at bedtime, was not effective in
controlling sexsomnia. Carbamazepine and
dopamine agonist therapies were also not
effective.
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
523
This case represents the fourth reported
case of sexsomnia presumably emerging with
RBD, with the other three cases reported from a
single tertiary sleep center (Guilleminault et al.,
2002). However, this case is the most compelling
of the four cases for linking sexsomnia with RBD,
as the wife described his aggressive and violent
sleep behaviors and sexual behaviors emerging
during the second half of the sleep period, which
is when REM sleep predominates. The association
with (sexual) dreaming also supports REM sleep
as the sleep stage promoting the sexsomnia. Also,
his male gender and middle age (46 years old)
are typical for RBD, besides the aggressive and
violent sleep behaviors. Finally, he had no prior
history of non-REM sleep parasomnia. The other
three sexsomnia cases diagnosed with RBD did
not have dream-enacting behaviors (atypical for
RBD), involved younger males (atypical for RBD),
and also did not demonstrate any sexual or non-
sexual behaviors in REM sleep during their vPSG
studies (Guilleminault et al., 2002). Their
sexsomnia episodes by history did not emerge
mainly in the second half of the night, as did the
sexsomnia episodes in this Italian patient. The
only positive objective finding in all four cases of
presumed RBD with sexsomnia was the
intermittent loss of REM-atonia.
The possible association of sexsomnia and
RBD remains an intriguing open question. Sexual
behaviors during REM sleep have not yet been
documented during vPSG studies, which would
establish that sexsomnia can be a variant of RBD
besides being a variant of CAs and SW. In the
largest study to date on vPSG monitoring of
Parkinson disease (PD) patients (n=457), despite
210 (46%) of these patients demonstrating RBD,
none had any sexual behaviors during REM sleep
during their vPSG studies (Sixel-Döring et al.,
2011). However, these elderly, medicated PD-
RBD patients represent only one subgroup of all
RBD patients, and so the lack of any sexual
behaviors during REM sleep cannot be
generalized for all RBD patients, thus
underscoring the need for further research in this
area.
Finally, from a Freudian psychoanalytic
perspective, it is surprising that RBD is not a
sexual parasomnia (or that sexsomnia is not
RBD), since RBD is a dream-enactment disorder
which for Freud would constitute the
continuation of the "royal road" (beginning with
dreaming) for wish fulfillment and sexual acting-
out during sleep. However, a controlled study on
dreams in RBD (Fantini et al., 2005) found a
major shift in bias towards certain types of
dreams (e.g. confrontational, aggressive), and
away from other types of dreams (viz. sexual).
Therefore, the dreams to be enacted in RBD are
rarely sexual. This study supports the many
anecdotal observations found in large and
smaller case series on RBD in which sexual dream
enactment is virtually absent.
5) Two sexsomnia cases were reported from
France, involving married women who were 36
years old and 40 years old (Bejot et al., 2010).
Both patients reported traumatic sexual
experiences during adolescence, involving
"sexual abuse" at age 16 years in one patient, and
witnessing a mother's rape at age 15 years in the
other patient. Both patients reported current
sexsomnia, with sexual moaning, “dirty talk”,
masturbation, sexual assaults of their bed
partners, with sexual intercourse, and
subsequent complete amnesia. The 36-year-old
woman had a childhood-onset history of SW with
current persistence, along with a 6-year history
of sexsomnia. The 40-year-old woman had a 5-
year history of sexsomnia in which she violently
attacked her husband sexually--and also violently
attacked herself sexually during sleep. Some
examples include: "she was violently
masturbating and inserting a deodorant stick into
her vagina and anus. During another one, she
tried to push marbles into her husband's anus.
One time, he was awakened by intense pain
caused by 3 padlocks placed around his penis and
testicles. In another one, his penis was placed
into the cover of a mincing machine."
During their vPSGs, both patients had
multiple, abrupt, spontaneous arousals from N3
(slow-wave) sleep, without any associated
behaviors. These findings led to the diagnosis of
non-REM sleep parasomnia (CAs) as the basis for
the sexsomnia in each patient. Therapy with the
SSRI escitalopram, 10 mg/day for each patient
(one with depression, one without depression)
resulted in complete control of sexsomnia that
was maintained at 9 months and 2-year follow-
up, respectively. No rationale was given for the
SSRI therapy of the sexsomnia. (However, in the
second patient, escitalopram efficacy was not
maintained after two years; substitution of
lamotrigine, 1,000 mg at bedtime, was beneficial
at 4-year follow-up [Isabelle Arnulf, personal
communication]).
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
524
Both these females had sexsomnia
associated with CAs, a non-REM sleep
parasomnia, the most common cause of
sexsomnia. Their childhood traumatic histories
might have predicted sexsomnia emerging from a
nocturnal, sleep related dissociative disorder
(Schenck et al., 1989a; 1989b), a psychogenic
disorder emerging during the nocturnal sleep
period with a wakeful EEG. This condition can
feature the reenactment of past sexual traumatic
experiences. A heightened suspicion for
nocturnal sexual dissociation could be justified in
these two cases, since sexual abuse often occurs
at night and in a bedroom. This underscores the
importance of conducting vPSG studies to
objectively document, to the extent possible, any
underlying sleep related disorder promoting the
sexsomnia.
6) Two cases of sexsomnia embedded in a
longstanding, complex history of five
parasomnias affecting each patient, were
reported from Italy (Cicolin et al., 2011).
These cases represented the first two cases of a
novel category of Parasomnia Overlap Disorder
involving REM Sleep Behavior Disorder (RBD)
and a non-REM sleep parasomnia in the same
patient (Schenck et al., 1997; American Academy
of Sleep Medicine, 2014). Sexsomnia as a non-
REM sleep parasomnia was found in patients who
also had RBD. Furthermore, legal charges were
involved on account of sexsomnia in one of these
patients, with eventual acquittal.
The first case involved a 60 year-old
married woman who presented to a sleep
disorders center on account of RBD of four years’
duration, with her husband complaining of her
repeated, aggressive, dream-enacting behaviors.
She also had a childhood-onset, lifelong history of
SW, sleep talking, and some recurrent episodes of
sleep related eating (Schenck et al., 1991;
American Academy of Sleep Medicine, 2014).
vPSG demonstrated RBD behaviors with
loss of the customary REM-atonia, and also non-
REM sleep parasomnias emerging from N3 sleep.
She also had an episode of sexsomnia with
masturbation (placing a hand under her panty to
masturbate) during N3 sleep, which lasted
several minutes. The masturbation was preceded
by a hypersynchronous delta EEG pattern, and
during the episode, the EEG pattern showed the
persistence of delta rhythms with increasing
alpha activity, thus confirming that the sexual
behavior occurred during sustained sleep.
Treatment was not mentioned.
The second case involved a 41-year-old
man with childhood-onset, lifelong SW, sleep
(night) terrors, and sleep talking, and a six-year
history of violent RBD episodes with dream-
enactment. His ex-wife and current girlfriend
both confirmed repeated sexsomnia episodes,
with sexual fondling and sexual intercourse. He
faced a legal sexual assault charge from repeated
sexual fondling of the 11-year-old daughter of his
current girlfriend one night while he was
reportedly asleep, and for which he was
completely amnestic.
He underwent five vPSGs as part of the
forensic sleep medicine evaluation related to his
legal charge, which confirmed RBD, with
behaviors emerging from REM sleep and loss of
REM-sleep muscle atonia. He also had
parasomnia behaviors that emerged from non-
REM sleep, but solely non-sexual behaviors were
documented by vPSG. He therefore had
documented Parasomnia Overlap Disorder, with
the sexual behaviors presumably emerging from
non-REM sleep. He pleaded innocent to the
charge of sexual assault by using the Parasomnia
Defense, with sexsomnia/sleepsex being
considered a non-insane automatism. The
testimonies of his ex-wife and current girlfriend
about his history of recurrent sexsomnia
episodes, together with the vPSG findings, the
absence of any prior history of sexual assault or
deviance, and the lack of any motivation for
intentionally engaging in sexual assault, resulted
in his acquittal. The patient subsequently always
slept with an infrared door alarm on his bedroom
door, as a safeguard for aborting any future
parasomnia episode, including sexsomnia
associated with SW.
These two cases illustrate the common
clinical scenario of sexsomnia being embedded
within a longstanding, complex Parasomnia
Multiforme.” In fact, apart from sexsomnia
emerging with OSA or emerging as an ictal
sexsomnia, sexsomnia typically emerges late in
the course of a preexisting, longstanding non-
REM sleep parasomnia, and is usually the last
parasomnia to emerge in a series of previously
established parasomnias. This documented
observation has important legal implications: a
first-time alleged sexsomnia episode that results
in a legal sexual assault charge should be viewed
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
525
with great skepticism, and raises the strong
suspicion of a "sexsomnia excuse" for intentional
sexual assault behavior. Furthermore, the role of
any alcohol use or intoxication (or illicit drug
use) in alleged sexsomnia behavior should be
explored, since alcohol intoxication and illicit
drug use cannot absolve culpability for any
subsequent sexual assault or other criminal
behavior.
7) A report from Turkey on two cases of
spontaneous orgasm during sleep (Özcan et al.,
2012) was translated from Turkish to English for
this manuscript by S. Cankardeş, Istanbul:
"First case was a 37 year-old, married,
employed woman. She presented to the
psychiatry clinic in 2008 with the symptom of
orgasms during sleep [of unspecified
duration] without any arousal or sexual
dream content. Sleep orgasms had appeared
on most nights. With an ictal orgasm
prediagnosis, a brain MRI was performed, but
no pathology found. A sleep EEG [not with
polysomnography] was performed, but no
epileptic activity was observed even though
the patient reported that she had experienced
orgasm [in her sleep]. Patient was informed
about having a parasomnia. Clonazepam
therapy, 0.5 mg, was offered, but she refused
treatment.
Second case was a 48 year-old,
married, housewife. She presented to a
menopouse clinic with the complaint of sleep
orgasm. She had sleep orgasm [of unspecified
duration] at least 2-3 times in a month
without any sexual dream content or arousal.
She also had sleep orgasms after she had
sexual intercourse. She reported that her 77-
year-old mother had the same problem, which
she discovered three years previously, when
her mother wanted to take a shower before
surgery because she had experienced orgasm
during sleep on the preceding night [she was
complying with the Muslim full ablution
religious ritual, to become "pure" again after
engaging in any form of sexual activity--even
spontaneous orgasms--that had made her
"impure"]. This was when she learned that
her mother also had [spontaneous] orgasms
at night. Clonazepam therapy (in liquid form)
was initiated, 0.375 mg at bedtime, and the
sleep orgasms ceased within one month.
Although prior to this therapy an EEG and
brain MRI were recommended, they were not
performed.
Since both patients presented with the
complaint of spontaneous sleep orgasms, they
had awareness of their sexsomnia, and so
sleep orgasm (in females) is the only form of
sexsomnia reported to date in which there is
recall of the sexsomnia by the affected person.
Both patients had normal mental
health and medical histories and
examinations. Both patients also did not have
histories of any sexual abnormality." [No
information was provided about a history of
parasomnias or other sleep disorders].
8) Four cases of sexsomnia were reported from
Spain, involving patients who presented to a
multi-disciplinary hospital sleep clinic (Arino et
al., 2014). None of the patients had a psychiatric
or sexual disorder history. vPSG was performed
in all 4 cases.
The first case was a 38-year-old male who
came with wife; they reported a stable 17-year
marriage, with conventional, satisfactory sex
occurring 2-3 times weekly. There was a negative
personal and family medical history, except for
nasal septoplasty five years previously. There
was no history of traumatic sexual experiences.
Parasomnia history was positive only for isolated
sleeptalking as a child.
The wife described her husband's seven-
year history of sexsomnia: he would sleep for 2-3
hours, then while still asleep he would abruptly
attempt sexual intercourse for 10-30 minutes.
The sexsomnia behavior differed from his waking
sexual behavior, in that it was more vigorous,
forceful sex with "lewd language" while trying to
penetrate his wife. His wife observed an erect
penis during each episode. The frequency of the
sexsomnia was once weekly.
The wife reported one notable episode in
which he immobilized her by placing his arm
around her neck in a stranglehold. "Although he
attempted penetration, she never permitted it
because she believed that the episodes were not
normal sexual behaviour and that her husband's
actions were involuntary...The patient had
awakened in a confused state during some of
these episodes and was surprised by his wife's
account of his behaviour."
There was complete amnesia for the
sexsomnia, and no apparent associated dreaming.
Also, there was no identified trigger, such as
stress or prior sexual stimuli, for these weekly
sexsomnia episodes.
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
526
There was a 20-year history of snoring,
apneas observed by his wife, and excessive
daytime sleepiness (EDS), which resulted in a
nasal septoplasty five years earlier, without a
prior PSG being performed, but there was no
benefit for the snoring, EDS or sexsomnia from
the septoplasty.
A waking EEG was unremarkable. vPSG
detected sleep-disordered breathing, with an
Apnea-Hypopnea Index of 13/hr, which
increased to 40/hr while lying supine. No other
abnormality was found, including the absence of
any parasomnia behavior.
The presumptive diagnoses were sleep-
disordered breathing (SDB), and sexsomnia as
either an isolated parasomnia and/or a
comorbidity of SDB with CAs. The patient refused
treatment of the SDB and also refused
clonazepam therapy of sexsomnia. However,
nCPAP therapy should have been offered first as a
potentially effective monotherapy of these two
sleep-related disorders before considering
clonazepam therapy.
The second case involved a 41-year-old
female with a one-year history of sexsomnia. Her
husband observed sleep masturbation three
nights weekly, without involving him, even
though they slept in the same bed. Sometimes she
would achieve orgasm from her sleep
masturbation. The episodes occurred around
5:00 a.m. There was complete subsequent
amnesia for the masturbation, and "she felt
ashamed" when her husband described these
episodes to her. Her husband also observed
repetitive and periodic non-sexual limb
movements during sleep, especially in the lateral
decubitus position. Upon questioning, she
reported occasional symptoms of Restless Legs
Syndrome (RLS) while resting, especially at night.
There was no history of snoring, apneas, EDS or
insomnia. Their waking sexual activity was
described as being "regular, satisfactory, and
pleasant sexual intercourse, with no sexual
problems when awake."
Parasomnia history was positive for
childhood SW until age 14 years.
There was a one-year history of
metrorrhagia, of unknown origin, causing
recurrent iron deficiency with periodic therapy
with oral iron supplements.
vPSG was performed, which did not detect
apneas, epileptiform activity, parasomnia
behaviors, or any other abnormalities. However,
there was a PLM index of 24/hr throughout the
night. The PLM index with microarousals,
partially disrupting sleep, was 7/hr. Also, with
foot movements there was sudden abduction of
the lower limbs. On two occasions during the
vPSG study, there were more prolonged
movements, accompanied by repetitive arm
movements. Of note is that she also placed her
hand on her genitals for a few seconds but did not
masturbate.
Although not stated explicitly, the
presumed diagnosis appeared to be sexsomnia
associated with RLS, PLMs and other periodic
movements of sleep serving as precipitating
factors, with a prior history of non-REM
parasomnia (i.e. SW) serving as a predisposing
factor. Treatment with pramipexole and an iron
supplement improved RLS, but did not benefit the
sexsomnia, as reported at 90-day follow-up. The
patient was then lost to long-term follow-up.
The third case involved a 43-year-old male
whose live-in partner of the past year observed
four episodes of sexsomnia that occurred in the
context of a more complex, non-sexual
parasomnia disorder, which also dated back to
childhood, when he experienced frequent
sleeptalking and shouting, occasionally with
distressing nightmares.
During the preceding year, when he started
cohabitating with his current partner, he had
started rotating shift work. His partner would
observe that two hours after his falling asleep, he
would occasionally sit up abruptly, with
confusion and fear. He could engage in a partially
coherent conversation with her for several
minutes, always with his eyes open, and he would
move and at times swat at something imaginary
in the air. He appeared to be asleep and never
had recall for these events.
The four similar episodes that involved the
added component of sexual behavior occurred
after he had slept 2-4 hours. He attempted to
initiate sex with his partner by fondling her body
and genitals. The partner rejected the advances,
since to her they were inappropriate and
involuntary behavior on his part. He never
displayed aggressive or insistent sexsomnia
behavior, "but merely moved to the other side of
the bed, expressing his frustration and annoyance
in such terms as 'no fun.'" There was total
amnesia for these four sexsomnia episodes. These
four episodes posed no problems for the couple's
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
527
relationship. The couple reported satisfactory
conventional waking sex, and he had no history of
any sexual disorder.
Of particular importance is that these four
sexsomnia episodes occurred on a day when he
had changed shifts at work.
The patient reported similar sexsomnia
episodes with a former partner, who had on
occasion consented to his advances, with both of
them achieving orgasm. These episodes had been
described to him by the previous partner, as he
had only vague recall of the end of the sex acts.
The history strongly suggests that he was not
engaged in shift work while having sexsomnia
with his former partner.
vPSG was performed for two nights, and no
parasomnia activity was detected. Sleep-
disordered breathing was found, with an AHI of
16/hr and 7/hr, respectively, during the two
studies. OSA was especially common while
supine, and particularly in REM sleep: 37/hr and
40/hr, respectively, during the two vPSG studies.
Neither PLMs nor EEG epileptiform activity was
detected, and normal REM-atonia was
documented.
The patient refused therapy of both sleep-
disordered breathing and sexsomnia.
From a diagnostic perspective, this case
presents interesting possibilities, alone and in
combination, to account for the emergence of
sexsomnia. The patient had a childhood-onset,
complex parasomnia history that persisted
throughout adulthood up to the time of referral.
Therefore, sexsomnia may have represented
another non-REM sleep parasomnia in his
evolving parasomnia history. He also had
documented sleep-disordered breathing that
could have promoted sexsomnia during CAs, as
described above in other cases, and as previously
published. And finally, rotating shift work was an
apparent circadian rhythm disturbance trigger
that promoted all four observed sexsomnia
episodes. Therefore, this case reveals some of the
complexity that can surround sexsomnia, both for
individual patients and for the spectrum of
affected patients. NREM parasomnia, sleep
disordered breathing, and circadian rhythm
disturbance may each have played a role in
triggering sexsomnia in this patient.
The fourth case involved a 28-year-old
male whose bed partner of nine months observed
complex non-sexual and sexual parasomnia
activity. During 3-6 nights weekly, while they
were asleep, he would abruptly sit up in bed or
turn towards her and shake her before uttering
incoherent phrases, such as "look at that house"
or "the devil". They could engage in
conversations, and occasionally he would cry out
or laugh. He also displayed mimicking behaviors
such as driving a car, having a conversation, or
searching for something in the bed. His partner
believed that he seemed to be acting out a dream.
During these episodes, his eyes remained open
and he appeared restless and worried. His
partner would generally be able to calm him by
telling him to go back to sleep. He never left the
bed during these episodes.
Similar, but exclusively sexual episodes,
occurred 2-3 times monthly, when he would
masturbate or touch his partner with the intent
to initiate sex. She reported that he was never
aggressive or violent, but "it isn't him", describing
the behavior as "more lewd and vulgar." His penis
was always erect during these episodes. She
would always refuse sex during these nocturnal
episodes, and he would immediately cease the
sexual advances without any complaint.
All the reported parasomnia episodes, both
sexual and non-sexual, occurred no more than
once nightly, 2-3 hours after sleep onset. He was
always subsequently amnestic for these episodes,
and would feel tired the next day. There was
never any reported nightmares or erotic dreams.
The couple's waking sex life was regular and
mutually satisfactory.
Of note is that past partners had observed
similar sexual and non-sexual sleep behaviors.
The patient reported a history of SW and
sleeptalking, and a brother had SW.
vPSG study did not reveal any parasomnia
behaviors, nor SDB, PLMs, EEG epileptiform
activity, nor any other abnormality. The diagnosis
was sexsomnia associated with CAs and other
non-REM sleep parasomnias.
Treatment was directed both to improve
sleep habits (establish regular sleep hours, and
obtain 8 hrs of total sleep nightly), and to start
taking clonazepam, 0.5 mg q HS. This dual
therapy was beneficial, as the CAs decreased in
frequency to 1-2 nights weekly, and the
sexsomnia frequency was decreased to 1-2
episodes monthly.
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
528
B) Published abstracts on Sexsomnia
(publications 9-11)
9) Familial sexsomnia for the first time has been
reported involving a father and a son in an
abstract from Australia (Kennedy et al., 2010).
The son, 28 years-old, along with his female
partner, described a history of abnormal sleep-
related sexual behavior consisting of "rough
automaton-like intercourse that usually occurred
about 60 to 90 minutes after they retired for
sleep." The frequency of this sexsomnia was
almost nightly and was not influenced by
scheduled sexual intercourse before sleep onset.
"Sleep hygiene" interventions were initially
attempted for two months, but were ineffective
for controlling the sexsomnia. The second
treatment option that was tried for 20 days was a
1.0 mg dose of clonazepam at bedtime, which
proved to be efficacious in completely stopping
the sexsomnia.
One month after the patient was
successfully treated, his father, 58 years old,
presented at the same clinic with a lifelong
history of sexsomnia. His condition was also
subsequently treated successfully with a 1.0 mg
bedtime dose of clonazepam.
vPSG studies in both the son and the father
reportedly were consistent with slow-wave sleep
parasomnias, but without any details provided.
Both patients had little or no memory of events,
and were difficult to wake up.
10) A published abstract from Brazil provided the
first description of sexsomnia with Parkinson's
disease (PD) in four patients, but without age or
gender being stated (Neto et al., 2012).
All four patients had amnesia for the sexsomnia,
and the bed partners reported that the sexsomnia
involved sexual intercourse, sexual vocalization
and/or masturbation during sleep.
Of note is that in all four cases, the
sexsomnia began with the initiation, or with dose
increase, of pramipexole therapy of PD. Also, two
of the four patients had impulse dyscontrol
disorders during wakefulness, involving
hypersexuality, compulsive eating, and excessive
spending--all of which have been previously
reported side effects of dopamine receptor
agonist therapy of PD and RLS. Therefore, two of
the four patients treated with pramipexole
developed impulse dyscontrol disorders during
sleep and wakefulness as behavioral side effects.
Additionally, RLS, OSA, RBD, and insomnia
(related to depression) were documented in
these patients. vPSG data were not given in the
abstract. None of the patients had a prior history
of parasomnia or sexual disorder. This abstract
did not contain sufficient information to be
included in Table 1.
11) A recently published abstract from a tertiary
care sleep clinic in London, United Kingdom
reported on the largest case series to date on
sexsomnia (Muza et al., 2015).
This was an observational case series study of
individuals presenting during a six-year period
(2008-2014) with symptoms suggestive of
sexsomnia. Of the 41 patients identified, the mean
age was 32 years (range, 22-50 years); 90.2%
(n=37) were male, and 9.8% (n=4) were female.
Most were married and were Caucasian. The
sexsomnia behaviors predominantly involved
masturbation in 3 of the 4 females; and sexual
intercourse, fondling and groping in 22 of the 37
males. In 11 cases there was aggression and
violence, with forensic consequences in one case.
Amnesia was reported by all patients. Self-
reported triggers for sexsomnia episodes
included sleep deprivation (n=8); stress (n =6);
contact with a bed partner (n=2); and alcohol use
(unspecified amount; n=3). 73.2% (30/41) of
patients had a past history of another
parasomnia, mainly non-REM sleep parasomnias
such as SW and sleeptalking. Forty of the 41
patients underwent an overnight vPSG, and in
70% (28/40) there were sudden arousals from
N3 (slow wave) sleep, strongly supporting the
clinical history of a non-REM sleep parasomnia.
Sexual behaviors did not occur during the vPSG
studies. In the remaining 30% (12/40) of
patients, positive findings during the vPSG
included loss of REM sleep atonia, EEG
epileptiform features, and mild OSA (no data
were provided). However, the clinical correlates,
if any, of the latter three positive findings were
not provided in the abstract. Virtually all the
findings reported on the 41 patients in this
abstract from a single sleep center are highly
congruent with the cumulative clinical profile of
sexsomnia involving 53 patients reported as
single cases and case series in the world-wide,
peer-review literature on sexsomnia, as
summarized and described in this manuscript
and in table 1. Since most of the quantitative
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
529
findings contained in table 1 summarizing the
world literature through 2015 were not
contained in the just-described abstract by Muza
et al. (2015), findings from the latter abstract
were not included in table 1. However, the
following updated data in the world literature on
sexsomnia, incorporating the data from the Muza
et al. (2015) abstract, are as follows: i) n=90
reported cases; ii) male predominance: 82%
males (n=74), 18% females (n=16); iii) mean age
at evaluation, 32-35 years; iv) amnesia for the
sexsomnia in 97.8% (88/90); v) aggression and
violence during sexsomnia episodes in 32%
(29/90); vi) forensic consequences in 14%
(13/90). The 4 reported cases of sexsomnia
emerging with Parkinson's disease (Neto et al.,
2012) are excluded from this analysis on account
of insufficient data being provided, except for
there being a total of 94 reported cases of
sexsomnia in the world literature, with 97.9%
(92/94) amnesia for the sexsomnia.
It is important to emphasize that all these
cases represent individuals who presented for
medical evaluation and therapy, primarily at
sleep clinics, on account of sexsomnia-related
complaints. A separate issue is the range and
prevalence of sexsomnia behaviors in society at
large, and their negative and/or positive
consequences.
A rare example of sexual behavior during
sleep associated with REM Sleep Behavior
Disorder (RBD, a parasomnia of dream-
enactment) has been briefly mentioned: "In one
patient, a behavior resembling sexual intercourse
with an imaginary partner and accompanied by a
disgusting comment occurred on a single night, as
reported by his wife". (Fernandez-Arcos et al.,
2016). And in the RBD section of the
International Classification of Sleep Disorders,
3rd Edition (American Academy of Sleep
Medicine, 2014), sexual/sexualized behaviors
were briefly mentioned: "Rarely there can be
smoking a fictive cigarette, masturbation-like
behavior, pelvic thrusting, and mimics of eating,
drinking, urinating, and defecating. The eyes
usually remain closed during an RBD episode,
with the person attending to the dream action
and not to the actual environment."
A case of sexual hypnagogic hallucinations
with out-of-body experience
Since parasomnias involve abnormal sleep
related experiences besides abnormal sleep
related behaviors, a case study from Brazil on
abnormal sleep related sexual experiences at
sleep onset will be described (Coelho et al.,
2011). A 46-year-old man presented with a six-
year history of sexual hypnagogic hallucinations
(HH) —and "out-of-body-experiences" triggered
by the start of sex with his wife, mainly in the
evenings. While floating up in air, he had an out-
of-body experience (OBE) in which he was seeing
the sex he was having with his wife in bed at that
moment—but he had already stopped the actual
sexual activity with his wife in bed. Therefore, he
was hallucinating the sex with his wife, since the
sex had stopped when he started hallucinating.
The OBE & sexual HH had been present
continually for six years.
His wife repeatedly complained, since the
sexual activity with her husband would be
interrupted when he started to have sexual HH
and OBE. For the husband, the sexual activity
with his wife in bed continued without
interruption since he had a rapid, fluid transition
from actual sex to hallucinatory sex (combined
sexual HH/OBE), as an abnormal narcoleptic
brain-mind state, during a wake-sleep
transitional period that was initiated by actual
sexual activity.
A diagnosis of narcolepsy-cataplexy (NC)
was established after a formal sleep medicine
consultation and sleep lab studies (vPSG and a
daytime multiple sleep latency test that
confirmed excessively short sleep latencies
across five nap opportunities, with REM-onset
sleep during all five naps), and the determination
of a pathologically low CSF Hypocretin-1 level.
Therapy of NC with daytime methylphenidate
(and subsequently with modafinil) and bedtime
amitriptyline was highly effective in controlling
excessive daytime sleepiness and the sexual HH
and OBE.
II) Ictal Sexsomnia
An additional case of Epileptic Sexsomnia has
been reported (Pelin et al., 2012) since the 2007
report by Schenck et al. Also, during this
subsequent time period a case of bupropion-
induced ictal orgasmic sexsomnia has been
reported (Şengül et al., 2014). Furthermore, a
third case of presumed ictal sexsomnia has been
reported, in a postmenopausal woman (Demir,
2014). Therefore, three additional cases of ictal
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
530
(or presumed ictal) sexsomnia have been
reported since 2007 (all from Turkey), for a total
of 10 cases in the world literature.
The additional case of epileptic sexsomnia
(Pelin et al., 2012) involved a 31-year-old
married man with an eight-year history of
masturbation during sleep that was embedded in
a complex set of wakeful and sleep related
epileptic symptoms, with the sleep related
symptoms, besides masturbation, also including
laughing, unintelligible vocalizations, clapping his
hands and banging on the wall 3-4 times nightly
at any time during the sleep period, and with
duration of approximately 15 minutes. It was
virtually impossible to abort these episodes,
which sometimes emerged from daytime naps.
Video-EEG (not vPSG) documented an episode of
masturbation during sleep associated with
hypersynchronous delta waves (2-3 Hz) that
were most prominent in the anterior temporal
and temporal regions. There was no epileptiform
activity detected during the sleep masturbation.
However, right temporal EEG neuronal
hyperexcitability was detected in periods during
sleep apart from the masturbation episode. The
initiation of carbamazepine therapy (in
conjunction with prior topiramate therapy)
completely stopped the sleep related
masturbation and the other abnormal sleep
related behaviors. He then developed what is
commonly referred to as the "temporal lobe
personality disorder" that is often found in
"temporal lobe epilepsy" (complex partial seizure
disorder), characterized by suspiciousness,
jealousy, "emotional viscosity", irritability, and
aggression that was finally controlled with the
addition of aripiprazole therapy to his medication
regimen. The patient had a completely negative
premorbid psychiatric, neurologic and medical
history.
Although in this case frank EEG
epileptiform activity was not documented during
the recorded sleep masturbation episode, the
most compelling reasons that the authors
provided, and also as contained in the case
description, for why temporal lobe epilepsy
(rather than a parasomnia) was the most likely
etiology for the sleep related masturbation
included: i) multiple nightly episodes; ii) right
temporal neuronal hyperexcitability during sleep;
iii) no prior parasomnia history, such as SW,
sleep terrors, sleeptalking, etc.; iv) presence of
the typical "temporal lobe personality disorder";
v) prompt and full response to the anticonvulsant
carbamazepine (a first-line drug for temporal
lobe seizures). Also, in regards to the
"hypersynchronous delta EEG activity" (HSD)
documented during the sleep masturbation
episode in this patient, although a number of
authors over the years have touted this finding to
be a common, specific, and virtually diagnostic
feature of a non-REM parasomnia, in fact HSD
should now be regarded as a non-specific finding
that is also found in other (non-parasomnia)
conditions, including respiratory arousals from
sleep (Pressman, 2004). With the patient just
described with epileptic sexsomnia, the HSD
activity documented predominantly in the
anterior temporal and temporal regions may
have been a marker of epileptic activity related to
the right temporal neuronal hyperexcitability as
CNS manifestations of temporal lobe epilepsy.
The case of bupropion-induced orgasmic
seizure (Şengül et al., 2014) was translated from
Turkish to English for this manuscript by S.
Cankardeş, Istanbul:
"RA is a 67 year-old, high-school graduate,
married woman. She is a housewife with two
children and living with her husband. She came to
our clinic with her husband one year ago. Her
complaints were anxiety, worries, tediousness,
insomnia, irritability, claustrophobia and being
unable to do the housework. These complaints
had been present for six months and they had
worsened. She had presented to psychiatry
clinics several times previously. She was taking
sertraline 100 mg/day, and alprazolam 1mg/day.
Mental status examination revealed motor
symptoms of anxiety (frequent wringing of the
hands, swinging her feet, inability to sit still), and
irritability. She complained of insomnia and there
were depressive themes in her thought content.
Generalized anxiety disorder was diagnosed.
Routine blood chemistry and a complete blood
count were normal. Sertraline dose was reduced
to 50mg/day, and the alprazolam dose was
reduced to 0.5 mg/day. Venlafaxine therapy, 37.5
mg/day, and quetiapine therapy, 25 mg/day,
were started. During follow-ups, the venlefaxine
dose was gradually increased to 150 mg/day, and
the quetiapine dose was increased to 100mg/day.
Sertraline and alprazolam were discontinued.
The patient achieved remission for one year with
this combined venlafaxine and quetiapine
therapy. Because of weight gain (in one year her
weight increased from 89 kg to 95 kg) and
sedation, the quetiapine dose was reduced 25
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
531
mg/day. However, due to her complaints of
anergy, lack of motivation, sedation and weight
gain, the dose of venlafaxine was reduced to 75
mg/day, and bupropion HCI therapy, 150
mg/day, was added. Venlafaxine was gradually
reduced to 37.5 mg/day, and then discontinued
after a month. The dose of bupropion HCI was
increased 300mg/day. The motivation and level
of functioning of the patient increased, she began
to lose weight, and the sedation was reduced.
However, during the third month of bupropion
therapy, 300 mg/day, the patient started to
complain of spontaneous orgasms every night at
any time during sleep, without any stimulation or
sexual dream content. Brain MRI was normal. An
EEG [presumably a waking EEG, without a sleep
component being mentioned], performed with a
preliminary diagnosis of ictal orgasm, revealed
sharp slow wave activity in both frontal and left
temporal lobes. These findings indicate a possible
frontal attack. Bupropion was then discontinued.
The patient’s sleep orgasm frequency went down
to once every two weeks, and disappeared in
three months. A subsequent EEG, performed
when she was no longer taking bupropion, did
not show any epileptiform activity."
In this case there was apparently no history
of prior seizures or head trauma, nor any prior
history of parasomnia, although these negative
findings were not explicitly stated. There was
also no comment about any family history of
epilepsy.
Bupropion has been reported to induce
seizures (generally grand mal seizures) during
wakefulness, but usually at doses of 400-450
daily (the highest allowed dose). In the case
reported above, the (presumably ictal) sleep
orgasms occurred while the patient was taking
300 mg/day of bupropion (and also 25 mg/day
quetiapine). However, sleep is a state that is
known to facilitate seizures on account of
increased synchronized EEG activity, and so the
combination of the sleep state and the 300 mg
bupropion dose (presuming no prior history of
seizures) may have conspired to lower the
seizure threshold and produce seizures, with the
only seizure manifestation being ictal orgasm
during sleep, without any waking ictal
manifestation. The specificity of sleep-related
orgasm as the sole manifestation of recurrent,
medication-induced, ictal events is difficult to
explain.
The third case of (presumed) ictal
sexsomnia, published as a letter-to-the-editor
(Demir, 2014), was also translated from Turkish
to English for this manuscript by S. Cankardeş,
Istanbul:
"The patient is a 69-year-old, married
housewife. She suffered from spontaneous
orgasms during sleep for 12 years, but had
never sought help because of feeling ashamed.
She finally went to a gynecologist because her
orgasms started to be severe enough to
rupture the veins in her eyes, and after each
orgasmic sexsomnia episode she had whole
body pain. She reported that upon awakening
there were contusions on her genitals and on
her body. Immediately before these sleep-
related orgasms she would usually have a
dream in which she was climbing a tree and
when climbing down the tree her vagina
would be rubbed on the tree. Her orgasmic
sexsomnia attacks occurred once a week, and
at most twice weekly.
The gynecologist referred her to a
psychiatrist. Mental status examination did
not reveal any psychopathology. Complete
blood count, blood chemistry, thyroid
function tests, and serum lipid profile were all
normal, along with serum levels of vitamin
B12, folate, estradiol, follicle stimulating
hormone, luteinising hormone, prolactin, and
testosterone; urine test results were also
normal. The presumptive diagnosis was ictal
orgasm during sleep. MRI of the brain was
normal. An EEG did not show any epileptiform
activity. Polysomnography was not conducted
on account of very limited availability in the
province where she resided. Clonazepam
therapy, 1 mg at bedtime, was started, and at
3-month follow-up there was no further
complaint of orgasm during sleep.
During her clinical interview, she
reported being sexually normal in her waking
life, with the ability to experience both clitoral
and vaginal orgasms. She denied
masturbating. On account of her husband's
neurologic disorder, they had not engaged in
sex for the past 15 years. Orgasm episodes
during sleep had emerged at any time of the
night.
Discussion: When compared with
other case reports in the literature, our case is
the oldest reported patient with sexsomnia.
Although the patient’s EEG showed no
abnormality, this negative finding does not
completely eliminate epileptic seizures as the
cause of orgasmic sexsomnia. Because the
patient had benefit from clonazepam [a
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
532
benzodiazepine anticonvulsant], the diagnosis
of epileptic seizures could not be excluded."
Comments: The recurrent, stereotypical
dream occurring before (and/or during) most of
the sleep orgasms strongly suggests a nocturnal
seizure rather than a parasomnia, especially since
dreaming with sexsomnia (as a parasomnia) has
very rarely been reported, and when it has been
reported, there was never a stereotypical quality
to the dream. In this case, the woman was always
climbing a tree in her recurrent dream, and
would always rub her vagina on the tree on the
way down, which was followed by an orgasm
during sleep (or the dream occurred during the
orgasm), with subsequent awakening. Therefore,
the sequence of symptoms associated with the
orgasm (followed by awakening with immediate
realization of having had an orgasm during sleep)
began with a stereotypical dream involving a
genital area (viz. vagina) being rubbed against a
tree.
The author's claim that this case involved
the oldest reported patient with sexsomnia is
correct for either sexsomnia or ictal sexsomnia.
Furthermore, the author's comment that
although the patient’s EEG showed no
abnormality, this negative finding did not
eliminate epileptic seizures as the cause of
orgasmic sexsomnia is also true, and calls
attention to the important point that seizures (i.e.
ictal events) are primarily a clinical diagnosis
based on the patient report of symptoms, and a
negative cortical EEG (especially during
wakefulness, when for this patient the clinical
events always occurred during sleep) does not
diminish the probability of nocturnal seizures
causing the sleep orgasm.
The full response to clonazepam does not
clarify the diagnosis, since clonazepam is an
anticonvulsant that also controls parasomnias,
including sexsomnia. So based on the treatment
response, her sleep orgasms could have been a
parasomnia or a seizure event, with the same
medication being able to control either
abnormality.
It appears that this was the first
parasomnia that this 69-year-old woman had
experienced in her life, beginning at the age of 57
years, although there was no explicit mention in
the publication about there being a negative past
sleep history. If true, then this would be
extremely unusual for sexsomnia (as a
parasomnia), since in the updated review of the
world literature reported herein, sexsomnia
predominantly emerges in patients with either (i)
an established, longstanding history of multiple
parasomnias (up to five in some patients), and
then sexsomnia becomes the latest parasomnia to
appear in these patients, or (ii) or with
obstructive sleep apnea, and the successful
therapy of sleep apnea (with nasal CPAP) also
controls the sexsomnia. But in this case, there
was no mention of snoring or daytime sleepiness
or other signs suggestive of sleep apnea.
Therefore, her history was very atypical for the
two most common clinical scenarios reported
with sexsomnia, which also lends support to the
diagnosis of ictal orgasmic sexsomnia, together
with the other reasons stated above.
Additionally, this patient eventually
ruptured superficial ocular veins and had whole
body pain immediately after her sleep orgasms,
which have never been reported in sexsomnia.
These symptoms are extreme for orgasms during
wakefulness and for sleep orgasms (as a
parasomnia), and are much more consistent with
an ictal (epileptic) event, with generalized
increased body pressure from tonic seizures
being suspected to cause the whole body pain
and the ruptured eye veins, particularly in the
context of having a stereotypical dream involving
her vagina immediately before (and/or during)
most of the sleep orgasms. Therefore, the
preponderance of the clinical information
contained in this published letter strongly
supports the diagnosis of ictal sleep orgasm more
than sexsomnia as a parasomnia. This would also
include the recurrent, stereotypical dream that
immediately preceded the onset of sleep
orgasms, since stereotypical dreams and
nightmares are often associated with nocturnal
temporal lobe seizures (Silvestri et al., 2004), and
can be considered as "seizure equivalent"
experiences. Various other types of abnormal
dreams and dream-enacting behaviors associated
with nocturnal seizures have been reported, as
reviewed (Schenck, et al., 2002). Unfortunately,
in this case, polysomnography with full EEG could
not be performed, and so we don't have the
complete data available, and a definitive
diagnostic basis of the sleep orgasm remains
indeterminate.
Results and Discussion
Novel findings from the additional Sexsomnia
cases described herein
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
533
The 22 additional cases of sexsomnia described
above both reinforce and further clarify the
clinical profile of sexsomnia cases compiled and
categorized in the first classification of sleep and
sexual disorders (Schenck et al., 2007). Moreover,
nine novel findings related to sexsomnia were
found, which expands knowledge on sexsomnia
and helps point the way to future clinical
research.
The nine novel findings on sexsomnia
include:
1) Spontaneous sleep orgasms as parasomnia
events, in two female cases (Özcan et al., 2012).
Previously reported cases of sleep orgasms
involved ictal sexsomnia events, as reviewed
(Schenck et al., 2007), and also as described
above (Demir, 2014).
2) Sexual dreams during sexsomnia episodes, in
two cases (Schenck et al., 2008; Della Marca et al.,
2009).
3) Medication (SSRI)-induced sexsomnia (Krol,
2008).
4) Successful SSRI therapy of sexsomnia (Bejot et
al., 2009).
5) Sexsomnia with a history of sexually traumatic
events in adolescence, in two female cases, who
both demonstrated non-REM sleep parasomnias
during their vPSG studies, rather than a nocturnal
sleep related psychogenic dissociative disorder
(Bejot et al., 2010).
6) Sexsomnia associated with Parasomnia
Overlap Disorder, in two cases, with sexsomnia
embedded in a longstanding, complex set of five
parasomnias (REM sleep behavior disorder and
non-REM parasomnias) (Cicolin et al., 2011).
7) Sexsomnia emerging with a change in shift-
work schedule, indicating that a circadian rhythm
disturbance can trigger sexsomnia in a
predisposed individual (Arino et al., 2014).
8) Familial sexsomnia, affecting a son and father
(both adults) (Kennedy et al., 2010), and a
daughter and mother (both adults) (Özcan et al.,
2012).
9) Sexsomnia emerging with Parkinson disease,
in four patients, with the sexsomnia emerging
with initiation or dose increase of pramipexole
therapy of the PD, and in two patients the
sexsomnia also emerged in tandem with wakeful
disinhibited behaviors (Neto et al., 2012).
Additional clinical findings
In the clinical setting of a sleep disorders center,
the two most common causes of sexsomnia are i)
a non-REM sleep parasomnia (Disorder of
Arousal), consisting of Confusional Arousals
(CAs) in most cases and SW in a lesser number of
cases; there is usually a longstanding history of
parasomnias, often with a childhood-onset,
preceding the emergence of sexsomnia, as
discussed above; and ii) Obstructive Sleep Apnea
(OSA) triggering CAs with associated sexsomnia.
The typical history involves the onset of
sexsomnia with the onset or increase of snoring
and observed apneas, along with daytime
sleepiness. The strong association of sexsomnia
with CAs, in which the individual engages in sex
with the bed partner (and/or oneself) and does
not leave the bed to seek a sex partner, is in line
with what is known about Disorders of Arousal
with problematic (including legal) consequences,
viz. the predominant role played by physical
proximity and contact (Pressman et al., 2007a).
As reported herein, only 6.1% (3/49) of reported
cases of sexsomnia involved SW episodes with
sexsomnia. In 93.9% (46/49) of reported cases,
the affected individuals remained in bed during
CAs when they engaged in sexsomnia. Also, the
role of OSA triggering CAs with sexsomnia is in
line with what is known about sleep-disordered
breathing arousal reactions predisposing to DOA
parasomnia events during non-REM sleep (Espa
et al., 2002). The one case reported and discussed
herein of changes in shift work schedule (as a
circadian rhythm disturbance) triggering
repeated sexsomnia episodes (Arino et al., 2014)
is similar to the release of another instinctual
behavior during sleep, viz. eating, that can be
triggered by a circadian rhythm disturbance
(Schenck et al., 1993). This supports the current
concept of circadian rhythm "misalignments"
between the "master clock" in the hypothalamic
Suprachiasmatic Nucleus and the recently
discovered peripheral clocks distributed
throughout the major organs (e.g. alimentary
organs) and tissues (e.g. adipose) (Summa et al.,
2015), thus promoting the inappropriate timing
in the release of instinctual behaviors, such as
eating and sex during sleep--which is another
instinctual behavior.
Problems with sexsomnia include the
following: i) disrupting the sleep of the bed
partner; ii) physical injury to the bed partner or
to oneself from aggressive sexual behaviors; iii)
psychological disturbance to the bed partner
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
534
from offensive sleepsextalking; iv) psychological
disturbance to the bed partner from the
inappropriate time of sex, the inappropriate type
of sex, and the non-consensual nature of the
sexual behaviors (since the bed partner is
asleep).
Some of the negative psychological
consequences for the bed partner include shock,
worry, alarm, anger, annoyance, and
bewilderment. Also, there can be accusations of
sexual assault/rape, even in a marriage. Some of
the psychological disturbances to the sexsomniac
include shame, guilt, confusion, and even despair
experienced within the context of amnesia for the
event: being told about one’s objectionable,
involuntary, and even aggressive sexual
behaviors during sleep after awakening in the
morning can be very disturbing. And there is
often a major negative impact on a marriage or
other intimate relationship.
Nevertheless, as previously reported
(Schenck et al., 2007), sexsomnia can have some
positive consequences for the bed partner
together with the negative consequences. Sex can
be experienced as more pleasurable, even "kinky"
in a positive manner. Sex can be less hurried than
waking sex. The sexsomniac can be a gentler and
more amorous lover, and more oriented toward
satisfying his partner when he is asleep
compared to when he is awake. Unfortunately,
the sexsomniac is not aware of these positive
sexual behaviors because he is asleep and has
subsequent amnesia for these behaviors.
To date, there has not been any reported
association of sexsomnia with increased sex
drive, sexual deprivation, or sexual perversion
(paraphilia).
Besides pharmacotherapy for sexsomnia
related to a non-REM parasomnia, or nCPAP
therapy of OSA, the clinician should consider
referral of the patient and spouse/significant
other to a psychologist or psychiatrist for one of
two reasons (or both): i) explore the marital/
interpersonal relationship as a possible
contributing factor to the sexual parasomnia; ii)
optimally address any adverse consequences
(personal and interpersonal) from the sexsomnia.
The almost universal amnesia associated
with sexsomnia, along with the almost universal
bed partner-driven clinical referral, may help
explain the occasional patient refusal to engage in
the proposed therapy. There may also be various
degrees of denial, apart from the amnesia, of
having this condition, which can be reflected by
the refusal to initiate therapy.
The issue of penile erection (NPT--
nocturnal penile tumescence) associated with
sexsomnia needs to be addressed. In a number of
reports described above, the female partner
observed penile erections in the male sexsomniac
during the sexual activity, which included at
times intercourse with climax. However, NPT is a
well-documented and reportedly exclusive REM
sleep phenomenon, which poses an explanatory
problem, since sexsomnia is predominantly a
non-REM sleep related disorder. This quandry is
carefully addressed by Andersen et al., 2007 from
a basic science-clinical medicine perspective. The
authors propose that sexsomnia is an arousal
phenomenon from non-REM sleep, and not
during non-REM sleep, with NPT (and vaginal
lubrication) emerging in the context of other
autonomic nervous system (ANS) activations
during multi-faceted arousals, such as enhanced
cardiorespiratory responses, sweating, etc. This
arousal-driven ANS activation from non-REM
sleep could help explain the penile erections (and
clitoral/vaginal engorgement) with sexsomnia as
a Disorder of Arousal from non-REM sleep.
The curious and striking finding of male
predominance in sexsomnia in the peer-reviewed
medical literature needs to be better understood
and explained, since one possible explanation is
referral bias for clinical evaluation. Do males and
females in the United States and Western Europe
(the geographical regions represented in most of
the reported cases) have different thresholds for
identifying sexsomnia as a problem in their bed
partners, and do they have different personal
criteria for determining when clinical
intervention should be sought? What are the
boundaries for normal and abnormal sexual
behavior surrounding sleep? These are mainly
bed-partner related questions, since the
sexsomniacs are usually amnestic for their
episodes. Psychological, interpersonal,
sociological, cultural and religious factors need to
be considered in this discussion.
The case of sexual hypnagogic
hallucinations with OBE emerging as a
longstanding symptom of narcolepsy-cataplexy
(Coelho et al., 2011) calls attention to a related
sexual narcoleptic condition called "orgasmic
cataplexy" in which the state of orgasm (an
intense emotional state) triggers an immediate
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
535
cataplectic response, with generalized or focal
muscle paralysis lasting seconds or minutes, and
which can be very disturbing to the affected
individual and the partner, until they are
educated about the benign, albeit peculiar, basis
for this phenomenon.
Epidemiology of Sexsomnia
An epidemiologic study was published from
Norway that estimated lifetime and current
prevalence of various parasomnias in the general
population, defined as the person having
experienced the specific parasomnia at least once
during the previous three months (Bjorvatn et al.,
2010). This was a population-based, cross-
sectional study. One thousand randomly selected
adults (51% female), 18 years and above,
participated in a telephone interview. Lifetime
and current prevalence of sexual acts during
sleep were 7.1% and 2.7%, respectively. About
12% of all responders reported having five or
more parasomnias (reminscent of the study of
Cicolin et al., 2011, in which the two sexsomnia
patients each had five parasomnias). The authors
cautioned that the data needed to be interpreted
with caution due to methodological issues, such
as a low response rate to participate in the
telephone interview, and the single questions
used in the survey.
The frequency of sexsomnia in a general
sleep clinic patient population was reported for
the first time in an abstract from Canada (Chung
et al., 2010). In this study, sexsomnia was defined
as a parasomnia-like behavior characterized by
individuals performing sexual acts (e.g.,
masturbation, sexual intercourse with a bed
partner) during sleep. A retrospective chart
review of patients undergoing PSG evaluation
was conducted. Patients had been asked about
various sleep-related symptoms. Patients
answering "yes" to having initiated sexual activity
with a bed partner while asleep were considered
to have symptoms of sexsomnia. Charts from 832
consecutive patients (428 males and 404
females) were reviewed. The frequency of
reported sexsomnia was 7.6% (63/832; males,
11.0% vs. females, 4.0%). Only 6% of patients
reporting sexsomnia also reported other
symptoms of parasomnia, which is highly
divergent from the cumulative published clinical
reports on sexsomnia, and is difficult to explain.
However, those patients endorsing sexsomnia did
admit to greater use of illicit drugs (sexsomnia,
15.9% vs. no sexsomnia, 7.7%) and of alcohol use
(sexsomnia, 41.3% vs. no sexsomnia, 27.4%), but
statistics on these differences were not reported.
Although this study had major limitations on
account of its retrospective design, the results on
illicit drug and alcohol use being more common
in patients reporting sexsomnia merit further
attention in future prospective studies.
Internet-based surveys of sexual behaviors
during sleep provide another useful method for
better understanding sexsomnia, its problems, its
contributing and associated features, and its
consquences (negative and positive). To date,
three internet-based surveys have been
published (Mangan, 2004; Trajanovic et al., 2007;
Mangan et al., 2007), with the first two studies
previously being cited and discussed (Schenck et
al., 2007), although the second study was cited as
an abstract prior to its publication as a peer-
reviewed journal article. In the third published
study on internet-based research on sexsomnia
(Mangan et al., 2007), two sources of data were
collected from the website <Sleepsex.org>. First,
among visitors to this website, there were 157
responders to a link for completing a 28 item
web-based survey on sexsomnia. Second, there
were 69 responders to links for the same website
sent by email to 409 visitors to the
<Sleepsex.org> website, a 16.9% response rate.
Among the web-based responders, 74% were
male, and among the email responders, 59%
were male. Combining these two data sets, 69%
of all responders were male. While
acknowledging the limitations of this research
design, such as the lack of direct clinical
evaluations, the authors pointed out the following
strengths of their web-based survey: "it
supported access to a population that is often too
ashamed or scared to present in a clinical setting
and second...it provided easy access to persons
with a rare condition...Also, since sexsomnia
sometimes involves adults coming into contact
with minors...the legal implications of reporting
this to a health care provider are serious...In
short, given the increased sense of anonymity
that the Web-based survey provided, people
probably disclosed facts about their experiences
that they might not have revealed in a face-to-
face interaction." Furthermore, the authors
stressed the ease of reaching participants across
the internet. This should encourage web-based
surveys across countries that could shed
important new light on cultural, gender, and
other differences related to sexsomnia.
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
536
A recent review article has been published
in Turkish that touched on epidemiologic issues
(Sarisoy et al., 2014). Selected passages from that
article were translated into English by I. Dedecan,
Istanbul: "Page 81: It is difficult to detect the
actual epidemiology of this disorder because (1)
it is not well-known by health-workers, (2)
diagnostic criteria are not clear enough, (3)
practitioners other than sleep medical specialists
are not looking for the characteristic symptoms
of the disorder while they are getting the
patient’s medical history, (4) the patient or the
partner are not likely to share the sexual
symptoms of the disorder with the doctor
because they are ashamed (Yılmaz, 2011)"..."Page
82: Approach to the patient with sexsomnia
suspicion: It is assumed that there are a lot more
cases of sexsomnia than the detected ones. When
faced with a case of atypical sexual behaviors that
are harmful to himself/herself or other people,
the incidents should be examined thoroughly.
The patient and the family should be evaluated
about the present and past sleep disorders. The
information should be gathered from the bed
partner or the family: timing of the sexual
behavior, frequency, any related traumas, level of
amnesia, the attitude of the patient when
awakened after the incident, the attitude of the
patient in regards to past sleep disorders if there
are any, and the relation of sexsomnia with daily
activities (stress, alcohol, sleep deprivation, etc.).
Because of the possibility of the existence of
sexsomniac behaviors related to complex partial
seizures, EEG should definitely be applied as well
as polysomnography (Guilleminault et al., 2002;
Pelin et al., 2012)." And lastly from this report,
"Maybe the most important necessity about
sexsomnia is that the doctor should ask questions
to the patient about sexsomnia when he/she is
aware of and suspecting sexsomnia. The reason
for this is that the patient and/or their partners
are not eager to talk about sexsomnia unless they
are asked, or if there is a legal issue."
Forensic aspects of sexsomnia
Recent publications that provide a current update
on a new intersecting branch of (sleep) medicine
and the law will be discussed. It is evident that
there is a pressing need for establishing an
international consensus regarding the optimal
sleep medicine evaluation of forensic parasomnia
cases, including those involving purported
sexsomnia.
A book chapter written by a leading expert
in the parasomnias forensic field utilized a
medicolegal, case-based approach in analyzing
putative sexsomnia cases presenting in legal
settings (Cramer Bornemann, 2013). The author
compiled and integrated his arguments from the
following clinical-scientific sources: current
clinical knowledge on sexsomnia; the basic and
clinical sciences of state dissociation and sleep-
related behaviors; the neuroscience of "central
pattern generators" and "fixed action patterns"
(first described by ethologists); clinical
behavioral analysis of each case presented,
including associated clinical conditions and
influences; the role of Mens Rea in forensic
analysis; and process fractionation as a tool to
assess cognition. Furthermore, the author
provided the following contemporary definition
of Sleep Forensics: "The application of the
principles and tools of neuroscience as applied to
somnology and sleep medicine that have been
widely accepted under international peer-review
to the investigation in understanding unusual,
irrational, and/or bizarre human behaviors
associated with criminal allegations which is to
undergo further examination in a conflict
resolution legal atmosphere and/or courtroom."
In addition, the author made the following
comments on the utility of polysomnography, and
of technical scientific data, presented in the
courtroom in medicolegal cases, "Even frank
sleepwalking during a formal sleep study would
only indicate that the individual was a
sleepwalker--not that sleepwalking was involved
at the time of the crime. Thus, a diagnostic tool as
polysomnography would not be temporally
associated with any questions related to mens rea
in a criminal allegation... In a court of law, the
undisciplined use of scientific technical data is a
real concern especially given the public
misperception that science is a field that deals
with absolute certainties when in actuality it is a
field that reflects probabilities of occurrence."
A recently published abstract from the
United States focused on the interface of
sexsomnia and sleep forensics (Cramer
Bornemann et al., 2014). The reported study
gathered data over seven years (2006-2013), in
which a sleep forensics team comprised of three
sleep medicine physicians known for their
contributions to the field of parasomnias were
consulted by the legal community to review
criminal cases involving a potential sleep
disorder (262 total cases). Parasomnias were the
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
537
most prevalent sleep disorder subtype implicated
(131 cases), of which sleep-related abnormal
sexual behavior, i.e. sexsomnia, was the most
common condition implicated (103 cases).
Virtually all the sexsomnia perpetrators were
male (102/103), with an age range of 18-55
years, while gender of the victim was virtually
always female (99/103), with an age range of 3-
17 years in 70.9% (73/103). 86% of the victims
knew the perpetrator as a family member,
significant other, or friend. Sexsomnia behavior
was divided into three subtypes: i) inappropriate
touch, in isolation or combined with touching the
breasts/genital regions (n=65); ii) sexual contact,
in isolation or combined with oral/genital/anal
regions(n=37); and iii) indecent exposure (n=1).
Proximity between victim and perpetrator during
the course of the behavior was: i) confined to the
bed (n=47); ii) confined to the bedroom (n=19);
or iii) began outside of the bedroom (n=37).
The authors concluded that this was the
first published methodical analysis of
parasomnias in a formal medico-legal arena and
underscored the forensic implications of violent
parasomnias that are common from the
perspective of sexual assault. Analysis from such
forensics data provides further insight into sleep-
related abnormal sexual behaviors to enhance
public safety, and provides an important avenue
to improve the legal system's understanding, or
lack thereof, of these sleep-related conditions.
A peer-reviewed journal article focused on
a systematic review of medical-legal case reports
on sleep-related violence and sexual behavior in
sleep (SBS) (Ingravallo et al., 2014). Nine case
reports were found in which SBS (ranging from
sexual touching to rape) was the defense used
during a criminal trial, and in which information
about the forensic evaluation of the defendant
was provided. Victims were usually 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. Eight of the nine cases resulted in
acquittal, with the verdict not stated for the other
case. The forensic evaluations widely differed
from case to case, calling attention to the need to
establish an international consensus on forensic
evaluations of forensic parasomnia cases,
including those with SBS. The same conclusions
and recommendations were stated by different
authors in three other recent publications,
including an emphasis that sexsomnia should be
recognized as a bona fide sleep disorder
(Morrison et al., 2014; Banerjee, 2014; Organ et
al., 2015). In fact, sexsomnia is a recognized
variant of Confusional Arousals (and
Sleepwalking) from non-REM sleep in the
International Classification of Sleep Disorders, 2nd
(2005) and 3rd (2014) editions, published by the
American Academy of Sleep Medicine.
The issue of the use and abuse of alcohol in
the context of evaluating both clinical cases of
sexsomnia (and other parasomnias), and forensic
cases involving purported sexsomnia (and other
parasomnias) needs to be addressed. Although
the literature at first glance appears to be
controversial, the preponderance of valid
scientific evidence weighs heavily in favor of
stating unequivocally that the abuse of alcohol
disqualifies the valid use of the "parasomnia
[sexsomnia] defense" in medical-legal cases
(Pressman et al., 2007b; Pressman et al., 2013;
Pressman et al., 2015). Also, apart from the rare
clinical case in which the patient, and importantly
also a spouse or "significant other" serving as an
observer, report that modest consumption of
alcohol on occasion can trigger an episode of
parasomnia (including sexsomnia) in a person
already demonstrating a propensity for this
parasomnia, alcohol use or abuse cannot be
considered to be the cause of sexsomnia.
Finally, in the Turkish review article on
sexsomnia described above, medicolegal aspects
were touched upon (Sarısoy et al., 2014), which
will now be described, courtesy of the translation
into English by I. Dedecan, Istanbul: "Medicolegal
Aspects: When sexsomnia is considered as a type
of parasomnia, items of Turkish Criminal Code
related to the criminal liability of the sexsomniac
patient are listed below:
Item 32, article 2: By 'the person who is
less able to recognize one’s behaviors is to be
sentenced for 25 years instead of for life' and part
of their sentence can be diminished.
Item 34: By 'the person who is significantly
less able to recognize one’s behavior or not be
able to understand the legal meaning and
consequences of his actions because of a
temporary cause, or under the effect of
alcohol/drug taken involuntarily is not to be
sentenced', and they might not get sentenced at
all.
There are some legal cases related to
sexsomnia in Turkey too. A case had been sent to
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
538
the clinic to be evaluated about whether he had
sexsomnia or not for a legal case. After the
evaluation and literature review, it was decided
that the person did not have sexsomnia. As it was
thought that the topic is not well-known (or not
known at all) in Turkey, we were encouraged to
do this review study.
This study’s limitations were that very few
cases are published, sexsomnia is not clearly
named in diagnostic systems, and there is not
enough information about it. There might be legal
aspects of sexsomnia as well as its psychosocial
aspects. When sexsomnia is suspected, the
patient should be evaluated for other possible
comorbidities too. Experts should be very
cautious when they are diagnosing sexsomnia in
order to prevent legal exploitations."
Conclusion and Outlook
Further multi-pronged research is needed across
the basic and clinical sciences and other
disciplines to better understand the full scope of
determinants (predisposing and precipitating
factors) and consequences related to sexsomnia
(including epileptic sexsomnia), along with the
forensic consequences. For example, the basic
research related to the neurobiology of sexual
desire (Kim et al., 2013) may apply to a
substantial extent to the underlying mechanisms
of sexsomnia. The world literature needs to be
expanded so that national, cultural, religious, and
gender differences related to all aspects of
sexsomnia can be better understood, which will
also benefit the clinical management of the
patients. (The recent review article on sexsomnia
published in Turkey, as cited above, is a good
example [Sarisoy et al., 2014]). The interpersonal
psychology and the sociology of sexsomnia merit
careful study in order better understand the
dynamics resulting or not resulting in
presentation for clinical evaluation and
management. The epidemiology of sexsomnia is
at present poorly known, and needs to be
systematically and comprehensively studied.
Please see next page for Table 1.
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
539
Table 1. Data from 18 Published Cases of Sexsomnia from 2007-2015 Compared and Combined with Data from 31
Previously Published Cases from 1986-20071,2
Category N=18 N=31 N=49
Gender, % (n)
Male 66.7% (12) 80.6% (25) 75.5% (37)
Female 33.3% (6) 19.4% (6) 24.5% (12)
Age, years, mean+SD (n)
Total 39.6+ 9.5 (18) 31.9+8.0 (30)3 34.8+ 9.6 (48)
Male 37.6+ 8.9 (12) 32.1+8.5 (24)3 33.8+ 8.7 (36)
Female 44.2+10.1 (6) 30.8+6.4 (6) 37.5+10.9 (12)
Age, sexsomnia onset, years, mean+SD (n)
Total 33.0+ 5.8 (10)4 25.9+ 8.7 (17) 28.5+ 8.6 (27)
Male 32.1+ 6.3 (7) 27.4+ 7.9 (15) 28.9+ 7.9 (22)
Female 35.5+ 5.0 (3) 14.5+ 3.5 (2) 27.1+11.9 (5)
Duration, sexsomnia, years, mean+SD (n)
Total 5.0+ 3.5 (8)5 9.5+ 6.1 (8) 7.3+ 5.8 (16)
Male 5.6+ 4.1 (5) 8.3+ 6.5 (6) 7.1+ 5.7 (11)
Female 4.0+ 2.6 (3) 13.0+ 4.2 (2) 7.6+ 5.6 (5)
Sexsomnia behaviors, % of patients (n)
Masturbation 25.0% (4) 22.7% (7) 23.4% (11)
(4 female) (4 male, 3 female) (7 female, 4 male)
Sleep orgasms 11.1% (2) 4.1% (2)
(spontaneous) (2 female) (2 female)
Sexual vocalizations, 18.7% (3) 19.3% (6) 19.1% (9)
talking, shouting (2 female, 1 male) (4 female, 2 male) (6 female, 3 male)
Fondling another person 31.2% (5) 45.2% (14) 40.4% (19)
(5 male) (13 male, 1 female) (18 male, 1 female)
Sexual intercourse/
attempted intercourse 62.5% (10) 41.9% (13) 48.9% (23)
(8 male, 2 female) (13 male) (21 male, 2 female)
Total # sexsomnia behaviors 24 40 64
Agitated/assaultive
sexsomnia behaviors, % (n) 22.2% (4) 45.2% (14) 36.7% (18)
Sexsomnia with minors, % (n) 5.5% (1) 29.0% (9) 20.4% (10)
Legal consequences, % (n) 5.5% (1) 35.5% (11) 24.5% (12)
Amnesia for sexsomnia,%(n) 88.9% (16) 100.0% (31) 95.9% (47)
Video-Polysomnography,%(n) 83.3% (15) 83.9% (26) 83.7% (41)
Total # parasomnias 32 71 103
Mean # (+SD) per patient 1.8+ 1.4 2.2+ 1.0 2.1+ 1.2
(range, 1-5)
Final diagnosis, sexsomnia etiology, % (n)
Disorder of Arousal (DOA)6, % (n) 77.8% (14) 90.3% (28) 85.7% (42)
Obstructive Sleep Apnea 16.7% (3) 12.9% (4) 14.3% (7)
REM sleep behavior disorder 5.5% (1) 9.7% (3) 8.2% (4)
Other conditions7 16.7% (3) - 6.1% (3)
Treatment efficacy, % (n) (controlling sexsomnia)
Clonazepam at bedtime 75.0% (3/4) 90.9%(9/10) 85.7%(12/14)
Nasal CPAP at bedtime 100.0% (2/2) 100.0% (2/2) 100.0% (4/4)
SSRI (escitalopram) 100.0% (2/2)8 - 100.0% (2/2)8
SSRI discontinuation 100.0% (1) - 100.0% (1)
Other therapies9 0.0% (0/2) - 0.0% (0/2)
1 Schenck CH, Arnulf I, Mahowald MW. Sleep and Sex: What Can Go Wrong? A Review of the Literature On Sleep Related Disorders and Abnormal Sexual Behaviors And
Experiences. Sleep 2007; 30: 683-702.
2 Four other cases of sexsomnia (emerging with Parkinson's disease) published after 2007 were excluded from table 1 on account of insufficient data being provided (Neto, et al.,
2012). Therefore, a total of 22 new cases of sexsomnia has been published since 2007.
3 N=1, age not reported (male patient).
4 Age of onset not known for 8 patients (5 males, 3 females)
5 Duration not known for 10 patients (7 males, 3 females)
6 DOA (Non-REM sleep parasomnia): Confusional Arousals, n=13 and n=26 for each group, respectively; Sleepwalking, n=1 and n=2 for each group, respectively. The obstructive
sleep apnea (OSA) data are contained within the DOA data, since the OSA events presumably induced confusional arousals that triggered sexsomnia episodes.
7 Other conditions: SSRI (Serotonin Specific Reuptake Inhibitor)-induced (n=1); combined disorders: RLS (restless legs syndrome)/periodic leg and arm movements of sleep/other
abnormal movements of sleep/prior history of NREM parasomnia (SW) (n=1); combined disorders: obstructive sleep apnea, NREM parasomnia, shift work related circadian rhythm
disturbance (n=1).
8 In one of the two patients, escitalopram efficacy was not maintained after two years; substitution of lamotrigine therapy at bedtime was beneficial and maintained at 4-year follow-
up [Isabelle Arnulf, personal communication]).
9 Carbamazepine, dopaminergic agonists (n=1); dopaminergic agonist (n=1).
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
540
References
American Academy of Sleep Medicine. International
classification of sleep disorders, 2nd edition.
Westchester, Illinois, 2005.
American Academy of Sleep Medicine. International
classification of sleep disorders, 3rd edition. Darien,
Illinois, 2014.
Andersen ML, Poyares D, Alves RSC, Skomro R, Tufik.
Sexsomnia: abnormal sexual behavior during sleep.
Brain Res Reviews 2007; 56: 271-282.
Arino H, Iranzo A, Gaig C, Santamaria J. Sexsomnia:
parasomnia associated with sexual behaviour during
sleep. Neurologia 2014; 29 (3): 146-152.
Banerjee D. A case-based review of sleep-related criminal
behaviours, treatment & outcomes. Sleep and Biological
Rhythms 2014; 12: 7.
Bejot Y, Juenet N, Garrouty R, Maltaverne D, Nicolleau L,
Giroud M, Didi-Roy R. Sexsomnia: an uncommon variety
of parasomnia. Clin Neurol Neurosurg 2010; 112 (1): 72-
75.
Bjorvatn B, Gronli J, Pallesen S. Prevalence of different
parasomnias in the general population.
Sleep Medicine 2010; 11:1031-1034.
Chung SA, Yegneswaran B, Natarajan A, Trajanovic N,
Shapiro CM. Frequency of sexomnia in sleep clinic
patients. Sleep 2010; 33: A226.
Cicolin A, Tribolo A, Giordano A, et al. Sexual behaviors
during sleep associated with polysomnographically
confirmed parasomnia overlap disorder. Sleep Med
2011;12: 523-528.
Coelho FMS, Moszczynski A, Narayansingh M, Parekh N,
Pradella-Hallinan M. Sexual hypnagogic hallucinations
and narcolepsy with cataplexy: a case report. Sleep
Science 2011;4(3): 110-112.
Cramer Bornemann MA. Sexsomnia: a medicolegal case-
based approach in analyzing potential sleep-related
abnormal sexual behaviors. In: Kothare SV, Ivanenko A,
eds. Parasomnias. New York: Springer Science + Business
Media 2013; pp. 431-461.
Cramer Bornemann MA, Mahowald MW, Schenck CH.
Sexsomnia and sleep forensics: the interface between
sleep-related abnormal sexual behaviors and the law.
Sleep 2014; 37: A210.
Della Marca G, Dittoni S, Frusciante R, et al. Abnormal sexual
behavior during sleep. J Sex Med 2009; 6 (12): 3490-
3495.
Demir EY. Uykuda Orgazm Olan Postmenopozal Kadın Hasta.
[Post-menopausal female patient with orgasm during
sleep]. Düşünen Adam: The Journal of Psychiatry and
Neurological Sciences 2014; 27 (3): 270–271. [Turkish]
Espa F, Dauvilliers Y, Ondze B, Billiard M, Besset A. Arousal
reactions in sleepwalking and night terrors in adults: the
role of respiratory events. Sleep 2002; 25: 32-36.
Fantini ML, Corona A, Clerici S, Ferini-Strambi L. Aggressive
dream content without daytime aggressiveness in REM
sleep behavior disorder. Neurology 2005;65(7):1010-
1015.
Fernandez-Arcos A, Iranzo A, Serradell M, Gaig C, Santamaria
J. The clinical phenotype of idiopathic REM sleep
behavior disorder at presentation: a study in 203
consecutive patients. Sleep 2016 (in press).
Guilleminault C, Moscovitch A, Yuen K, Poyares D. Atypical
sexual behavior during sleep. Psychosom Med
2002;64(2):328-336.
Ingravallo F, Poli F, Gilmore EV, Pizza F, Vignatelli L, Schenck
CH, Plazzi G. Sleep related violence and sexual behavior
in sleep: a systematic review of medical-legal case
reports. J Clin Sleep Med 2014; 10: 927-935.
Iranzo A, Santamaría J. Severe obstructive sleep
apnea/hypopnea mimicking REM sleep behavior
disorder. Sleep 2005;28(2):203-206.
Kennedy GA, Elzo F. Case studies of familial sexsomnia. Sleep
and Biological Rhythms 2010; 8: A73-A74.
Kim SW, Schenck CH, Grant JE, Yoon G, Dosa P, Odlaug BL,
Schreiber LRN, Hurwitz TD, Pfaus JG. The neurobiology
of sexual desire. NeuroQuantology 2013; 2: 332-359.
Krol DG. Sexsomnia during treatment with a selective
serotonin reuptake inhibitor. Tijdschr Psychiatr [J of
Psychiatry] 2008; 50 (11): 735-739. [Dutch]
Mangan MA. A phenomenology of problematic sexual
behavior occurring sleep. Arch Sex Behav 2004; 33: 287-
293.
Mangan MA, Reips U-D. Sleep, sex, and the Web: surveying
the difficult-to-reach clinical population suffering from
sexsomnia. Behav Res Methods 2007; 39 (2): 233-236.
Morrison I; Rumbold JM; Riha RL. Medicolegal aspects of
complex behaviours arising from the sleep period: a
review and guide for the practising sleep physician. Sleep
Medicine Reviews 2014; 18(3):249-260.
Muza RT, Lawrence M, Williams A. The reality of sexsomnia:
characteristics and manifestations of sexsomnia. Sleep
2015; 38: A250.
Neto SMA, Pena-Pereira M, Sobreira ES, Chagas M,
Fernandes RM, Eckeli AL, Tumas V. Sexsomnia in
parkinson's disease patients. Sleep 2012; 35: A253-
A254.
Organ A, Fedoroff JP. Sexsomnia: sleep sex research and its
legal implications. Current Psychiatry Reports 2015;
17(5): 34. doi: 10.1007/s11920-015-0568-y.
Özcan H, Taşın C, Tandoğan M, ÖZakşit G. Uyku Esnasında
Orgazm Olan İki Kadın. [Two women having orgasms
during sleep]. Düşünen Adam Psikiyatri ve Nörolojik
Bilimler Dergisi 2012; 25: 187–188. [Turkish]
Pelin Z, Yazla E. Abnormal sexual behavior during sleep in
temporal lobe epilepsy: a case report. Balkan Med J
2012; 29: 211-213.
Penas-Martinez ML, Guerrero-Peral AL, Toledano-Barrero
AM, et al. Sexsomnia: descripcion de un nuevo caso.
[Sexsomnia: description of a new case]. Revista de
Neurologia 2008; 47 (6): 331-332. [Spanish]
Pressman MR. Hypersynchronous delta sleep EEG activity
and sudden arousals from slow-wave sleep in adults
without a history of parasomnias: clinical and forensic
implications. Sleep 2004;27(4):706-710.
Pressman MR. Disorders of arousal from sleep and violent
behavior: the role of physical contact and proximity.
Sleep 2007a; 30: 1039-1047.
Pressman MR, Mahowald MW, Schenck CH, Bornemann MC.
Alcohol-induced sleepwalking or confusional arousal as a
defense to criminal behavior: a review of scientific
evidence, methods and forensic considerations. J Sleep
Res 2007b;16(2):198-212.
Pressman MR, Mahowald MW, Schenck CH, Cramer
Bornemann MA, Banerjee D, Buchanan P, Zadra A.
Alcohol, sleepwalking and violence: lack of reliable
scientific evidence. Brain 2013; 136(Pt 2):e229. doi:
10.1093/brain/aws248.
Pressman MR1, Grunstein RR, Mahowald MW, Schenck CH,
Montplaisir JY, Bornemann MC, Zadra A, Buchanan PR.
Alcohol and sleep review: flawed design, methods, and
statistics cannot support conclusions. Alcohol Clin Exp
Res 2015;39(5): 941-3.doi: 10.1111/acer.12712.
NeuroQuantology | December 2015 | Volume 13 | Issue 4 | Page 518-541 | doi: 10.14704/nq.2015.13.4.873
Schenck CH., Update on sexsomnia, sleep related sexual seizures, and forensic implications
eISSN 1303-5150
www.neuroquantology.com
541
Sarisoy G, Özdin S. Seksomnia: Bir Gözden Geçirme
(Sexsomnia: A Review). J of Mood Disorders 2014; 4 (2):
80-87. [Turkish]
Schenck CH, Milner DM, Hurwitz TD, Bundlie SR, Mahowald
MW. A polysomnographic and clinical report on sleep-
related injury in 100 adult patients. American J
Psychiatry 1989a; 146: 1166-1173.
Schenck CH, Milner DM, Hurwitz TD, Bundlie SR, Mahowald
MW. Dissociative disorders presenting as
somnambulism: polysomnographic, video and clinical
documentation (8 cases). Dissociation 1989b; 2: 194-
204.
Schenck CH, Hurwitz TD, Bundlie SR, Mahowald MW. Sleep-
related eating disorders: polysomnographic correlates of
a heterogeneous syndrome distinct from daytime eating
disorders. Sleep 1991;14(5):419-431.
Schenck CH, Hurwitz TD, O'Connor KA, Mahowald MW.
Additional categories of sleep-related eating disorders
and the current status of treatment. Sleep 1993; 16: 457-
466.
Schenck CH, Boyd JL, Mahowald MW. A parasomnia overlap
disorder involving sleepwalking, sleep terrors, and REM
sleep behavior disorder in 33 polysomnographically
confirmed cases. Sleep 1997; 20:972-981.
Schenck CH, Mahowald MW. REM sleep behavior disorder:
clinical, developmental, and neuroscience perspectives
16 years after its formal identification in SLEEP. Sleep
2002;25: 120-138.
Schenck CH, Arnulf I, Mahowald MW. Sleep and sex: what
can go wrong? A review of the literature on sleep related
disorders and abnormal sexual behaviors and
experiences. Sleep 2007; 30: 683-702.
Schenck CH, Mahowald MW. Parasomnias associated with
sleep-disordered breathing and its therapy, including
sexsomnia as a recently recognized parasomnia.
Somnology 2008; 12: 38-49.
Şengül MCB, Hanci E. Uyku sırasında orgazm: Bupropiona
bağlı bir nöbet olgusu. (Orgasm during sleep:
bupropione induced seizure). Pam Med J 2014; 7(2):155-
157. [Turkish]
Silvestri R, Bromfield E. Recurrent nightmares and disorders
of arousal in temporal lobe epilepsy. Brain Res Bull
2004;63(5):369-376.
Sixel-Döring F, Trautmann E, Mollenhauer B, Trenkwalder C.
Associated factors for REM sleep behavior disorder in
Parkinson disease. Neurology 2011;77(11):1048-1054.
Summa KC, Turek FW. The clocks within us. Scientific
American 2015; 312 (2): 51-55.
Trajanovic NN, Mangan M, Shapiro CM. Sexual behaviour in
sleep: an internet survey. Soc Psychiatry Psychiatr
Epidemiol 2007; 42: 1024-1031.
Yılmaz H. Uykuda Seks Hastalığı. Uyku Fizyolojisi ve
Hastalıkları içinde, Kaynak H, Ardış S (editörler). Türk
Uyku Tıbbı Derneği Yayını, 2011:345. [Turkish]
... The most common behaviors included sexual intercourse and fondling. 8 The most common diagnosis for individuals engaged in sexsomnic behaviors was disorder of arousal (86%), and the second most common was obstructive sleep apnea (14.3%). About a quarter of the cases resulted in legal consequences. ...
... 7 Most sexsomnia patients do not have any recall of the sexual episodes; in one study, 96 percent of patients reported complete amnesia for the episode. 8 A minority of patients have reported patchy or full recall of sexsomnia, especially if the partner reciprocated the sleeper's sexual engagement. 13 Patients do not often attempt to conceal their actions and are typically upset when they become aware of them. ...
... In studies of forensic and nonforensic samples, full recall of the alleged sexual activity is uncommon. 8,13 A malingering defendant may openly report recollections of the alleged episode. For defendants reporting no memory of the alleged offense, the use of misleading questions containing false information about the event may elicit a response demonstrating an accurate recollection. ...
Article
Full-text available
Sexsomnia is a non-rapid eye movement parasomnic behavior characterized by sexual activity during sleep. Recognized in the most recent editions of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Sleep Disorders, sexsomnia is likely to arise with increasing frequency in court as a potential explanation for sexual offending. The forensic psychiatrist has a unique role in the evaluation and management of sexsomnia. The psychosexual evaluation may elucidate the presence or absence of paraphilias and paraphilic disorders and identify any overlap between the alleged sexsomnic behavior and paraphilic interest. In addition, forensic psychiatrists may assess for malingered sexsomnia, provide an opinion regarding criminal responsibility, or evaluate the risk for committing future sexual offenses. Forensic psychiatrists should therefore understand basic information regarding the disorder, as well as how to conduct a psychosexual evaluation effectively in cases of alleged sexsomnia. This article describes the various considerations involved in the forensic evaluation of sexsomnia.
... Sexsomnia is a type of non-rapid eye movement (NREM) parasomnia in which sexual behaviors arise during sleep. 1 The behaviors manifesting during a sexsomnia episode vary and include masturbation, sexual vocalizations and talking, sexual fondling, orgasms with or without self-stimulation, and attempted or completed intercourse with the bed partner. [2][3][4] The sexual behaviors observed during sexsomnia tend to last a few minutes and usually involve the immediate bed partner, and the individual is generally amnestic of the event. However, cases of preserved memory of the event have been reported. ...
... However, cases of preserved memory of the event have been reported. 2,5 It is unusual to capture sexsomnia episodes during polysomnography (PSG) studies, but typical PSG findings show arousals with diffuse slowing during N3 sleep. 2 Affected individuals usually have a prior history of other NREM sleep parasomnias (e.g., sleep walking and sleep eating) dating back to childhood. 2,6 Sexsomnia is considered a relatively rare condition, with a review published in 2016 compiling a total of 63 cases reported in the medical literature worldwide. ...
... 2,5 It is unusual to capture sexsomnia episodes during polysomnography (PSG) studies, but typical PSG findings show arousals with diffuse slowing during N3 sleep. 2 Affected individuals usually have a prior history of other NREM sleep parasomnias (e.g., sleep walking and sleep eating) dating back to childhood. 2,6 Sexsomnia is considered a relatively rare condition, with a review published in 2016 compiling a total of 63 cases reported in the medical literature worldwide. ...
Article
Sexsomnia is a type of non-rapid eye movement (NREM) parasomnia in which sexual behaviors arise during sleep; these behaviors are varied and can include masturbation, orgasms with or without self-stimulation, sexual vocalizations and talking, and sexual fondling and/or intercourse with the bed partner. The military creates a challenging environment, with sleep deprivation, shift work, and increased psychosocial stress that may predispose service members to an increased risk for all NREM parasomnias, including sexsomnia. Given that sexsomnia is sometimes invoked in sexual assault military lawsuits, it may behoove the military community to understand how this condition usually manifests so that its medicolegal implications can be addressed more clearly. Here, we present the largest case series of sexsomnia to date in active duty military service members, which adds to the limited literature on such cases in the military and to the broader but still growing literature on this rare disorder. We compare and contrast these cases with the available literature to highlight their similarities and differences in addition to commenting on the relevance of these cases in forensic investigations. As none of these cases were involved in legal issues, they could provide useful information about this rare condition in individuals who are less likely to be affected by the biases that are inherent to litigation.
... 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][3][4][5][6] . ...
... The pharmacological treatment with clonazepam had no effect on the parasomnia complaints. Clonazepam is commonly used as first line pharmacotherapy for sexsomnia 2,4 . Also, in 1996, there was a report on a series of 170 patients with various parasomnias treated with benzodiazepines, primarily clonazepam (n=136), and followed long-term for clinical response, which showed that the vast majority of all patients (86%) reported good control after an average follow up of 3.5 years 18 . ...
Article
Full-text available
We describe a 42-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. We discuss the misinformation and delay of proper diagnosis and treatment that occurs with sexsomnia and emphasize the importance of understanding the broad set of problems and consequences related to sexsomnia, including physical, psychological, marital/relationship and at times legal aspects that affect the lives of sexsomniac patients and their bed partners.
... Unfortunately to date, this consensus has not been created. Schenck in 2015 provided an excellent review of sexsomnia [81]. He noted that they almost always were associated with confusional arousals from deep slow wave sleep. ...
Article
Full-text available
The objective of this article is to provide a comprehensive personal survey of all the major parasomnias with coverage of their clinical presentation, investigation, physiopathogenesis and treatment. These include the four major members of the slow-wave sleep arousal parasomnias which are enuresis nocturna (bedwetting), somnambulism (sleepwalking), sleep terrors (pavor nocturnus in children, incubus attacks in adults) and confusional arousals (sleep drunkenness). Other parasomnias covered are sleep-related aggression, hypnagogic and hypnopompic terrifying hallucinations, REM sleep terrifying dreams, nocturnal anxiety attacks, sleep paralysis, sleep talking (somniloquy), sexsomnia, REM sleep behavior disorder (RBD), nocturnal paroxysmal dystonia, sleep starts (hypnic jerks), jactatio capitis nocturna (head and total body rocking), periodic limb movement disorder (PLMs), hypnagogic foot tremor, restless leg syndrome (Ekbom syndrome), exploding head syndrome, excessive fragmentary myoclonus, nocturnal cramps, and sleep-related epileptic seizures. There is interest in the possibility of relationships between sleep/wake states and creativity.
... Fisher et al. (1983) demonstrated that increases in vaginal blood flow (VBF) were associated with dreams that contained sexual content. Whether the experience of orgasm is preceded or accompanied by sexual dreams has been supported by only a handful of studies, with some respondents associating sexual dreams with their experience of sleep orgasm and others describing non-sexual dreams associated with sleep orgasms (Ellis, 1905;Henton, 1976;Kinsey et al., 1953;Pirzada et al., 2019;Schenck, 2015;Winokur et al., 1959). Ellis (1905) speculated that "involuntary sexual orgasm during sleep" could occur as a consequence of experiencing sexual excitation, but not orgasm, from activities such as using sewing machines (for women) or cycling (for men). ...
Article
Full-text available
Prior research has described women’s experiences with exercise-induced orgasm (EIO). However, little is known about men’s experiences with EIO, the population prevalence of EIO, or the association of EIO with other kinds of orgasm. Using U.S. probability survey data, the objectives of the present research were to: (1) describe the lifetime prevalence of exercise-induced orgasm (EIO) and sleep orgasm; (2) assess respondents’ age at first experience of EIO as well as the type of exercise connected with their first EIO; (3) examine associations between lifetime EIO experience and orgasm at respondents’ most recent partnered sexual event; and (4) examine associations between lifetime EIO experience and sleep orgasms. Data were from the 2014 National Survey of Sexual Health and Behavior (1012 men and 1083 women, ages 14 years and older). About 9% of respondents reported having ever experienced exercise-induced orgasm. More men than women reported having experienced orgasm during sleep at least once in their lifetime (66.3% men, 41.8% women). The mean age for women’s first EIO was significantly older than men (22.8 years women, 16.8 years men). Respondents described a wide range of exercises as associated with their first EIO (i.e., climbing ropes, abdominal exercise, yoga). Lifetime EIO experience was associated with lifetime sleep orgasms but not with event-level orgasm during partnered sex. Implications related to understanding orgasm and recommendations for clinicians and sex educators are discussed.
... Self-injuries, pseudo-suicide and high risk of falling are often portrayed, and injuries (or risk of injuries) to others and even homicide are found in 11 movies. In contrast to documented medical cases [29,30], there is no rape committed by sleepwalkers in movies portraying sexsomnia (although it is implicitly suggested in two movies that the sleepwalking woman has been raped) but some sleepwalkers do enter someone else's bed. ...
Article
Background Long before being described as a disorder, sleepwalking was considered as a mysterious phenomenon inspiring artwork. From the early beginning of cinema, sleepwalkers were shown to populations, playing a crucial role in storytelling and collective knowledge. Objective We characterized how sleepwalking has been portrayed in a large number of movies from the origins of cinema to recent years. Methods Movies containing the words “sleepwalking” or “somnambulism” were searched for in International Movie Databases. Types of movies, sleepwalking characters, postures and behaviors during episodes, triggers, and suggested treatments were collected. Results Production of 87 movies and 22 cartoons portraying sleepwalkers was clustered around two peaks, in the 1910s and 2010s. Comedies predominated before 1960, and thriller/horror movies as a dominant genre after 1960. In contrast with real-life sleepwalking epidemiology, sleepwalkers are more often portrayed as women than men (and often wearing a transparent white nightgown), as adults more than children on-screen, and 23% suffered psychiatric comorbidities. The unrealistic posture of outstretched arms and eyes closed was found in 20% of movies and 79% of cartoons. Night terrors, sexsomnias (kissing, having sex, initiated pregnancy), sleep-related eating and sleep driving were also featured. Homicides and falls while sleepwalking were recurrent fear-inducing topics. The first sleep EEG was featured in a sleepwalking movie in 1985, and a sleep specialist gave his first advice in 1997. Discussion The representation of sleepwalking on the screen seems to have evolved from popular, unrealistic stereotypes of somnambulism towards a medical condition, paralleling the development of sleep medicine.
... Two cases of sexsomnia associated with OSA have been reported in which sustained control of both conditions was achieved with mandibular advancement device (MAD) therapy of the OSA 26,27 . There had been previous reports of CPAP therapy of OSA also controlling the comorbid sexsomnia, as reviewed 28,29 . Therefore, it is the control of the OSA, regardless of the therapy, that is crucial for the control of the secondary sexsomnia resulting from apnea-induced confusional arousals. ...
Article
Disorders of arousal (DOA) is an umbrella term initially covering classical sleepwalking, sleep terrors, and confusional arousals, and now including a wider spectrum of specialised forms of non rapid eye movement (non REM) parasomnias such as sexsomnia, sleep‐related eating disorder, and sleep‐related choking syndrome. Growing evidence has shown that DOA are not restricted to children but are also prevalent in adults (2%–4% of the adult population). While DOA run in family, genetics studies remain scarce and inconclusive. In addition to the risk of injury on themselves and others (including sexual assaults in sexsomnia), adults with DOA frequently suffer from excessive daytime sleepiness, pain, and altered quality of life. The widespread view of DOA as automatic and amnesiac behaviours has now been challenged by subjective (dream reports) and objective (dream‐enacting behaviours documented on video‐polysomnography) observations, suggesting that sleepwalkers are ‘dream walking’ during their episodes. Behavioural, experiential, cognitive, and brain (scalp electroencephalography [EEG], stereo‐EEG, high density‐EEG, functional brain imaging) data converge in showing a dissociated pattern during the episodes. This dissociated pattern resembles the new concept of local arousal with a wake‐like activation in motor and limbic regions and a preserved (or even increased) sleep intensity over a frontoparietal network. EEG and behavioural criteria supporting the DOA diagnosis with high sensitivity and specificity are now available. However, treatment is still based on controlling priming and precipitating factors, as well as on clinicians’ personal experience with sedative drugs. Placebo‐controlled trials are needed to improve patients’ treatment. DOA deserve more attention from sleep researchers and clinicians.
Article
Parasomnias are abnormal behaviors and/or experiences emanating from or associated with sleep typically manifesting as motor movements of varying semiology. We discuss mainly nonrapid eye movement sleep and related parasomnias in this article. Sleepwalking (SW), sleep terrors (ST), confusional arousals, and related disorders result from an incomplete dissociation of wakefulness from nonrapid eye movement (NREM) sleep. Conditions that provoke repeated cortical arousals, and/or promote sleep inertia, lead to NREM parasomnias by impairing normal arousal mechanisms. Changes in the cyclic alternating pattern, a biomarker of arousal instability in NREM sleep, are noted in sleepwalking disorders. Sleep-related eating disorder (SRED) is characterized by a disruption of the nocturnal fast with episodes of feeding after arousal from sleep. SRED is often associated with the use of sedative–hypnotic medications, in particular the widely prescribed benzodiazepine receptor agonists. Compelling evidence suggests that nocturnal eating may in some cases be another nonmotor manifestation of Restless Legs Syndrome (RLS). Initial management should focus upon decreasing the potential for sleep-related injury followed by treating comorbid sleep disorders and eliminating incriminating drugs. Sexsomnia is a subtype of disorders of arousal, where sexual behavior emerges from partial arousal from nonREM sleep. Overlap parasomnia disorders consist of abnormal sleep-related behavior both in nonREM and REM sleep. Status dissociatus is referred to as a breakdown of the sleep architecture where an admixture of various sleep state markers is seen without any specific demarcation. Benzodiazepine therapy can be effective in controlling SW, ST, and sexsomnia, but not SRED. Paroxetine has been reported to provide benefit in some cases of ST. Topiramate, pramipexole, and sertraline can be effective in SRED. Pharmacotherapy for other parasomnias continues to be less certain, necessitating further investigation. NREM parasomnias may resolve spontaneously but require a review of priming and predisposing factors.
Article
Full-text available
The aim of this paper is to elucidate the anatomical and molecular nature of sexual desire. As such we have focused our attention to the telodiencephalic reproductive complex and the functional interactions with the cortico-limbic circuit that regulate sexual and non-sexual motivation. Major focus of our review was on the animal studies that included hormones, peptides, neurotransmitters and the unique study paradigms that were designed to separate sexual motivation from the consumatory behavior. We also have covered limited number of clinical trials but our primary goal was to review the animal study results. We present rapidly evolving animal research data that we hope will contribute toward the development of new drugs that ameliorate the symptoms of hypoactive sexual desire disorders.
Chapter
Sexual behaviors in sleep have gained wide recognition and can take on many expressions. These behaviors have been given many popular terms including “sexsomnia” and “sleep sex” but the most common primary pathway through the platform of sleep is as a disorder of arousal from NREM sleep. The public’s fascination with “sexsomnia” may equate this condition with unrestrained libidinous sexual intercourse between strangers but the most common expression of this condition may be an inappropriate and unwanted emerging intimacy between individuals who by tacit agreement have chosen to sleep in close proximity. Major influences for which there is clinical-based evidence that may promote sleep-related abnormal sexual behaviors include sleep deprivation and obstructive sleep apnea (OSA). Alcohol has long been erroneously cited in the past as a priming influence for disorders of arousal from NREM sleep, including sleep-related abnormal sexual behaviors. The sleep forensics experience in the United States has revealed an alarming increase in the number of cases of sexual assaults purported to be attributed to “sexsomnia”. If such legal cases are indeed a bellwether, a proposal could be made for more rigorous controlled epidemiologic studies into this condition to better define its prevalence and characteristics as part of public policy to ensure personal and public safety—especially in those who cosleep with children. Despite its increasing recognition, there also remains significant skepticism, if not disdain, related to “sexsomnia” as witnessed by published reports served by the National District Attorneys Association’s National Center for Prosecution of Child Abuse. To counteract media driven bias and the general skepticism emanating from an adversarial-driven court system, this chapter presents a progressive medicolegal case-based approach in analyzing potential sleep-related abnormal sexual behaviors to equip the sleep medicine professional with a combination of cognitive neuroscience constructs and salient clinical features to navigate the topology of sexual behavior in sleep in order to provide the most appropriate patient-centered care with the potential to be a resource to the legal community when indicated.
Article
Objective: To describe the clinical phenotype of idiopathic rapid eye movement (REM) sleep behavior disorder (IRBD) at presentation in a sleep center. Methods: Clinical history review of 203 consecutive patients with IRBD identified between 1990 and 2014. IRBD was diagnosed by clinical history plus video-polysomnographic demonstration of REM sleep with increased electromyographic activity linked to abnormal behaviors. Results: Patients were 80% men with median age at IRBD diagnosis of 68 y (range, 50-85 y). In addition to the already known clinical picture of IRBD, other important features were apparent: 44% of the patients were not aware of their dream-enactment behaviors and 70% reported good sleep quality. In most of these cases bed partners were essential to convince patients to seek medical help. In 11% IRBD was elicited only after specific questioning when patients consulted for other reasons. Seven percent did not recall unpleasant dreams. Leaving the bed occurred occasionally in 24% of subjects in whom dementia with Lewy bodies often developed eventually. For the correct diagnosis of IRBD, video-polysomnography had to be repeated in 16% because of insufficient REM sleep or electromyographic artifacts from coexistent apneas. Some subjects with comorbid obstructive sleep apnea reported partial improvement of RBD symptoms following continuous positive airway pressure therapy. Lack of therapy with clonazepam resulted in an increased risk of sleep related injuries. Synucleinopathy was frequently diagnosed, even in patients with mild severity or uncommon IRBD presentations (e.g., patients who reported sleeping well, onset triggered by a life event, nocturnal ambulation) indicating that the development of a neurodegenerative disease is independent of the clinical presentation of IRBD. Conclusions: We report the largest IRBD cohort observed in a single center to date and highlight frequent features that were not reported or not sufficiently emphasized in previous publications. Physicians should be aware of the full clinical expression of IRBD, a sleep disturbance that represents a neurodegenerative disease. Commentary: A commentary on this article appears in this issue on page 7.
Article
N A RECENT publication, Ebrahim and colleagues state in their abstract that they have provided an assessment of “all known scientific studies of the effects of alcohol on the nocturnal sleep of healthy volunteers” (Ebrahim et al., 2013, p. 539). Our review of this article found it to be seriously flawed by research design and statistical problems. Ebrahim and colleagues (2013) selected 20 published articles concerned with the effects of alcohol on sleep in humans. Numerous articles were excluded from consideration. Within these articles are 38 groups of subjects based on other criteria such as sex or dose of alcohol administered. Although all sleep stages were addressed, Ebrahim and colleagues (2013) focus on the effects of alcohol on slow-wave sleep (SWS); variously known as or abbreviated as SWS, deep sleep, Stages 3 + 4. Current nomenclature combines stages 3 and 4 sleep and renames them “N3”(Iber et al., 2007). As noted in their conclusion, One area of debate and sometimes controversy has been the issue of the impact of alcohol on SWS. For the first time, all the available data are presented here and based on the findings from all available studies, and in the majority, alcohol clearly increases SWS in the first part of sleep at all doses, across gender and ages. Data for the impact of alcohol on total night SWS display a dose dependent effect with low doses showing no clear trend, moderate doses show a trend toward an increase in SWS and with high doses there is a significant and clear effect of increasing total SWS. This effect is consistent across gender and age groups. (Ebrahim et al., 2013, pp. 547–548)
Article
"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.
Article
Genes in the liver, pancreas and other tissues (not just the brain) keep the various parts of the body in sync. Timing miscues may lead to diabetes, depression and other illnesses