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| CLINICO-PATHOLOGICAL PEARLS |
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| Year : 2018 | Volume
: 1
| Issue : 2 | Page : 85-88 |
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A snoring man with an abnormal sexual behavior during sleep
Aljohara S Almeneessier1, Ahmed S Bahammam2
1 Department of Family Medicine, College of Medicine, King Saud University; Department of Medicine, The University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Medicine, The University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| Date of Web Publication | 6-Jun-2018 |
Correspondence Address:
Ahmed S Bahammam
Department of Medicine, University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh
Saudi Arabia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JNSM.JNSM_36_18
How to cite this article:
Almeneessier AS, Bahammam AS. A snoring man with an abnormal sexual behavior during sleep. J Nat Sci Med 2018;1:85-8 |
| Case Report | |  |
A 38-year-old male presented with complaints of loud snoring at night for 5 years. His wife noticed that he stops breathing during sleep for a few seconds followed by a big snort. He also complained of choking attacks during sleep, dry mouth, and headache on awakening and unrefreshing sleep. He denied excessive daytime sleepiness but complained of daytime fatigue and decreased concentration.
On further questions, he reluctantly mentioned that he had had sexual relations during sleep with his wife three nights per week for 3 years. On several occasions, these sexual relations take a violent nature usually occurring in the first half of the night. In addition, his wife told him that he used to say sexual terms and phrases during sleep that are not appropriate. He had no recollection of this in the morning. He was surprised when his wife told him about these recurrent actions and started to have feelings of guilt and shame. In addition, the patient mentioned that he started to have marital problems, as his wife thinks that a genie (Jinn) is controlling his body and soul, and became scared to sleep with him in the same bed. The patient has no history of other medical illnesses; however, he admitted to having a history of sleepwalking during childhood and a family history of sleepwalking. There was no history of regular use of medications or alcohol.
Physical examination revealed a body mass index 28.6 kg/m 2, neck girth 16 inches, and a Mallampati class of II designation. The remaining physical examination was normal.
[Figure 1] and [Figure 2] show epochs of the overnight sleep study of the patient. | Figure 1: A zoomed 2-min epoch showing obstructive apneas. Airflow is absent despite persisting respiratory paradoxical effort. The obstructive events are followed by arousal and desaturation and snorting sounds
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 | Figure 2: A 30-s epoch of the sleep study; in the first half, the patient was in stage N3 (slow wave nonrapid eye movement sleep), and in the second half of the epoch, there is an increase in chin and legs electromyographic tone indicating movement
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Overnight polysomnography revealed frequent obstructive respiratory events during sleep [Figure 1] with an apnea–hypopnea index of 37/h. In addition, the patient had multiple similar spells of arousals occurred exclusively from nonrapid eye movement sleep (NREM) sleep (particularly slow wave sleep) that were associated with movements in the bed [Figure 2]. No epileptiform activity was recorded on the limited electroencephalogram recording during these episodes.
The patient was diagnosed to have obstructive sleep apnea (OSA) and was started on continuous positive airway pressure therapy at home during sleep. The patient returned to the clinic for follow-up after 3 weeks and stated that the abnormal sleep behaviors have disappeared.
| What is the Diagnosis? | | |
Discussion
[Figure 1] shows a zoomed 2-min epoch showing obstructive apneas. Airflow is absent despite persisting respiratory paradoxical effort. The obstructive events are followed by arousal and desaturation. The sleep behavior that occurs during sleep in this patient is a type of parasomnia. Parasomnias (“para” means next to, and “somnus” means sleep) comprise a group of the most challenging, fascinating, and unusual behavioral disorders that occur during sleep, which are characterized by sleep-related acute, abnormal behavioral or physiological events. The International Classification of Sleep Disorders, Third Edition (ICSD-3) defines parasomnias as undesirable physical events or experiences that occur during entry into sleep, within sleep, or during arousal from sleep.[1] Human physiological consciousness states consist of wake, NREM sleep, and REM sleep. Parasomnias may occur during NREM, REM, or during transitions to and from sleep.[1] It is thought that parasomnias are associated with central nervous system activation, increases in skeletal muscle activity, and autonomic nervous system changes.[2] Parasomnias may result in sleep disruption and physical harm to affected individuals or the bed partner. NREM parasomnias tend to run in families; it has long been suspected that genetic factors are involved.[2] In general, patients with parasomnias receive wrong diagnoses, and the correct diagnosis is usually delayed.[3]
The ICSD-3 classifies NREM parasomnias into confusional arousal, sleep terror, sleepwalking and sleep-related eating disorder; and REM parasomnias into REM sleep behavior disorder, recurrent isolated sleep paralysis, and nightmare disorder.[1] NREM parasomnias are usually observed early in the sleep period when the slow wave sleep pressure is most pronounced as occurred in the present case.
The discussed patient has a parasomnia called “sexsomnia,” which is considered to be an NREM parasomnia. [Figure 2] shows a 30-s epoch of the sleep study; in the first half of the epoch, the patient was in stage N3 (slow-wave NREM sleep), and in the second half of the epoch, there is an increase in chin and legs electromyographic tone indicating movement.
Sexsomnia was described in 2003, and is considered as a clinical variant of confusional arousal or sleepwalking depending on the observed behavior.[1],[4] So far, approximately, 95 published cases have been described; therefore, clinical descriptions of sexsomnia are based on case reports and small series.[5] Sexsomnia in our patient is triggered by OSA-induced arousals, as different parasomnias have been reported to be triggered by sleep deprivation, alcohol, some medications such as serotonin-reuptake inhibitors (SSRIs), and other sleep disorders such as periodic leg movements or endogenous triggers such as pain or a full bladder.[6] Therefore, a detailed medication history with the bed partner's assistance is essential in the evaluation of a patient with sexsomnia.
The characteristic features of sexsomnia include sexual arousal accompanied by autonomic activation such as nocturnal penile tumescence, vaginal lubrication, nocturnal emission, and dream orgasm.[7] In a series of 49 patients with sexsomnia, males represented 75%, with a mean age of onset of 28 years and mean age at presentation of 35 years.[8] A wide-range of sexual behaviors had been reported including sexual intercourse/attempted intercourse (49%), fondling the bed partner (40%), agitated/assaultive sexual behaviors (37%), masturbation (23%), sexsomnia with minors (20%), sexual vocalizations (19%), and spontaneous sleep orgasm (4%).[8] The abnormal sexual behavior can affect any person co-sleeping with the patient in the same room. Therefore, it is not surprising that sexsomnia may lead to adverse legal consequences.[8],[9]
The exact prevalence of abnormal sexual behavior during sleep is unknown. However, insights into the prevalence of sleep-related abnormal sexual behaviors (suggestive of sexsomnia) have been reported in a retrospective analysis of medical records of sleep medicine patients to be 7.6%.[10] An epidemiologic study from Norway that estimated lifetime and current prevalence of various parasomnias in the general population using a telephone interview revealed that lifetime and current prevalence of sexual acts during sleep were 7.1% and 2.7%, respectively.[11] Nevertheless, the authors stressed that the results need to be interpreted with caution due to methodological shortcomings, such as a low response rate to participate in the telephone interview, and the single questions used in the survey.[11]
In the present case, the patient did not present the abnormal sexual behavior during sleep as the primary complaint. In fact, he volunteered the information after questioning about abnormal sleep behaviors. This probably, reflects the sensitive nature of the complaint and the associated feelings of guilt and shame, which underscore the need to ask patients, and their bed partners, about comorbid parasomnias when evaluating patients with OSA symptoms.
General practitioners, neurologists, and psychiatrists should be aware of sexsomnia presentation and diagnosis as they are often consulted for evaluation of unusual behaviors, including sleep-related abnormal sexual behaviors. However, it is important to realize that sleep-related sexual behaviors may rarely arise from nocturnal seizures, which can often be successfully treated.[12] A striking contrast between ictal sexsomnia episodes and sexsomnia is the fact that following an ictal sexsomnia episode, the patient usually has a high rate of recall for the episode, while there is amnesia after sexsomnia.[8] Nevertheless, differentiating nocturnal seizures from parasomnia can occasionally be difficult on clinical grounds alone; therefore, a multidisciplinary approach is required in some cases.
Current data on the treatment of sexsomnia are limited. The therapeutic approach should include both behavioral and pharmacological treatments. The patient should know that sleep deprivation and exhaustion before sleep may provoke the occurrence of parasomnia, as increased sleep debt results in rebound slow-wave sleep. In addition, avoidance of alcohol and medications that are known to trigger parasomnias is essential. If a comorbid sleep disorder that is known to trigger parasomnias is discovered, it should be treated before initiating pharmacological treatment. Treatment of the comorbid sleep disorder may result in complete disappearance of the parasomnia and alleviate the need for pharmacological treatment as occurred in the present case. In one series, 86% of patients had control of sexsomnia with bedtime clonazepam.[8] Clonazepam at a dose of 0.5–1 mg at night is effective in most cases. Although SSRIs have been shown to provoke sexsomnia in some patients, recently, paroxetine 5–10 mg in the evening have been reported to be effective in some patients.[5]
Final diagnosis
Sexsomnia triggered by OSA with complete elimination of sexsomnia after treating OSA.
| Clinicopathological Pearls | | |
- Sexsomnia is classified as a subtype of NREM parasomnia disorders of arousal in the ICSD-3
- Amnesia of the episode is an important feature of all NREM parasomnias, including sexsomnia
- here is no evidence that sexsomnia is secondary to psychiatric conditions, or is the result of sexual frustration/repression
- Treatment of comorbid sleep disorders such as OSA may result in a complete cure of the parasomnia.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This work was supported by the Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of Saudi Arabia (MED511-02-08). The study sponsors played no role in the study design, the collection, analysis or interpretation of data, writing the manuscript, or the decision to submit the manuscript.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
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