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Brás J, Schenck CH, Andrade R, Costa AP, Teixeira C, Meira e Cruz M. A challenging case of sexsomnia in an adolescent female presenting with depressive-like symptoms. J Clin Sleep Med 2023; 19:1845-1847. [PMID: 37421331 PMCID: PMC10546004 DOI: 10.5664/jcsm.10714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/28/2023] [Accepted: 06/28/2023] [Indexed: 07/10/2023]
Abstract
Sleep-related sexualized behaviors occur in the parasomnia known as sexsomnia, recognized as a variant of confusional arousals in the International Classification of Sleep Disorders, third edition. These instinctive behaviors of a sexual nature emerge from deep non-rapid eye movement sleep, and patients often present with distinguishing features within this sleep disorder category. There are often adverse psychosocial consequences and not uncommonly medicolegal implications. While associations to psychiatric consequences from the sexsomnia have been demonstrated and efforts to further typify this condition have been made, sexsomnia remains incompletely characterized in the more than 200 published cases to date, with male predominance. We now present the first reported case of an adolescent female with sexsomnia that was triggered by the onset of Crohn's disease and its treatment with azathioprine and with interpersonal consequences leading to an initial psychiatric consultation on account of depressive symptoms. These symptoms were deemed to be secondary to the sexsomnia. In addition to describing unusual and clinically relevant features in this case of sexsomnia, this original case provides insights into triggers, predisposing factors, perpetuating factors, and therapeutic considerations that are important for raising awareness in sleep clinicians, primary care providers, and mental health professionals. CITATION Brás J, Schenck CH, Andrade R, et al. A challenging case of sexsomnia in an adolescent female presenting with depressive-like symptoms. J Clin Sleep Med. 2023;19(10):1845-1847.
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Affiliation(s)
- João Brás
- Department of Psychiatry and Mental Health, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Carlos H. Schenck
- Minnesota Regional Sleep Disorders Center and Departments of Psychiatry, Hennepin County Medical Center and University of Minnesota Medical School, Minnesota, Minneapolis
| | - Rui Andrade
- Department of Psychiatry and Mental Health, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Ana Pinto Costa
- Department of Psychiatry and Mental Health, Centro Hospitalar Tondela-Viseu, Viseu, Portugal
| | - Carlos Teixeira
- Instituto Politécnico de Saúde do Norte–CESPU, Famalicão, Portugal
| | - Miguel Meira e Cruz
- Instituto Politécnico de Saúde do Norte–CESPU, Famalicão, Portugal
- Sleep Unit, Centro Cardiovascular da Universidade de Lisboa, Lisbon School of Medicine, Lisbon, Portugal
- European Sleep Center, Lisbon, Portugal
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2
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Rossi J, Gales A, Attali V, Leu-Smenescu S, Dodet P, Groos E, Arnulf I. Do the EEG and behavioral criteria of NREM arousal disorders apply to sexsomnia? Sleep 2023:7068072. [PMID: 36866491 DOI: 10.1093/sleep/zsad056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Indexed: 03/04/2023] Open
Abstract
STUDY OBJECTIVES To establish whether the recent EEG and behavioral criteria of arousal disorders apply to sexsomnia. METHODS EEG and behavioral markers upon N3 sleep interruptions in videopolysomnography were retrospectively compared in 24 participants with sexsomnia, 41 participants with arousals disorders, and 40 healthy controls. The specificity and sensitivity of previously suggested EEG and behavioral cutoffs for supporting arousal disorders diagnosis were measured in the sexsomnia vs. control groups. RESULTS Participants with sexsomnia and arousals disorders showed a higher N3 fragmentation index, slow/mixed N3 arousal index, and number of eye openings during N3 interruptions than healthy controls. Ten (41.7%) participants with sexsomnia (vs. one sleepwalker and no control) displayed an apparently sexual behavior (masturbation, sexual vocalization, pelvic thrusting, and hand within the pajama) during N3 arousal. An N3 sleep fragmentation index ≥ 6.8/h of N3 sleep and two or more N3 arousals associated with eye opening was 95% specific but poorly (46% and 42%) sensitive for diagnosing sexsomnia. An index of slow/mixed N3 arousals ≥ 2.5/h of N3 sleep was 73% specific and 67% sensitive. An N3 arousal with trunk raising, sitting, speaking, showing an expression of fear/surprise, shouting, or exhibiting sexual behavior was 100% specific for a diagnosis of sexsomnia. CONCLUSION In patients with sexsomnia, videopolysomnography based markers of arousal disorders are intermediate between healthy individuals and patients with other arousal disorders, supporting the concept of sexsomnia as a specialized, but less neurophysiologically severe, NREM parasomnia. Previously validated criteria for arousal disorders partially fit in patients with sexsomnia.
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Affiliation(s)
- Jessica Rossi
- Sleep Clinic, Pitie-Salpetriere Hospital, APHP-Sorbonne, Paris, France.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Ana Gales
- Sleep Clinic, Pitie-Salpetriere Hospital, APHP-Sorbonne, Paris, France
| | - Valérie Attali
- Sleep Clinic, Pitie-Salpetriere Hospital, APHP-Sorbonne, Paris, France.,INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Smaranda Leu-Smenescu
- Sleep Clinic, Pitie-Salpetriere Hospital, APHP-Sorbonne, Paris, France.,Paris Brain Institute (ICM), INSERM, CNRS, Paris, France
| | - Pauline Dodet
- Sleep Clinic, Pitie-Salpetriere Hospital, APHP-Sorbonne, Paris, France.,Sorbonne University, Paris, France
| | - Elisabeth Groos
- Sleep Clinic, Pitie-Salpetriere Hospital, APHP-Sorbonne, Paris, France
| | - Isabelle Arnulf
- Sleep Clinic, Pitie-Salpetriere Hospital, APHP-Sorbonne, Paris, France.,Paris Brain Institute (ICM), INSERM, CNRS, Paris, France.,Sorbonne University, Paris, France
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3
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Idir Y, Oudiette D, Arnulf I. Sleepwalking, sleep terrors, sexsomnia and other disorders of arousal: the old and the new. J Sleep Res 2022; 31:e13596. [PMID: 35388549 DOI: 10.1111/jsr.13596] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 03/17/2022] [Accepted: 03/17/2022] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Yannis Idir
- Sorbonne University, Paris, France.,Institut du Cerveau - Paris Brain Institute - ICM, INSERM, CNRS, Paris, France.,APHP-Sorbonne, Pitie-Salpetriere University Hospital Sleep Disorders Unit, Paris, France
| | - Delphine Oudiette
- Sorbonne University, Paris, France.,Institut du Cerveau - Paris Brain Institute - ICM, INSERM, CNRS, Paris, France.,APHP-Sorbonne, Pitie-Salpetriere University Hospital Sleep Disorders Unit, Paris, France
| | - Isabelle Arnulf
- Sorbonne University, Paris, France.,Institut du Cerveau - Paris Brain Institute - ICM, INSERM, CNRS, Paris, France.,APHP-Sorbonne, Pitie-Salpetriere University Hospital Sleep Disorders Unit, Paris, France
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4
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Abstract
None Sexsomnia is a parasomnia consisting of sexual behavior during non-rapid eye movement sleep. To date, there have been 116 clinical cases of sexsomnia reported and most were treated with clonazepam. We present a case of an adult male with sexsomnia that started during his college days. He presented to us because of problems in his current marriage arising from sexual behavior during sleep. Polysomnography revealed no significant sleep-disordered breathing, electroencephalography abnormality, or abnormal movement during non-rapid eye movement and rapid eye movement (REM) sleep. Alcohol consumption was reported to worsen his sexsomnia. To avoid the neuro-depressant effects of benzodiazepines, paroxetine was administered and resulted in complete resolution of sexsomnia.
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Affiliation(s)
- Vineeth Kumar
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Vincent X Grbach
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Richard J Castriotta
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Southern California Keck School of Medicine, Los Angeles, California
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Abstract
NONE Sexsomnias are unconscious sexual behaviors during sleep (parasomnias) that are garnering more attention as they become increasingly evident in forensic cases. Presentations of sexsomnia in active duty service members are seldom described, and often evaluation is clouded by intoxication with substances such as alcohol, sleep deprivation, untreated sleep disturbances, or criminal behavior masquerading as a medical disorder. We present a case of a 40-year-old male soldier evaluated in our sleep clinic for multiple episodes of sleep masturbation occurring over a period of 2 years. The patient was concerned about his suitability for deployment to a combat zone and participation in field training exercises (both require sleeping in groups in an open environment). Video polysomnography confirmed moderate obstructive sleep apnea, and the patient showed improvement with continuous positive airway pressure therapy. The authors also discuss the relevance of this case compared with previously reported sexsomnia cases and expand on parasomnia topics that are more common in military populations.
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Affiliation(s)
- David S Kim
- Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Brian E Foster
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Internal Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jasmine A Scott
- F. Edward Herbert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Meagan M Rizzo
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Internal Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jacob F Collen
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Internal Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Rodolfo Soca
- Sleep Disorders Center, Walter Reed National Military Medical Center, Bethesda, Maryland.,Department of Internal Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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6
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Holoyda BJ, Sorrentino RM, Mohebbi A, Fernando AT, Friedman SH. Forensic Evaluation of Sexsomnia. J Am Acad Psychiatry Law 2021; 49:202-210. [PMID: 33579735 DOI: 10.29158/jaapl.200077-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
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.
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Affiliation(s)
- Brian J Holoyda
- Dr. Holoyda is Forensic Psychiatrist, Martinez Detention Facility, Martinez, CA, and Psychiatrist, Full Spectrum Health Services, Las Vegas, NV. Dr. Sorrentino is Director, Institute of Sexual Wellness, Weymouth, MA, and Assistant Professor, Harvard School of Medicine, Boston, MA. Dr. Mohebbi is Psychiatrist, Mission Viejo, CA. Dr. Fernando is Senior Lecturer, Department of Psychological Medicine, University of Auckland, Auckland, New Zealand. Dr. Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry, Case Western Reserve University, Department of Psychiatry, Cleveland, OH.
| | - Renée M Sorrentino
- Dr. Holoyda is Forensic Psychiatrist, Martinez Detention Facility, Martinez, CA, and Psychiatrist, Full Spectrum Health Services, Las Vegas, NV. Dr. Sorrentino is Director, Institute of Sexual Wellness, Weymouth, MA, and Assistant Professor, Harvard School of Medicine, Boston, MA. Dr. Mohebbi is Psychiatrist, Mission Viejo, CA. Dr. Fernando is Senior Lecturer, Department of Psychological Medicine, University of Auckland, Auckland, New Zealand. Dr. Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry, Case Western Reserve University, Department of Psychiatry, Cleveland, OH
| | - Amir Mohebbi
- Dr. Holoyda is Forensic Psychiatrist, Martinez Detention Facility, Martinez, CA, and Psychiatrist, Full Spectrum Health Services, Las Vegas, NV. Dr. Sorrentino is Director, Institute of Sexual Wellness, Weymouth, MA, and Assistant Professor, Harvard School of Medicine, Boston, MA. Dr. Mohebbi is Psychiatrist, Mission Viejo, CA. Dr. Fernando is Senior Lecturer, Department of Psychological Medicine, University of Auckland, Auckland, New Zealand. Dr. Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry, Case Western Reserve University, Department of Psychiatry, Cleveland, OH
| | - Antonio T Fernando
- Dr. Holoyda is Forensic Psychiatrist, Martinez Detention Facility, Martinez, CA, and Psychiatrist, Full Spectrum Health Services, Las Vegas, NV. Dr. Sorrentino is Director, Institute of Sexual Wellness, Weymouth, MA, and Assistant Professor, Harvard School of Medicine, Boston, MA. Dr. Mohebbi is Psychiatrist, Mission Viejo, CA. Dr. Fernando is Senior Lecturer, Department of Psychological Medicine, University of Auckland, Auckland, New Zealand. Dr. Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry, Case Western Reserve University, Department of Psychiatry, Cleveland, OH
| | - Susan Hatters Friedman
- Dr. Holoyda is Forensic Psychiatrist, Martinez Detention Facility, Martinez, CA, and Psychiatrist, Full Spectrum Health Services, Las Vegas, NV. Dr. Sorrentino is Director, Institute of Sexual Wellness, Weymouth, MA, and Assistant Professor, Harvard School of Medicine, Boston, MA. Dr. Mohebbi is Psychiatrist, Mission Viejo, CA. Dr. Fernando is Senior Lecturer, Department of Psychological Medicine, University of Auckland, Auckland, New Zealand. Dr. Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry, Case Western Reserve University, Department of Psychiatry, Cleveland, OH
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7
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Abstract
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.
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Affiliation(s)
- Muna Irfan
- Department of Neurology, Minneapolis Veterans Affairs Medical Center/ Pulmonary allergy, Critical Care and Sleep, University of Minnesota, Minneapolis, MN USA
| | - Carlos H. Schenck
- Department of Psychiatry, Hennepin Health Care, University of Minnesota, Minneapolis, MN USA
| | - Michael J Howell
- Department of Neurology, Sleep Disorders Center, University of Minnesota Medical Center, Minneapolis, MN USA
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8
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Munro NA. Alcohol and Parasomnias: The Statistical Evaluation of the Parasomnia Defense in Sexual Assault, Where Alcohol is Involved. J Forensic Sci 2020; 65:1235-1241. [PMID: 32259289 DOI: 10.1111/1556-4029.14322] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/18/2020] [Accepted: 03/03/2020] [Indexed: 12/28/2022]
Abstract
Sleep sex may be a defense for alleged sexual assault. The International Classification of Sleep Disorders (ICSD3) states: "Disorders of arousal should not be diagnosed in the presence of alcohol intoxication… The former [alcohol blackouts] are exponentially more prevalent." A panel member of ICSD3, quoting ICSD3 asserts: "alcohol intoxication should rule out a sleep-walking defense". This implies extremely strong support for a prosecution hypothesis (Hp ) over a defense hypothesis (Hd ). I use Bayesian methodology to evaluate the evidential probity of alcohol intoxication. The likelihood ratio, LR, measures the amplification of prior odds of guilt, LR = Posterior odds of guilt after considering alcohol intoxication /Prior odds of guilt before considering alcohol intoxication . By Bayes' theorem, LR = p ( alcohol intoxication, given H p ) / p ( alcohol intoxication, given H d ) . I use data from cross-sectional studies of sexual assault and prevalence of alcohol use, in college students, with data from longitudinal studies, and data from the epidemiology of parasomnias to evaluate LR (alcohol). LR ~1.5 or 5, depending whether alcohol does, or does not, increase the risk of parasomnias. The proposition of extremely strong support for Hp implies a LR ~1,000,000, so the proposition in ICSD3 is not supported by formal analysis. The statistical reasoning in ICSD3 is unclear. There appears to be inversion of the Bayesian conditional (confusing intoxication given assault, and assault given intoxication) and failure to evaluate alcohol intoxication in Hd . Similar statistical errors in R. v Sally Clark are discussed. The American Academy of Sleep Medicine should review the statistical methodology in ICSD3.
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Affiliation(s)
- Neil A Munro
- East Grinstead Sleep Centre, Queen Victoria Hospital NHS Foundation Trust, Holtye Rd, East Grinstead, RH19 3DZ, U.K.,Neurology Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, U.K.,East Kent University NHS Foundation Trust, Ethelbert Road, Canterbury, Kent, CT1 3NG, U.K
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9
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Abstract
ABSTRACT Sexsomnia has been reported and is well described in 115 prior cases in the literature. There have been associations with other sleep disorders serving as triggers for confusional arousals, thereby worsening sexsomnia episodes. We present a case of an adolescent boy with a history of resected and treated pineoblastoma who later developed sexsomnia marked by multiple episodes of masturbatory events per night. He had additional suspicions of obstructive sleep apnea. Polysomnography confirmed severe obstructive sleep apnea and captured multiple episodes of sexsomnia from both REM and NREM sleep. The patient also had daytime symptoms of severe anxiety and hypersomnia that required pharmacological intervention, cognitive behavioral techniques, and hypnosis. The patient showed improvement with hypnosis along with a multimodal approach to the treatment of sexsomnia.
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Affiliation(s)
| | - Jarrett Richardson
- Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota.,Department of Psychiatry, Mayo Clinic, Rochester, Minnesota
| | - Suresh Kotagal
- Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota.,Department of Neurology, Mayo Clinic, Rochester, Minnesota
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10
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Martynowicz H, Smardz J, Wieczorek T, Mazur G, Poreba R, Skomro R, Zietek M, Wojakowska A, Michalek M, Wieckiewicz M. The Co-Occurrence of Sexsomnia, Sleep Bruxism and Other Sleep Disorders. J Clin Med 2018; 7:jcm7090233. [PMID: 30142877 PMCID: PMC6162860 DOI: 10.3390/jcm7090233] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 08/19/2018] [Accepted: 08/19/2018] [Indexed: 11/16/2022] Open
Abstract
Background: Sleep sex also known as sexsomnia or somnambulistic sexual behavior is proposed to be classified as NREM (non-rapid eye movement) parasomnia (as a clinical subtype of disorders of arousal from NREM sleep—primarily confusional arousals or less commonly sleepwalking), but it has also been described in relation to REM (rapid eye movement) parasomnias. Methods: The authors searched the PubMed database to identify relevant publications and present the co-occurrence of sexsomnia and other sleep disorders as a non-systematic review with case series. Results: In the available literature the comorbidity of sexsomnia and other sleep disorders were reported mainly in case reports and less in case series. Sexsomnia was reported both with one and with multiple sleep-related disorders, with NREM parasomnias and obstructive sleep apnea (OSA) being the most commonly reported. Furthermore, the authors enrich the article with new findings concerning two novel cases of sleep bruxism triggering recurrent sexsomnia episodes. Conclusions: Sexsomnia has still not been reported in the literature as often as other parasomnias. The coexistence of sexsomnia and other sleep-related disorders should be more thoroughly examined. This could help both in sexsomnia as well as other sleep-related disorders management.
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Affiliation(s)
- Helena Martynowicz
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, 50-367 Wroclaw, Poland.
| | - Joanna Smardz
- Department of Experimental Dentistry, Wroclaw Medical University, 50-367 Wroclaw, Poland.
| | - Tomasz Wieczorek
- Department and Clinic of Psychiatry, Wroclaw Medical University, 50-367 Wroclaw, Poland.
| | - Grzegorz Mazur
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, 50-367 Wroclaw, Poland.
| | - Rafal Poreba
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, 50-367 Wroclaw, Poland.
| | - Robert Skomro
- Division of Respiratory Critical Care and Sleep Medicine, Department of Medicine, University of Saskatchewan, Saskatoon, SK S7N 5A2, Canada.
| | - Marek Zietek
- Department of Periodontology, Wroclaw Medical University, 50-367 Wroclaw, Poland.
| | - Anna Wojakowska
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, 50-367 Wroclaw, Poland.
| | - Monika Michalek
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, 50-367 Wroclaw, Poland.
| | - Mieszko Wieckiewicz
- Department of Experimental Dentistry, Wroclaw Medical University, 50-367 Wroclaw, Poland.
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11
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Lundetræ RS, Saxvig IW, Pallesen S, Aurlien H, Lehmann S, Bjorvatn B. Prevalence of Parasomnias in Patients With Obstructive Sleep Apnea. A Registry-Based Cross-Sectional Study. Front Psychol 2018; 9:1140. [PMID: 30026716 PMCID: PMC6042013 DOI: 10.3389/fpsyg.2018.01140] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 06/14/2018] [Indexed: 12/05/2022] Open
Abstract
Objective: To assess the prevalence of parasomnias in relation to presence and severity of obstructive sleep apnea (OSA). We hypothesized higher parasomnia prevalence with higher OSA severity. Methods: The sample comprised 4,372 patients referred to a Norwegian university hospital with suspicion of OSA (mean age 49.1 years, 69.8% males). OSA was diagnosed and categorized by standard respiratory polygraphy (type 3 portable monitor). The patients completed a comprehensive questionnaire prior to the sleep study, including questions about different parasomnias during the last 3 months. Pearson chi-square tests explored differences according to the presence and severity of OSA. Furthermore, logistic regression analyses with the parasomnias as dependent variables and OSA severity as predictor were conducted (adjusted for sex, age, marital status, smoking, and alcohol consumption). Results: In all, 34.7% had apnea-hypopnea index (AHI) <5 (no OSA), 32.5% had AHI 5-14.9 (mild OSA), 17.4% had AHI 15-29.9 (moderate OSA), and 15.3% had AHI ≥30 (severe OSA). The overall prevalence of parasomnias was 3.3% (sleepwalking), 2.5% (sleep-related violence), 3.1% (sexual acts during sleep), 1.7% (sleep-related eating), and 43.8% (nightmares). The overall parasomnia prevalence was highest in the no OSA group. In the chi-square analyses, including all OSA groups, the prevalence of sleep-related violence and nightmares were inversely associated with OSA severity, whereas none of the other parasomnias were significantly associated with OSA severity. In adjusted logistic regression analyses the odds of sleepwalking was significantly higher in severe compared to mild OSA (OR = 2.0, 95% CI = 1.12–3.55). The other parasomnias, including sleep-related violence and nightmares, were not associated with OSA presence or severity when adjusting for sex and age. Conclusions: We found no increase in parasomnias in patients with OSA compared to those not having OSA. With the exception of sleepwalking, the parasomnias were not associated with OSA severity.
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Affiliation(s)
- Ragnhild S Lundetræ
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Ingvild W Saxvig
- Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
| | - Ståle Pallesen
- Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway.,Department of Psychosocial Science, University of Bergen, Bergen, Norway
| | - Harald Aurlien
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Sverre Lehmann
- Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Bjørn Bjorvatn
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Norwegian Competence Center for Sleep Disorders, Haukeland University Hospital, Bergen, Norway
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12
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Abstract
ABSTRACT We report a case of problematic spontaneous orgasms during sleep in a 57-year-old woman who also complained of hypnic jerks and symptoms of exploding head syndrome. To our knowledge, this is the first case report in the English language literature of problematic spontaneous orgasms during sleep. She had a complex medical and psychiatric history, and was taking oxycontin, venlafaxine, amitriptyline, and lurasidone. Prolonged video electroencephalogram monitoring did not record any ictal or interictal electroencephalogram discharges, and nocturnal video polysomnography monitoring did not record any behavioral or orgasmic event. Periodic limb movement index was zero events/h. Severe central sleep apnea was detected with apnea-hypopnea index = 130 events/h, but she could not tolerate positive airway pressure titration. Sleep architecture was disturbed, with 96.4% of sleep spent in stage N2 sleep. Bedtime clonazepam therapy (1.5 mg) was effective in suppressing the sleep-related orgasms and hypnic jerks.
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Affiliation(s)
- Muna Irfan
- Minnesota Regional Sleep Disorders Center, Department of Neurology, Hennepin County Medical Center, Minneapolis, Minnesota.,University of Minnesota, Minneapolis, Minnesota
| | - Carlos H Schenck
- Minnesota Regional Sleep Disorders Center, Department of Psychiatry, Hennepin County Medical Center, Minneapolis, Minnesota.,University of Minnesota Medical School, Minneapolis, Minnesota
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Khawaja IS, Hurwitz TD, Schenck CH. Sleep-Related Abnormal Sexual Behaviors ( Sexsomnia) Successfully Treated With a Mandibular Advancement Device: A Case Report. J Clin Sleep Med 2017; 13:627-628. [PMID: 28095975 DOI: 10.5664/jcsm.6560] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 12/22/2016] [Indexed: 11/13/2022]
Abstract
ABSTRACT Sleep-related abnormal sexual behaviors (sexsomnia) are classified as a subtype of non-rapid eye movement sleep parasomnias. There are reported cases of control of sexsomnia with treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure. We present a case of sexsomnia controlled with the treatment of OSA with a mandibular advancement device.
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Affiliation(s)
- Imran S Khawaja
- Department of Neurology, VA Medical Center, Dallas, Texas.,Department of Psychiatry and Neurology, UT Southwestern Medical Center, Dallas, Texas
| | - Thomas D Hurwitz
- Department of Psychiatry, VA Medical Center, Minneapolis, Minnesota.,Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | - Carlos H Schenck
- Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, Minnesota.,Minnesota Regional Sleep Disorders Center, Hennepin County Medical Center, Minneapolis, Minnesota
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14
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Soca R, Keenan JC, Schenck CH. Parasomnia Overlap Disorder with Sexual Behaviors during Sleep in a Patient with Obstructive Sleep Apnea. J Clin Sleep Med 2016; 12:1189-91. [PMID: 27166304 DOI: 10.5664/jcsm.6066] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 04/07/2016] [Indexed: 11/13/2022]
Abstract
ABSTRACT Sleep-related abnormal sexual behaviors (sexsomnia) are classified as a subtype of NREM sleep parasomnias. Sexsomnia has been reported as part of parasomnia overlap disorder (POD) in two other patients. We present the case of a 42-year-old male patient with video-polysomnography (vPSG) documented POD. The patient had sleepwalking, sleep-related eating, confusional arousals, sexsomnia, sleeptalking, and REM sleep behavior disorder (RBD). Confusional arousals and RBD were documented during the vPSG. This case had the added complexity of obstructive sleep apnea (OSA) playing a role in sleepwalking and sleep related eating, with good response to nasal continuous positive airway pressure (nCPAP). The sexsomnia did not respond to nCPAP but responded substantially to bedtime clonazepam therapy.
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Affiliation(s)
- Rodolfo Soca
- Sleep Care Center, HealthEast Care System, St. Paul, MN
| | - Joseph C Keenan
- Pulmonary and Intensive Care Center, HealthEast Care System, St. Paul, MN
| | - Carlos H Schenck
- Minnesota Regional Sleep Disorders Center, Departments of Psychiatry, Hennepin County Medical Center and University of Minnesota Medical School, Minneapolis, MN
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15
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Yeh SB, Schenck CH. Sexsomnia: A case of sleep masturbation documented by video-polysomnography in a young adult male with sleepwalking. ACTA ACUST UNITED AC 2016; 9:65-8. [PMID: 27656267 PMCID: PMC5022330 DOI: 10.1016/j.slsci.2016.05.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 05/25/2016] [Accepted: 05/30/2016] [Indexed: 11/24/2022]
Abstract
The first case of video-polysomnography (vPSG) documented sleep masturbation in a male is reported, and the second reported case of shift work induced sexsomnia. A 20 y.o. soldier with childhood sleepwalking (SW) developed sleep masturbation and SW triggered by military shift work. vPSG documented two episodes of sleep masturbation from N2 sleep in the fourth sleep cycle and from N3 sleep during the fifth sleep cycle. There was no sleep-disordered breathing nor periodic limb movements. vPSG thus confirmed confusional arousals from NREM sleep as the cause of the masturbation. Bedtime clonazepam therapy controlled the SW but not the masturbation.
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Affiliation(s)
- Shih-Bin Yeh
- Department of Neurology (and Sleep Center), Changhua Christian Hospital Yun Lin Branch, Chiayi City, Taiwan, ROC; Department of Neurology (and Sleep Center), St Martin de Porres Hospital, Chiayi City, Taiwan, ROC
| | - Carlos H Schenck
- Minnesota Regional Sleep Disorders Center and Department of Psychiatry, Hennepin County Medical Center, 701 Park Ave. South, Minneapolis, MN 55415, USA; Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, USA
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Idzikowski C, Rumbold J. Sleep in a legal context: The role of the expert witness. Med Sci Law 2015; 55:176-182. [PMID: 26378109 DOI: 10.1177/0025802415579373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Sleep experts are called to assist the jury in deciding the mental state of the accused at the time of their alleged criminal behaviour. This task is difficult as the literature on many sleep disorders, particularly sleepwalking and other parasomnias, is still largely a matter of case reports and case series. The probative value of much of the evidence given is not known. Sleep behaviour in the courts present a number of difficulties which illustrate the dilemmas that face an expert witness faced with ambiguous data and uncertain principles with which to interpret them. Additionally there are substantial policy issues involved which are not always adequately addressed in expert evidence. We outline the role of expert witnesses in such cases.
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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; 10:927-35. [PMID: 25126042 DOI: 10.5664/jcsm.3976] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To review systematically medical-legal cases of sleep-related violence (SRV) and sexual behavior in sleep (SBS). SEARCH METHODS We searched Pubmed and PsychINFO (from 1980 to 2012) with pre-specified terms. We also searched reference lists of relevant articles. SELECTION CRITERIA Case reports in which a sleep disorder was purported as the defense during a criminal trial and in which information about the forensic evaluation of the defendant was provided. DATA EXTRACTION AND ANALYSIS Information about legal issues, defendant and victim characteristics, circumstantial factors, and forensic evaluation was extracted from each case. A qualitative-comparative assessment of cases was performed. RESULTS Eighteen cases (9 SRV and 9 SBS) were included. The charge was murder or attempted murder in all SRV cases, while in SBS cases the charge ranged from sexual touching to rape. The defense was based on sleepwalking in 11 of 18 cases. The trial outcome was in favor of the defendant in 14 of 18 cases. Defendants were relatively young males in all cases. Victims were usually adult relatives of the defendants in SRV cases and unrelated young girls or adolescents in SBS cases. In most cases the criminal events occurred 1-2 hours after the defendant's sleep onset, and both proximity and other potential triggering factors were reported. The forensic evaluations widely differed from case to case. CONCLUSION SRV and SBS medical-legal cases did not show apparent differences, except for the severity of the charges and the victim characteristics. An international multidisciplinary consensus for the forensic evaluation of SRV and SBS should be developed as an urgent priority.
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Affiliation(s)
- Francesca Ingravallo
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesca Poli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Emma V Gilmore
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; ; IRRCS Institute of Neurological Sciences, Bologna, Italy
| | | | - Carlos H Schenck
- University of Minnesota, Minnesota Regional Sleep Disorders Centre, Minneapolis, MN
| | - Giuseppe Plazzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; ; IRRCS Institute of Neurological Sciences, Bologna, Italy
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Arnulf I, Zhang B, Uguccioni G, Flamand M, Noël de Fontréaux A, Leu-Semenescu S, Brion A. A scale for assessing the severity of arousal disorders. Sleep 2014; 37:127-36. [PMID: 24470702 DOI: 10.5665/sleep.3322] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Arousal disorders may have serious health consequences. OBJECTIVE To develop a scale assessing the severity of arousal disorders (Paris Arousal Disorders Severity Scale, PADSS). SETTING University hospital. DESIGN Controlled study. PARTICIPANTS Consecutive patients (older than 15 y), with sleepwalking (SW) and/or sleep terrors (ST), subjects with previous SW/ST, normal controls and patients with rapid eye movement sleep behavior disorder. INTERVENTION The self-rated scale listed 17 parasomniac behaviors (PADSS-A), assessed their frequency from never to twice or more per night (PADSS-B) and evaluated the consequences (PADSS-C: disturbed sleep, injuries, fatigue, and psychological consequences). The clinimetric properties and face validity of the scale were tested. RESULTS Half of the 73 patients with SW/ST (more men than women) had injured themselves or others, whereas 15% had concomitant sexsomnia and 23% had amnestic eating behaviors. The total PADSS score (range: 0-50) was 19.4 ± 6.3 (range: 8-36) in this group, 11.7 ± 5.9 in 26 subjects with previous SW/ST, 8.8 ± 3.2 in 26 patients with RBD, and 2.0 ± 3.5 in 53 normal controls (P < 0.05). The PADSS demonstrated high sensitivity (83.6%), specificity (87.8%), internal consistency, and test-retest reliability (0.79). The best cutoff for the total score was at 13/14. Exploratory factor analysis revealed two components: wandering and violence/handling. The complexity of behaviors emerging from N3 sleep (scored on videopolysomnography) positively correlated with scores for the PADSS-total, PADSS-A, PADSS-C, and the "violence/handling" factor. CONCLUSION This scale had reasonable psychometric properties and could be used for screening and stratifying patients and for evaluating the effects of treatments.
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Affiliation(s)
- Isabelle Arnulf
- Sleep Disorder Unit, Pitié-Salpêtrière Hospital, Centre de Recherche de l'Institut du Cerveau et de la Moëlle épinière - Pierre and Marie Curie University; Inserm UMR_S 975; CNRS UMR 7225, Paris, France
| | - Bin Zhang
- Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangdong Mental Health Centre, Guangzhou 510120, China
| | - Ginevra Uguccioni
- Sleep Disorder Unit, Pitié-Salpêtrière Hospital, Centre de Recherche de l'Institut du Cerveau et de la Moëlle épinière - Pierre and Marie Curie University; Inserm UMR_S 975; CNRS UMR 7225, Paris, France
| | - Mathilde Flamand
- Sleep Disorder Unit, Pitié-Salpêtrière Hospital, Centre de Recherche de l'Institut du Cerveau et de la Moëlle épinière - Pierre and Marie Curie University; Inserm UMR_S 975; CNRS UMR 7225, Paris, France
| | - Alix Noël de Fontréaux
- Sleep Disorder Unit, Pitié-Salpêtrière Hospital, Centre de Recherche de l'Institut du Cerveau et de la Moëlle épinière - Pierre and Marie Curie University; Inserm UMR_S 975; CNRS UMR 7225, Paris, France
| | - Smaranda Leu-Semenescu
- Sleep Disorder Unit, Pitié-Salpêtrière Hospital, Centre de Recherche de l'Institut du Cerveau et de la Moëlle épinière - Pierre and Marie Curie University; Inserm UMR_S 975; CNRS UMR 7225, Paris, France
| | - Agnès Brion
- Sleep Disorder Unit, Pitié-Salpêtrière Hospital, Centre de Recherche de l'Institut du Cerveau et de la Moëlle épinière - Pierre and Marie Curie University; Inserm UMR_S 975; CNRS UMR 7225, Paris, France
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Pelin Z, Yazla E. Abnormal sexual behavior during sleep in temporal lobe epilepsy: a case report. Balkan Med J 2012; 29:211-3. [PMID: 25206999 DOI: 10.5152/balkanmedj.2011.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 09/17/2011] [Indexed: 11/22/2022] Open
Abstract
Herein, we describe a case who presented with abnormal sexual behaviour during sleep. Video-electroencephalography monitoring during sleep revealed an abnormality suggesting an epileptic basis. The patient was successfully treated with carbamazepin. The psychiatric symptoms that were thought to be related to abnormal sexual behaviours were controlled with antipsychotic treatment. Our findings strongly emphasize the fact that efforts should be spent to increase awareness of seizure activity at night, which can be misinterpreted as benign parasomnias. Such a misinterpretation may have serious consequences, such as insufficient seizure control, progressive personality changes, and cognitive impairment.
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Affiliation(s)
- Zerrin Pelin
- Department of Neurology, Vocational School for Health-Related Professionals, Gazikent University, Gaziantep, Turkey ; Department of Neurology, Somnus Sleep Disorders Center, İstanbul, Turkey
| | - Ece Yazla
- Department of Psychiatry, Erenköy Psychiatry and Neurology Training and Education Hospital, İstanbul, Turkey
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