Sleep-Related Orgasms in a 57-Year-Old Woman: A Case Report

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.

Citation:

Irfan M, Schenck CH. Sleep-related orgasms in a 57-year-old woman: a case report. J Clin Sleep Med. 2018;14(1):141–144.

INTRODUCTION

Sleep-related sexual behaviors and experiences are classified as a subtype of non-rapid eye movement (NREM) sleep parasomnias in the International Classification of Sleep Disorders, 3rd Edition (ICSD-3),¹ and most reported cases have responded to bedtime clonazepam therapy.^2,3 There has not been a previous case report in the English language literature on problematic spontaneous orgasms during sleep, although a brief mention of 1 case was included in a case series on sexsomnia.⁴ However, 2 cases in women (ages: 37 and 48 years) have been reported in a Turkish language journal, with the 77-year-old mother of 1 patient also having suffered from sleep-related orgasms.⁵ Ictal orgasms during sleep have been reported in 4 women (ages: 41, 55, 67, and 69 years) and 1 man (age: 31 years).^2,3 We now 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 (EHS).¹

REPORT OF CASE

A 57-year-old woman presented to an author's (MI) neurology clinic with the complaint of shaking of the limbs, which after evaluation and comprehensive testing was concluded to be a functional movement disorder. The patient also reported sudden jerks and twitches, occurring mostly before sleep onset at night, and occasionally could be of such great magnitude as to result in a sudden awakening from a drowsy state. She also hesitantly shared that since her 30s she has experienced nocturnal sleep-related orgasms. She described sometimes having a strange and intense orgasmic feeling shortly after sleep initiation, in the middle of the night, or in the early morning around 4:00 AM. The feeling would arouse her from sleep. She described it as a “systemic kind of orgasm, feeling like the whole uterus is involved.” A heightened sense of visceral feeling was described during these orgasmic episodes. The patient did not endorse experiencing such vigor with orgasm related to regular intercourse.

The frequency fluctuated from several times weekly to every 6 months, without an identified trigger. The duration varied from 30 seconds to a few minutes. No dream mentation with sexual connotation was reported. These events were associated with clear recollection. She denied having any auras, stereoty-pies, automatisms, tongue biting, pain, loss of bladder control, falling out of bed, or injuries associated with the sleep-related orgasms. The patient denied masturbating at night or engaging in any provocative activities, such as watching programs with sexual content on television or electronic media. The occur-rence of presleep intercourse did not have any effect on the frequency of sleep-related orgasms.

In the past, she had brought up this problem with her gynecologist, but was chastised that the orgasms must be related to intentional masturbation. This unsympathetic medical response led to a profound sense of guilt and added further strain to a marriage already in discord. She felt that the sleep orgasms were probably a sign of marital discontent, which led to remorse. She did not share this formulation with her husband as she feared a rebuke from him. The rift with her spouse widened, ultimately leading to divorce.

Subsequently, she was evaluated by a psychiatrist for anxiety and depression. To alleviate anxiety exacerbated in the evening, she was started on clonazepam 1.5 mg at bedtime, which substantially decreased the frequency of the sleep-related orgasmic episodes to once every few months and improved the nocturnal myoclonic jerks. The clonazepam dose over the years was decreased to 0.5 mg as the patient's anxiety improved, but at the time of presentation to the neurology clinic she reported that in the preceding year the frequency of sleep orgasms had increased to approximately once a week. After an arousal from sleep orgasm, she had difficulty returning to sleep for a few hours. She expressed that these nocturnal events were “ruining my life,” and she was afraid to fall sleep. She was very distressed and thus sought management of these nocturnal orgasmic episodes.

The patient also reported the sensory symptoms of EHS,¹ which she described as the “feeling of a cannon ball being shot by my ear,” and infrequent sleep paralysis. She also reported mild snoring. Epworth Sleepiness Scale score was 1. There was no history of parasomnia.

Medical history included Sjögren syndrome, arthritic low back pain, hypothyroidism, and anxiety and bipolar disorders. Bipolar symptoms were fairly stable with the use of antipsychotic agents. The sleep-related orgasms were not associated with any shifts in mood state (hypomanic or depressive cycles). Medications included oxycontin 20 mg daily, roxicodone 10 mg every 4 hours, lurasidone 20 mg daily, venlafaxine 225 mg daily, amitriptyline 75 mg at night, and clonazepam (0.5 mg nightly, at the time of evaluation and video polysomnography [PSG]). Physical examination revealed a neck circumference of 15 inches, and crowded oropharynx with Freidman stage IV. Overbite and overjet were also noted. The tongue was large with dental indentation. Oropharyngeal diameter was narrow in lateral dimensions. Neurological examination did not reveal any abnormal findings with cranial nerves, motor or sensory system, or coordination. Brain magnetic resonance imaging (MRI) did not reveal any intracranial pathology. Prolonged video electroencephalogram (EEG) monitoring captured an episode of non-rhythmic shaking movements of the right leg of variable amplitude and frequency, during which she could still respond to extrinsic stimuli. No ictal or inter-ictal EEG discharges correlating with the event were recorded.

Since an increase in the frequency of sleep-related orgasmic episodes correlated with a decrease in the clonazepam dose, it was increased back to 1.5 mg at bedtime. In an attempt to characterize the presumed hypnic jerks, and also to assess if there might be a component of sleep-disordered breathing that could be aggravating the frequency of sleep-related orgasms, as has been found in other NREM parsomnias,⁶ a video PSG with extended EEG montage was performed that revealed severe central sleep apnea with apnea-hypopnea index of 130 events/h that was attributed to narcotic use, as other causes of central sleep apnea, such as congestive heart failure, stroke, and intracranial pathology, were ruled out based on history, physical examination, and testing including echocardiogram and MRI. The patient did not exhibit any abnormal behavior, including rhythmic or nonrhythmic movements in the awake or sleep state. A brief episode of incomprehensible vocalization out of stage N2 sleep was noted. Sleep latency was normal. There were 27 arousals on the diagnostic portion of the study, with an hourly arousal index of 9.8 events/h. Sleep efficiency was 87.3%; 3.6% of total sleep time was spent in stage N1 sleep, 96.4% in stage N2 sleep, 0% in stage N3 sleep, and 0% in stage R sleep. Excessive spindle activity was also noted. Periodic limb movement index was zero events/h. EEG did not reveal any epileptiform activity. Successful titration of positive airway pressure could not be achieved due to limited time for multiple therapeutic trials including continuous positive airway pressure, bilevel device, and auto servoventilation in a single-night study.

At later follow-up, the patient related that increasing the clonazepam dose to the prior strength of 1.5 mg at bedtime greatly lessened the frequency of both the sleep-related orgasms and hypnic jerks. She was disinclined to repeat a titration PSG. Therefore, it was suggested to discuss a reduction of narcotic medication with her pain specialist, if possible, followed by reassessment of the central sleep apnea with a repeat PSG.

The patient was also reassured that the abnormal sleep-related orgasms were not due to emotional conflict or a result of masturbatory activities, and are considered a distinct category of clinical sleep disorder, namely NREM sleep parasomnia. She was thus encouraged not to blame herself, but rather focus on having a positive attitude and self-assurance. The counseling helped the patient alleviate self-remorse, build self-confidence, and to promote her making positive strides in developing a new relationship. Clonazepam at a dose of 1.5 mg nightly was continued because of its ongoing benefit.

DISCUSSION

To our knowledge, this is the first case report of problematic sleep-related orgasms as a presumed NREM sleep parasomnia published in English, with 2 prior cases published in Turkish. In a recently published study, a case of sleep orgasm was included in group data on sexsomnia, with a brief description about a female with almost nightly orgasms awakening her within the first hours of sleep, with genital wetness and “a disagreeable (not pleasurable) feeling.”⁴

Sleep-related orgasm thus represents a novel category of sexsomnia as a clinical disturbance. Compared with the other published cases of sexsomnia as an NREM parasomnia, involving masturbation, sexual fondling, intercourse/attempted intercourse, and sexual vocalizations,^1–4 this case has some typical and atypical features. Typical features include the personal distress and marital strain caused by the chronic sexsomnia, and the benefit derived from bedtime clonazepam therapy. Atypical features include female sex, recall of the episodes, the absence of any prior parasomnia history or of any current obstructive sleep apnea; the association with hypnic jerks and EHS; the sleep phobia resulting from the long, recurring history of sleep-related orgasms; and the highly complex comorbid medical and psychiatric history.

It may be argued that because an episode was not captured during the video PSG with extended EEG montage, nor during prolonged EEG monitoring, seizures cannot be unequivocally ruled out. Clonazepam is also used as an adjunctive antiepileptic agent and hence the therapeutic response is not exclusive only to a parasomnia disorder. Nonetheless, the historical course, clinical characteristics, lack of stereotypical rhythmic motor or sensory features, and absence of interictal temporal lobe discharges found in epileptic seizures are indicative of a diagnosis of parasomnia. It is important to recognize and share further cases of this underreported form of parasomnia in order to enhance our knowledge for better characterization.

We will now briefly describe the other 2 cases (from Turkey) of spontaneous orgasm during sleep, translated into English by S. Cankardeş, Istanbul.⁵

The first case is of:

“ A 37-year-old, married, employed woman, presented to the psychiatry clinic with the symptom of almost nightly spontaneous orgasms during sleep without sexual dreams or build-up of sexual arousal. Brain MRI was normal. Sleep EEG was unremarkable during an episode of sleep orgasm.”

The second case is of a:

“ 48-year-old, married Turkish housewife, who presented to a menopause clinic with the complaint of spontaneous sleep orgasms, at least 2–3 times a month without any sexual dream content. She also had sleep orgasms after she had sexual intercourse. She reported that her 77-year-old mother had the same problem. Clonazepam therapy, 0.375 mg at bedtime stopped the sleep orgasms within one month.”

Both patients had normal mental health, medical histories, and normal examinations. They also did not have any history of sexual abnormality. The mother-daughter sexsomnia case is the second published report of familial sexsomnia, with the first reported familial case being of an Australian father and son with histories of sexual intercourse with their partners during sleep.³

It is noteworthy that these 3 cases of sleep orgasms in females presented with the same sleep sexual complaint to 4 different types of non-sleep clinics: psychiatry, menopause, gynecology, and neurology clinics. This underscores the importance of increasing awareness of the existence of sexsomnia, and its range of manifestations, in the sleep medicine field and across medical disciplines, to facilitate appropriate triage and early management, especially because sexsomnia in all its manifestations is usually treatable.

A medical dilemma posed by our case concerns the concurrent use of narcotics and a benzodiazepine, which is important to consider because it can increase the risk of sleep-disordered breathing. In our case, the patient exhibited central sleep apnea as a result of oxycontin use and did not show an obstructive component. Consequently, the patient and her pain specialist were urged to discuss a plan for reducing the dose of oxycontin, as guided by clinical prudence. Also, it is noteworthy that onset of sleep-related orgasms predated the initiation of narcotics for pain management. No change in frequency of nocturnal episodes was noted as a result of any narcotic dose adjustment.

Although it is possible that the sleep orgasms were another manifestation of (light) sleep-wake transitional phenomena, together with EHS and hypnic jerks, it may be more likely that the sleep orgasms were disordered arousal phenomena from deep NREM sleep (stage N3 sleep), since the only 2 previously documented cases of sexsomnia by video PSG, involving sleep masturbation, emerged from stage N3 sleep in a 60-year-old woman⁷ and from stage N3 sleep and stage N2 sleep in a 20-year-old man.⁸ Also sleep-related abnormal sexual behaviors are classified as a variant of a disorder of arousal from deep NREM sleep in the ICSD-3,¹ primarily because most reported cases of sexsomnia have involved complex histories of slow wave sleep NREM parasomnias. It is notable, however, that all 3 sleep-related phenomena in our patient involved sudden, strong experiential events: spontaneous orgasms, EHS, and hypnic jerks.

A relevant clinical problem exemplified by our case is the delay from onset of problematic sleep orgasms to presentation, diagnosis, and therapy. Patients usually feel embarrassed and discredited, and are hesitant in sharing personal and potentially self-incriminating information. Physician reception and handling of this underrecognized sensitive complaint shapes the patient's behavior in seeking future medical attention, as evidenced by the patient's reluctance and timidity after the rebuke she received from her gynecologist. It is important to highlight that in our case, the nonjudgmental evaluation of her complaint by a female physician helped build trust and a therapeutic relationship that allowed her to fully share her historical account that ultimately resulted in a proper diagnosis and effective therapy.

The first classification of sexsomnia was published in 2007,² which instigated further reporting of cases from across the world. It is recognized as a discrete clinical and pathophysiological subtype of confusional arousals in the NREM parasomnia category in the ICSD-3.¹ Sleep-related abnormal sexual behavior can vary in morphology from sexual vocalizations, moaning, grunting, masturbation, fondling, rhythmic pelvic thrusting movements, orgasm with or without coitus, to amorous, aggressive, and violent intercourse.^2–4

The predominant form of sexsomnia is manifested as a disorder of NREM arousal, which can be aggravated by stress, sleep deprivation, medications, and sleep-disordered breathing. It can lead to physical (genital injuries, especially in cases of ictal etiology) and psychosocial social consequences, thus affecting quality of life. In ictal sexsomnia, antiepileptic agents are the mainstay of treatment, whereas in sexsomnia as a parasomnia, treatment with clonazepam, or treatment of comorbid sleep-disordered breathing (with continuous positive airway pressure^2,3 or a mandibular advancement device⁹) have usually been successful.^2–4 Careful history-taking with details regarding sleep, and any medical and psychiatric conditions and therapies, together with appropriate testing (eg, video PSG and prolonged EEG monitoring) are instrumental in the evaluation and formulation of a management plan for sexsomnia.

DISCLOSURE STATEMENT

The case was encountered and evaluated at Hennepin County Medical Center. All authors have seen and approved the manuscript. Off-label or investigational use: Use of benzodiazepine clonazepam for the treatment of sexsomnia is off-label. Dr. Irfan reports no conflict of interest. Dr. Schenck serves as a consultant for Sunovion Pharmaceuticals, Inc.

ABBREVIATIONS

EEG

electroencephalogram

EHS

exploding head syndrome

ICSD

International Classification of Sleep Disorders

MRI

magnetic resonance imaging

NREM

non-rapid eye movement

PSG

polysomnography