Resolution of sexsomnia with paroxetine

Abstract

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.

Citation:

Kumar V, Grbach VX, Castriotta RJ. Resolution of sexsomnia with paroxetine. J Clin Sleep Med. 2020;16(7):1213–1214.

INTRODUCTION

Sexsomnia or sleepsex is a parasomnia consisting of sexual behavior during non–rapid eye movement sleep. These behaviors may include vocalizations, fondling, kissing, masturbation, and full sexual intercourse without recall after awakening. Often the sexsomnia is part of an overlap syndrome combined with other parasomnias: REM behavior disorder, confusional arousals, sleep walking, and sleep terrors. The sexsomnia may be accompanied by obstructive sleep apnea. The differential diagnosis includes focal epileptic seizures, nocturnal frontal lobe epilepsy/sleep-related hyper motor epilepsy, and REM sleep behavior disorder. Sleep-related sexual behaviors are classified in the third edition of the International Classification of Sleep Disorders as a subtype of arousal disorder.¹ This usually occurs during non–rapid eye movement sleep; however, case reports have mentioned such behavior occurring during REM sleep as well.² To date, 116 clinical cases of sexsomnia have been reported, mostly in men with a history of other parasomnias. Although most cases have been described in adult men, it can occur in adolescents and women. The most frequently used medication for sexsomnia is clonazepam, but other benzodiazepines, as well as tricyclic antidepressants and selective serotonin reuptake inhibitors, have been used.

REPORT OF CASE

We present a case of 40-year-old man with long-standing symptoms of sexsomnia since his college years. He had not had a prior sleep evaluation. Patient has about 2–6 episodes a month, which can range from kissing to sexual intercourse. He has no recollection of the episode until informed by his wife the next morning. Recently, the sexsomnia episodes have stunted his sex life, but in the past, he has had normal sexual relations with his wife between episodes. He and his wife had been sleeping apart for 6 weeks before his first clinic visit at our sleep office. His psychiatric history is notable for recurrent depression. He has experienced parasomnias since childhood, including sleepwalking and sleep talking. Sexual parasomnias began in college, with escalating aggression in his second marriage. The patient relays significant shame, guilt, and stress associated with his behavior, as well as diminished trust in his marriage. Both he and his wife are currently seeing mental health care providers to address these issues; he is in individual and couples’ therapy. He denies taking any psychotropic medications at this time, relaying that a trial of sertraline many years ago left him feeling flat. He is unsure about whether the sertraline exacerbated his symptoms. Alcohol seems to worsen the problem. He has been counseled for alcohol cessation. He was asked to maintain a sleep log, and full-night diagnostic polysomnography was performed. He kept a sleep diary during a recent vacation when the two shared a room: this indicated 7.78 hours of sleep per night on average over 10 days. He was told he had 4 episodes of sexsomnia while asleep during this period. His polysomnography showed a total sleep time of 411.5 minutes, with 40 minutes (9.7%) in stage N1 sleep, 198 minutes (48.1%) in stage N2 sleep, 53 minutes (12.9%) in stage N3 sleep, and 120.5 minutes (29.3%) in REM sleep. His apnea-hypopnea index was 1.3 events/h of sleep. There were no significant periodic limb movements in sleep and no parasomnias or abnormal electroencephalography. His treatment was implemented in a stepwise approach. He was initially advised to maintain complete abstinence from alcohol. Once that was accomplished, the couple began to share the bedroom again. Sexsomnia persisted after cessation of alcohol consumption. Because alcohol had made his symptoms worse, it was felt that clonazepam, which is a benzodiazepine with action on γ-aminobutyric acid receptors, could potentially have similar effects as alcohol. Hence, we discussed using paroxetine, which may have sexual side effects such as decreased libido. The patient was in agreement with this plan. Since beginning paroxetine, he has had complete resolution of his symptoms in the last 1 year. He and his wife are still attending counseling. He has a normal sexual relationship with his wife; however, he does note that his libido has decreased slightly compared with the past. He, however, prefers the side effect over having episodes of sexsomnia.

DISCUSSION

The first clear description of sexual activity during sleep was reported by Wong³ in 1986, with the case of a 34-year-old man who masturbated during sleep and also manifested sleep talking and night terrors. In 2007, Schenk et al⁴ reported 31 cases with sexsomnia. In 2015, Schenk⁵ published an update with 22 additional patients diagnosed with sexsomnia. Another case series with 41 patients was published in 2016 by Muza et al.⁶ In 2017, Dubessy et al⁷ reported 17 additional cases of sexsomnia. Summarizing the previously published reports, it is clear that sexsomnia may be manifested in many different ways. There is a male predominance with age of presentation varying from adolescence to late adulthood. The sexual behavior is usually reported by the bed partner because of total amnesia of the event by the patient. Events include moaning, vocalizations with dirty talk, masturbation, sexual assault, and sexual intercourse. It may be a component of an overlap parasomnia syndrome such as sexsomnia–REM behavior disorder, sexsomnia-sleepwalking, sexsomnia–sleep terrors, sexsomnia–sleep-related eating disorder, and sexsomnia–confusional arousals. Obstructive sleep apnea is a predisposing condition for disorders of arousal and, when treated, may result in resolution of sexsomnia.⁵ In the most recent case series by Dubessy et al⁷ with 17 patients, 47.6% of patients with sexsomnia had a history of sleepwalking and/or night terrors, mostly in childhood. Patients with sexsomnia also had more stage N3 awakenings than healthy-matched controls and the same amount as regular sleepwalkers.⁷

Various treatment modalities have been described, varying with the comorbid disorders associated with sexsomnia. Various reports also mention successful treatment with hypnosis and cognitive behavioral therapy.⁸ No randomized controlled trials have been performed that assess the efficacy of neuromodulating drugs in the management of sexsomnia. Most data and experience based on currently published literature have been with use of clonazepam because of the association of sexsomnia with confusional arousals. Other drugs that have been used with limited success include trimipramine, lamotrigine, olanzapine, carbamazepine, clomipramine, fluoxetine, escitalopram, and duloxetine.^4,5,8 We highlight with this case the successful treatment with paroxetine and complete resolution of sexsomnia in a patient with no other significant current comorbidities. Paroxetine has a high incidence of associated sexual dysfunction and has been reported to have sexual-depressant effects in 65–71% of patients,^9,10 with decreased libido found in 64% of patients without prior sexual dysfunction in a multicenter, prospective study.¹⁰ As a selective serotonin reuptake inhibitor, paroxetine raises serotonin availability, and it seems that increased serotonin levels diminish sexual function.¹¹

Sexsomnia has several legal implications because of the inherent nature of the condition.¹² Behavior associated with sexsomnia can lead to charges of sexual assault, rape, and child molestation. These patients may have a higher frequency of anxiety, depression, shame, and guilt. Psychiatric assessment when appropriate can be helpful.¹³ With continued publications, there is more awareness about sleepsex as an atypical parasomnia. Given its association with adverse psychological consequences and medico-legal issues, this deserves more attention in the medical community.

DISCLOSURE STATEMENT

All authors have seen and approved this manuscript. The authors report no conflicts of interest.