Sexsomnia in a Young Man: A Non-REM Parasomnia With Diagnostic and Therapeutic Challenges

Introduction

In the third edition of the International Classification of Sleep Disorders, “sexsomnia,” which is a type of non-REM parasomnia associated with aberrant sexual behaviors during sleep, is classified as a distinct subgroup under disorders of arousal (ICSD-3-TR) [1]. It manifests as a full range of sexual behaviors during confusional arousal (a mixed state of sleep and waking when a person is awake but conscious awareness is not fully regained) that includes fondling, sexual vocalization, masturbation, vaginal intercourse with climax, and in extreme cases attempted sexual assault or rape [2]. Parasomnia includes a spectrum of sleep-related sexual behaviors and is also related with sleep-related sexual seizure [3]. Sleep-related sexual seizure can be manifest as genital arousal, sexual moaning/shouting, sexual automatism, libidinal hyper-arousal, and ictal orgasm [2]. Furthermore, sexual automatisms can manifest during focal epileptic seizures, notably in conditions such as nocturnal frontal lobe epilepsy and sleep-related hyper-motor epilepsy (SHE) [4].

The prevalence of sexsomnia is mainly estimated based on the prevalence of parasomnia in the general population [5]. According to a literature survey of 832 clinic patients with sleep-related disorder, showed that 7.6% of the participants had symptoms of sleep-related sexual disorder [6]. The literature also emphasizes the occurrence of these sexual behaviors in males with a previous history of other NREM parasomnias and obstructive sleep apnea [2,7,8]. This case is noteworthy because the patient exhibited recurrent sexual behaviors during sleep, demonstrated complete amnesia for events, and showed an unusually strong therapeutic response to valerian root after limited benefit from various pharmacologic options. By detailing the clinical features, psychosocial consequences, diagnostic evaluation, and treatment response, this report contributes to the limited literature on NREM-related sexual behaviors and underscores the importance of recognizing sexsomnia as a condition with significant clinical, interpersonal, and medico-legal relevance.

Case Report

A 29-year-old man with a 2-year history of abnormal nocturnal behavior reported by his partner, presented to our sleep clinic for further evaluations of his sleep disturbances, excessive daytime sleepiness, and abnormal movements during sleep. According to the patient’s partner, the nocturnal episodes involved repetitive pelvic thrusting, forceful hip movements, involuntary fondling of the partner’s breasts and genital area, masturbation during sleep, sexual vocalizations, and on several occasions, attempted intercourse. The behaviors appeared automatic, purposeful, and occurred without any preceding wakefulness or conscious engagement. The patient had complete amnesia for all episodes. He consistently denied any recollection of the behaviors, sensory awareness, dream content, or sexual urges during the events. Initially, he presented with concerns of these symptoms occurring daily, but now the frequency of these episodes has been reduced to 3 times per week only. The patient also had a previous history of childhood sleep terrors but reported no symptoms of sleep talking, sleepwalking, or sleep eating. The patient was also screened for restless legs syndrome (RLS). He denied experiencing any urge to move the legs, nocturnal leg discomfort, or relief of discomfort with movement, thus suggesting RLS was absent. He also reported no history of snoring, morning headaches, or sleep apnea.

He was also assessed for the symptoms of obstructive sleep apnea; his Epworth Sleepiness Scale score was 5, and his STOP-BANG score was 2, indicating low risk. His symptoms of abnormal nocturnal behavior were mainly associated with anxiety and insomnia, and he reported several significant life stressors during the 2 years preceding the onset of sexsomnia. These included high occupational workload with frequent late-night tasks, irregular sleep–wake schedule, and ongoing interpersonal strain within his intimate relationship. He reported that episodes tended to become more frequent during periods of heightened work-related pressure, suggesting that psychosocial stressors contributed to increased sleep fragmentation and vulnerability to NREM arousal events.

His body mass index was 29.3 kg/m2 and there was no significant past medical history. He was diagnosed with obsessive compulsive disorder (OCD) in 2014 and was treated with selective serotonin reuptake inhibitors (SSRIs). He has a positive family history of parasomnia, and sleep talking was reported in his mother. Initially he was treated with fluoxetine 20 mg/day, consistent with reports that selective serotonin reuptake inhibitors (SSRIs) can attenuate NREM parasomnia behaviors by increasing sleep stability and reducing intrusive arousal phenomena [9]. Melatonin 3 mg nightly was also added to regulate circadian rhythm and decrease sleep fragmentation, but this was not effective. After 1 month, clomipramine 25 mg nightly was prescribed due to its potent serotonergic activity and evidence from prior case reports demonstrating its benefits in parasomnia-related sexual behaviors, but the patient was not compliant with the treatment.

During the subsequent visit, brain MRI and EEG were conducted and results were unremarkable. He also underwent nocturnal polysomnography (PSG), including time-synchronized video and audio recording, a 16-channel electroencephalogram (EEG), electromyogram (EMG) monitoring of the arms and legs, and standard cardiopulmonary monitoring. He was completely off medications when the PSG was conducted.

Results from the PSG showed a total of 443.9 min of data recordings, demonstrating a sleep efficiency of 65.9% with representation of all sleep stages. The apnea–hypopnea index (AHI) was 2.3 events per hour, while the REM respiratory disturbance index was 15.5. No noticeable episodes of abnormal movements were observed during REM sleep, and REM atonia was preserved. Additionally, there were no episodes of abnormal arousals from N3 (slow-wave) sleep. The PSG parameters showed a sleep latency of 5.9 min and a REM sleep latency of 127 min. The sleep architecture distribution was as follows: N1 constituted 18.3% of total sleep time, N2 accounted for 67.2%, N3 was absent (0%), and REM sleep comprised 14.5%. Periodic limb movement analysis revealed no events, with a total periodic limb movement (PLM) count of zero, resulting in a PLM index of 0.0 events per hour and a PLM-related arousal index of 0.0 events per hour.

However, when he independently started medicating himself with a valerian root supplement, he reported 90% improvement in his symptoms. Valerian root supplementation may have contributed to symptom reduction through its GABAergic effects. Valerian has been shown to increase brain levels of γ-aminobutyric acid (GABA) by inhibiting GABA reuptake and stimulating GABA release, producing anxiolytic and sedative properties that lower central nervous system hyper-arousal. This action may help stabilize NREM sleep and reduce the frequency of confusional arousals that precipitate sexsomnia [10]. Additionally, valerian has been associated with improved slow-wave sleep continuity and reduced sleep fragmentation, both of which are relevant in disorders of arousal. Due to concern about adverse effects after reading about it, he discontinued the intake of valerian root supplementation and his symptoms returned, although with a reduced frequency of 1 episode per week. At a subsequent visit, clomipramine 10 mg was prescribed, but the patient did not take this medication. Instead, he independently started taking vortioxetine 20 mg, which that he continued for approximately 3 months, reporting marked and sustained symptomatic improvement. All prior medications were discontinued before initiation of vortioxetine. The patient achieved complete remission of sexsomnia episodes for 3 months, with no recurrences. This improvement shows that emotional distress, anxiety, and sleep fragmentation can precipitate NREM sleep disorders [11].

At the most recent follow-up visit, conducted 2 weeks prior to manuscript preparation, the patient reported continued use of vortioxetine with ongoing clinical improvement. Recently, he also disclosed that he had undergone a divorce, which he attributed to the long-term negative impact of sexsomnia on his personal life.

Discussion

To date, 220 cases of sexsomnia have been reported worldwide across 15 countries, with a prominent male predominance of 84% and age ranging from 14 to 77 years. Sexsomnia frequently occurred with other parasomnias, with individuals exhibiting up to 5 concomitant parasomnia diagnoses, both in the presence and absence of obstructive sleep apnea (OSA). Isolated sexsomnia is rare, buy it has been documented as the sole parasomnia in cases where OSA-induced confusional arousals served as the primary triggering factor [12]. Many cases of sexsomnia are likely to remain unrecognized or improperly identified, either because individuals are unaware of their behaviors during sleep, or because these episodes are dismissed, misattributed to other conditions, or never discussed due to feelings of shame or misunderstanding. As a result, the true number of people affected by the disorder is probably much higher than mentioned in clinical reports or published studies [13]. The literature shows sexsomnia is more common in males, typically with onset between the ages of 26 and 63 years, occurring mostly among the young men [8,14]. Similarly, an internet survey conducted on sexual sleep behavior (SBS) showed that these symptoms can be associated with a history of stress and fatigue, and that females can be affected at higher rates than males, contrary to previous assumptions [15]. In this case, a 29-year-old man presented with a 2-year history of abnormal nocturnal behaviors during sleep, which initially occurred daily the frequency subsequently decreased to 3 times per week. His symptoms were exacerbated by stress and insomnia, as reported by previous studies indicating that emotional and psychological factors can significantly influence the occurrence of parasomnias like sexsomnia. While the patient had no history of snoring, morning headaches, or symptoms commonly associated with sleep apnea, his Epworth Sleepiness Scale score was 5, suggesting mild daytime sleepiness and his STOP-BANG score was 2, which is low, suggesting no significant risk for obstructive sleep apnea (OSA). This is consistent with prior reports associating sexsomnia with underlying conditions, such as sleepwalking or OSA, but no such comorbidity was found in this case [16]. Similarly, the differential diagnosis of sleep-related hyper-motor epilepsy and focal epileptic seizures with sexual automatisms was considered in this patient [17]. However, the absence of epileptiform discharges on prolonged EEG monitoring, unremarkable brain MRI findings, preserved REM atonia on video-polysomnography, and the stereotyped emergence of episodes from NREM sleep with complete post-event amnesia favored a diagnosis of sexsomnia rather than a seizure-related disorder. In our patient, psychological stress, anxiety, and an irregular work schedule appeared to be key precipitating factors. An irregular sleep–wake cycle is also a well-recognized trigger for NREM parasomnias in predisposed individuals, likely through destabilization of slow-wave sleep and increased confusional arousals. Multiple therapeutic approaches were required to minimize the occurrence of sleep-related sexual activities, including treatment of obstructive sleep apnea with CPAP if applicable, daytime Modafinil for excessive daytime sleepiness, bedtime clonazepam, psychological therapy, and hypnosis [18]. Treatment of sleep-related sexual activities in patients with sexsomnia mainly consists of a comprehensive treatment strategy, including the use of various pharmacotherapies like clonazepam and SSRIs, cognitive-behavioral therapy (CBT), and hypnosis [19]. Our patient had tried taking fluoxetine and melatonin, which proved ineffective in managing his symptoms. However, self-administered valerian root supplementation resulted in a 90% improvement in his symptoms, supporting the idea that natural therapies may have a role in treatment for some patients with anxiety, stress, and sleep-related problems [10]. Hypnosis, which is a state of consciousness with increased focus and reduced peripheral awareness has shown effective results in refractory cases of sexsomnia. This modality works by inducing a deep state of relaxation while maintaining focus, which allows for the introduction of new thoughts and behaviors. In a prospective study of 36 patients with various parasomnias, 54% reported being symptom-free or much improved at 18 months, with 50% maintaining this level of improvement for 5 years following 1 to 2 hypnosis sessions [20]. One of the advantages of hypnosis is its relatively short treatment duration, requiring only 1 to 6 sessions, in contrast to cognitive-behavioral therapy, which may require a more extended period of treatment [21]. Given the rarity of the disorder, systematic pharmacological trials specific to the condition are still lacking. However, case reports suggest that pharmacotherapy may provide beneficial outcomes in some patients. Medications such as clonazepam, fluoxetine, trimipramine, lamotrigine, paroxetine, escitalopram, and duloxetine have been reported to reduce symptoms in certain cases, with some positive effects [9]. Our patient did not respond to pharmacological therapy but showed significant improvement with valerian root supplementations, suggesting that alternative natural treatments may be more effective for some individuals and antidepressants with multimodal serotonergic activity such as vortioxetine may reduce vulnerability to parasomnia events by enhancing sleep stability and attenuating hyper-arousal pathways.

Conclusions

This case report may not fully address the challenging nature of sexsomnia, particularly in adolescents and young adults, but it highlights the need for a comprehensive diagnostic and treatment approach. Collaboration between the primary care provider, a sleep specialist, and possibly a psychiatrist or psychologist is essential for managing the complex nature of sleep disturbances, parasomnias, and co-occurring conditions such as anxiety and insomnia can be the main cause of NREM sleep disorders. Exploring natural treatments like valerian root for the treatment of sexsomnia may be useful, and more research on non-conventional therapies is needed.